Correspondence
3. Walls RM, Resnick J. The Joint Commission on Accreditation of
Healthcare Organizations and Centers for Medicare and Medicaid
Services Community-Acquired Pneumonia Initiative: What went
wrong? Ann Emerg Med. 2005;46:409-411.
4. BTS Pneumonia Guidelines Committee. BTS guidelines for the
management of community acquired pneumonia in adults: 2004
update. Available at: http://www.brit-thoracic.org.uk/c2/uploads/
MACAPrevisedApr04.pdf. Accessed December 9, 2005.
5. Moran GJ, Abrahamian FM. Blood cultures for community-acquired
pneumonia: can we hit the target without a shotgun? Ann Emerg
Med. 2005;46:407-408.
In reply:
We greatly appreciate Dr. Bratzler’s thoughtful and reasoned
response, and we are heartened by the modifications to the
community-acquired pneumonia measures. The “new”
measures are unquestionably an improvement. We are also
grateful for the decision to include a single emergency physician
on the oversight panel, a long overdue correction of a serious
structural deficiency. While we are appreciative of the ongoing
efforts by Dr. Bratzler, CMS, JCAHO, and others to improve
patient care across the country, we remain inclined to chasten
those involved in the development and deployment of the
community-acquired pneumonia initiative, so that they might,
in future, feel a more compelling sense of direct responsibility,
not simply to patients who might fall within the purview of the
proposed measure, but to all patients. Although it may now
finally be reaching a state in which it can be both justified and
properly executed, this measure created a very significant
disruption to patient care and flow, at a time when emergency
departments should have been focusing their energies on issues
of much greater impact. We repeat our implicit plea for a more
thoughtful, inclusive, and realistic process when next guidelines
are being considered, lest we replicate the unpleasant chaos
invoked by the needless inclusion of measures that lack evidence
support, but are nonetheless externally imposed on front-line
providers.
Ron M. Walls, MD
Joshua B. Resnick, MD, MBA
Brigham and Woman’s Hospital
Department of Emergency Medicine
Boston, MA
doi:10.1016/j.annemergmed.2006.01.041
Difficult Airways are “LEMONS”: Updating the
LEMON Mnemonic To Account for Time and
Oxygen Reserve
To the Editor:
The assessment of a patient’s airway is a critical point in
developing a plan for rapid sequence intubation or procedural
sedation. The “LEMON” mnemonic has become a common
tool to teach students about assessing airways and predicting the
difficult airway.1 The mnemonic stands for: L ⫽ Look
Volume , .  : June 
externally, E⫽Evaluate the 3-3-2 rule, M⫽Mallampati,
O⫽Obstruction, N⫽Neck Mobility. This mnemonic has been
shown to have limited predictive value in the emergency
department (ED)2,3,4 yet it is still a useful cognitive model for
approaching airway assessment. It reminds the emergency
provider to look inside the mouth, look for trauma, facial hair
and anatomic abnormalities, consider obstruction and consider
neck mobility, which is routinely impaired in emergency
practice due to cervical spine precautions and often overlooked
as a source of airway difficulty.
One of the most critical elements in airway management and
deep procedural sedation is the time allowed to successfully
complete the procedure. The primary determinant of time in
these procedures is the oxygen saturation and, in turn, your
ability to preoxygenate and create an oxygen reserve.1,3,5 We use
and teach a modified mnemonic “LEMONS” to emphasize the
time/oxygenation component, adding “S” for saturations.
We refer to the patient whose oxygen saturation is 100%
following preoxygenation as having “adequate reserve,” above 90%
but less than 100% as having “limited reserve” and less than 90%
despite appropriate preoxygenation as having “no reserve.”
Although typical rapid sequence intubation technique is predicated
on avoidance of positive pressure ventilation,1 the “no reserve”
group is at particularly high risk of requiring supplemental
ventilation before and between intubation attempts and during
procedural sedation. In these cases the provider should consider
alternatives or be prepared to provide optimal bag-valve-mask
ventilation and place a rescue airway device. It is important to note
that some patients with an oxygen saturation of 100% may still
desaturate rapidly, especially if they have underlying lung disease,
morbid obesity or very high metabolic demands.
We encourage the use of this modified mnemonic
“LEMONS” for teaching the assessment of the airway and for
use in clinical practice.
Darren Braude, MD, EMT-P
Steve McLaughlin, MD
University of New Mexico School of Medicine
Emergency Medicine
Albuquerque, NM
doi:10.1016/j.annemergmed.2006.02.030
1. Walls RM (ed). Manual of Emergency Airway Management, 2nd
edition. Philadelphia, PA: Lippincott Williams and Wilkins; 2004.
2. Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway
prediction in the emergency department. Ann Emerg Med. 2004:
44:307-313.
3. Levitan RM. The Airway*Cam Guide to Intubation and Practical
Airway Management. Wayne, PA: Airway Cam Technologies, Inc;
2004.
4. Reed MJ, Remmie LM, Dunn ME et al. Is the “LEMON” method an
easily applied emergency airway assessment tool? Eur J Emerg
Med. 2004;11:154-157.
5. Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation
will occur before return to an unparalyzed state following 1 mg/kg
intravenous succinylcholine. Anesthesiology. 1997;87:979-82.
Annals of Emergency Medicine 581