Advanced Airway Course

1. AIRWAY ASSESSMENT &
RECOGNITION OF POSSIBLE
COMPROMISED AIRWAY
DR. KHAIRUNNISA BINTI AZMAN
Anaesthesia Dept TGH

2. INTRODUCTION
• The human airway is a dynamic structure that
extends from the nares to the alveoli
• Obstruction can occur at any point because of
anatomic collapse or a foreign body which
includes:
– Mucuous
– Blood
– Gastric content

3. DIFFICULT AIRWAY
American society of Anesthesiologist (ASA)
suggested that when sign of inadequate
ventilation could not be reversed by mask
ventilation OR oxygen saturation could not
be maintained above 90% OR
if a trained Anaesthetist using conventional
larangoscope take’s more than 3 attempts OR
more than 10 minute are required to complete
tracheal intubation

4. TERMINOLOGY
• Difficult airway
– Difficult with mask ventilation, tracheal intubation or both
• Difficult mask ventilation
– an unassisted anaesthesiologist unable to maintain SpO2 >90%
using 100% oxygen & positive pression mask ventilation
• Difficult laryngoscopy
– Unable to visualize any portion of vocal cords with conventional
laryngoscopy  CL 3 & 4
• Difficult endotracheal intubation
– proper insertion of ETT wth conventional laryngoscopy requires
> 3 attempts or > 10 minutes

6. WHY IS IT IMPORTANT TO ASSESS
AIRWAY
• Respiratory events are the most common
anaesthetic related injuries, following dental
damage
• Main causes:
– Inadequate ventilation
– Oesophageal intubation
– Difficult tracheal intubation

7. • To look at patient physical features to predict
ability to see the vocal cords (with
laryngoscopy) and therefore predict ease of
intubation
• Predicting a difficult airway allows you to
– Have extra equipment available
– Change your approach (eg: awake intubation)
WHY IS IT IMPORTANT TO ASSESS
AIRWAY

8. Airway Asssessment
• History
• Physical examination:
– Mallampati Classification
– Mouth opening
– Dentitian
– TMJ Mobility
– Thyromental distance (TMD)
– Cervical spine range of motion
– Other factors: Obesity, pregnancy

9. HISTORY
• Adverse events related to prior airway
management
• Radiation/surgical history
– Distortion of Anatomy
– Scar Tissue
– Fixed Flexion Deformity of the Spine
• Burns/swelling/tumor/masses
• Obstructive sleep apnoea
• Problem with phonation
• C-spine disease

10. Airway Compromising conditions:
1. CONGENITAL:
Pierre-Robin Syndrome:
- Micrognathia, Macroglossia, Cleft Soft palate
Treacher-Collins Syndrome:
- Auricular & Ocular defects
- Malar & Mandibular hypoplasia
Down’s Syndrome:
- Poorly developed or absent nasal bridge
- Macroglossia
Kippel-Feil Syndrome:
- Congenital Fusion of cervical vertebrae
- Restriction of neck movement

11. Pierrre- Robin

12. Treacher-Collins

13. Goldenhar

14. Down’s Syndrome

15. Klippel-Feil

16. ACQUIRED:
1. Infections:
Supraglottis
Croup
• Laryngeal Oedema
Abscess (Intra-Oral,
Retropharyngeal)
Ludwigs Angina
• Distortion of airway & Trismus
2. Obesity • Short & thick neck
• Redundant tissue in oropharynx
• Sleep apnoea
3. Acute Burns • Airway Oedema

17. Ludwig’s angina

18. 4. Arthritis:
Rheumatoid
Arthritis
• Temporomandibular joint
ankylosis, Cricoarythenoid
arthritis,
• Larynx deviation,
• Restricted mobility of cervical
spine
Ankylosing
Spondylitis
• Cervical spine ankylosis
• Lack of mobility of cervical spine
5. Tumor • Stenosis or distortion of airway
• Fixation of larynx or adjacent
tissue 2’ infiltration or irradiation

19. Arthritis
Rheumatoid Arthritis Ankylosing Spondylitis

20. Acromegaly

21. Examination
1. Dentitian:
• Prominent upper incisors
• Receding chin
• Teeth: Loose, chipped, dentures

22. 2. Mouth opening:
• Male assessor: 2 finger
breadths
• Female assessor: 3
finger breadths

23. 2. Ability to visualize uvula
• Malampati scoring
3. Mallampati Scoring

24. Technique:
• Sitting Up
• Head in sniffing position
• Open mouth, protrude tongue without phonation

25. Cormack & Lehane classification
Actual view of glottic on direst laryngoscopy
• Grade I: entire laryngeal structure
• Grade II: posterior portion of laryngeal aperture
• Grade III: tip of epiglottis
• Grade IV: soft palate

26. 4. Mobility
• Cervical spine mobility
• Temporomandibular mobility
• Thyromental distance (TMD)
Examination

27. Neck mobility:
• Ask patient to place their chin on their chest &
tilt head backwards as far as possible
– Not possible in trauma patient

28. Thyromental distance:
• Measure from upper edge of thyroid cartilage to
chin with head fully extended
• 6cm
• >3- 4 FB

30. Atlanto-occipital movement:
• Flexion of the neck, by elevating the head
approximately 10 cm, aligns the laryngeal and
pharyngeal axes.
• Extension of the head on the atlanto-occipital joint
is important for aligning the oral and pharyngeal
axes to obtain a line of vision during direct
laryngoscopy
• Sniffing position

31. STERNOMENTAL DISTANCE:
• From sternum to tip of the mandible with the
head extended
• > 12.5cm: Difficult intubation
Mandibular Protrusion:
• If the patient able to protrude the lower teeth
beyond upper incisor intubation usually
straight foward
• if patient cannot get upper & lower incisor
into alignment  intubation likely difficult

32. Mandibular Protrusion

34. The Three Pillars of airway management:
• Patency  Airflow integrity
• Protection against aspiration
• Assurance of Oxygenation & Ventilation

35. Clinical Signs of Compromised
Airway

36. Patency
• Inspiratory stridor
• Snoring ( pharyngeal obstruction )
• Gurgling ( foreign matter/ secretions )
• Drooling ( epiglottitis )
• Hoarseness ( laryngeal edema/ vc paralysis)
• Paradoxical chest wall movement
• Tracheal tug

37. Protection
• Blood in upper airway
• Pus in upper airway
• Persistant vomiting
• Loss of protective airway reflexes

38. Oxygenation and Ventilation
• Central cyanosis
• Obtundation and diaphoresis
• Rapid shallow breathing
• Accessory muscle use
• Retractions
• Abdominal paradox

39. LEMON Airway assessment method
L Look externally (Facial trauma, large incisors, beard or
moustache, large tongue
E Evaluate the 3-3-2 rule
- Incisor distance: 3 FB
- Hyoid-mental distance: 3 FB
- Thyroid-to-mouth distance: 2 FB
M Mallampati Score > 3
O Obstruction : Presence of any condition like
epiglotitis, Peritonsillar abscess, trauma
N Neck Mobility (Limited neck mobility)

40. WILSON RISK SCORE
Risk factor Level Point
Weight <90kg
90-110kg
>110kg
0
1
1
Head and neck
movement
>90
About 90
<90
0
1
2
Jaw movement IG> 5cm, SLux>0
IG< 5cm,SLux=0
IG< 5cm, SLux<0
0
1
2
Receding mandible Normal
Moderate
Severe
0
1
2
Buck teeth Normal
Moderate
Severe
0
1
2

41. • Score > 3 75% of difficult intubations
• score> 4 predicts 90%.
• The test has a poor specificity and may fail to predict
more than 50% of difficult intubations.
• IG: interincisor gap: distance between upper & lower
incisor measured with mouth fully open
• Slux: subluxation: maximal forward protrusion of lower
incisor beyond upper incisiors
• SLux>0: upper incisor can protrude beyond upper
incisor
• SLux=0: both are edge to edge
• SLux<0: lower incisors cannot be brought edge to edge
WILSON RISK SCORE

42. Indications for Active Airway Intervention
• Patency - relief of obstruction
• Protection from aspiration
• Hypoxic/ hypercapnic respiratory failure
– Failure to oxygenate
– Failure to remove CO2
• Neuromuscular weakness
• CNS failure
• Cardiovascular failure

43. Management of Compromised Airway
• Bag-Valve-Mask Ventilation
• Endotracheal Intubation
• Rapid Sequence Intubation
• Airway adjuncts

49. Take Home Messages
• Learn Basic Theory
• Practice basic principles on an airway trainer
• Perform technique or procedure in a patient
under supervision
• Perfect the acquired skills
• Place an airway in patients with an anticipated
difficult airway
• Participate in continuing education and training
And....