Evaluating The Airway for difficult

Intubation
Medical history:
Past and present, is important in assessing the patient airway. The
presence of certain physiological and pathological conditions can
predispose to difficulty in managing the Airway

Clinical Examination: LM MAP (Laryngeal Mask

MAP) Rule For Airway Assessment

LM - MAP (Laryngeal Mask MAP)

For Airway Assessment

L = Look for External face Deformities.

M = Mallampati
Class I = visualization of the soft palate, fauces, uvula, anterior and posterior
pillars.
Class II = visualization of the soft palate, fauces and uvula.
Class III = visualization of the soft palate and the base of the uvula.
Class IV = soft palate is not visible at all.

M = Measurements 3-3-2-1 OR 1-2-3-3 Fingers.

3- Fingers Mouth Opening
3- Fingers Hypomental Distance. 3Fingers between the tip of
the jaw and the beginning of the neck (under the chin)

2- fingers between the thyroid notch and the floor of the

mandible (top of the neck)
1- Finger Lower Jaw Anterior sublaxation

A = A- O Extension (Atlanto- Occipital)

The angle between the erect and extended the "normal" amount of extension
equals 35 degrees. The atlantooccipital joint. Additionally, limited A-O joint
extension is present in certain pathological states such as spondylosis,
rheumatoid arthritis, halo-jacket fixation, and in patients with symptoms indicating
nerve compression with cervical extension.

P = Pathological obstructive Conditions, Oedema/ Glottic

Trauma

The following Four D's also suggest a difficult airway:

Dentition (prominent upper incisors, receding chin)

Distortion (edema, blood, vomits, tumor, infection)
Disproportion (short chin-to-larynx distance, bull neck, large
tongue, small mouth)
Dysmobility (TMJ and cervical spine)

Suggested approach to evaluating a difficult airway includes the

following clinical evaluations:

Look externally for evidence of face or neck pathology, a short

receding mandible or a bull neck
Check whether the patient can open his mouth to 3 patient-sized
fingers, and check that the patient can readily jut his jaw forward 1
patient-sized finger.
Check that the hyoid-to-chin distance is > 3 adult fingers (> 6 cm)
in an adult, and > 2 adult fingers (> 3cm) in a child, and 1 adult
finger (> 2cm) in an infant
Check that there is room for 2 fingers between the top of the
thyroid cartilage and the floor of the mouth (adult patient)
Check that the upper incisor teeth are not prominent, that the
mouth is not narrow and that the palate is not high-arched and
narrow
Check the relative tongue-to-pharyngeal size by noting whether the
base of the uvula is visible when the patient opens his mouth

widely, and check whether the tongue is disproportionately large

(modified Mallampati technique using a tongue blade in a supine
patient)
Check that the patient can extend his neck > 35 at the atlantooccipital joint (if a C-spine injury is not a clinical consideration)

(Ron Walls uses the LEMON law - Look externally, Evaluate the 3-3-2
rule, Mallampati, Obstruction, Neck mobility - in his National Emergency
Airway Management Course)

or
Lemon OR Melon

Physical
signs
Look
externally

Less difficult
airway

Evaluate the
3-3-2 rule

More difficult airway

Normal face
and neck
No face or
neck pathology

Abnormal face shape

Sunken cheeks
Edentulous
"Buck teeth"
Receding mandible
"Bull-neck"
Narrow mouth
Obesity
Face or neck pathology

Mouth opening
> 3F
Hyoid-chin
distance > 3F
Thyroid
cartilagemouth floor

Mouth opening < 3F

Hyoid-chin distance <
3F
Thyroid cartilagemouth floor distance <
2F

distance > 2F

Mallampati

Class I and II
(can see the
soft palate,
uvula, fauces
+/- faucial
pillars)

Class III and IV (can

only see the hard palate
+/- soft palate +/- base
of uvula)

Obstruction

None

Pathology within or
surrounding the upper
airway (e.g. peritonsillar abscess,
epiglottis, retropharyngeal abscess)

Neck
mobility

Can flex and

extend the
neck normally

Limited ROM of the

neck

Lemon OR Melon
Evaluating for Difficulty of the Airway
It is estimated that between 1 and 3% of the patients who need endotracheal intubation
there exists airway problems that makes this procedure difficult. Recognition of these
difficult airways allows the paramedic to proceed with caution and consider other options
for airway maintenance. It affords the paramedic the time for equipment preparation
such as the cricothyrotomy kit, which is not part of the normal airway security
procedure. The pneumonic LEMON is useful in the evaluation of a patient prior to
endotracheal intubation and may identify some of the potential problems for the
endotracheal intubation.

Look Externally
External indicators of either difficult intubation or difficult ventilation include: presence of
a beard or moustache, abnormal facial shape, extreme malnourishment, a person

without teeth, facial trauma, obesity, large front teeth or buck teeth, high arching
palate, receding mandible, and/or a short bull neck.

Evaluate 3-3-2- 1 Rule

3 fingers between the patients teeth (patients mouth should be opened adequately to
allow for the placement of three fingers between the upper and lower teeth)
3 fingers between the tip of the jaw and the beginning of the neck (under the chin)
2 fingers between the thyroid notch and the floor of the mandible (top of the neck)
1 Finger lower Jaw Anterior Sublaxation.

Mallampati Scale
This scoring system was first introduced in 1985 in the Canadian Anesthesia Society
Journal based on the work of Mallampati. Place the patient in a seated position and have
them hold head in a neutral position with mouth open wide and the tongue fully
extended. The paramedic should visualize on of the following classifications:
Class I (easy)visualization of the soft palate, fauces, uvula, and both anterior and posterior pillars
Class IIvisualization of the soft palate, fauces, and uvula
Class IIIvisualization of the soft palate and the base of the uvula
Class IV (difficult)the soft palate is not visible at all

Obstruction
Besides the obvious difficulty if the airway is obstructed with a foreign body, the
paramedic should also consider other obstructions such as tumor, abscess, epiglottis, or
expanding hematoma.

Neck Mobility
Ask the patient to place their chin on their chest and tilt head backwards as far as
possible. Obviously, this will not be possible in the presence of a trauma patient.

Magboul M.D March 14th 2007