Prediciting
Difficult Airways
Dr. Abdulwahab Borahmah
Resident Physician – Kuwait Board of Anesthesia (KBA)
Al-Adan Hospital – Department of Anesthesia & ICU
Morning Meeting Academic Day
What is a Difficult Airway?
• The American Society of Anesthesiologists defined it as ‘a clinical
situation in which a conventionally trained anesthesiologist
experiences difficulty with mask ventilation, difficulty with tracheal
intubation or both’
• Should include difficulties with the insertion of a laryngeal mask airway
• Three regions:
• Upper (Face, mouth, nose) – BMV
• Middle (Larynx) – Laryngoscopy & Intubation
• Lower (Trachea, Bronchoalveolar) – Ventilation
Objectives
• Clinical Assessment
• Radiological
• Advanced Techniques
• Recommendations
Clinical Assessment
History
• Patient – verbally
• Documented – Institutional letter or bracelet
Clinical Assessment
Examination
• Gross abnormalities
Clinical Assessment
Oropharyngeal View
• Mouth Opening (TMJ mobility)
• Three fingers / 4-6cm – interincisors
• Pharyngeal View (Mallampati score)
Clinical Assessment
Neck & Mandible
• Jaw protrusion (Lip bite)
• Worse grade:
• Cannot displace jaw anteriorly
• Cannot displace tongue anteroinferiorly
• Narrow sublingual space
• Neck ROM, TMD, SMD
Radiological
X-Ray and CT
• Neck X-Ray
• Atlantooccipital (stiffness/fracture/instability) - Down's, RA, DM
• Bamboo spine
• CXR/CT
• Trachea - stenosis/deviation
Advanced Techniques
Nasoendoscopy
• Flexible nasoendoscopy is underused in
anesthesia despite there being a
recommendation in NAP4 to consider it before
induction of general anesthesia in patients
with neck masses and stridor
• It allows assessment of whether the pathology
may preclude face mask ventilation (e.g.,
extensive supraglottic oedema), prevent direct
laryngoscopy (e.g., a base of tongue tumor) or
impede successful tracheal tube placement
(e.g., secondary to a mass or lateral
displacement of the larynx)
• Limitations: Pharyngeal tone pre and post
induction
Advanced Techniques
Ultrasound
• Point-of-care ultrasound (POCUS) can be used
at various stages of airway management, from
airway assessment to confirming the position
of the tracheal tube, and readiness for
extubation.
• Studies comparing ultrasound with CT
scanning have shown that upper airway
structures can be reliably visualized and
assessed with ultrasound
• Uses include:
• TT size, tracheal deviation/stenosis
• mark the location of CTM before anesthesia
• Fasting status
Recommendations
• “Difficult Airway” form
• Update MoH Pre-operative assessment form
• ENT clinic visits/ Nasoendoscopy workshops
• POCUS training/ workshops
References
• Ralph S Vaughan, Predicting difficult airways, BJA CEPD Reviews, Volume 1,
Issue 2, April 2001, Pages 44–47, https://doi.org/10.1093/bjacepd/1.2.44
• Comparison of modified mallampati classification with Cormack and
Lehane grading … . Ann Med Surg (Lond). 2022;79:103912. Published 2022
Jun 24. doi:10.1016/j.amsu.2022.103912
• Sachin Kheterpal, Richard Han, Kevin K. Tremper, Amy Shanks, Alan R.
Tait, Michael O’Reilly, Thomas A. Ludwig; Incidence and Predictors of
Difficult and Impossible Mask Ventilation. Anesthesiology 2006; 105:885–
891 doi: https://doi.org/10.1097/00000542-200611000-00007
• J. O’Carrol, Advanced Airway Assessment Techniques, BJA Review Article,
Volume 21, Issue 9, September 2021,
https://doi.org/10.1016/j.bjae.2021.04.004
Thank You
Questions?
