This document discusses difficult airways and how to anticipate them. A difficult airway is defined as difficulty with face mask ventilation, laryngoscopy, or endotracheal intubation. There are several factors that can indicate a difficult airway, such as breathing issues, swallowing problems, voice changes, Mallampati score, limited mouth opening, and short thyromental distance. The Cormack-Lehane grade is used to evaluate laryngeal views during intubation. Common causes of difficult airways include lesions, masses, scarring, anatomical abnormalities, and cervical spine issues. Careful patient evaluation using tools like X-rays can help identify risks pre-operatively to be prepared in case of a difficult air

1. Difficult Airway
Dr Shrikant Phatak
Head of ENT Department
Choithram Hospital & Research Center
Indore

2. Difficult Airway
• A difficult airway is defined as the clinical situation
in which one experiences difficulty with facemask
ventilation of the
upper airway, difficulty with. tracheal intubation, or
both.

3. 1. Difficulty with facemask ventilation
2. Difficult laryngoscopy
• 3.Difficult endotracheal intubation
• MORE THAN THREE ATTEMPTS OR MORE THAN
TEN MINUTES FOR INTUBATION
4. Post extubation stridor

4. • There can be following situations
• Can ventilate & can intubate
• Can ventilate but cant intubate
• Can intubate but cant ventilate
• Cant intubate & cant ventilate

5. • The goal of airway assessment is to identify
patients who may have difficult airways
• In patients who have never been intubated,
there is no method of prediction of difficult
intubation that is both highly sensitive and
highly specific

6. Anticipating Difficult Airway
• Breathing Difficulty ,Strider, Cough
• Difficulty in Swallowing ,Regurgitation of fluids
• Change in Voice. Glottis is the narrowest part of adult
airway a voice change should arouse suspicion of difficult
airway.
• Evaluation
• IDL
• Auscultate Neck
• VLS
• Radiological
• X-Ray ST-Neck AP & Lateral Views
• CT Scan, MRI

7. Mallampati Classification
• Class I = visualization of
the soft palate, fauces,
uvula, anterior and
posterior pillars.
• Class II = visualization of
the soft palate, fauces
and uvula
• Class III = visualization of
the soft palate and the
base of the uvula.
• Class IV = soft palate is
not visible at all.

8. • Usually Class 3 & Class 4indicate difficult
laryngeal exposure & intubation.

9. Large Tongue
Lesions
Restricted
Mouth
Opening

10. Thyromental Distance
Distance less than 3 Fingers or less than 6cm indicates
difficult intubation

11. Normal Laryngeal View

12. Laryngeal Exposure: Cormack- Lehane
• Grade I = visualization of
the entire laryngeal
aperture.
• Grade II = visualization of
just the posterior portion
of the laryngeal aperture.
• Grade III = visualization of
only the epiglottis.
• Grade IV = visualization of
just the soft palate only,
not even the epiglottis is
visible

13. Difficult Airway
Scarred Larynx Post Cricoid mass
Glottic Mass
Can not intubate can not
ventilate

14. Infantile Epiglottis
Infantile epiglottis with medially placed arytenoids will
accommodate tube smaller than usual

15. Airway X-Ray soft tissue neck

16. Widening pre vertebral soft tissue

17. Laryngeal Trauma
A scar on the neck due to injury can cause tracheal
stenosis. Here one can intubate but cannot ventilate

18. Tracheal Narrowing C7-T1 level
Stenosed subglottis difficult intubation chance of post
extubation stridor.

19. Supraglottic Mass
Cant intubate cant
ventilate

20. Anterior Glottic Web
Difficult Intubation will accommodate smaller
size tube .Post extubation chance of stridor if
not diagnosed pre op for non ENT surgery

21. Subcutaneous Air Obscuring Landmarks
Surgical emphysema Surgical emphysema

24. APPEARENCE MAY DECEIVE

25. Widening pre vertebral soft tissue
Retropharyngeal A-V Malformation

26. Base tongue soft tissue

27. Epiglottic cyst

28. Mass Epiglottis

29. Stenotic Narrowing
Supraglottic Narrowing Subglottic stenosis
Can accommodate smaller size tube difficult to
ventilate and chance of post extubation stridor

30. Stenotic Narrowing
Narrow Trachea Narrow Trachea
Can intubate difficult to ventilate

31. Block Vertebra

32. Abnormality of Cervical Spine

33. • Thank You

34. Disclaimer
• The information contained in the presentation is based on the personal
experience and cases collected at Choithram Hospital Indore over the last
20 years.
• It is intended for the use of Medical students ENT & Anaesthesia post
graduates Intensivists
• The views expressed are purely on personal opinion. viewers can make
their own opinion. For any confusion please contact sole author.
• Everybody is allowed to copy or download the material best suited to him.
I am not responsible for any controversies arising out of the presentation.
• For any suggestions or corrections you may please contact
phatak_shrikant@yahoo.in