Assessment and management of Airway for BSc Nursing Students

1. AIRWAY
ASSESSMENT

2. Airway
 Anatomically, airway is the passage through
which the air/gas passes during respiration.
It may be divided into:
 Upper airway, and
 Lower airway

3. Upper airway
 Upper airway comprises of the mouth/oral
cavity, nasal cavity, pharynx, nasopharynx,
oropharynx, and the larynx.
 MOUTH/ORAL CAVITY: Extends from the
mouth opening to anterior tonsillar pillars.
Includes lips, cheeks, teeth and the tongue.
 NASAL CAVITY: Extends from naris to the end
of the turbinate's.

4. Upper Airway

5. Upper Airway

6. Lower airway
Lower airway includes trachea, bronchi and bronchioles, which
after multiple divisions finally terminate into alveoli.
TRACHEA : Trachea extends from lower border of cricoid
cartilage (C₆) to its division into 2 main bronchi (T₄). (C6-T4)
It is 11-13 cm long.

7. Lower Airway

8. DEFINITION OF DIFFICULT AIRWAY
(A.S.A. 1993)
 A Difficult Airway is defined as the “clinical situation in
which a conventionally trained emergency
professional experiences difficulty with mask
ventilation, difficulty with tracheal intubation or both”.

9. Airway Difficulties
 Difficult to mask ventilate : 0.1-5 % prevalence
 Difficult laryngoscopy
 Difficult to intubate: 1-2% normal surgical population.
50% of rheumatic cervical disease
 Difficult LMA: 0.1-5 % prevalence

10. Why airway assessment…..
 Optimal patient preparation
 Proper selection of equipment and technique, and
 Participation of personnel experienced in the difficult
airway management

11. How do you assess?
Difficult airway can be assessed by:
 Individual indices
 Group indices (with or without scoring)
Mask ventilation precedes laryngoscopy , which in
turn followed by intubation.
So the assessment should be in following manner

12. What to assess ? ( components of
the airway examination)
I. Nostril patency
II. Length of upper incisor and alignment
III. Condition of the teeth
IV. Relationship of upper incisor to the lower incisor
V. Ability to protrude the lower incisor in front of the upper
incisor
VI. Inter incisor distance
VII. Tongue size
VIII. Visibility of uvula
IX. Presence of heavy facial hairs
X. Compliance of mandibular space
XI. Thyromental distance with the head in maximum extension
XII. Circumference of neck
XIII. Range of motion of head and neck

13. EVALUATION OF THE AIRWAY
(A) History
(B) General Examination
(C) Specific Tests / indices
(D) Advanced indices

14. History
 Patient/ notes/chart/ medic- alert
Any difficulty
S urgery / burns
C oncurrent disease
R eflux / recent meals

15. II. General Examination
Starts with global assessment as soon as we see the
patient.
Look for:
1. Dentition
2. Distortion (edema, blood, vomits, tumor, infection)
3. Disproportion ( bull neck, large tongue, small
mouth)
4. Dys mobility( TMJ and cervical spine)
5. 0bese or pregnant

16. Specific tests / indices
A. Anatomical criteria
1. Relative to tongue/ pharyngeal size –mallampatti
test
2. Atlanto occipital joint extension -DELLIKAN`S TEST
3. Mandibular space
 Thyromental distance(Patil’s test)
 Hyomental distance
 Sterno mental distance(savva test)
4. TMJ assessment
B. Direct Laryngoscopy

17. Anatomical criteria
 1. Relative to tongue / pharyngeal size(mallampatti)
test)

18. 2. Atlanto-occipital joint
extension
DELLIKAN`S TEST
 Patient is asked to look straight ahead. The index finger of the
left hand of the clinician is placed under the tip of the jaw
while the index finger of the right hand is placed on the
patient's occipital tuberosity. The patient is now asked to look
at the ceiling. If the left index finger becomes higher than the
right, extension is considered normal.

19. WARNING SIGN OF DELIKAN

20. 3. Assessment of the mandibular
space
 This space determines how easily the laryngeal and
pharyngeal axes will fall in line when the A-O joint is
extended and it also accommodates the tongue during
laryngoscopy.

21. Assessment of the mandibular
space
 Thyromental distance(Patil’s test)
 Hyomental distance
 Sterno mental distance(savva test)

22. 3.1. Thyromental Distance (Patil’s
test)
 Distance from the mentum to the thyroid notch.
 Ideally done with the neck fully extended.
 Helps determine how readily the laryngeal axis will
fall in line with the pharyngeal axis.

24. Thyromental Distance (patil’s
test)
 If the thyromental distance is short, <3
finger widths, the laryngeal axis makes a
more acute angle with the pharyngeal
axis and it will be difficult to achieve
alignment.
 Less space to displace the tongue.
 > 6.5 cm ; no problem with laryngoscopy
and intubation.

25. 3.2. Hyomental distance
 It is the distance between mentum and the hyoid bone.
 It is graded as:
 Grade 1: >6.0 cm
 Grade2: 4-6 cm
 Grade3: <4.0 cm
 Grade3 hyomental distance is usually associated with
difficult laryngoscopy and intubation.

26. 3.3. Sternomental distance ( Savva
Test)
 This is measured with head in full extension and mouth
closed.
 <12.5 cm predicts difficult Laryngoscopic intubation.
< 12.5 cm: limited neck
movement

27. 4. TMJ assessment
a. Inter incisor distance
b. Mandibular protrusion test
c. Upper lip bite / catch test

28. TMJ assessment

30. b. 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

31. 2. Direct laryngoscopy
Cormack & Lehane grading
 Grade 1: Full aperture visible
 Grade 2: Lower part of cords visible
 Grade 3: Only epiglottis visible
 Grade 4: Epiglottis not visible

32. Laryngoscopic View Grades
Graded in order from the best view to worst.
Grade 1: Visualization of the entire laryngeal aperture.

33. Laryngoscopic View Grades
 Grade 2: Visualization of just the posterior portion of
the laryngeal aperture . Anterior commissure not
visualized.

34. Laryngoscopic View Grades
 Grade 3: Visualization of only the epiglottis

35. Laryngoscopic View Grades
 Grade 4:
No glottis structure
visible.

36. Individual indices
 1) Presence of beard
 2) Obesity
 3)Abnormality of teeth :
edentulous, irregular teeth or
artificial teeth.
 4) Elderly patients
 5) Snorers
 6) Jewellery and facial piercings

37. Difficult to mask ventilate:
MOANS
 Mask Seal
 Obesity or Obstruction
 Age > 55
 No Teeth
 Stiff

38. Mask Seal
 Receding mandible
 Burn strictures
 Beard
 Facial Trauma

39. Obesity or Obstruction
 Obesity
 Heavy chest
 Abdominal contents inhibit movement of the
diaphragm
 Increased supraglottic airway resistance
 Difficult mask seal
 Quick desaturation

40. LEMON
 L – Look externally ( facial trauma, large incisors, beard or
moustache, large tongue )
 E – Evaluate the 3-3-2 rule
 inter incisor distance – 3 finger breadths
 hyoid- mental distance – 3 finger breadths
 thyroid to floor of mouth distance – 2 finger breadths
 M – Mallampati
 O – Obstruction
 epiglottitis,
 peritonsillar abscess
 trauma
 N – Neck mobility

41. Advanced Indices
1. Radiographic assessment
 From skeletal films
 Fluoroscopy
 Oesophagogram
 Ultrasonography
 Computed tomography / MRI
 Video optical intubation stylets
2. Flow volume loop
3. Acoustic response
measurement

42. Others
Palm Print & Prayer sign:

43. To Summarize
 Airway assessment is a critical part of the airway
management.
 The airway assessment must always be performed
prior to ALL RSI attempts.
 While these criteria help identify difficult airway, it
does not guarantee an easy intubation—Be
Prepared!

44. Difficult Airways - Assess the
Risks
 Develop your skills and ways to assess the airway.
 There are lot of scores and numbers , adapt what suits
you…..What you can remember and apply.
“The difficult airway is something one
anticipates; the failed airway is something
one experiences.” -Walls 2002