Topics in Airway Management: Intelligent Airway Evaluation

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Topics in Airway ManagementIntelligent Airway
Evaluation

• Donald M. Voltz, MD
• Assistant Professor of Anesthesiology
• Case Western Reserve University / University
  Hospitals of Cleveland
• 3 November 2004

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What we focus on and our mental models determine
what we see.
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What is Intelligence?
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Intelligence Behavior
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Turing Test
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Intelligence Prediction
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Is There Such a Thing as an Unexpected Difficult
Intubation?
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What is the Problem?
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More than 85 of respiratory-related closed
claims involve a brain-damaged or dead patient.

• Jonathan Benumof, MD

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Incidence of Difficult Intubation

• Successful with multiple attempts
• Successful, many attempts, many people
• Unsuccessful
• Can not ventilate or intubate

• 100-1800/10,000
• (1-18)
• 100-400/10,000
• (1-4)
• 5-35/10,000
• (0.05-.35)
• 0.01-2/10,000
• (0.0001-0.02)

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What do we want to Predict?
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Cormack-Lehane Classifications
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Airway Prediction Models
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Airway Prediction Models

• Mallenpatti Classification
• Neck Range of Motion
• Thyromental/Thyrosternal Distance
• Upper Lip Bite Test
• Multivariate Analysis

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Mallinpatti Classification
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Mallinpatti Classification
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Upper Lip Bite Test
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Upper Lip Bite Test
Table 1. Relationship Between the Results of Two
Predicting Tests and Laryngoscopy Grades in 300
Patients
Predicting test
Predicting test
Modified Mallampati
    Classes I and II 189 3
    Classes III and IV 94 14
Upper lip bite
    Classes I and II 251 4
    Class III 32 13
Laryngoscopic view


I and II
III and IV

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ASA Difficult Airway Algorithm

• Updated 2003

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Airway Evaluation

• Mouth (4)
• Oral Cavity (3)
• Neck (4)

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Airway Evaluation - Mouth

• Length of Upper Incisors
• Relationship of Maxillary Incisors to Mandibular
  Incisors
• Ability to Prognath the Mandible
• Interincisor Distance

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Airway Evaluation Oral Cavity

• Visibility of the Uvula
• Shape of the Palate
• Compliance of the Mandibular Space

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Airway Evaluation - Neck

• Thyromental/Thyrosternal Distance
• Length of the Neck
• Thickness of the Neck
• Range of Motion of the Head and Neck

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Approaching the Difficult Airway Algorithm

• William H. Rosenblatt, M.D.
• Yale University School of Medicine

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Is Airway Management Required?
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Do you predict difficult direct laryngoscopy?
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Will superlarngeal ventilation be possible?
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Predictors of Difficult Mask Ventilation

• Age greater than 55 years
• Body mass index greater than 26 kg/m2
• History of snoring
• Edentulous
• Presence of facial hair

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Is the patient at an increased risk of aspiration?
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Will the patient tolerate a judgment error?
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Problems with Prediction Methods
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Future of Airway Prediction
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References

• Rosenblatt, W.H. Decision making in airway
  evaluation. ASA Refresher Course in
  Anesthesiology, V. 32, 2004.
• Benumof, J.L. Airway Management, pp. 121-158,
  1996.
• ASA Task Force on Airway Management. Practice
  Guidelines for Management of the Difficult
  Airway An Updated Report by the American Society
  of Anesthesiologists Task Force on Management of
  the Difficult Airway, Anesthesiology, 98(5),
  1269-1277.