AIRWAY MANAGEMENT

PROF. NIKKO ALEXANDER PACQUING / ADAPTED FROM MODULE / WED (10:00-1:00) Padayon!

UNIT 2: EVALUATION OF THE The examination should be performed with the patient sitting
upright, and the individual should not be asked to phonate,
AIRWAY because this may elevate the palate and improve the view
while the airway is examined. Despite the use of this
A. AIRWAY EXAMINATION classification system and other components of the airway
 The risks of airway management in the critically ill are examination, a difficult intubation often is
greater than for patients undergoing elective unanticipated.
procedures. The incidences of both difficult airway
management and inadvertent esophageal intubation
are significantly higher than with airway management in
the controlled environment of the operating room.
 During elective surgery, the incidence of failed
intubation is quite low (0.05% to 0.35%), and the
incidence of failed intubation and inability to provide
mask ventilation is even lower (0.01% to 0.03%).
Because difficulties with airway management occur
even under ideal conditions, reliable methods of
predicting these problems have been sought.
 Specialized equipment and advanced planning can
improve success and prevent a catastrophe with an
unanticipated difficult airway. It is imperative to obtain
an airway history from the patient or from a review of
past medical records before attempting to establish an
artificial airway. Important points that indicate a problem KEY FEATURES OF A COMPLETE AIRWAY
may exist include; EXAMINATION
(a) a known history of difficult intubation;
(b) the presence of obstructive sleep apnea;  Assessment of:
(c) temporomandibular joint disease; 1. OROPHARYNGEAL SPACE
(d) previous airway surgery; a. Examine the mouth and oral cavity
(e) anatomic abnormalities of the head, neck, or airway, i. Noting the extent and symmetry of opening (three
including significant micrognathia; finger breaths is optimal)
(f) a small mouth opening—patients may have been told this 1. The health of the teeth
by their dentist; or a. Loose, missing, or cracked
(g) significant overbite of the teeth. teeth should be documented (As
well as the presence of dental
Patient mouth opening, a dental examination, cervical range appliances)
of motion, and the thyromental distance are all common b. Prominent buck teeth may
components of the airway examination.This system (Table 5- interfere with the use of a
3) attempts to predict the difficulty of visualizing the glottis laryngoscope
structures during laryngoscopy. 2. Size of tongue
a. Large tongues –more difficult
3. Arch of the palate

b. Mallampati score
Class I
- The soft palate, fauces, uvula, and tonsillar pillars
are visiable
Class II
- The soft palate, fauces, and uvuala are visible
Class III
- The soft palate and base of the uvula are visible
Class IV
- The soft palate is not visible

2. ATLANTO-OCCIPITAL EXTENSION/NECK MOBILITY

a. Flexion of the neck, by elevating the head approximately
10 cm
i. Aligns the laryngeal and pharyngeal axes

N.Y IRIGAYEN / BS RESPIRATORY THERAPY 3C / CSU ANDREWS 1

AIRWAY MANAGEMENT
PROF. NIKKO ALEXANDER PACQUING / ADAPTED FROM MODULE / WED (10:00-1:00) Padayon!

b. Extension of the head on the atlanto-occipital joint is 14. Ability to maximally extend the atlantooccipital joint
important for aligning the oral and pharyngeal axes to obtain (normal extension is 35°)
a line of vision during direct laryngoscopy. 15. Airway appears normal in profile

3. THYROMENTAL/STERNOMENTAL DISTANCE SIGNS INDICATIVE OF AN ABNORMAL AIRWAY

a. A thyromental distance (mentum to thyroid cartilage) 1. Trauma, deformity; burns, radiation therapy, infection,
i. Less than 6-7 cm correlates with poor swelling; hematoma of the face, mouth, pharynx, larynx,
laryngoscopic view and/or neck
This is typically seen in patients with a receding mandible or 2. Stridor or “air hunger”
a short neck 3. Hoarseness or “underwater” voice
b. Distance is often estimated in fingerbreadths 4. Intolerance of the supine position
i. Three ordinary finger breaths approximate this 5. Mandibular abnormality:
distance (a) Decreased mobility or inability to open the mouth at least
4. SUBMANDIBULAR COMPLIANCE three finger- breadths
(b) Micrognathia, receding chin:
5. BODY HABITUS (i) Treacher Collins, Pierre Robin, other syndromes
(ii) Less than 6 cm (three finger-breadths) from tip
6. LENGTH OF THE NECK of the mandible to thyroid notch with neck in full
extension (adolescents and adults)
7. THICKNESS OF THE NECK (c) Less than 9 cm from angle of the jaw to symphysis
(d) Increased anterior or posterior mandibular depth
B. THE NORMAL/ABNORMAL AIRWAY
There are a number of wide-ranging characteristics and 6. Laryngeal abnormalities: fixation of the larynx to other
measurements in adults that constitute a “normal airway”. structures of neck, hyoid, or floor of mouth
7. Macroglossia
When patients with these features present for airway 8. Deep, narrow, high-arched oropharynx
management, problems do not usually occur. There are also 9. Protruding teeth
a number of features that make up the “difficult airway” and 10. Mallampati/Samsoon classes III and IV, inability to
when patients with these characteristics present for airway visualize the posterior oropharyngeal structures (tonsillar
management, problems frequently occur. fossae,pillars, uvula) on voluntary protrusion of the tongue
with mouth wide open and the patient seated
Factors Characterizing the Normal Airway in 11. Neck abnormalities:
Adolescents and Adult (a) Short and thick
1. History of one or more easy intubations without sequelae (b) Decreased range of motion (arthritis, spondylitis,
2. Normal appearing face with “regular” features disk disease)
3. Normal clear voice (c) Fracture (possibility of subluxation)
4. Absence of scars, burns, swelling, infection, tumor, or (d) Obvious trauma
hematoma; no history of radiation therapy to head or neck 12. Thoracoabdominal abnormalities:
5. Ability to lie supine asymptomatically; no history of snoring (a) Kyphoscoliosis
or sleep apnea (b) Prominent chest or large breasts
6. Patent nares (c) Morbid obesity
7. Ability to open the mouth widely (minimum of 4 cm or (d) Term or near-term pregnancy
three fingers held vertically in the mouth) with good TMJ 13. Age between 40 and 59 years
function 14. Gender (male)
8. Mallampati/Samsoon class I (i.e., with patient sitting up 15. Snoring and sleep apnea syndrome
straight, opening mouth as wide as possible, with protruding
tongue; the uvula, posterior pharyngeal wall, entire tonsillar C. PREDICTIVE TEST FOR DIFFICULT AIRWAY
pillars, and fauces can be seen)  Often a difficult airway can be visually identified. A
9. At least 6.5 cm (three finger-breadths) from tip of mandible congenital defect or traumatic injury to the face or neck
to thyroid notch with neck extended can compromise the patient’s airway.
10. At least 9 cm from symphysis of mandible to mandibular  Macroglossia is an example of a congenital defect that
angle can cause a partial airway obstruction with inspiratory
11. Slender supple neck without masses; full range of neck stridor. A child with this condition has an excessively
motion large tongue that is often seen to protrude out of the
12. Larynx movable with swallowing and manually movable mouth.
laterally (about 1.5 cm on each side)  a “difficult airway” is one that we cannot tracheally
13. Slender to moderate body build intubate. In reality, a truly difficult airway is one that
prevents us from delivering that vital gas, oxygen, to

N.Y IRIGAYEN / BS RESPIRATORY THERAPY 3C / CSU ANDREWS 2

AIRWAY MANAGEMENT
PROF. NIKKO ALEXANDER PACQUING / ADAPTED FROM MODULE / WED (10:00-1:00) Padayon!

the lungs. So before we even think about difficulties Note: Oropharyngeal structures visible in an upright, seated
placing an endotracheal tube in the airway, we must patient.
ask a more fundamental question. “Will I be able to
maintain this patient’s airway when he is unconscious Obstruction
and if not can I at least maintain oxygenation?” Note: anything that might interfere with visualization or ET
tube placement.
PREDICTING DIFFICULT INTUBATION  Foreign body
 In terms of predicting difficult intubation, the L-E-M-O-N  Obesity
mnemonic is useful.  Hematoma
L - Look externally  Masses
E - Evaluate external anatomy
M - Mallampati classification Neck mobility
O - Obesity/Obstruction  Sniffing position is ideal
N - Neck mobility  Neck mobility problems most common with:
 Risk factors for difficult intubation include the following:  Trauma patients
• Mouth opening less than 4 cm  Elderly patients
• Thyromental distance less than 6 cm
• Mallampati Class III or higher PREDICTING DIFFICULT BAG VALVE MASK
• Neck movement less than 80% VENTILATION
• Inability to advance the mandible (prognathism) Bag/valve/mask ventilation can be difficult under certain
• Body weight greater than 110 kg circumstances – for instance:
• Positive history of difficult intubation  in bearded individuals
 the edentulous
 very obese.

The M-O-A-N-S mnemonic can help the clinician predict

difficult BVM ventilation.
 Mask seal
 Obesity/Obstruction
 Aged
 No teeth (edentulous)
 Stiff lungs.

Once BVM ventilation begins, the following signs indicate

difficulty with the airway:
 absent/inadequate chest rise or breath sounds,
 gastric air entry or gastric distension,
 cyanosis or inadequate SpO2,
Look externally  absent or inadequate exhaled CO2, and
The following can make intubation difficult:  hemodynamic changes associated with hypoxemia or
 Short, thick necks hypercapnia (e.g., hypertension, tachycardia,
 Morbid obesity arrhythmias).
 Dental conditions
Evaluate 3-3-2. “Death occurs from failure to Ventilate, not failure to Intubate”
 3 — mouth width of more than 3 fingers is best
 3 — mandible length of 3 fingers is best What can be done to improve mask ventilation:
 2 — distance from hyoid bone to thyroid notch of 2 1. Good position
fingers wide is best a. The facemask should be held to the patient’s face with
Mallampati Classification the fingers of the anesthesia provider’s left hand lifting the
The examiner sits opposite the patient at eye level and mandible (chin lift, jaw thrust) to the facemask
observes various intraoral structures using a flashlight: i. Pressure on the submandibular soft tissue
 Class I: soft palate, tonsillar fauces, tonsillar pillars, and should be avoided because it can cause airway OB.
uvula visualized b. The anesthesia provider’s left thumb and index finger
 Class II: soft palate, tonsillar fauces, and uvula apply counter pressure on the facemask
visualized
 Class III: soft palate and base of uvula visualized 2. Displacement of the mandible, atlanto-occipital joint
 Class IV: soft palate not visualized extension, chin lift, and jaw thrust combine to maximize the
pharyngeal space

N.Y IRIGAYEN / BS RESPIRATORY THERAPY 3C / CSU ANDREWS 3

AIRWAY MANAGEMENT
PROF. NIKKO ALEXANDER PACQUING / ADAPTED FROM MODULE / WED (10:00-1:00) Padayon!

3. A two- or three handed facemask technique can be used

a. Assistant can help by squeezing the reservoir bag
i. While the anesthesia provider uses the right
hand to mirror the hand position of the left and
improve the facemask seal

4. Airway adjuncts
a. Oral or nasal airways
i. Are designed to create an air passage by
displacing the tongue from the posterior pharyngeal
wall

What clues do you have to indicate you’re adequately

ventilating the patient?
1. Condensation in ETT corresponding to bag-valve
mask breaths
2. Improving pulse ox reading

N.Y IRIGAYEN / BS RESPIRATORY THERAPY 3C / CSU ANDREWS 4