Airway Assessment by Dr (Mrs) Abikoye, feb.

4, 2013

Outline
Introduction
Definition Importance of Airway to Anaesthetist

Causes of Airway Compromise Airway Assessment

History Examination
Predictive Airways Tests

Special considerations in Pediatrics and Diabetes Mellitus Investigations Acronyms

Conclusions / Recommendations

Introduction
Airway
In its day-to- day use usually refers to the upper airway which may be defined as the extra-pulmonary air passage consisting of the nasal and oral cavities, pharynx, larynx, trachea and large bronchi. Evaluation of the airway is done in accident and emergency room, intensive care unit, during preanaesthesia visit, on the wards or in designated difficult airway clinics. Airway assessment predicts the ease of ventilation either with facemask, tracheal intubation or both. A number of intraoperative anesthetic complications resulting in patient morbidity and mortality has been attributed to ill judgement and insufficient evaluation of airway.

Anatomy of upper airway

Definitions by the ASA

Difficult Airway
The clinical situation in which a conventionally-trained anaesthetist experiences difficulty with mask ventilation, tracheal intubation or both.

Difficult Ventilation
The inability of a trained anaesthetist to maintain the oxygen saturation >90% using a facemask for ventilation and 100% inspired oxygen, provided that the pre-ventilation oxygen saturation level was within the normal range.

Difficult Intubation
More than 3 attempts Longer than 10 minutes Failure of optimal best attempt

Conditions causing airway compromise

Conditions causing airway compromise ACQUIRED

Trauma Facial Injuries - hematoma , unstable fracture of maxilla and mandible. C-spine injuries Laryngeal/tracheal trauma Acute burns -oedema of airway Neoplasm -cystic hygroma , adenoma ,goitre , nasopharyngeal and laryngeal tumours , nasal tumours. - stenosis or distortion of the airway ,fixation of larynx or adjascent tissues due to infilteration or fibrosis from radiation Obesity - short thick neck, redundant tissue in the airway , sleep apnea Acromegaly

Causes of airway compromise contd

Infections Supraglottis , croup -laryngeal oedema,hyperactive airway Abscesses e . g intraoral, retropharyngeal -cause distortion of airway Ludwig angina -cause distortion of airway Arthritis Rheumatoid arthritis - temporomandibular joint ankylosis ,cricoarythenoid arthritis, restricted mobility of cervical spine Ankylosing spondylitis - ankylosis of cervical spine ,TMJ , lack of mobility of cervical spine Pregnancy -upper airway oedema,breast enlargement,weight gain,upward displacement of diaphragm

 History will include but not limited to the following:

Review old records whenever possible e.g. history of difficult airway and interventions. Hoarseness of the voice Presence of dental bridges, caps, fillings, dentures, loose teeth. Snoring, obstructive sleep apnoea syndrome, nasal blockage Catarrh, cough, wheezing, asthma, COPD, smoking. Joint diseases like osteo-arthritis, rheumatoid arthritis, ankylosing spondylitis and other connective tissue disorders affecting temporo-mandibular and atlantooccipital joints. Bleeding abnormalities especially before nasal intubation. Diabetes Mellitus

Assessment

Physical Examination
General Examination Airway Examination Systemic Examination

General Examination
Level of consciousness Abnormal facie (pointer to congenital abnormalities or malformations) Body Mass Index >26kg/m Respiratory distress Presence or absence of cyanosis Pregnancy

Airway Examination
Outline
Head Neck Mouth Predictive Airway Tests

Airway Examination (contd.)

Face and Head
Facial features may suggest a syndrome or disease state e.g. Downs syndrome, Pierre-Robin syndrome, acromegaly, hydrocepahlus long face, prognatism, retrognatism Contractures from burns injury, surgery or radiotherapy Facial tumours e.g. maxillary, mandibular, parotid, Burkitts , Ludwigs angina. Facial injuries evidenced by oedema, hematoma, Unstable jaw(as in jaw fracture) Beards and moustaches Hair dos and attachments (occipital hump) Cosmetic attachments nose-piercing, tongue piercing

Airway Examination (contd.)

Neck
Short in some congenital abnormalities e.g KippelFeil syndrome and Downs syndrome Short thick neck in obese Swellings goitre, cystic hygroma, Ludwids angina, oedema, subcutaneuos emphysema. Contractures post burns or radiotherapy Surgical scars e.g. previous tracheostomy scar

 Mouth opening.

Mouth

Normal should admit 3 fingers of the patient vertically in the midline or inter-incisors gap >4cm. limited in temporo-mandibular joint disease, masseter spasms, contracture from burns injury

Teeth
Arrangement: normal or anarchy as in oral tumours and Burkitts lymphoma Prominent upper incisors, protruding teeth(buck) Edentulous (problem of mask seal during bag mask ventilation because of distortion of the contours of the face. Gaps in between teeth Missing tooth

Palate
High arched palate or a long narrow mouth may present difficulty.

Mouth (contd.)
Tongue
Enlarged in tumours, oedema following injury, congenital malformation with macroglossia e.g Downs syndrome, acromegaly Cosmetic; Tongue-splitting, tongue rings, studs etc.

Tonsils and adenoids

Enlarged in children Snoring and sleep apnea Bleeding during nasal intubation Careful intubation to avoid tonsilar bleeding

Pharynx
Tumours and masses, secretions, blood, foreign bodies, false membrane in diphtheria, retro-pharyngeal abscess, acute epiglottitis.

Predictive Airway Tests

These are tests done to predict the ease of face mask ventilation and intubation.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Inter-incisor Distance Mallampati Test Mandibular protrusion Test Mandibulo-Hyoid Distance Thyromental Distance, Patils Test Sternomental Distance Atlanto-occipital Joint Extension Prayer Sign Palm Print Test Comark and Lehane Test

Inter-incisors distance
Its a test of temporo-mandibular joint (TMJ) mobility. Measures the distance between the upper and lower incisors. 3 finger breadths of patient is placed vertically in the mouth in the midline. Normal->4cm(40-60mm) or 3 finger breadth. If less than 30mm,indicates TMJ dysfunction, and patient with less than 25mm is likely to have difficult laryngoscopy.

Mallampati Test
Designed by S. Rao Mallampati an indian- born Boston anaesthetist. Classification was modified by Samson and Young in 1987. Further evaluated by Tham who discovered through his study that phonation produced marked improvement of view and a more favourable classification.

Mallampati Test (contd.)

Access the size of the tongue to pharyngeal size. Its performed with the patient sitting up, head in neutral position, looking straight ahead with anaesthetist at the same level with patient. The mouth is wide open with the tongue protruding to its maximum without phonating. Classification is based on the extent to which the base of the tongue is able to mask the visibility of pharyngeal structures.

Mallampati classification

 Original

Mallampati

Class 1-visualisation of the soft palate, fauces ,uvula, anterior and posterior pillars Class 2-visualisation of the soft palate, fauces and uvula Class 3-visualisation of soft palate and base of uvula

Modified
By Samson and Young in 1987 Class 4-only the hard palate is visible Classes 3 and 4 are predictive of difficult intubation

 Assess temporo-mandibular joint function Patient is told to advance the mandible as far as possible.
1. Class A- lower incisors can be protruded beyond the upper incisors 2. Class B- the lower incisors can only be advanced to the level of upper incisors. 3. Class C- lower incisors cannot reach the level of upper incisors

Mandibular Protrusion Test

Classes B and C predicts difficult mask ventilation and tracheal intubation

Mandibulo-hyoid distance
Measures the mandibular length from the chin to the hyoid bone. Distance should be at least 4cm or 3 fingers breadth.

 It measures mandibular space. Defined as the distance from the mentum to the thyroid notch while the patients neck is is fully extended. Helps in determining how readily the laryngeal axis will fall in line with the pharyngeal axis when atlanto-occipital joint is extended. Greater than 6cm is normal in adult, less than 6cm or 3 finger breadth predicts difficulty. Positive in patients with short mandible, protruding upper incisors, reduced intra and submandibular space.

Thyro-mental Distance(Patils test)

Diagram of thyromental distance

Sterno-mental distance
Proposed by Sauva in 1948 Also a measure of mandibular space Estimation of the distance from the suprasternal notch to the mentum with the head fully extended on the neck and the mouth closed. Normal is 12.5cm. Less than this predicts difficult intubation.

Sternomental distance

 Assess the ease to assume a sniffing or Magils position for intubation i.e. alignment of oral, pharyngeal and laryngeal axes in an arbitrary straight line. Patient holds the head erect, looking straight ahead and he is asked to maximally extend the head. Grade 1- > 35 degrees (normal) Grade 2- 22-34 degrees Grade 3- 12-21 degrees Grade 4- < 12 degrees

Atlanto occipital joint extension

Atlanto-axial joint extension

Airway Assessment in Diabetes Mellitus

Diabetics have limited joint mobility due to glycosylation of tissue proteins and collagen. The same process affect the spine, temporomandibular joint and larynx. Incidence is about 30-40% in IDDM Two tests are used
Palm print Prayer sign

The two tests have higher sensitivity for diabetics

Prayer Sign
Patient is asked to bring both palms together. Its categorized as follows;
Positive-when there is a gap between the palms Negative-when there is no gap.

Palm Print
Patient is made to sit. Palms and fingers are painted with ink. Patient presses hand firmly against a white paper placed on a hard surface. Grade 0-All the phalangeal areas are seen Grade 1-Deficiency in the inter-phalangeal areas of the 4th& 5th digits Grade 2-Deficiency in inter-phalangeal areas of 2nd-5th digits Grade 3-only the tips of the digits are seen

Airway Assessment in Paediatrics

Factors responsible for difficult airway Large head and tongue Narrow nasal passages Anterior and proximal larynx Long epiglottis Short trachea and neck Prominent adenoids and tonsils Teeth eruption Loose tooth

 Indirect

Laryngoscopy

Usually done otolaryngologists Visualising the larynx through a series of mirrors and head lamp Detects vocal cord paralysis, masses and other lesions

Direct
Conventional
Cormack-Lehane Grading of View on laryngoscopy

Rigid Fibreoptic

Cormack-Lehane Classification
Its used to describe laryngeal view on direct visualization at conventional laryngoscope. Class 1- most of the glottis is visible Class 2- only the posterior glottis is visible Class 3- only the epiglottis is visible Class 4- the epiglottis is not seen

Limitations Inadequate knowledge of the grading system Poor intra-observer and fair inter-observer reliability Validity questioned

Mallampati and Comack-Lehane classification

Investigations
Radiological
Plain radiographs of neck , thoracic inlet and chest (AP and lateral)
Mandibulo-hyoid distance Atlanto-occipital gap Anterioir/posterioir depth of mandible Cervical ribs Abnormal curvature of cervical spine

Fluoroscopy for dynamic imaging

Cord mobility Airway malacia Emphysema

Investigations (contd.)
Ultrasonography
Mediastinal mass, lyphadenopathy, cyst, abscess etc

Computerized Tomography Magnetic Resonance Imaging

Acronyms
LEMON Airway Assessment OBESE Uses
For rapid assessment in emergency situations

Acronyms
LEMON Airway Assessment L- Look externally(facial trauma,large incisors,beard/moustache,large tongue). E- Evaluate the 3-3-2 rule(incisors distance-3 finger breadth,hyoidmental distance-3 finger breadth,thyromental distance-2 finger breadths. M-Mallam Patti(score 0f 3 and above) O- Obstruction (conditions like epiglottitis,peritonsillar abcess,trauma) N-Neck mobility( limited neck mobility) maximum score of 10 with 1 point for each criteria

Predictors of face mask ventilation

O-the Obese(body mass index >26kg/m2) B- Bearded E- the Elderly(older than 55yrs) S- the Snorers E- the Edentulous

Conclusion
Airway assessment helps to identify patients with difficult airway or those with potential airway problems and to decide on the appropriate method of ventilation. This will help to reduce complications occuring due to airway problems.

Thank you for

listening