HOW TO ASSESS

AIRWAY
Lecture of
DR. MASSOUD
Surgical Consultant

AIRWAY
Defined as the PASSAGE BY WHICH
AIR REACHES A PERSONS LUNGS
Or the PASSAGE BY WHICH THE
AIR ENTERS AND LEAVES THE
LUNGS
Any obstruction in the airway can
usually lead to death if no
immediate intervention is done.
(e.g. CHIN LIFT or JAW THRUST
can save a persons life)

SIGNS & SYMPTOMS OF AIRWAY

OBSTRUCTION

Increased Respiratory Effort

Sternal Retractions labored
breathing where there is sucking of
the skin, around the ribs and top of
the sternum.
Inspiratory Stridor - narrowing of
airway; commonly in young age
Hypoxemia Pt is anxious or
agitated; Often misdiagnosed as PAIN

SIGNS & SYMPTOMS OF AIRWAY

OBSTRUCTION

HYPERCAPNIA Pt is OBTUNDED
(Altered level of
consciousness/alertness; dulled or
less sharp)
Absence or Decreased Breath Sounds
Dyspnea

ASSESSMENT OF AIRWAY (L.E.M.O.N.S.)

L - LOOK EXTERNALLY
E - EVALUATE 3-3-2
M - MALLAMPATI TEST
O - OBSTRUCTION
N - NECK MOBILITY
S SCENE & SITUATION

1. LOOK/ASSESS EXTERNALLY
ANATOMICAL/CONGENITAL /SURGICAL anomalies
in the Face, Neck and/or MouthArea
Relatively LONG UPPER INCISORS; Prominent
OVERBITE
Mandibular space stiff, indurated, occupied by
mass and/or nonresilient
Thyromental distance < 3 ordinary finger
breadths (3-3-2 test)
Short neck length
Thick neck circumference
Inflammed tongue that covers entire oral
cavity

2. EVALUATE WITH RULE OF 3-2-2

3 FINGERS between PATIENTS TEETH
(Temporomandibular Joint Exam)
3 FINGERS between the TIP OF JAW &
BEGINNING OF NECK (Thyromental Exam)
Hyoid Bone is the Tip of Neck just
slightly above Cricothyroid area)
2 FINGERS between the THYROID NOTCH
& FLOOR OF MANDIBLE
NOTE: Tip of NOSE to EYEBROW and
Tip of NOSE to CHIN should have
equal parts

3. MALLAMPATI TEST
Named after Indian-born American
Anaesthesiologist SESHAGIRI
MALLAMPATI
This is used to predict ease of
ENDOTRACHEAL INTUBATION
Composed of visual assessment of the
DISTANCE FROM THE TONGUE BASE to
the ROOF OF THE MOUTH; therefore the
AMOUNT OF SPACE IN WHICH THERE IS
TO WORK WITH.

MALLAMPATI TEST

Procedure:
Pt is in SITTING POSITION
HEAD is NEUTRAL
MOUTH is WIDE OPEN
TONGUE is PROTRUDED
DEPRESS TONGUE TO ASSESS
AIRWAY
Assess Oral Orifice

MALLAMPATI TEST
CLASS 1
Soft Palate, Tip & Base of Uvula,
Fauces, Anterior & Posterior Pillars
noted
CLASS 2
Soft Palate, Tip & Base of Uvula,
Fauces visible
CLASS 3
Soft Palate, Base of Uvula
CLASS 4
Hard Palate noted

MALLAMPATI TEST

CORMACK-LEHANE CLASSIFICATION
SYSTEM
Assessment obtained by direct
LARYNGOSCOPY and viewing the VOICE
BOX or LARYNX
initially described by R.S. Cormack and J.
Lehane in 1984
Done by Anesthesiologists
Classified into FOUR (4) GRADES
Recently, there is a MODIFICATION of this
classification
Grade 2 is subdivided into Grade 2a and
Grade 2b

Entrance to the LARYNX

CORMACK-LEHANE CLASSIFICATION
SYSTEM
Approximat
Likelihood of
e frequency difficult intubation

Grade

Description

Full view of GLOTTIS

68%

<1%

2a

Partial view of GLOTTIS

24%

4.3%

2b

Only posterior extremity of glottis seen or only

ARYTENOID CARTILAGES

6.5%

67.4%

Only EPIGLOTTIS seen, none of glottis seen

1.2%

87.5%

Neither glottis nor epiglottis seen

very rare

very likely

4. OBSTRUCTION
Defined as A THING THAT IMPEDES OR
PREVENTS PASSAGE OF AIR IN THE
AIRWAY OR RESPIRATORY TRACT
Common obstruction is caused by
FOREIGN OBJECT
Common foreign object is FOOD
Common food that can cause
obstruction is MEAT
Others such as SMALL OBJECTS ( pins,
brooch, etc)

5. MOBILITY OF THE NECK

NECK MOBILITY
Neck can be extended 35 BACKWARDS
Ask Patient to place CHIN on the CHEST
& TILT HEAD BACKWARDS as FAR AS
POSSIBLE
NOT DONE IN TRAUMA PATIENTS
NECK PROBLEM
Cervical Spine Immobilization,
Ankylosing Spondylitis, Rheumatoid
Arthritis, Halo Fixation Device etc.

6. SCENE & SITUATION

Be a SAFE HEALTH PRACTIONER

Assess the situation as per your
capability
KNOW YOUR LIMITATIONS
PATIENTS WELFARE IS TOP
PRIORITY

5 INDICATORS OF DIFFICULTY IN USE

OF MASK OR BAG (O.B.E.S.E.)

O - OVERWEIGHT (BMI is >26 kg/m)

B - BEARDED
E - ELDERLY (age is >55 years old)
S - SNORERS
caused by a narrowing of the upper
airway during sleep. This can be due to
large tonsils, a soft palate, a long uvula
or excessive flabby tissue at the throat.
All of these areas relax during sleep.
E EDENTULOUS (Lacking or no teeth)

SIMPLIFIED AIRWAY RISK INDEX

(S. A. R. I.)

A MULTIVARIATE RISK SCORE for

predicting DIFFICULT TRACHEAL
INTUBATION
Ranges from 0 to 12 POINTS
The Higher the score indicates a
more difficult airway
Includes SEVEN (7) PARAMETERS
for scoring

1. MOUTH OPENING

Measurement of distance
between the INCISORS
If distance is greater than
4 CENTIMETERS: score is 0
If distance is less than
4 CENTIMETERS: score is 1

2. THYROMENTAL DISTANCE
is measured from the THYROID NOTCH
to the TIP OF THE JAW with the head
extended
If distance is greater than
6.5 centimeters: score is 0
If distance is between
6 - 6.5 centimeters: score is 1
If distance is below
6 centimeters: score is 2

3. Modified MALLAMPATI SCORE

Class I and Class II: scores 0 point

Class III: scores 1 point
Class IV: scores 2 points

4. MOVEMENT OF THE NECK

Measured through the ABILITY TO
MOVE THE NECK OF VARYING
DEGREES
More than 90:
scores 0 point
Movement range of 80-90:
scores 1 point
Movement range below 80:
score 2 points

5. UNDERBITE

Ability of the patient to

PROTRUDE THE JAW, creating
an UNDERBITE
If YES:
score is 0
If NO:
score is 1

6. BODY WEIGHT

A weight below 90 kg :
score is 0 point
A weight between 90 to 110
kg:
score is 1 point
A weight above 110 kg:
score is 2 points

7. PREVIOUS INTUBATION HISTORY

If previously intubated without

any difficulties: score is 0
points
Not previously intubated, not
sure whether there is difficulty or
no records: score is 1 point
Positive history of difficult
intubation: score is 2 point

TABLE OF S.A.R.I.
PARAMETER

0 POINT

1 POINT

2 POINTS

> 4 cm

< 4 cm

> 6.5 cm

6 to 6.5 cm

< 6 cm

3. Mallampati Scoring

I or II

III

IV

4. Neck Movement

> 90

80 to 90

< 80

Can protrude
jaw

Cannot protrude
jaw

< 90 kg

90 to 110 kg

> 110 kg

No difficulty

Unsure or
Unknown

Known Difficulty

1. Mouth Opening
2. Thyromental
Distance

5. Underbite
6. Body Weight
7. Previous Intubation
Hx
SCORE 4 :

A PREDICTOR OF DIFFICULT INTUBATION

THANK YOU!
A simple act can
SAVE LIVES!
Thank You Dr. Massoud.
FROM:

PRINCE MUTAEB HOSPITAL, SAKAKA, AL

JOUF
NURSING ADMINISTRATION & NURSING EDUCATION