RACELIS, Melinna Giann A.

3D
AIRWAY MANAGEMENT

CASE : A 56 year old female nurse came into the emergency room complaining of difficulty of
breathing. She has been experiencing dry cough, high-grade fever, and headache of 2-day duration
since she started isolating herself at home for having been exposed to a Covid-19 Probable in the
OPD triage in the same hospital. Pertinent medical history includes Hypertension, Diabetes Mellitus
Type 2, Hyperlipidemia, & Obstructive Sleep Apnea Syndrome. Her vital signs on admission :
170/100 mm Hg, 126 beats per minute, 32 cycles per minute, 39.3 ‘ C, 92% oxygen saturation. She
was conversant. However upon arrival at the COVID ICU, her oxygen saturation dropped to 70 %,
patient becoming more dyspneic, and drowsy. You as the anesthesiologist on duty was phoned in to
intubate the patient.

1. What Airway Assessment Scoring/Index you will utilize in determining the difficulty of
intubation in this patient?

MACOCHA scoring which includes Mallampati score of III or IV, Apnea syndrome,
Cervical spine limitation, Opening mouth of <3cm, Coma, Hypoxemia, Anesthetic non-
trained. De Jong et.al.

2. What are the Factors/Variables and corresponding points according to the scoring system
you decided to employ? What is the total score of this patient?

Factors related to patient would include Mallampati class of III or IV which

corresponds to 5 points, Obstructive Sleep Apnea syndrome which corresponds to 2 points,
Cervical spine limitation and limited mouth opening, which both correspond to 1 point.
With the factors related to pathology, coma and severe hypoxemia both correspond to one
point. Factor related to non-trained operator or anesthetist would also correspond to one
point. From the patient's medical history of having OSA, she incur 2 points to her total score.
Another point from having severe hypoxemia of less than 80%. The patient in total would
have 3 points since her Mallampati score was not mentioned along with other factors like
cervical spine limitation and limited mouth opening. De Jong et.al.

3. How do you classify the patient’s airway according to ASA guidelines on Airway
Management? Define.

Her score can be classified as easy since difficult to intubate classification is given to
those patients scoring 12. Presence of OSA syndrome, however, may incur the patient
difficult to intubate since there could be anatomical anomalies in upper airway present
causing OSA.

4. Describe the intubation technic recommended for this patient.

According to ASA guideline, consideration of Rapid Sequence Induction is

recommended for the patient. Drugs that can be used for induction include etomidate as
well as neuromuscular blocking agents including Rocuronium. RSI is recommended in order
to prevent aerosolization and manual ventilation of the patient's lungs. Positioning of 45
degrees should be ensured first. Using two-hand face mask technique, ensure
preoxygenation for 5 minutes. To maximize operator and airway's distance, Video
laryngoscopy is used with the screen used to indirectly view the airway. With VL, first step
is to look for the auditory sternal notch then open the mouth with cross finger technique.
Blade is then inserted about 1 inch to the mouth. It could be done horizontally if there are
upper airway deformities. The silvery structure epiglottis is then searched for followed by
external laryngeal manipulation until valeculla becomes the actual space found. Posterior
notch is then visualized followed by horizontal entry of ET. Conduct RSI with no ventilation
prior to intubation unless there is a need for rescue oxygenation. Triggering cough should
be avoided while waiting for 60 seconds for paralysis to take place.