Descibe airway anatomy and helps in thoriugh knowledge of the same

1. AIRWAY ANATOMY
IT’S Anaesthetic Implications
Presenter-
Dr SATYENDRA YADAV
ASSISTANT PROFESSOR
Dept. Of Anaesthesiology
VCSG Medical college and Hospital
Srinagar

2. ANAESTHESIOLOGIST – CRUCIAL ROLE IN
AIRWAY MANAGEMENT
ANATOMY
OF AIRWAY
PHYSIOLOGY
OF AIRWAY
SKILLS
AIRWAY
ASSESSMENT

3. DEFINITION
Airway is defined as a passage through
which the air/ gas passes during
respiration.

4. CLASSIFICATION OF AIRWAY
UPPER AIRWAY –
-Mouth, oral cavity, oropharynx,
Nostrils, nose, nasal cavity, nasopharynx, pharynx, larynx.
 LOWER AIRWAY –
-Trachea, bronchi, bronchioles, alveoli.
SIGNIFICANCE -
-Upper airway serves to warm, filter, humidify the air/gas before
it enters the lower airway. Bypassing these structure during ETT
intubation makes it essential to provide warm humidified air/gas
- Lower airway serves in exchange of gases.

6. ORAL CAVITY
• EXTENSION
LIPS TO OROPHARYNGEAL ISTHMUS
i.e. UPTO LEVEL OF ANTERIOR
PILLARS OF TONSIL
• BOUNDARIES -
 ROOF Hard and soft palates.
 FLOOR Soft tissues, which
include a muscular diaphragm and
the tongue.
 LATERAL WALLS Cheeks
 POSTERIOR aperture of the oral
cavity is the oropharyngeal isthmus

7. SIGNIFICANCE
• JAW THRUST MANUEVER
This manuever uses the sliding component of TM joint to
move the mandible and attached tongue anteriorly
relieving airway obstruction caused by posterior
displacement of tongue into oropharynx (During sleep,
decreased consciousness, during general anaesthesia)

8. NOSE AND NASAL CAVITY
• Airway functionally begins at nostril, the external
opening of nasal passage
• Only externally visible part of the respiratory system

9. • Nose is divided into two regions
– External nose
– Internal nasal cavity
• EXTERNALLY ALAE NASI
• Lateral margins of the nostrils
• Flaring of ala nasi Airway obstruction
• Infolded while introducing any tube via the nostril
• Distance from alae nasi to various points on external
ear(tragus,meatus)
Estimate the length of airway device

10. NASAL CAVITY
• Extends from external nares to the post. nasal
aperture
• Divided by nasal septum into rt. & lt. Halves
• Each half has a roof, floor, lateral wall &
medial wall

11. NASAL CAVITY
ROOF -
-Cribriform plate of ethmoid bone
Fracture leading to CSF rhinorrhea, is a contraindication for passing nasogastric
tube or nasotracheal tube
Positive pressure mask ventilation is also a contraindication as it may leads
to entry of infection.
FLOOR-
Palatine process of maxilla in its anterior 3/4th and horizontal part of
palatine bone in posterior 1/4th
Almost perpendicular to the plane of the face
So the tube should be inserted perpendicular to the plane of face.
LATERALWALL-
3 bony turbinates or conchae , 3 meatus
Easily damaged by force during passage of nasotracheal tube
Paranasal sinuses opening & its drainage may be impaired by prolonged
nasotracheal intubation.
INFERIOR MEATUS IS THE PREFERRED PATHWAY FOR PASSAGE OF
NASAL AIRWAY DEVICES.IMPROPER PLACEMENT IN NOSE CAN RESULT
IN AVULSION OF A TURBINATE

13. FUNCTION OF NOSE
• Inspired air is:
– Humidified by the high water content in the nasal
cavity
– Warmed by rich plexuses of capillaries
• Ciliated mucosal cells remove contaminated mucus
• Turbinates increase mucosal area(166cm2) for
humidification & enhance air turbulence & help filter air
• During exhalation these structures:
– Reclaim heat and moisture
– Minimize heat and moisture loss

14. Significance
• In endotracheal intubation, nose is bypassed so to maintain the
humidity of inspired air, humidifiers should be used.
• Tracheal intubation & high fresh gas flow bypasses this humidification
system
exposing lower airway to dry(<10cm h2o/l)room temperature gases.
• Prolonged exposure of lower reapiratory tract to this non – humidified air
leads to
:
– 1) dehydration of mucus
– 2)altered ciliary function
– 3)inspissation of secretion
– 4)atelectasis
– 5)ventilation-perfusion
mismatch
PARTICULARLY I N
UNDERLYING LUNG
DISEASE

15. PHARYNX
• Extends from base of skull to cricoid cartilage anteriorly and to inferior
border of sixth cervical border posteriorly
• 12-14 cm long
• 3.5cm wide at its base
• 1.5cm at pharyngoesophageal junction(narrowest part of digestive
system
• Posterior pharyngeal wall made up of buccophayngeal fascia which
separates pharngeal structures from retropharyngeal space.Improper
placement of gastric or tracheal tube can result in laceration of fascia.
Pharynx is further subdivided into :
• Nasopharynx
• Oropharynx
• Laryngopharynx or hypopharynx.

16. NASOPHARYNX
• Extends from posterior nasal aperature to the posterior pharyngeal wall
above the soft palate.
• Ends at soft palate , this area is called velopharynx & is common site for
airway obstruction in both awake and anaesthesised patient
• Roof of nasopharynx forms an acute angle with the posterior pharyngeal
wall – while passing any tube through the nose into the oropharynx a
simple maneuver of extension of head will straighten out this angle &
facilitates the passage of tube
• Adenoids are located in its roof – which are frequently hypertrophied
during childhood & may cause obstruction or hemorrhage while passing
any tube through the nose.
• Retropharyngeal & peritonsillar abscess possess anaesthetic challenges.

18. OROPHARYNX
•
• EXTENSION
Soft palate to epiglottis
Includes tonsil, uvula & epiglottis.
Most important area in terms of airway obstruction & management as
it is made of collapsible soft tissue all around.
• Previously it has been thought that upper airway obstruction occur due
to tongue fall but now it shows that airway obstruction occur mostly at
the level of soft palate & epiglottis.
• Jaw thrust & neck extension will helps to create space between the
epiglottis & posterior pharyngeal wall.
• VALLECULA -
The entire space between epiglottis & base of tongue & has paired
depression of the two sides of median glossoepiglottic fold.
Laryngoscope blade tip lies in vallecula during classical macintosh
Laryngoscopy.

19. LARYNGOPHARYNX OR
HYPOPHARYNX
• It extends from epiglottis to the
beginning of oesophagus.
• On each side of the laryngeal
inlet, the lateral wall of laryngo-
pharynx presents the piriform
fossa which is a deep
depression.It acts as a catch
point for foreign body.

20. LARYNX
SITUATION &EXTENT
• It lies in the midline of neck opposite C3 to C6 vertebra in
adult & C1 to C4 vertebra in children. It extends from the
upper border of epiglottis to lower border of cricoid
cartilage.
MEASUREMENT
• Vertical Length -
MALE
44mm
FEMALE
36mm
• Transverse diameter - 43mm 41mm
• A-P diameter - 36mm 26mm

21. SKELETON OF LARYNX
• Composed of hyoid bone & a series of cartilage & are
moved by a number of muscle. The cavity of larynx is
lined by mucous membrane. Larynx contains 9
cartilages
• 3 Unpaired -Thyroid
-Cricoid
-Epiglottis
3 Paired - Arytenoid
- Corniculate
- Cuneiform

22. ⚫ "B U R P “ T EC HN I Q UE -
(Backwards Upwards Rightwards Pressure) manoeuvre, which is
used to improve the view of the glottis during laryngoscopy and
tracheal intubation . It requires a clinician to apply pressure on
the thyroid cartilage posteriorly, then cephalad (upwards) and,
finally, laterally towards the patient's right.

23. CRICOID CARTILAGE
• It represent the anatomical lower limit of Larynx & is the only complete
cartilaginous ring in the airway.
• It is the narrowest part of upper airway in children, so uncuffed ETT are
used in children.
• Cricoid doesn’t allow space for edema to spread outwards & thus any
injury in this area can worsen quickly.
SELL IC K’ S MAN EAU VE R
– In patients who are at risk of
gastric aspiration, during airway
management downward pressure
over cricoid cartilage will prevent
passive regurgitation without
subsequent airway obstruction. This
is known as Sellick’s Maneuver

24. EPIGLOTTIS
• Thin leaf like plate of elastic fibrocartilage projects obliquely upward
behind the tongue and hyoid body and in front of laryngeal inlet.
Attached part
Free end
 Broad and
notched in
midline
 Long and narrow
 Connected to elastic
thyroepiglottic
ligament
Sides: Attached to arytenoids by aryepiglottic folds

25. Function of epiglottis
⚫During Deglutition
closure of the laryngeal inlet during deglutition takes place by the
apposition of the aryepiglottic folds due to contraction of
aryepiglotticus musle.the epiglottis does not fall back to close the inlet
like a lid, instead it moves upward and comes in contact with the dorsal
surface of the posterior third of tongue.
⚫Assist in phonation
⚫Prevent aspiration of food into the trachea.

26. MUSCLE OF THE LARYNX
• EXTRINSIC MUSCLE – which attaches larynx to the
surrounding structures.
• INTRINSIC MUSCLE - which attaches laryngeal
cartilages to each other.
EXTRINSIC MUSCLE
SUPRAHYOID MUSCLE – Attaches larynx to the hyoid bones & elevate
the larynx.
eg. – Geniohyoid, Stylohyoid, Mylohyoid, Diagastric, Thyrohyoid,
Stylopharyngeus.
INFRAHYOID MUSCLE – Strap muscle, in addition to lowering of larynx,
can modify the internal relationship of laryngeal cartilage & folds to one
another.
eg. – Sternohyoid, Sternothyroid, Omohyoid, Thyrohyoid.

27. • INTRINSIC MUSCLE
• I – ACTING ON VOCAL CORD
 Abductor – Posterior crico arytenoid
 Adductor – Lateral crico arytenoid
Transverse & oblique
arytenoid
 Tensor (Elongation) – Cricothyroid
Partly Vocalis
 Relaxor (Shortening)– Thyro arytenoid
Partly Vocalis
• II – ACTING ON LARYNGEAL INLET
 Openers - Thyro epiglotticus
Thyroarytenoid
 Closer – Ary epiglotticus
Oblique arytenoid

28. Laryngeal cavity
• Extends from laryngeal inlet
down to lower
cricoid cartilage
border of
where it
continues into trachea
By paired upper and lower
•
cavity
mucosal fold projecting into
is
lumen laryngeal
divided into-
UPPER(SUPRAGLOTTIC)
MIDDLE(SINUS)
LOWER(INFRAGLOTTIC)
 Upper fold : Vestibular
fold(FALSE VOCAL CORD)
guarding rima vestibuli.
 Lower fold :Vocal fold(TRUE
VOCAL CORD)guarding rima
glottidis

29. UPPER FOLD – Vestibular fold (False Vocal Cord)
Pink in colour
LOWER FOLD – Vocal fold (True Vocal Cord)
Pearly white in colour
Vocal fold is attached to
the middle of thyroid
angle anteriorly & to the
vocal process of arytenoid
cartilage posteriorly.

30. GLOTTIS
It is the narrowest part of the larynx
in adult.
A-P length Male – 24 mm
Female – 16 mm
It is divided into two part –
I – Anterior inter-
membranous part (3/5) –
Situated between the two vocal
fold.
II- Posterior inter-
cartilaginous part (2/5) – Passes
between the two arytenoids
cartilage.

31. COMPARISION BETWEEN
PEDIATRIC & ADULT AIRWAY
5 DIFFERENCES -
1– Relatively larger tongue – Obligate nasal breather.
2 – Large & omega-shaped epiglottis
3 – More rostral larynx
4 - Funnel shaped larynx - Narrowest part of pediatric airway is cricoid
cartilage.
5 – Angled vocal cord – Infant VC have more angled attachment to
thyroid angle whereas adult VC are more perpendicular.

32. LARYNGEAL FUNCTION
• AIRWAY PROTECTION
• PHONATION-
The vocal cords:
Adducted for phonation;
Abducted for inspiration.

33. Laryngoscopic anatomy
• Tohaveproper view of larynx
Mouth, oropharynx and larynx must be in one plane.

34. CRICOTHYROTOMY
• ‘Surgical’ airway via the cricothyroid membrane in
acute emergency when obsruction at or above the
larynx not relieved.
• Patient positon: supine and the neck in the
neutral position or (in the absence of cervical
spine injury) in extension.

35. Airway
Assessment

36. Predictors of difficulty to face mask
ventilate
(OBESE)
1. The Obese (body mass
index > 26 kg/m2)
2. The Bearded
3. The Elderly (older than 55
y)
4. The Snorers
5. The Edentulous
(=BONES)
• Patient having ≥2 of the
predictors likely to have
difficult mask ventilation
(MOANS)
• MOANS
This is identicle to BONES except ‘M’.
-Mask seal difficult due to receding
mandible,syndromes with facial
abnormalities,burn,stricture etc.
-Obesity, upper airway Obstruction
-Advanced age
-No teeth
-Snorer

37. Predictors of difficulty face mask ventilate
Individual Indices
-Physical examination indices
-Radiological indices
-Advanced indices
Group Indices
- Wilson’s score
- Benumof’s 11 parameter analysis
- Saghei & safavi Test
- LEMON assesment
- Arne’s simplified score
- Magboul’s 4 M’s

38. ASSESSMENT OF CERVICAL &
ATLANTO-OCCIPITAL JOINT
• DIRECT ASSESSMENT – Assess the neck movement by asking
the patient to touch his manubrium sternii with his chin. If
done this assures neck flexion of 25-30°.
• Then ask the patient to look at ceiling without raising eyebows
to test a-o joint extension
• GRADE 3 & 4 -- INDICATE DIFFICULT
LARYNGOSCOPY
Grade Reduction of
A.O.Extension
1 none
2 1/3RD REDUCTION
3 2/3RD REDUCTION
4 COMPLETE
REDUCTION

39. Warning sign of DELIKAN
Place the index finger of each hand,
one underneath the chin and one under
the inferior occipital prominence with the head in neutral position.
The patient is asked to fully extend the
head on neck. If the finger under the
chin is seen to be higher than the other,
there would appear to be no difficulty
with intubation. If level of both fingers
remains same or the chin finger remains
lower than the other,
increased difficulty is predicted.

40. PRAYER SIGN
A positive "prayer sign" can be elicited on examination with the
patient unable to approximate the palmar surfaces of the
phalangeal joints while pressing their hands together.
Seen in Diabetes mellitus patients
This represents:- cervical spine immobility and the potential for a
difficult endotracheal intubation.

41. Palm Print test
* Grade 0 -All phalangeal areas visible.
* Grade 1 - Deficiency in the interphalangeal area of 4th or 5th digits.
• Grade 2 - Deficiency in the interphalangeal area of 2nd to 5 th digit.
• Grade 3 - Only tip of digits seen.

42. ASSESSMENT OF TMJ FUNCTION
TM joint exhibits 2 function.
1.
2.
Rotation of the condyle in the s.cavity.
Forwarddisplacement of the condyle.
First movement is responsible for 2-3cm mouth
opening & the second is responsible for
further 2-3cm mouth opening.
SUBLUXATIONOF THE MANDIBLE
Index finger is placed in front of the tragus &
the thumb is placed in front of the the lower
part of the mastoid process.
patient is asked to open his mouth as wide as
possible.
Index finger in front of the tragus can be
indented in its space and the thumb can
feel the sliding movement of the condyle as
the condyle of the mandible slides forward.

43. CALDER’S TEST

44. INTER-INCISOR GAP
• Inter-incisor distance with
maximal mouth opening
• Normal value > 5 cm / admits
3 fingers.
Significance :
• Positive results: Easy insertion
of a 3 cm deep flange of the
laryngoscope blade
• < 3 cm: difficult laryngoscopy
• < 2 cm: difficult LMA insertion
• Affected by TMJ and upper
cervical spine mobility
STERNOMENTAL DISTANCE
(SAVVA TEST)
• Distance from the upper border of
the manubrium
mentum, neck
to the tip of
fully extended,
mouth closed
• Minimal acceptable value – 12.5 cm
• Single best predictor of difficult
laryngoscopy and intubation ( Has
high sensitivity & specificity).

45. UPPER LIP BITE /CATCH TEST
Class I: Lower incisors can bite the upper lip above vermilion line
Class II: can bite the upper lip below vermilion line
Class III: cannot bite the upper lip
Significance
• Assessment of mandibular movement and dental architecture
• Less inter observer variability

46. Test for assessing adequacy of the
oropharynx for laryngoscopy and
intubation
• Mallampati grading (samsoon and young’s
modification)
• Narrowness of the palate- EVALUATED WHILE
PERFORMING MALLAMPATI GRADING. A NARROW ,
HIGH ARCHED PALATE MAY HAVE DIFFICULT
LARYNGOSCOPY & INTUBATION

47. MALLAMPATTI GRADING
• Suggest optimal tongue size in relation to
oropharyngeal cavity permitting easy
laryngoscopy.
• Indicate amount of space within the oral
cavity to accommodate the laryngoscope
& ETT
• Assessed when the patient is
-seated
-upright with head neutral
-the mouth open
-tongue protruded as much as possible
- no phonation.
The observer’s eye At the level of
patient’sopen mouth
• Higher scores poor visibility of the
oropharyngeal structures Large
tongue relative to the size of the
Difficult
oropharyngeal space
laryngoscopy

48. Assessment for quality of glottic
viewing during laryngoscopy
Indirect mirror laryngoscopic view-closely
relates with cormack & lehane grading
Direct laryngoscopy ‘awake look’
-cormack and lehane grading
Grading ease of intubation
POGO (percentage of glottic opening) scoring

49. CORMACK - LEHANE
Grading at Direct laryngoscopy
• Grade 1:
•
Full exposure of glottis
(anterior + posterior commissure)
Anterior commissure not visualised
Epiglottis only
No glottic structure visible.
Grade2:
Grade3:
Grade 4:
• Grade I =  success & ease of intubation

50. Grading ease of intubation
Grade 1 Extrinsic manipulation of
larynx not required
Grade 2 Extrinsic manipulation of
larynx required
Grade 3 Intubation possible with
stylet guided
Grade 4 Failed intubation
POGO SCORING
• Percentage of glottic opening
during direct laryngoscopy
• 100%- entire glottic structures
visible
• 33%-only lower third of vocal
cord & arytenoid visible
• 0%-no glottic structure visible
• USEFUL WHEN NEW INTUBATING
DEVICE TO RECORD EXACT % OF
GLOTTIC OPENING THAT CAN BE
VISUALISED BY THIS DEVICE

51. Group indices
- Wilson’s score
- Benumof’s 11 parameter analysis
- Saghei & safavi test
- Lemon assesment
- Arne’s simplified score
- Magboul’s 4 M’s
- 4 D’S

52. Wilson’s risk score
Score
Weight 0=<90kg
1=90-110kg
2=>110kg
Head and neck movement 0=Above 90degrees
1=About 90degrees
2=Below 90degrees
Jaw movement 0=IG>5cm or SLux >0
1=IG=5cm and SLux = 0
2=IG<5cm and SLux<0
Receding mandible 0=Normal
1=Moderate
2=Severe
Buck teeth 0=Normal
1=Moderate
2=Severe
•Head movement
assessed with pencil taped
to a patient’s forehead.
•IG = Interincisor gap
measured with mouth
fully open.
•SLux = Maximal forward
protrusion of the lower
incisors beyond the upper
incisors.
•score <=5 =easy
laryngoscopy
•Score 6-7=moderate
difficulty
•Score 8-10 =severe difficulty
in laryngoscopy

53. BENUMOF’S 11 PARAMETER
ANALYSIS
Parameters Minimum acceptable value
1. Bucked tooth No overriding
2.Inter–incisor gap >3cm
3.Length of upper incisors <1.5cm
4.Mandible protrusion test Mandibular teeth can be
protruded beyond maxillary
teeth
5.Mallampati class < Class 2
6.Palate configuration No arching or narrowness
7.Thyromental distance >5cm/>3 finger breadth
8.Mandibular space
compliance
Soft to palpation
9.Neck length Qualitative
10.Neck thickness Qualitative
11. Head /neck mvt Normal range
4-2-2-3 rule
4 for tooth
2 for inside of
mouth
2 for mandibular
space
3 for neck
examination

54. SAGHEI & SAFAVI’S
• Weight
• Tongue protrusion
• Mouth opening
• Upper incisor length
• Mallampati class
• Head extension
Any 3 indices if
present
>80kg
< 3.2cm
<5cm
>1.5cm
>1
<70 degree
Prolonged laryngoscopy

55. Arne’s simplified score model
• Risk factor simplified score
• Previous knowledge of difficult intubation
No
Yes
0
10
• Pathologies associated with difficult intubation
No
Yes
0
5
• Clinical symptoms of airway pathology
No 0
Yes 3
• Inter-incisor gap (IG) and mandible luxatum (ML)
IG > 5 cm or ML >0
IG 3.5-5cm and ML=0
IG<3.5 cm and ML<0
0
3
13
• Thyromental distance
>=6.5cm
< 6.5cm
simplified score
0
4
• Maximum range of head & neck movement
Above 100° 0
About 90° (90° ± 10°) 2
Below 80° 5
• Mallampati’s modified test
Class 1
Class 2
Class 3
Class 4
0
2
6
8
Total...... 48
Score of >11 is predictive of difficult tracheal intubation

56. LEMON trial
●REPRESENTS 5 SIMPLE RAPID ASSESSMENT METHODS
ON UNCOPERATIVE & COPERATIVE PATIENT
●Look
□ Facialtrauma
□ 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 mobility – chin to chest

57. LOOK Externally
• Beards or facial hair
• Short, fat neck
• Morbidly obese patients
• Facial or neck trauma
• Broken teeth (can lacerate
balloons)
• Dentures (should be removed)
• Large teeth
• Protruding tongue
• A narrow or abnormally
shaped face
EVALUATE 3-3-2
• Mouth Opens at least 3
finger widths.
• Three finger widths
thyromental distance.
• Two finger widths
hyomental distance.

58. Obstruction
• Laryngoscopy or intubation
may be more difficult in the
presence of an obstruction
– LOCATION
– FIXITY
– PROGRESSION
Neck Mobility
• NORMAL
• NECK EXTENSION >80-85 ,
• FLEXION > 25- 30
• ROTATION > 70-75
• ASSESS ALL 3 ANGLES

59. Magboul’s 4 M’s
• For Intubationremember the 4(M & Ms)
with (STOP)sign
• Mallampati
• Measurement
• Movement
• Malformation & STOP
• M =Malformation of the skull, teeth,
obstruction,& Pathology (the Macros and
Micros).We can memorize them with the
word (STOP)
• S = Skull (Hydro and Microcephalus)
• T = Teeth (Buck, protruded, & loose teeth.
Macro and Micro mandibles)
• O= Obstruction(due to obesity, short Bull
Neck and swellings around the head and
neck)
• P = Pathology (Craniofacial abnormalities &
Syndromes: Treacher Collins, Goldenhar's,
Pierre Robin, Waardenburg syndromes) .
• PATIENTSCORE >= 8 DIFFICULT
INTUBATION

60. 4 Ds
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)
RADIOGRAPHIC PREDICTORS
1. X-Ray neck (lateral view) :
• Occiput - C1 spinous process
distance< 5mm.
• Increase in posterior mandible
depth > 2.5cm.
• Ratio of effective mandibular
length to its posterior depth
<3.6.
• Tracheal compression.
2. CT Scan:
• Tumors of floor of mouth, pharynx,larynx
• Cervical spine trauma, inflammation
• Mediastinal mass
3. Helical CT (3D-reconstruction):
• Exact location and degree of airway compression
• ADVANCED INDICES
• Flowvolume loop
• Acousticresponse measurement
• Ultra sound guided
• CT / MRI
• Flexiblebronchoscope
Points of
measurements from
skeletal films ; 1 =
Effective
mandibular length, 2 =
Posterior mandibular
depth, 3 = Anterior
mandibular
depth, 4 = Atlanto-
occipital gap, 5 = C1 –
C2 gap

61. How to predict difficult placement
of supraglottic devices (RODS)
• Restricted mouth opening
• Obstruction of the upper
airway
• Distrupted upper airway as
following trauma,burn,caustic
ingestion .
• Stiff lung (poor lung or
thoracic compliance)
Suggested by Hung and Murphy
How to predict difficulty in
creating surgical airway (BANG)
• Bleeding tendency
• Agitated patient
• Neck scarring
• Growth or vascular
abnormality in region of
surgical airway.

62. TO SUMMARIZE
• Airway assessment is a critical part .
• The difficult airway assessment must be
performed prior to ALL attempts.
• While this criteria helps identify difficult
airways, it does not guarantee an easy
intubation—Be Prepared!

63. THANK YOU