This document discusses the importance of airway management expertise and outlines factors that can indicate a difficult airway. It notes that respiratory events are the second most common cause of injuries in anesthesia practice. Various anatomical measurements and assessments are described that can help predict a difficult airway, including Mallampati score, thyromental distance, neck mobility, and mandibular range of motion. Radiographic assessments like CT scans can also provide useful information. No single test is perfectly predictive, so anesthesiologists must always be prepared for an unanticipated difficult airway.

1. By
Dr Riyas A

2.  Expertise in airway management is essential
in every medical speciality
 Maintaining a patent airway is essential for
adequate oxygenation and ventilation and
failure to do so ,even for a short duration
can be life threatening
 Respiratory events are the second common
injuries in anaesthesia practise
 Causes of respirtory related injuries are
 inadequate ventilation,oesophageal
intubation,difficult tracheal intubation

3. It’s is one in which there is a problem in
establishing or maintaining a gas exchange
via a mask ,an artificial airway or both
Recognising these difficulties before
anaesthesia allows time for optimal
preparation ,proper selection of equipments
and tehniques and participation of perssonal
who is experienced in DA management

4.  History
 Medical ,surgical or anaesthetic factor may
be indicative of a difficult airway
 Some factors which could prdispose to
difficult airway are
 1)burns
 2)oedema
 3)bleeding
 4)tracheal stenosis
 5)perforation,etc….

5. congenital 1)Pierre robbing
syndrome
2)Goldenhar’s
syndrome
3)Treacher collins
syndrome
4)Downs
5)Goiter
6)Kippel fiel
syndrome

6.  Acquired
 Infection 1)Croup
2)Supraglottic
3)Intra oral and
retropharyngeal abscess
4)Ludwigs angina
Arthirtis Ankylosing spondylitis

7.  Patency of nares
 Mouth opening of at least 2 large finger
breadths between upper and lower incisors
 Teeth:
 Palate:high arched plate ,enlarged
tonsilnarrow mouth
 Assesses patients ability to protrude the
lower jaw beyond the upper incisors
 Temporo mandibular joint movement

8.  Measurement of submental
space(hyomental/thyromental length should
be >6)
 Observation of patient neck
 Presence of hoarse voice /stridor or any
history of tracheostomy suggest stenosis
 Any systemic or congenital disease requiring
special attention during air way
management(respiratory ,significant
coronary artery disease,acromegaly)

9.  General assessment of body habitus can yield
important information
 Infections of airway
 Physiological conditions

10.  Presence of beard
 Body mass index
 Lack of teeth
 Age and snoring
 Jewellery worn by piercing the lips
,tongue,cheek ,chin eye brows and ear may
also create difficulty in mask ventilation…

11.  A ) Anatomical criteria
1]tongue and phayngeal size relation…..
a) Mallampatti score….head in neutral position
, patient sitting , mouth wide open ,tongue
protruding maximum,patient shouldn’t be
actively encouraged to phonate as it can
result in contraction and elevation of soft
palate leading to false positive result

12.  Class 1:Visualisation of anterior and posterior
pillars,soft palate,uvula,hard palate
 Class 2:visualisation of uvula,soft palate and
hard palate
 Class 3:visualisation of softpalate and base of
uvula
 Class 4:(samsoon n young modified
mallampatti and added this)only hard palate
is visible
 To avoid false positive and negative results
this shoulb be repeated twice

14.  Atlanto occipital joint extension:it assess
fesibility to make sniffing or magills position
for intubation;ie,alignment of
oral,pharyngeal and laryngeal axis into an
arbitary straight line.
 Patient is asked to hold head in erect
position ,facing directly to front ,then he is
asked to extend his head maximally and
examiner estimates the angle transversed by
occlusional surface of upper teeth

15.  It’s expressed in grades …
1. grade 1:>35
2. grade 2: 22-34
3. grade 3: 12-21
4. grade 4: <12
o Noraml angle of extension is 35 or more

16. A. Thyro mental distance(pail’s test):it’s defined
as the distance from the mentum to the
thyroid notch while the patient neck is fully
extended,
this measurement helps in determining how
readily the laryngeal axis will fall in line with
the pharyngeal axis when AO joint is fully
extended
alignment of these two axis is difficult if the
distance is <3 finger breadth or <6 cm in adults
6-6.5 cm less difficulty ,while more than
6.5 is normal

18. B ) Sterno mental distance:it’s measured from
suprasternal notch to the mentum
It was mesured with head fully extended
on the neck with the mouth closed
Value <12 cm found to predict the difficult
intubation
C )mandibulo hyoid distance:Measurement of
chin to hyoid should be atleast 4cm or
three finger breadths
D ) Inter incisor distancedistance b/w upper
and lower incisors normal is 4.6cm while
<3.8 predicts difficult airway

19. They took 5 variables
1. Weight
2. Head ,neck and jaw movements
3. Mandibular recession presence or absence of
buck teeth
Risk score was developed b/w 0-10
Arne and collegues introduced a new soring system
WILSON AND COLLEGUE SCORING SysteM +presence
or absence of overt airway pathology

20. L= look externally
E= evaluate 3-3-2 rule(inter incisor
distance,hyoid mental distance,thyroid
mental distance)
M= mallampatti
O= obstruction
N= neck mobility

22.  B )direct laryngo scopy and fibro optic
broncho scopy
I. Grade 1-visualisation of entire laryngeal
aperture
II. Grade 2-visualisation of only posterior
commisure
III. Grade 3-visualistion of only epiglottis
IV. Grade 4-just soft palate
Grade 3 & 4 predict difficult intubation

23. C ) Radio graphic assesssment
 From skeletal films…lateral cervical x ray film of
the patient with the head in neutral position is
recquired for the following measurments
i. Mandibulo hyoid distance
ii. Atlanto occipital gap:A-O gap is the major factor
which limits the extension of head and neck
iii. Relation of mandibular angle and hyoid bone with
cervical vertebrae and laryngoscopy grading:a
definite increase in difficulty in laryngoscopy was
observed when the mandibular angle tended to be
more rostral and hyoid bone to be more caudal

24. 4)Anterior posterior depth of the mandible:
the distance b/w the boney alveolus
immediately behind the 3rd molar tooth and
the lower border of the mandible is an
important masure in determining the
laryngoscopy
5)C1-C2 gap
Calcified stylohyiod ligaments are manifested by
crease over hyoid bones on radiographic
examination
Laryngoscopy is difficult because of inability to lift
the epiglottis from the posterior pharyngeal
wall

25.  Fluroscopy
 Oesophagogram
 Ultrasonography
 CT / MRI
 Video optical intubation stylets

26.  Preditors of difficult airway in diabetics
1. Palm print:the patient is made to sit ;palm
and fingers of the right hand are painted
with blue ink,patient then pressess the
hand firmly against a white paper placed on
hard surface
Grade 0-all the phalangeal areas are
visible
Grade 1-deficiency in the
interphalyngeal areas of the 4th and 5th
digits

27. Grade 2-deficiency in interphalyngeal areas of
2nd -5th digits
Grade 3-only tips of the digits are seen

28.  Prayer sign…patient is asked to bring both
the palms together as namaste and
categorized as
positive …when there is gap b/w palms
negative… when there is no gap

29. a) Poor flexion extension mobility of the head
on neck
b) A receding mandible and presence of
prominent teeth
c) A reduced A-O distance, reduced space b/w
C1 and occiput
d) Large tongue size

30.  Tempero mandibular mobility(one finger)
 Inspection of muth ,oropharynx—mallampatti
classipfication(two finger)
 Measurement of mento-hyoid distance in
adults(three finger)
 Measurement of distance from chin to
thyroid notch(four fingers)
 Ability to flex head towards chest,extend
gead at atlanto occipital junction and rotate
head ,turn right and left(five movements)
 Symmetry and patency of nose

31.  TM joint movement
 Neck movement
 Jaw movement
 mallampatti

32.  Same like adults begins with history and
physical examination
 History regarding complaints of snoring,day
time somnolence,apnea,hoarse voice,prior
surgery or radiation treatment to face or
neck
 Any anesthetic previous history of
oropharyngeal injury,awake
intubation,damage to teeth,or postponement
of surgery following anaestheisa

33.  Physical examination:it should focus on the
anomalies of face ,head ,neck and spine
 Evaluate size and shape of head ,gross
features of the face,size and symmetry of
the mandible,presence of sub mandibular
pathology,size of tongue,shape of palate
 Presence of retraction of intercostal muscles
 Breath sounds
 Trancutaneous co2 determinants are very
helpful in infants and young childrens

34.  Plain radiography
 CT and MRI
 Direct or Indirect laryngoscopy
 Fluroscopy
 USG studies
 Pulmonary function studies

35.  No single airway test can provide a high
index of sensitivity and specificity for
prediction of difficult airway
 However in some patients difficult airway
will remain undetectable
 Anaesthetologist be always prepared with a
variety of plans for an unanticipated
difficulty airway

36.  THANK YOU