Airway Assessment

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Preoperative endoscopic airway examination is an underutilised technique in anaesthesia that may provide useful information regarding the supraglottic airway architecture in patients with suspected or known abnormal anatomy from either deep neck infections, such as retropharyngeal abscess and tumours. Preoperative endoscopic airway examination may improve theatre efficiency and patient experience by reducing the number of unnecessary awake fibreoptic intubations. Lesions of the tongue base, epiglottis, or larynx may not be fully appreciated following a routine preoperative airway assessment as clinical signs and symptoms may be unreliable indicators of the significance of these lesions 91 . Rosenblatt and colleagues found the additional information afforded by flexible endoscopy altered clinical practice. Anaesthetists reassured by relatively normal findings on endoscopic examination in patients with suspected airway difficulty where an awake intubation had initially been planned, resulted in a safe, standard induction. Also, where the additional information suggested difficulty, a standard induction was abandoned in favour of an awake technique 92 . Diagnostic endoscopy can be easily and rapidly performed with minimal fuss and preparation 93 . The nares are not always symmetrical and selection of the more patent nostril may reduce trauma. Topical anaesthesia together with a vasoconstrictor may improve patient compliance and minimises the risk of bleeding secondary to instrumentation 94 . The glottis should be inspected from above without local anaesthetic being applied directly, as this may result in laryngospasm. Nasopharyngoscopy is a relatively safe procedure with few contraindications and complications in experienced hands. Extreme caution should be used in epiglottitis and then by experienced personnel only, as it may result in laryngospasm and subsequent airway compromise 95 . Significant bleeding may occur in patients with a coagulopathy even from minor trauma. In the setting of craniofacial trauma, the benefits should be carefully weighed against the risks of inadvertent intracranial instrumentation and exacerbation of nasopharyngeal injuries. Mucosal trauma may result in epistaxis (a smaller diameter scope may help mitigate this problem. Tearing, coughing and, less frequently, a residual foreign body sensation, transient laryngospasm and vasovagal syncope are also potential complications. Laryngospasm is rare, incidence approximately 1 per cent, and is usually self-limited but can lead to desaturation and airway obstruction 96 . REFERENCES 1. Cobley M, and Vaughan RS. Recognition and management of difficult airway problems. British Journal of Anaesthesia, 1992. 68(1): pp. 90-7. 2. PS07 Recommendations for the Pre-Anaesthesia Consultation. Australian and New Zealand College of Anaesthetists 2008. ABN 82 055 042 852. 3. Raising the Standard: a compendium of audit recipes (3rd edition 2012). Dr B McGuire. Section 1.6 Preoperative care: Preoperative airway assessment. Royal College of Anaesthetists. Available from: www.rcoa.ac.uk/ARB2012. 4. Shiga T, et al. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology, 2005. 103(2): pp. 429-37. 5. Core Topics in Airway Management 2nd edition ed. Ian Calder and Adrian Pearce. Chapter 7 Difficult airways: causation and identification. Published by Cambridge University Press, 2011. 6. Yentis SM. Predicting difficult intubation - worthwhile exercise or pointless ritual? Anaesthesia, 2002. 57(2): pp. 105-9. 7. El-Orbany M, and Woehlck HJ. Difficult mask ventilation. Anesth Analg, 2009. 109(6): pp. p1870-80. 30 Airway Assessment
8. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology, 1993. 78(3): pp. 597-602. 9. Han R, et al. Grading scale for mask ventilation. Anesthesiology, 2004. 101(1): pp. 267. 10. Langeron O, et al. Prediction of difficult mask ventilation. Anesthesiology, 2000. 92(5): pp. 1229-36. 11. Kheterpal S, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology, 2006. 105(5): pp. 885-91. 12. Asai T, Koga, K, and Vaughan, RS. Respiratory complications associated with tracheal intubation and extubation. British Journal of Anaesthesia, 1998. 80: pp. 767-675. 13. Rose DK, and Cohen, MM. The airway: problems and predictions in 18,500 patients. Canadian Journal of Anaesthesia, 1994. 41(5 Pt 1): pp. 372-83. 14. Redfern D, et al. Comparison of face masks in the bag-mask ventilation of a manikin. Eur J Anaesthesiol, 2006. 23(2): pp. 169-72. 15. Greenberg RS. Facemask, nasal and oral airway devices. Anesthesiol Clin North America, 2002. 20(4): pp. 833-61. 16. Yildiz TS, Solak M, and Toker K. The incidence and risk factors of difficult mask ventilation. J Anesth, 2005. 19(1): pp. 7-11. 17. Ho AM, et al. Airway difficulties caused by improperly applied cricoid pressure. J Emerg Med, 2001. 20(1): pp. 29-31. 18. Kheterpal S, et al. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology, 2009. 110(4): pp. 891-7. 19. Goodwin MW, et al. The effect of neuromuscular blockade on the efficiency of mask ventilation of the lungs. Anaesthesia, 2003. 58(1): pp. 60-3. 20. Calder I, and Yentis SM. Could “safe practice” be compromising safe practice? Should anaesthetists have to demonstrate that face mask ventilation is possible before giving a neuromuscular blocker? Anaesthesia, 2008. 63(2): pp. 113-5. 21. Verghese C, and Brimacombe JR. Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional and nonconventional usage. Anesth Analg, 1996. 82(1): pp. 129-33. 22. Airway management in the anesthetised adult, except for difficult intubation. Annales Francaises d’Anesthesie et de Reanimation, 2003. 22 Suppl 1: pp. 3s-17s. 23. Ramachandran SK, et al. Predictors and clinical outcomes from failed laryngeal mask airway unique: a study of 15,795 patients. Anesthesiology, 2012. 116(6): pp. 1217-26. 24. Rose DK, and Cohen MM. The incidence of airway problems depends on the definition used. Canadian Journal of Anaesthesia, 1996. 43(1): pp. 30-4. 25. Khan ZH, Kashfi A, and Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg, 2003. 96(2): pp. 595-9, table of contents. 26. Wilson ME, et al. Predicting difficult intubation. British Journal of Anaesthesia, 1988. 61: pp. 211-6. 31 Airway Assessment
Page 1 and 2: Airway Assessment Authors: Dr Pierr
Page 3 and 4: Part 1. Introduction This airway as
Page 5 and 6: REFERENCES 1. Yentis SM. Predicting
Page 7 and 8: SUMMARY Preoperative airway assessm
Page 9 and 10: Table 3. Difficult airway screening
Page 11 and 12: PREDICTORS OF DIFFICULT BAG-MASK VE
Page 13 and 14: INCIDENCE OF IMPOSSIBLE MASK VENTIL
Page 15 and 16: DIFFICULT ENDOTRACHEAL INTUBATION D
Page 17 and 18: Figure 1. A 100 per cent POGO score
Page 19 and 20: When the patient has risk factors,
Page 21 and 22: TONGUE ABNORMALITIES Direct laryngo
Page 23 and 24: Class A B C Position of the lower t
Page 25 and 26: Table 18. Wilson risk sum score. Wi
Page 27 and 28: Table 20. Arne risk index. Risk fac
Page 29: fibreoptic intubation has a finite
Page 33 and 34: 46. Samsoon GL, and Young JR. Diffi
Page 35 and 36: 86. Komatsu R, et al. Ultrasound qu
Page 37 and 38: RE-EXAMINING THE FOUNDATIONS OF AIR
Page 39 and 40: Figure 3. Stylised orientatation of
Page 41 and 42: Figure 5. Retrognathic patient (lef
Page 43 and 44: POSTERIOR COLUMN The original descr
Page 45 and 46: It is postulated that any reduction
Page 47 and 48: 7. Chou HC, Wu TL. A reconsideratio
Page 49 and 50: CHANGING THE PARADIGM: THE NEXT STE
Page 51 and 52: Compression of submandibular struct
Page 53 and 54: Figure 5. Passage of a bevel-tipped
Page 55 and 56: Figure 7. Predicted alteration in p
Page 57 and 58: Figure 9. Accentuation of primary a
Page 59 and 60: LARYNGEAL MASK-FACILITATED INTUBATI
Page 61 and 62: 17. Sanuki T, Sugioka S, Hirokane M
Page 63: 54. Law-Koune JD, Liu N, Szekely B,

Airway Assessment

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