PRINCIPLES OF AIRWAY ASSESSMENT

1. Moderator : Dr. Anil Ohri Presented by : Dr. Arun Kumar Sharma PRINCIPLES OF AIRWAY ASSESSMENT

2. Airway: Extra pulmonary passage. Difficult airway: Problem in establishing or maintaining gas exchange via a mask , artificial airway or both. Difficult airway is single most important cause of anesthesia related morbidity and mortality. Upto 30% deaths attributable to anesthesia are due to inadequate airway management. Difficult airway clinics: allows time for optimal preperation , proper selection of equipment and technique and personal experienced in difficult airway management.

3. History • General, physical and regional examination • Specific tests for assessment *Mallampati test *Atlanto occipital joint (AO) extension *Mandibular spaces *Wilson’s clasification *Ame &co. *LEMON Score *Radiological assessment Objectives

4. History and physical examination: History : Medial , surgical and anesthetic factors. Anesthetic factors: edema , burns , bleed, tracheal compression , pneumothorax or aspiration of gastric contents. ASSESSMENT

5. Patency of nares: Mass,DNS, etc Mouth opening : atleast 3 fingers btw upper and lower incisors. Teeth : prominent upper incisors. Palate : high arched palate or long narrow mouth. Tongue size Patients ability to protrude lower jaw. Mandible TMJ movement Submental space Observation of patients neck-mass ,mobility , and ability to assume sniff position. Hoarse voice/stridor or h/o tracheostomy: stenosis Airway infections Physiological conditions : pregnancy and obesity. Physical Examination

6. Factors affecting- Presence of beard Disfiguring malignancy of jaw BMI >26 Absence of teeth Age >55 H/o snoring Obstuctive sleep apnoea Mallampati class 3&4 Difficult to mask ventilate

7. Specific Tests

9. Based on tongue/ pharyngeal size: Mallampatti test (Dr.S.RaoMallampati): sitting position,headneutral,mouth wide open,tongue protruding to its maximum(not to phonate) Class I : soft palate, fauces,uvula, anterior and posterior pillars. Class II : soft palate, fauces and uvula. Class III : soft palate and base of uvula. (samsoon & young 1987) Class IV : Hard palate only. Its indirect means of relative proportionality so it should be repeated twice to avoid false positive/ negative.

10. Failure of Mallampati Failure to include evaluation of two important factors affecting visualization of glottis • Neck mobility • Size of mandibular space

11. i) AO extension- sniffing or magill position • Oral,Pharyngeal,Laryngeal axis--straight line • Angle traversed by occlusional surface of upper teeth. Grade I : >35*-- (N) Grade II : 22-34* Grade III: 12-21* Grade IV : <12* • For movement at A-O joint ask patient to place the chin on the chest, clasp both hands behind the neck, pull downwards and try to move head upwards.

12. Sternomental distance-(savva 1948) <12.5cm predicts diff. intubation(PPV 82%) • Inter incisor distance- • 6 cm or 3 fingers---(N) • <4 cm-makes intubation difficult. • <2.5cm-LMA insertion will be difficult. • Intraoral/ pharyngeal masses e.gtumours or lingual tonsils (difficult LMA) Mandibular Space

13. Thyromental Distance-3 fingers? • T-M distance(patil’s test)—with neck fully extended • 6cm ---normal <3 fingers(<6 cm) difficult(75%) Combined Patil and mallampati tests (<6cm and class 3-4)increases specificity(97%)

14. Hyo-mental distance: distance btw mentum and hyoid Grade I :<4cm(2 fingers)--normal Grade II :4-6 cm Grade III >6cm

15. Wilson score ≤5 Easy intubation; 8-10 very difficult intubation

16. A total score of >0r =2 predicts 75% of difficult intubation;12% False positives. 2)Ame &co –wilson + airway pathology(+ or-) Sensitivity and specificity ----90%

17. L= Look externally (facial trauma, large incisors, beard or moustache, large tongue) E= Evaluate the 3-3-2 rule (incisor distance-3 finger breadths, thyroid-mental distance-3 finger breadths, mento-to-hyoid distance-2 finger breadths) M= Mallampatiscoring O= Obstruction (presence of any condition like peritonsillarabscess, trauma,edema,foreign body). N= Neck mobility (limited neck mobility) The score with a maximum of 10 points is calculated by assigning 1 point for each . Patients in the difficult intubation group have higher LEMON scores. LEMON Airway assessment (Dr. Binnions Lemon )

18. Cormack and Lehane(1984) defined 4 Grades • Grade I – Visualization of entire laryngeal aperture. • Grade II – Visualization of only posterior commissureof laryngeal aperture. • Grade III – Visualization of only epiglottis. • Grade IV – Visualization of just the soft palate. Grade III and IV predict difficult intubation. Direct laryngoscopy and fibreopticbronchoscopy

19. Grade IIa: visualization of posterior part of vocal cord. Grade IIb :only arytenoid seen. Grade IIIa:epiglotisliftable. Grade IIIb:epiglotis adherent. Grade I & IIa can be intubated easily. Grade IIb & IIIa needs some support(bougie) Grade IIIb & IV requires alt. techniques. Cook’s modification(1999)

20. M : Mallampatti classification , mandibular space) O : Obesity,opening of mouth) U : Upper lip bite T : Teeth H :Head and neck movement. *(The only system which includes upper lip bite test) Other scoring systems: a)MOANS(mask seal,obesity,age,noteeth,stiff lungs) b)RODS(restrcted oral opening,obstruction,distorted,stiff lungs) c)4Ds(dentition,distortion,disproportion,dismobility) d)LMMAP(look,mallampatti,measurement,A-O extn.,pathology of teeth) Mouth classification:

21. Palm print: Grade 0 – All the phalangeal areas are visible. Grade 1 – Deficiency in the interphalangealareas of the 4th and 5th digits. Grade 2 – Deficiency in interphalangeal areas of 2ndto 5th digits. Grade 3 – Only the tips of digits are seen collagen disorders: (Diabetic stiff joint syndrome)

22. Prayer sign : Patient is asked to bring both the palms together as ‘Namaste’ and sign is categorized as– Positive – When there is gap between palms. Negative – When there is no gap between palms. If positive: Grade I-metacarpo-phalangeal gap Grade II-proximal interphlyngeal involved Grade III- distal interphalyngeal joint is also involved

23. Radiological investigations

24. i . Mandibulo-hyoid distance ii . Atlanto-occipital gap(5mm)Longer the A-O gap, more space is available for mobility of head at that joint with good axis for laryngoscopyand intubation. iii. Relation of mandibular angle and hyoid bone with cervical vertebra and laryngoscopy grading : Difficult when the mandibular angle tended to be more rostral and hyoid bone to be more caudal. iv. Anterior/Posterior depth of the mandible (<3.6) White and Kander (1975) v. C1-C2 gap vi.Calcifiedstylohyoid ligaments :Difficult because of inability to lift the epiglottis from posterior pharyngeal wall. Radiological assessment

25. Fluoroscopy for dynamic imaging for cord mobility,airwaymalacia. Ultrasonography- Ant. Mediastinalmass,lymohadenopathy,d/d cyst from mass,cellulitis from abssess CT/MRI – congenital anomalies. Other Radiological investigations

26. No single airway test can provide a high index of sensitivity and specificity for prediction of difficult airway. Therefore it has to be a combination of multiple tests. It must be recognized, however, that some patients with a difficult airway will remain undetected despite the most careful preoperative airway evaluation. Thus , anesthesiologists must always be prepared with variety of preformulated and practiced plans for airway management in the event of an unanticipated difficult airway. Conclusion

27. This is my airway thanks