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BY
DR SALONI SOOD
MODERATOR :-DR SHELLY RANA
Maintenance of airway is the fundamental
responsibility of the anesthetist.
30% of anesthesia related deaths attributable
to inability to manage DA.
Failed Tracheal intubation once in every 2230
attempts
Failed ventilation accounts for 44% of intra
operative cardiac arrests
THEREFORE IDENTIFICATION OF DA IS HOLY
GRAIL OF CLINICAL MX
 Diagnose the potential for difficult airway for
optimal patient preparation
 Proper equipment and technique selection
 Participation of personnel experienced in the
difficult airway management.
Difficult Airway :
Clinical scenario in
which conventionally
trained
anesthesiologist
experiences difficulty
with
 Face mask ventilation
 Tracheal intubation
 Both
It is not possible for the unassisted
anesthesiologist to maintain oxygen
saturation more than 90% using 100%
oxygen and positive pressure mask
ventilation in a patient whose oxygen
saturation was more than 90%before
anesthetic intervention
And/ or it is not possible for the unassisted
anesthesiologist to prevent or reverse signs
of inadequate ventilation during positive
pressure mask ventilation
2 MAIN REASONS ARE
INADEQUATE SEAL
INADEQUATE PATENCY OF AIRWAY
INCIDENCE:- 0.08 -5%
Difficult Laryngoscopy
Not possible to visualize any portion of the vocal
cords after multiple attempts at conventional
laryngoscopy
More than 3 attempts
Longer than 10 minutes
Failure of optimal best attempt
Tracheal intubation requiring multiple attempts
in presence or absence of tracheal pathology.
FAILED INTUBATION
Failure of passage of endotracheal tube after
multiple intubation attempts.
Airway assessment
Adverse outcomes associated with the difficult
airway
◦ Death
◦ Brain injury
◦ Cardio pulmonary arrest
◦ Unnecessary tracheostomy
◦ Airway trauma
◦ Damage to teeth
Painless – JUST SCREENING!!
Quick and simple to apply
Essentially bedside
Less inter examiner variation
Reproducible
High sensitivity and positive predictive value
HISTORY
PHYSICAL EXAMINATION:
:--GENERAL PHYSICAL EXAMINATION
:--SPECIFIC ASSESSMENT TOOLS
PHYSICAL RADIOLOGICAL
EXAMINATION
ADVANCED IND
Detect medical, surgical, and anesthetic
factors
◦ That indicate the presence of a difficult
airway
Previous anesthetic records
◦ History of difficult airway : single most reliable
predictor of a difficult airway
Previous anesthetic exposure
Snoring/ history s/o OSA
Trauma to airway/ neck
Burns (airway?)
Neck swelling
Hoarseness
Stridor
Previous neck surgery
Radiotherapy
Systemic diseases : DM/RA
History of piercing???
Airway assessment
Tounge
Palate :
 High arched
 Long &narrow
Elderly/ cachexic :
buccal pad of fat
Any burns/ wound
Dressings
Epidermolysis bullosa
Skin grafts
Nares :
patency/polyps/DNS
Mouth opening : >3FB
Jaw-
deformity/massive/mus
culatue
Teeth
 Prominent upper
incisors/canines
 Edentulous
 “Buck” teeth
 Hair bun : decreased extension of AO Joint
prevents sniffing position
 Beard : difficulty in mask seal
 Facial deformities
 Neck : Short, thick neck  difficult intubation
(17 in-M ; 16in –F)
 BMI : > 30 kg/m2
 Infections of airway
 URI
 Epiglottitis
 Abscess
 Croup
 Bronchitis
 Pneumonia
 Physiologic conditions : Pregnancy
1. The Obese (body mass index > 30 kg/m2)
2. The Bearded
3. The Elderly (older than 55 y)
4. The Snorers
5. The Edentulous
Patients with two or more of there risk factors are
likely to have difficult mask ventilation
Mask seal difficult(receding mandible,facial
abn,burn strictures)
Obesity or upper airway Obstruction
Advanced age
No teeth
Snorer
Physical Examination Indices
Radiological Indices
Advanced Indices
Functions :
Rotation of condyle in synovial cavity (initial
2-3cm of mouth opening)
Forward displacement of the condyle
:(further 2-3cm mouth opening)
Tests for TMJ function
1. Inter incisor gap (IG)
2. Mandible luxation (ML)
3. Mandibular protusion test
4. Upper lip bite test
INTER-INCISOR GAP :
Ask patient to open mouth
Place his 3 fingers (index, middle & ring)
Indicates IG >5cm Adequate for direct
laryngoscopy
MANDIBULAR LUXATION :
Index finger in front of tragus
Thumb in front of the lower part of the
mastoid process
Ask patient to open mouth
 Index finger enters in space of condyle
 Thumb feels the sliding of the condyle
Airway assessment
Airway assessment
Airway assessment
Airway assessment
Airway assessment
UPPER LIP BITE TEST : (KHAN ET AL)
◦ Range and freedom of mandibular
movement & architecture of teeth
◦ Class I:
Lower incisors can bite upper lip above vermilion
line
◦ Class II:
Lower incisors can bite upper lip below vermilion
line
◦ Class III:
Lower incisors cannot bite the upper lip
Class III upper lip bite test may have
C&L grade III-IV
Airway assessment
MALLAMPATI GRADING (1983)
Size of tongue wrt oral cavity
How much of the pharynx is obscured by
tongue
 Patient in sitting pst,observer’ eye at level wid
pt’s mth
 Maximal mouth opening in neutral position
 Maximal tongue protrusion without arching
 No phonation
ClassI
Faucial
pillars
Uvula
Soft palate
Hard palate
Class II
Uvula
Soft
palate
Hard
palate
Class III
Uvula
Base
Soft
palate
Hard
palate
Class IV
Hard
palate
Samsoon and Young’s modification of the Mallampati
classification, a IV class was added
Failure to consider
 Neck mobility
 Size of the mandibular space
 Inter-observer variability in
classification.
◦ Testing in supine position, phonation
and patient’s arching of tongue cause
inter-observer variability
Determines ease of alignment of
laryngeal and pharyngeal axes when the
atlanto-occipital joint is extended
It’s the space ant to larynx.
Inadequate exposure of glottis if space
reduced/narrowed as tongue is pushed in
here
◦ MTD
◦ RHTMD
◦ MSD
◦ MHD
THYROMENTAL DISTANCE (PATIL TEST)
Distance from the tip of thyroid cartilage to
the tip of mandible(mental symphysis)
Neck fully extended
• > 6.5cm: no problem with L/I
• 6.0 – 6.5cm: without other concomitant
anatomical problems L&I are difficult but
possible
• < 6cm: Laryngoscopy may be impossible
Airway assessment
RATIO OF HEIGHT TO THYROMENTAL DISTANCE
(RHTMD)
Modification to improve the accuracy
Useful bedside screening test
very sensitive predictor of difficult
laryngoscopy
RHTMD < 23.5 –easy laryngoscopy
MENTOSTERNAL DISTANCE : (SAVVA TEST)
Head in full extension and mouth closed
<12.5cm predicts difficult laryngoscopic
intubation
sensitivity of test is 0.82 and specificity is 0.89
Considered single best predictor
MODIFIED MEASURMENT
Distance between mentum and the hyoid
bone
Grade I: > 6.0 cm
Grade II: 4.0 – 6.0 cm
Grade III: < 4.0 cm
Grade III may be associated with impossible
laryngoscopy and intubation.
INDIRECT LARYNGOSCOPIC VIEW
 Grade 1: Vocal cords visible
 Grade 2: Posterior commisure visible
 Grade 3: Epiglottis visible
 Grade 4: No glottic structures visible
Grade 3 & 4: Predicted difficult
This correlates with Cormack and Lehane’s
laryngoscopic view
DIRECT LARYNGOSCOPY VIEW
Based on Cormack & Lehane
classification
◦ Grade I: Visualization of entire vocal cords
◦ Grade II: Visualization of posterior part of
laryngeal aperture
◦ Grade III: Visualization of epiglottis
◦ Grade IV: No glottic structures seen
Not a grading system for everyday
recording of view at laryngoscopy
Airway assessment
 Grade I : Same as C&L
 Grade II a: Partial view of glottis
 Grade II b: Arytenoids or posterior
part of the vocal cords only just
visible
 Grade III : Same as C&L
 Grade IV : Same as C&L
Percentage Of Glottic Opening
Seen during D/L
 100% : Entire glottic aperture visualized
 33% : Lower one third of VC & arytenoids
 0% : No glottic structures visible
Airway assessment
Patient to hold the head erect, facing
directly to the front  maximal head
extension  angle traversed by the
occlusal surface of upper teeth
◦ Grade I : > 35°
◦ Grade II : 22-34°
◦ Grade III : 12-21°
◦ Grade IV : < 12°
For greater accuracy a goniometer is used
to measure the angle traversed by upper
teeth
Airway assessment
Sniffing Position (Mc Gills Position)
Normal Alanto occipital extension 35
degrees
Placing two fingers on chin and occipital
protuberance
Result
◦ Finger on chin higher than one on occiput 
normal cervical spine mobility
◦ Level fingers  moderate limitation
◦ Finger on the chin lower than the second 
severe limitation
Prayer sign
Palm print test
1. Can place 3 finger breaths between the
teeth
2. Between the mandibular genu and hyoid
bone
3. Between thyroid cartilage and sternal
notch
Difficult L&I multifactorial problem
No simple test can predict difficult intubation
accurately
Effective prediction requires a combination of
tests
◦ Wilson Scoring System
◦ The Intubation Difficulty Scale (IDS)
◦ Benumoff’s 11parameter analysis
Risk factor Score
1. Weight 0
1
2
< 90 kg
90-100 kg
> 110 kg
2. Head & neck movement 0
1
2
Above 90°
About 90° (i.e. ± 10°)
Below 90°
3. Jaw movement 0
1
2
IG > 5 cm or S. Lux >
0
IG < 5 cm S. Lux = 0
IG < 5 cm S. Lux < 0
4. Receding mandible 0
1
2
Normal
Moderate
Severe
5. Buck teeth 0
1
2
Normal
Moderate
Severe
WILSONS SCORING SYSTEM
Subjective and Objective criteria
Intubation difficulty defined degree of
divergence from a predefined “ideal
intubation”
 performed without effort on the 1st attempt
 practiced by one operator
 using one technique
 full visualization of the laryngeal aperture and
vocal cords abducted.
PARAMETER SCORE
1. No. of attempts > 1 N1
2. No. of operators > 1 N2
3. No. of alternative techniques N3
4. Cormack Grade I N4
5. Lifting force required
Normal N5=0
sed N5=1
6. Laryngeal pressure
Not applied N6=0
Applied N6=1
7. Vocal cord mobility
Abduction N7=0
Adduction N7=1
TOTAL IDS = Sum of scores N1–
N7
Rules for calculating IDS Score
N1 Every additional attempt adds 1
pt
N2 Every additional operator adds 1
pt
N3 Each alternative technique adds
1 pt:
N4 Apply Cormack grade
N6 Sellick’s maneuver adds no
points IDS Score Degree of Difficulty
0 Easy
0 < IDS < 5 Slight difficulty
5 < IDS Moderate to Major difficulty
IDS =  Impossible intubation
1. Inter-incisor gap : >3cm
2. Buck teeth +/-
3. Length of incisor: <1.5cm
4. Upper Lip Bite
5. MMP class
6. Palate: arching / narrowing
7. TMD: >6cm
8. Mandibular compliance
9. Neck length: sufficient
10.Neck diameter: thin or thick
11.Neck movement
Look –anatomical features suggestive of difficulty
Facial trauma
Large incisors
Beard
Large tongue
Evaluate 3-3-2
Interincisor distance (3 fingers)
Hyoidmental distance (3 fingers)
Thyroid to floor of mouth (2fingers)
Mallampati
Obstruction
Neck movement – chin to chest-flexion
extension
follow a simple mnemonic - FOAM for assessing
the difficult bag-mask ventilation.
F: Facial hairs, piercings & deformities [but not
limited to] such as burn scarring, growths,
emaciated face precluding adequate fit of face
mask.
O: Obesity [BMI > 30], Obstructed breathing
[history of snoring].
A: Aged > 60 years, Absence of teeth.
M: Movement restriction of head & neck
[Extension: cannot look at the ceiling without
raising eyebrows; Flexion: cannot touch the chin
to the chest] and inability to slide the lower jaw
incisors beyond the maxillary jaw incisors.
HAEM for assessing and predicting difficult
laryngoscopy & tracheal intubation in patients.
H: History [but not limited to] of past difficult
laryngoscopy & intubation, snoring, joint
disorders, diabetes mellitus.
A: Appearance [but not limited to] such as
short neck, poor dental status, obesity, small
or large chin, buck teeth, facial trauma,
facial/oral swelling, tumor.
E: Examination [3-6-12-24]:
3: Assess oral opening for rigid laryngoscopy – <3 cm
inter-incisor space is inadequate for smooth
introduction of the laryngoscope blade.
6: Measure the ability of the mandibular space to
accommodate the tongue – <6 cm space between the
mentum and the thyroid notch is inadequate for
compressing the tongue during rigid laryngoscopy.
12: Assess ability to extend the head fully, thereby
aligning airway axis for easy laryngoscopy & intubation
– <12 cm distance between sternal notch and mentum
in a maximally extended head with mouth closed is
associated with difficult laryngoscopy.
24: Assess ratio of the patient height to thyromental
distance [in cm] for predicting easy laryngoscopy – a
ratio of >24 is abnormal and points to difficult
laryngoscopy & intubation.
M: Mobility of the head & neck and Mallampati grade II
or greater.
DROP for predicting the difficult supraglottic
device placement or subsequent ventilation
via it.
D: Disrupted upper airway [but not limited to]
trauma, ingestion of caustics.
R: Restricted mouth opening [<2 cm].
O: Obstruction of the upper airway [but not
limited to] mass, foreign body, edema.
P: Poor lung or thoracic compliance.
Lateral cervical x-ray film : head in neutral
position
ANTERIOR ATLANTO DENTAL INTERVAL (AADI)
 Between posterior surface of arch of C1
 Anterior surface of Dens
 Normal < 3mm adults <5mm Children
Airway assessment
Limits the extension of head on neck
Longer the A-O gap, more space for mobility
of head
Radiologically there is reduced space between
C1 and occiput
<5mm distance
POSTERIOR DEPTH OF THE MANDIBLE :
Distance between bony alveolus behind 3rd
molar tooth & lower border of the mandible
>2.5 cm predicts difficult L&I
RATIO OF EFFECTIVE MANDIBULAR
LENGTH TO POSTERIOR DEPTH
<3.6 predicts difficult L&I
DIFFERENT PATHOLOGIES ACQUIRED OR
CONGENITAL CAN BE PICKED UP
Airway assessment
Airway assessment
Seldom used clinically. These are:
a) Flow volume loops
b) Acoustic reflectometry
c) Ultrasound
d) MRI
TEST SENSTIVITY SPECIFICITY PPV
Mouth Opening 26-47 94-95 7-25
Jaw protrusion 17-26 95-96 5-21
Mallampati (original) 62 25 16
Mallampati (modified) 65-81 66-82 8-9
TMD 62 25 16
TMD + MMP 81 98 64
Mento sternal distance 82 89 27
Neck movement 10-17 98 64
Wilsons scoring 42-55 86-92 6-9
Indirect Laryngoscopy 69 98 31
No single airway test provides a high index of
sensitivity and specificity
Combination of multiple tests a MUST!
Some with difficult airway will remain
undetected
Pre-formulated and practiced plans for
unanticipated difficult airway
Airway assessment

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Airway assessment

  • 1. BY DR SALONI SOOD MODERATOR :-DR SHELLY RANA
  • 2. Maintenance of airway is the fundamental responsibility of the anesthetist. 30% of anesthesia related deaths attributable to inability to manage DA. Failed Tracheal intubation once in every 2230 attempts Failed ventilation accounts for 44% of intra operative cardiac arrests THEREFORE IDENTIFICATION OF DA IS HOLY GRAIL OF CLINICAL MX
  • 3.  Diagnose the potential for difficult airway for optimal patient preparation  Proper equipment and technique selection  Participation of personnel experienced in the difficult airway management.
  • 4. Difficult Airway : Clinical scenario in which conventionally trained anesthesiologist experiences difficulty with  Face mask ventilation  Tracheal intubation  Both
  • 5. It is not possible for the unassisted anesthesiologist to maintain oxygen saturation more than 90% using 100% oxygen and positive pressure mask ventilation in a patient whose oxygen saturation was more than 90%before anesthetic intervention And/ or it is not possible for the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation
  • 6. 2 MAIN REASONS ARE INADEQUATE SEAL INADEQUATE PATENCY OF AIRWAY INCIDENCE:- 0.08 -5%
  • 7. Difficult Laryngoscopy Not possible to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopy
  • 8. More than 3 attempts Longer than 10 minutes Failure of optimal best attempt Tracheal intubation requiring multiple attempts in presence or absence of tracheal pathology. FAILED INTUBATION Failure of passage of endotracheal tube after multiple intubation attempts.
  • 10. Adverse outcomes associated with the difficult airway ◦ Death ◦ Brain injury ◦ Cardio pulmonary arrest ◦ Unnecessary tracheostomy ◦ Airway trauma ◦ Damage to teeth
  • 11. Painless – JUST SCREENING!! Quick and simple to apply Essentially bedside Less inter examiner variation Reproducible High sensitivity and positive predictive value
  • 12. HISTORY PHYSICAL EXAMINATION: :--GENERAL PHYSICAL EXAMINATION :--SPECIFIC ASSESSMENT TOOLS PHYSICAL RADIOLOGICAL EXAMINATION ADVANCED IND
  • 13. Detect medical, surgical, and anesthetic factors ◦ That indicate the presence of a difficult airway Previous anesthetic records ◦ History of difficult airway : single most reliable predictor of a difficult airway
  • 14. Previous anesthetic exposure Snoring/ history s/o OSA Trauma to airway/ neck Burns (airway?) Neck swelling Hoarseness Stridor Previous neck surgery Radiotherapy Systemic diseases : DM/RA History of piercing???
  • 16. Tounge Palate :  High arched  Long &narrow Elderly/ cachexic : buccal pad of fat Any burns/ wound Dressings Epidermolysis bullosa Skin grafts Nares : patency/polyps/DNS Mouth opening : >3FB Jaw- deformity/massive/mus culatue Teeth  Prominent upper incisors/canines  Edentulous  “Buck” teeth
  • 17.  Hair bun : decreased extension of AO Joint prevents sniffing position  Beard : difficulty in mask seal  Facial deformities  Neck : Short, thick neck  difficult intubation (17 in-M ; 16in –F)  BMI : > 30 kg/m2  Infections of airway  URI  Epiglottitis  Abscess  Croup  Bronchitis  Pneumonia  Physiologic conditions : Pregnancy
  • 18. 1. The Obese (body mass index > 30 kg/m2) 2. The Bearded 3. The Elderly (older than 55 y) 4. The Snorers 5. The Edentulous Patients with two or more of there risk factors are likely to have difficult mask ventilation
  • 19. Mask seal difficult(receding mandible,facial abn,burn strictures) Obesity or upper airway Obstruction Advanced age No teeth Snorer
  • 20. Physical Examination Indices Radiological Indices Advanced Indices
  • 21. Functions : Rotation of condyle in synovial cavity (initial 2-3cm of mouth opening) Forward displacement of the condyle :(further 2-3cm mouth opening) Tests for TMJ function 1. Inter incisor gap (IG) 2. Mandible luxation (ML) 3. Mandibular protusion test 4. Upper lip bite test
  • 22. INTER-INCISOR GAP : Ask patient to open mouth Place his 3 fingers (index, middle & ring) Indicates IG >5cm Adequate for direct laryngoscopy MANDIBULAR LUXATION : Index finger in front of tragus Thumb in front of the lower part of the mastoid process Ask patient to open mouth  Index finger enters in space of condyle  Thumb feels the sliding of the condyle
  • 28. UPPER LIP BITE TEST : (KHAN ET AL) ◦ Range and freedom of mandibular movement & architecture of teeth ◦ Class I: Lower incisors can bite upper lip above vermilion line ◦ Class II: Lower incisors can bite upper lip below vermilion line ◦ Class III: Lower incisors cannot bite the upper lip Class III upper lip bite test may have C&L grade III-IV
  • 30. MALLAMPATI GRADING (1983) Size of tongue wrt oral cavity How much of the pharynx is obscured by tongue  Patient in sitting pst,observer’ eye at level wid pt’s mth  Maximal mouth opening in neutral position  Maximal tongue protrusion without arching  No phonation
  • 31. ClassI Faucial pillars Uvula Soft palate Hard palate Class II Uvula Soft palate Hard palate Class III Uvula Base Soft palate Hard palate Class IV Hard palate Samsoon and Young’s modification of the Mallampati classification, a IV class was added
  • 32. Failure to consider  Neck mobility  Size of the mandibular space  Inter-observer variability in classification. ◦ Testing in supine position, phonation and patient’s arching of tongue cause inter-observer variability
  • 33. Determines ease of alignment of laryngeal and pharyngeal axes when the atlanto-occipital joint is extended It’s the space ant to larynx. Inadequate exposure of glottis if space reduced/narrowed as tongue is pushed in here ◦ MTD ◦ RHTMD ◦ MSD ◦ MHD
  • 34. THYROMENTAL DISTANCE (PATIL TEST) Distance from the tip of thyroid cartilage to the tip of mandible(mental symphysis) Neck fully extended • > 6.5cm: no problem with L/I • 6.0 – 6.5cm: without other concomitant anatomical problems L&I are difficult but possible • < 6cm: Laryngoscopy may be impossible
  • 36. RATIO OF HEIGHT TO THYROMENTAL DISTANCE (RHTMD) Modification to improve the accuracy Useful bedside screening test very sensitive predictor of difficult laryngoscopy RHTMD < 23.5 –easy laryngoscopy MENTOSTERNAL DISTANCE : (SAVVA TEST) Head in full extension and mouth closed <12.5cm predicts difficult laryngoscopic intubation sensitivity of test is 0.82 and specificity is 0.89 Considered single best predictor MODIFIED MEASURMENT
  • 37. Distance between mentum and the hyoid bone Grade I: > 6.0 cm Grade II: 4.0 – 6.0 cm Grade III: < 4.0 cm Grade III may be associated with impossible laryngoscopy and intubation.
  • 38. INDIRECT LARYNGOSCOPIC VIEW  Grade 1: Vocal cords visible  Grade 2: Posterior commisure visible  Grade 3: Epiglottis visible  Grade 4: No glottic structures visible Grade 3 & 4: Predicted difficult This correlates with Cormack and Lehane’s laryngoscopic view
  • 39. DIRECT LARYNGOSCOPY VIEW Based on Cormack & Lehane classification ◦ Grade I: Visualization of entire vocal cords ◦ Grade II: Visualization of posterior part of laryngeal aperture ◦ Grade III: Visualization of epiglottis ◦ Grade IV: No glottic structures seen Not a grading system for everyday recording of view at laryngoscopy
  • 41.  Grade I : Same as C&L  Grade II a: Partial view of glottis  Grade II b: Arytenoids or posterior part of the vocal cords only just visible  Grade III : Same as C&L  Grade IV : Same as C&L
  • 42. Percentage Of Glottic Opening Seen during D/L  100% : Entire glottic aperture visualized  33% : Lower one third of VC & arytenoids  0% : No glottic structures visible
  • 44. Patient to hold the head erect, facing directly to the front  maximal head extension  angle traversed by the occlusal surface of upper teeth ◦ Grade I : > 35° ◦ Grade II : 22-34° ◦ Grade III : 12-21° ◦ Grade IV : < 12° For greater accuracy a goniometer is used to measure the angle traversed by upper teeth
  • 46. Sniffing Position (Mc Gills Position) Normal Alanto occipital extension 35 degrees
  • 47. Placing two fingers on chin and occipital protuberance Result ◦ Finger on chin higher than one on occiput  normal cervical spine mobility ◦ Level fingers  moderate limitation ◦ Finger on the chin lower than the second  severe limitation Prayer sign Palm print test
  • 48. 1. Can place 3 finger breaths between the teeth 2. Between the mandibular genu and hyoid bone 3. Between thyroid cartilage and sternal notch
  • 49. Difficult L&I multifactorial problem No simple test can predict difficult intubation accurately Effective prediction requires a combination of tests ◦ Wilson Scoring System ◦ The Intubation Difficulty Scale (IDS) ◦ Benumoff’s 11parameter analysis
  • 50. Risk factor Score 1. Weight 0 1 2 < 90 kg 90-100 kg > 110 kg 2. Head & neck movement 0 1 2 Above 90° About 90° (i.e. ± 10°) Below 90° 3. Jaw movement 0 1 2 IG > 5 cm or S. Lux > 0 IG < 5 cm S. Lux = 0 IG < 5 cm S. Lux < 0 4. Receding mandible 0 1 2 Normal Moderate Severe 5. Buck teeth 0 1 2 Normal Moderate Severe WILSONS SCORING SYSTEM
  • 51. Subjective and Objective criteria Intubation difficulty defined degree of divergence from a predefined “ideal intubation”  performed without effort on the 1st attempt  practiced by one operator  using one technique  full visualization of the laryngeal aperture and vocal cords abducted.
  • 52. PARAMETER SCORE 1. No. of attempts > 1 N1 2. No. of operators > 1 N2 3. No. of alternative techniques N3 4. Cormack Grade I N4 5. Lifting force required Normal N5=0 sed N5=1 6. Laryngeal pressure Not applied N6=0 Applied N6=1 7. Vocal cord mobility Abduction N7=0 Adduction N7=1 TOTAL IDS = Sum of scores N1– N7
  • 53. Rules for calculating IDS Score N1 Every additional attempt adds 1 pt N2 Every additional operator adds 1 pt N3 Each alternative technique adds 1 pt: N4 Apply Cormack grade N6 Sellick’s maneuver adds no points IDS Score Degree of Difficulty 0 Easy 0 < IDS < 5 Slight difficulty 5 < IDS Moderate to Major difficulty IDS =  Impossible intubation
  • 54. 1. Inter-incisor gap : >3cm 2. Buck teeth +/- 3. Length of incisor: <1.5cm 4. Upper Lip Bite 5. MMP class 6. Palate: arching / narrowing 7. TMD: >6cm 8. Mandibular compliance 9. Neck length: sufficient 10.Neck diameter: thin or thick 11.Neck movement
  • 55. Look –anatomical features suggestive of difficulty Facial trauma Large incisors Beard Large tongue Evaluate 3-3-2 Interincisor distance (3 fingers) Hyoidmental distance (3 fingers) Thyroid to floor of mouth (2fingers) Mallampati Obstruction Neck movement – chin to chest-flexion extension
  • 56. follow a simple mnemonic - FOAM for assessing the difficult bag-mask ventilation. F: Facial hairs, piercings & deformities [but not limited to] such as burn scarring, growths, emaciated face precluding adequate fit of face mask. O: Obesity [BMI > 30], Obstructed breathing [history of snoring]. A: Aged > 60 years, Absence of teeth. M: Movement restriction of head & neck [Extension: cannot look at the ceiling without raising eyebrows; Flexion: cannot touch the chin to the chest] and inability to slide the lower jaw incisors beyond the maxillary jaw incisors.
  • 57. HAEM for assessing and predicting difficult laryngoscopy & tracheal intubation in patients. H: History [but not limited to] of past difficult laryngoscopy & intubation, snoring, joint disorders, diabetes mellitus. A: Appearance [but not limited to] such as short neck, poor dental status, obesity, small or large chin, buck teeth, facial trauma, facial/oral swelling, tumor.
  • 58. E: Examination [3-6-12-24]: 3: Assess oral opening for rigid laryngoscopy – <3 cm inter-incisor space is inadequate for smooth introduction of the laryngoscope blade. 6: Measure the ability of the mandibular space to accommodate the tongue – <6 cm space between the mentum and the thyroid notch is inadequate for compressing the tongue during rigid laryngoscopy. 12: Assess ability to extend the head fully, thereby aligning airway axis for easy laryngoscopy & intubation – <12 cm distance between sternal notch and mentum in a maximally extended head with mouth closed is associated with difficult laryngoscopy. 24: Assess ratio of the patient height to thyromental distance [in cm] for predicting easy laryngoscopy – a ratio of >24 is abnormal and points to difficult laryngoscopy & intubation. M: Mobility of the head & neck and Mallampati grade II or greater.
  • 59. DROP for predicting the difficult supraglottic device placement or subsequent ventilation via it. D: Disrupted upper airway [but not limited to] trauma, ingestion of caustics. R: Restricted mouth opening [<2 cm]. O: Obstruction of the upper airway [but not limited to] mass, foreign body, edema. P: Poor lung or thoracic compliance.
  • 60. Lateral cervical x-ray film : head in neutral position ANTERIOR ATLANTO DENTAL INTERVAL (AADI)  Between posterior surface of arch of C1  Anterior surface of Dens  Normal < 3mm adults <5mm Children
  • 62. Limits the extension of head on neck Longer the A-O gap, more space for mobility of head Radiologically there is reduced space between C1 and occiput <5mm distance
  • 63. POSTERIOR DEPTH OF THE MANDIBLE : Distance between bony alveolus behind 3rd molar tooth & lower border of the mandible >2.5 cm predicts difficult L&I RATIO OF EFFECTIVE MANDIBULAR LENGTH TO POSTERIOR DEPTH <3.6 predicts difficult L&I DIFFERENT PATHOLOGIES ACQUIRED OR CONGENITAL CAN BE PICKED UP
  • 66. Seldom used clinically. These are: a) Flow volume loops b) Acoustic reflectometry c) Ultrasound d) MRI
  • 67. TEST SENSTIVITY SPECIFICITY PPV Mouth Opening 26-47 94-95 7-25 Jaw protrusion 17-26 95-96 5-21 Mallampati (original) 62 25 16 Mallampati (modified) 65-81 66-82 8-9 TMD 62 25 16 TMD + MMP 81 98 64 Mento sternal distance 82 89 27 Neck movement 10-17 98 64 Wilsons scoring 42-55 86-92 6-9 Indirect Laryngoscopy 69 98 31
  • 68. No single airway test provides a high index of sensitivity and specificity Combination of multiple tests a MUST! Some with difficult airway will remain undetected Pre-formulated and practiced plans for unanticipated difficult airway