DIFFICULT

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• DIFFICULT
• AIRWAY
• ASSESSMENT

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• This is a discussion on assessing the difficult
  airway.
• You will review different mnemonics for each
  phase of the process.

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MOANS, LEMON, SHORT, RODS

• MOANS Difficult Mask Ventilation
• LEMON Difficult Laryngoscopy
• SHORT Difficult Cricothyrotomy
• RODS Difficult EGD (extra-glottic device)

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MOANS

• M Mask Seal
• O Obesity/Obstruction
• A Aged
• N No Teeth
• S Stiff

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MASK SEAL

• Bushy beards, crusted blood on the face, or a
  disruption of lower facial continuity (lower
  facial fractures).

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OBESITY/OBSTRUCTION

• Pts who are obese, women in third-trimester.
  The difficulty bagging these is not solely due to
  their increased body mass, but can be due to
  redundant tissue creating resistance to air flow.
  
• Obstructions can be in the form of angioedema,
  upper airway abscesses, epiglottitis and others.

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AGED

• Age older than 55 years, due to loss of muscle
  and tissue tone in the upper airway.
• (55 is not a precise cutoff)

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NO TEETH

• An Adequate mask seal may be difficult in the
  edentulous pt because the face tends to cave in.
• An option is to leave them in while bagging and
  then take them out for the intubation.

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STIFF

• This refers to pts that have stiff lungs
• (hard to bag)
• Pts with reactive airway disease with small
  airway obstruction, pulmonary edema, ARDS,
  advanced pneumonia, and other conditions that
  reduces pulmonary compliance.

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LEMON

• L Look Externally
• E - Evaluate
• M - Mallampati
• O Obstruction/Obesity
• N Neck Mobility

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Look Externally

• Does the airway look difficult, do you have a
  feeling that this will be difficult
• Lower facial fractures, bleeding, obese, agitated
  pt, short neck, small mouth

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Evaluate

• The 3-3-2 Rule
• (Using pts fingers)
• Mouth opens 3 fingers or more
• Mandible is 3 fingers or more
• Glottis / Tongue 2 fingers or more

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Mallampati Scale

• Class I soft palate, fauces, uvula, pillars
• Class II soft palate, fauces, portion of uvula
• Class III soft palate, base of uvula
• Class IV hard palate only

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Obstruction/Obesity

• 4 cardinal signs of upper airway obstruction
  Muffled voice, difficulty swallowing secretions,
  stridor, and a sensation of dyspnea.
• Pts who are obese, women in third-trimester.
  The difficulty bagging these is not solely due to
  their increased body mass, but can be due to
  redundant tissue creating resistance to air flow.

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Neck Mobility

• Cervical Spine Immobilization, ankylosing
  spondylitis (It affects joints in the spine and
  the sacroilium in the pelvis, causing eventual
  fusion of the spine) , rheumatoid arthritis.

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SHORT

• S Surgery
• H Hematoma/Infection
• O Obese
• R Radiation
• T Tumor

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Surgery

• Or Airway Disruption
• The anatomy may be subtly or obviously distorted.

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Hematoma/Infection

• A hematoma (post-op or traumatic) or an infective
  process in the pathway or the cricothyrotomy may
  make the procedure technically difficult, but
  should never be considered a contraindication in
  a life-threatening situation.

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Obese

• This includes any access problem. Should be
  considered for any problem that makes access
  difficult. Short neck, large descending pannus,
  sub-q air.

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Radiation

• Past radiation therapy may distort and scar
  tissues making the process difficult.
• Like wise, a fixed flexion deformity of the spine
  may limit the working access to landmarks.

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Tumor

• Tumor, either in or around the airway may present
  difficulty from both an access and bleeding
  perspective.

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RODS

• R Restricted Mouth Opening
• O Obstruction
• D Distorted Airway
• S - Stiff

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Restricted Mouth Opening

• Depending on the EGD to be employed, more or less
  oral access may be needed.

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Obstruction

• Upper airway obstruction at the level of the
  larynx or below.
• An EGD will not bypass this obstruction.

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Distorted Airway

• The seat and seal using the EGD will be
  difficult.
• Fixed flexion deformity of the neck, or with
  upper airway distortion form angioedema.

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Stiff

• Stiff lungs or cervical spine.
• Ventilation with an EGD may be difficult or
  impossible.
• Because of increased airway resistance (asthma)
  or decreased compliance
• (pulmonary edema).
• There are reports of difficult LMA insertion in
  pts. With limited neck movement.

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Cormack-Lehane SystemAnother Tool to Determine
Difficult Intubation

• Class I the vocal cords are visible
• Class II the vocals cords are only partly
  visible
• Class III only the epiglottis is seen
• Class IV the epiglottis cannot be seen.