Airway assessment

Key points •• Previous radiotherapy to the neck

–– Traumatic
• Airway assessment is a dynamic process •• Dental, facial, laryngeal, tracheal
comprising many different elements trauma
• Bedside tests should not be used in •• Cervical spine injury
isolation •• Acute burns
• The actual assessment is one aspect of a –– Infection
two-part process; equally important is the •• Croup and epiglottitis
subsequent airway management plan •• Oral, pharyngeal, retropharyngeal
A thorough airway assessment is the abscesses
cornerstone of any anaesthetic assessment, •• Ludwig’s angina
allowing the practitioner to –– Endocrine/other
• Prepare necessary equipment and the •• Acromegaly
environment for airway management •• Diabetes
• Summon help if needed •• Obesity and obstructive sleep
The 4th National Audit Project, conducted apnoea
by the Royal College of Anaesthetists and •• Pregnancy
the Difficult Airway Society, highlighted
that airway assessment (and subsequent Examination
planning) in critical incidents was poor and
Examination comprises two parts: a general
may have contributed towards negative
systemic examination followed by a focused
outcomes.
airway examination. General patient features
The overall airway assessment is not only
that are associated with difficult airways
aimed at determining ease of intubation,
include
but also that of bag-mask ventilation and
• Presence of stridor
laryngoscopy and follows a multimodal
• Short neck
approach involving history, examination and
• Small or receding mandible (which may be
investigation.
disguised by a beard)
• Obvious neck swellings, e.g. goitre
History • Obesity
In addition to a previously documented • Large breasts
difficult airway, there are various congenital • Evidence of trauma or previous surgery
and acquired conditions that may pose
problems and should be sought during the Specific airway examination
preoperative assessment. Some examples
• Teeth
include
–– Prominent teeth can increase difficulty
• Congenital syndromes
of laryngoscopy
–– Down’s syndrome
–– Although the presence of restorative
–– Pierre Robin syndrome
dental work may not directly make
–– Treacher Collins syndrome
the airway difficult, it may be a source
–– Mucopolysaccharidoses
of anxiety for the inexperienced
• Acquired
laryngoscopist
–– Orthopaedic/rheumatological
–– Even though an edentulous mouth can
•• Rheumatoid arthritis
make laryngoscopy easier, it may make
•• Ankylosing spondylitis
bag-mask ventilation more difficult
–– Tumour
• Palate
•• Airway, neck or mediastinal masses,
–– High-arched palates are associated with
e.g. goitre
a superiorly displaced tongue, limited
2 Airway assessment
space for laryngoscope insertion and a
posterior oropharynx
–– Associated conditions include Marfan’s
syndrome, Pierre Robin syndrome,
trisomy 21
• Mouth opening
–– Is a marker of temporomandibular
joint (TMJ) mobility and ease of
laryngoscope insertion
–– A distance between the upper and
lower incisors of <3–4 cm (or three
patient finger breadths) is associated
with increased difficulty
• Mallampati class
–– Classes are based on the visibility
of pharyngeal structures on mouth
opening and tongue protrusion without
phonation
–– Classes I, II and III were proposed
initially with classes 0 (Shashtri) and IV
(Samsoon and Young) added later
•• Class 0 = epiglottis seen on mouth
opening and tongue protusion
•• Class I = tonsillar pillars, soft palate
and uvula visible
•• Class II = tip of uvula masked by
base of tongue
•• Class III = soft palate visible only
•• Class IV = hard palate visible only
–– Is a marker of several things
•• Adequacy of mouth opening for
laryngoscope insertion
•• Size of tongue relative to oral cavity
•• Potential ease of tongue
displacement
–– Mallampati class III or above is
associated with increased difficulty
• Prognathism
–– The ability to protrude the mandible
•• Class A = lower incisors protruded
anterior to upper incisors
•• Class B = lower incisors in-line with
upper incisors
•• Class C = lower incisors cannot reach
upper incisors
–– Is a marker of TMJ mobility
–– Limited prognathism is associated
with increased difficulty of bag-mask
ventilation and laryngoscopy
• Cervical mobility
–– The ability to flex/extend the atlanto-
occipital joint
–– Is a marker of the ability to align three
axes (oral, pharyngeal and laryngeal)
and achieve the ‘Sniffing the morning
air’ position
–– Neck extension <35° is associated with
increased difficulty
• Thyromental distance (Patil’s test)
–– The distance from the mental process to
the thyroid notch when head and neck
are extended
–– Is a marker of the submental space and
the ease of tongue displacement with
the laryngoscope blade
–– A distance of <6 cm is associated with
increased difficulty
• Sternomental distance (Savva’s test)
–– The distance from mental process to
sternal notch when the head and neck
are extended
–– Is a marker of head and neck mobility
–– A distance of <12 cm is associated with
increased difficulty
• Prayer sign
–– Inability to place both palms flat
together
–– Is seen in diabetic patients and is a
marker of limited joint mobility
–– It is thought that the same process
affects the cervical spine, TMJ and larynx
None of these tests are sensitive or specific
in isolation; however, when we amalgamate
them into an overall airway assessment
their sensitivity and specificity improve. The
combination of Mallampati and thyromental
distance has been suggested to have the
highest discriminative power.
Prediction tools
There are several scoring tools that take these
examination findings into account in order
to predict likelihood of difficult intubations;
however, the most widely cited is the Wilson
risk score. A score of 3 or more predicts
75% difficult intubation (12% false positive)
(Table 1).
 Airway assessment 3

Table 1  Wilson risk score for predicted difficult intubation

Variable Score
Weight 0 = <90 kg
1 = >90 kg
2 = >110 kg
Head and neck movement 0 = >90°
1 = ~90°
2 = >90°
Jaw movement [interincisor gap (IG) and subluxation (Slux)] 0 = IG >5 cm or SLux >0
1 = IG <5 cm or SLux = 0
2 = IG <5 cm or SLux <0
Receding mandible 0 = Normal
1 = Moderate
2 = Severe
Prominent teeth 0 = Normal
1 = Moderate
2 = Severe

Investigations information, e.g. subglottic stenosis. Such

techniques include:
Other investigations can be used to ascertain • Head, neck and chest X-rays
underlying anatomy and function, and • CT/MRI of neck and chest
although they may not predict difficult • Fibreoptic techniques, e.g. nasendoscopy
intubation, they can still provide useful or fibreoptic laryngoscopy
• Flow-volume loops

Further reading
Cook TM, Woodall N, Frerk C. Fourth National
Audit Project. Major complications of airway
management in the UK: results of the Fourth
National Audit Project of the Royal College
of Anaesthetists and the Difficult Airway
Society. Part 1: anaesthesia. Br J Anaesth 2011;
106:617–631.
Mallampati SR, Gatt SP, Gugino LD, et al. A clinical
sign to predict difficult tracheal intubation: a
prospective study. Can Anaesth Soc J 1985;
32:429–434.
Shiga T, Zen’ichiro W, Inoue T, Sakamoto A. Predicting
difficult intubation in apparently normal
patients: a meta-analysis of bedside screening
test performance. Anaesthesiology 2005;
103:429–437.
Wilson ME, Spiegelhalter D, Robertson JA, et al.
Predicting difficult intubation. Br J Anaesth. 1988;
61:211-216.

Related topics of interest

• Awake intubation (p. 13) • Airway – the emergency airway (p. 7)
• Airway – difficult and failed intubation (p. 4) • Airway – the shared airway (p. 10)