First - a detailed history of the patients past airway problems must be sought.
Second - to improve positive and negative predictive values of airway examinations all possible measurements must be taken into account.
Third - to have the knowledge and experience to overcome the "unpredicted difficult airway". This means learning practical airway management skills in an environment that is not urgent, stressful or life threatening i.e. at a course such as this!!
A. History - Obtain detailed history from patient and, if necessary, family or medical records, i.e.:
previous difficult intubation
congenital abnormalities
previous airway trauma
previous airway surgery
medical conditions, i.e. ankylosing spond/rheumatoid arthritis
B. Airway Examination - This should be conducted in an orderly fashion with a set of tools to aid measurements, i.e. light, centimeter ruler, bubble inclinometer and special investigations.
Order of examination:
Nares
Cervical spine
Temperomandibular joint
Mandibular-mental dist.
Mallampati
Hyomental dist.
Laryngeal lateral movement.
Laryngeal tilt
Auscultation
Airway -- Is the airway clear and patent??
Breathing -- Is the patient breathing spontaneously? With adequate tidal volume? Are the breath sounds clear? Is ventilation sufficient?
"Color" -- Is the patient oxygenated?
Skin color pink?
Oxyhemoglobin saturation?
Coexisting disease --
Consciousness/cranial pathology?
Hemodynamic stability
Cardiovascular disease
Coagulopathy
"Full stomach"
Trauma
Obesity
Surgical problems
A. Mask ventilation will be made difficult by:
poor mask seal --
beards
facial burns
facial scarring/cuts
facial dressings
edentulous patients
any evidence of airway obstruction
neck instability
penetrating neck trauma
repeated failed direct laryngoscopy
obesity/bull neck
B. Other ventilation techniques will be made difficult by:
lack of knowledge and experience
lower airway obstruction
neck instability
penetrating neck injury
C. Direct laryngoscopy will be made difficult by:
decreased mobility cervical spines
tempero-mandibular jt larynx decreased visualization oral structures
mandibular structures laryngeal tilt dentition secretions airway obstruction pharyngeal
laryngeal
tracheal
D. Indirect laryngoscopy will be made difficult by:
lack of knowledge and experience
nasal obstruction
neck instability
secretions
E. Fiberoptic laryngoscopy will be made difficult by:
lack of knowledge and experience
nasal obstruction
base of skull fractures (nasal route)
secretions
F. Cricothyroidotomy/airway surgery will be made difficult by:
coagulopathy
lack of knowledge and experience
soft tissue neck injury
obesity/"bull neck"
confused and combative patient
IV. Reference Articles
1. Clinical Anesthesia Updates Vol.5 Number 3. Barash Cullen and Stoelting.
2. Mallampati SR.et al. A Clinical sign to predict difficult intubation:a prospective study. Can Anaesth Soc J 1985;32:4,429-434.
3. McIntyre JWR,The difficult tracheal intubation.CME.Can J Anaesth 1987;34:2,204-213.
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