This document provides an overview of airway assessment and management. It discusses assessing the airway based on history, physical exam including tests like Mallampati score, and tertiary exams. The goals of airway management are maintaining a patent airway to allow for gas exchange. Difficult airways can occur due to anatomical abnormalities. Proper preparation includes thorough assessment, having a back-up plan, and calling for help if needed. Skills like manual techniques and use of airway devices are important for supporting the airway.

1. Sedation course 2011
By Dr Moutasem Al Mashour

2. Objectives:
 To refresh the basic knowledge about airway anatomy
 Assess and Recognize signs of a threatened airway
 Assess airway on emergency / elective basis
 Describe manual techniques for establishing an airway
and for mask ventilation with and without suspected
cervical spine injury.
 Hands on airway adjuncts such as LMA and ET

3. Airway Management
 The primary goal
Patent airway and ability to support gas exchange. The ”A”
in your ABC’s.
 Secondary goals
cardiovascular stability and prevention of aspiration during
airway management.
 Establishing and maintaining a patent airway is equally
important and often more difficult.
 Health care providers must be skilled in manually
supporting the airway and providing the essential
process of oxygenation and ventilation

4. Airway
 Nasal and oral cavities
 Pharynx
 Larynx
 Trachea and large bronchi

5. The oral cavity

6. Difficult Airways
“The difficult airway is something one
anticipates; the failed airway is something
one experiences.”
-Walls 2002

7. Is difficult airway common
in population ?

8. PREVALENCE
With proper evaluation only 15 to 50 % were picked up
While difficult face mask ventilation in general is about
1:10,000 out of which again 15% proved to be the
difficult intubation ,
While incidence of extreme difficult or abandons
intubation in general surgery patients are 1:2000 but in
obstetrics is 1:300 and of course most critical incidence
is Hypoxia

9. ASA Closed Claims Review Adverse
Respiratory Events
The average settlement payment for adverse respiratory events equaled
$200,000, with a range from $1,000 to $6,000,000.

10. Why does it happens ?
1. Exaggerated idea of personal ability.
2. Not requesting for experienced help.
3. No discussion with colleagues about proposed
management of the case .
4. Ill conceived plan (A) with no proper back up plan (B).
5. Even poorly conducted plan (A) or sticking extra time to
the plan (A) other way delaying the rescue plan late.

11. Causes of difficult airway
 Congenital
 Acquired

12. Congenital Causes
Pierre-Robin syndrome Micrognathia, macroglossia, cleft soft palate
Treacher-Collins Auricular and ocular defects, malar and
syndrome mandibular hypoplasia
Goldenhar’s
syndrome
Down’s syndrome Poorly developed or absent bridge of the
nose, macroglossia
Kippel-Feil syndrome Congenital fusion of cervical vertebrae,
restriction of neck movement
Goiter Compression of trachea, deviation of
larynx/trachea

13. Acquired Causes
 Short, thick neck
 Prominent upper incisors (“buckteeth”), Dentures
 Receding mandible
 Limited jaw opening, cervical mobility
 High, arched palate
 Face, neck, or oral trauma, Laryngeal trauma
 Airway edema or obstruction
 Acromegaly
 Epiglottitis
 Pregnancy
 Obesity

14. Airway management
Assess
(recognize)
Back-up Plan (prepare)
Manage (act)
Every case Every place

15. Airway Assessment
History
 Known
potentially difficult airway
Prior GA
 PMH
 Meds
 Allergies
 Recent respiratory illness
 NPO (number of hours)

16. Physical examination
 General appearance
Obesity syndrome features and beard
Receding mandible
 Vital signs

17. Assessment
 General assessment
 Primary assessment----- ABCD
 Secondary assessment----- SAMPLE
 Tertiary assessment------investigations

18. Assessment
• General appearance
Position, speech/cry, look/gaze
Cervical instability
Full stomach---- anti reflux meds
• Work of breathing
Increase (nasal flaring, retractions)
Decrease / absent respiratory efforts
Abnormal sound

19. Four D's also suggest a difficult airway
 Dentition (prominent upper incisors, receding chin)
 Distortion (edema, blood, vomitus, tumor, infection)
 Disproportion (short chin-to-larynx distance, bull
neck, large tongue, small mouth)
 Dysmobility (TMJ and cervical spine)

20. Advanced Airway Assessment Techniques
3 – 3 – 2
 Teeth Examination
 Mallampati Classifications
 Laryngoscope View Grading

21. Evaluate 3-3-2
 Will patients mouth open wide enough to accommodate
3 fingers?
 Will 3 fingers fit between the mentum and hyoid bone?
 Will 2 fingers fit between the hyoid and thyroid notch?
If not, expect a difficult intubation

22. Mouth opens at least 3 fingers width?

23. Thyromental Distance-3 fingers?

24. Mandibulohyoid Distance- 3 fingers?
 Measured from the
mentum to the top of the
hyoid bone.
 The epiglottis arises from
the thyroid and remains
dorsal to the hyoid bone.
 Therefore, the position of
the hyoid bone marks the
entrance to the larynx.

25. Upper & Lower Face
 Measure the size of the upper face as compared to the
lower face.
 Should be roughly the same.
 If the lower face is longer than the upper face then you
should anticipate some degree of difficulty lining up
the structures.

26. Upper and lower face equal?

27. Upper and lower face equal?

28. Teeth
 Protruded teeth
 Dentures
 Crowns ,bridges
 loose, Chipped and cracked teeth
 Missing teeth

29. Sensitivity: 44% - 81% , Specificity: 60% - 80%

30. Mallampati Score Roughly corresponds to Cormack
and Lehane’s laryngoscopy views

31. Secondary assessment
 S----- signs and symptoms
 A----- allergies
 M----- medication
 P----- PMH
 L----- last meal
 E----- events

32. Tertiary assessment
 Lab data– CBC, basic screen, ABG&VBG
 Radiology- chest x-ray
 ECG
 Consultation
 Flow –volume loops

33. Focused Airway Assessment
 This picture represents
a Mallampati Class
One airway.
 The entire uvula and
tonsillar pillars are
seen.
 This individual should
be easy to mask
ventilate or to intubate
with a laryngoscope
and endotracheal tube.

34. Focused Airway Assessment
 This picture represents a
Mallampati Class Three
airway.
 None of the uvula or
tonsillar pillars are seen.
 This individual may hard
to mask ventilate, and
quite difficult to intubate.

35. Focused Airway Assessment
 This image is
representative of an
extremely short
thyromental
distance, indicating
tremendous difficulty in
tracheal intubation, and
possible difficulty
establishing a satisfactory
mask seal

36. Focused Airway Assessment
 The patient undergoing conscious sedation should have a
thorough airway assessment focusing on
 mouth opening
 airway class
 thyromental distance (distance from chin to thyroid)
 range of motion of the neck
 For more information:
http://www.vh.org/Providers/ClinGuide/ProceduralSedatio
n/AirwayAssessment.html

37. THANK YOU
Questions & Discussion