Management of the difficult airway

Published on 07/02/2015 by admin

Filed under Anesthesiology

Last modified 07/02/2015

Print this page

This article have been viewed 1119 times

Management of the difficult airway

David R. Danielson, MD

Successfully managing difficult airways requires a combination of forethought, proper equipment, and decisiveness. Concentrating on the first two factors makes the third less stressful. Obtaining a thorough patient history and performing a physical examination with particular emphasis on the airway will not reveal every difficult airway but can often avert a crisis and prompt the anesthesia provider to take an alternate approach to managing the airway.

Preoperative evaluation

The anesthesia provider should preoperatively interview the patient and review the medical record to determine whether the patient has had any previous difficulty while being intubated. Three classic bedside measurements should be obtained: the size of the tongue, as compared with the pharynx; the extension of the atlanto-occipital joint; and the size of the anterior mandibular space. Although none of these parameters is a definitive predictor of airway ease or difficulty, evaluation of as many bedside measures as possible is recommended to increase the predictive power of the preoperative examination. In addition to obtaining the three classic measures, incisor prominence, interincisor distance, width of the palate, temporomandibular joint mobility, and length and thickness of the neck should also be evaluated.

Tongue versus pharyngeal size

Preinduction visualization of the faucial pillars, soft palate, and base of the uvula, with the patient in a sitting position, is used to classify patients according to how well pharyngeal structures can be seen (Table 240-1 and Figure 240-1). Mallampati and colleagues’ original recommendation was to examine these structures without the patient phonating and to assign a class level—I through III (see Table 240-1)—to the results. Class II was later subdivided based on whether all of the uvula or only its base can be visualized.

Table 240-1

Mallampati Classification of the Upper Airway

Class	Visible Structures
I	Palate, faucial pillars, entire uvula
II	Palate, faucial pillars, base of uvula
III	Palate, some of the faucial pillars
IV	Palate

Buy Membership for Anesthesiology Category to continue reading. Learn more here

Related

Fausts Anesthesiology Review Expert Consult 4e