Airway Assessment

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Part 3. The anatomical basis for airway assessment and management Dr Ben Crooke BSc, MBBS, FANZCA, PG Cert Clinical Ultrasound • Consultant anaesthetist, Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Qld. Dr Keith B Greenland MB BS, MD, FANZCA, FHKAM • Consultant anaesthetist, Wesley Anaesthesia and Pain Management, Qld. • Honorary associate professor, Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR. • Senior staff anaesthetist, Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Qld. 36 Airway Assessment
RE-EXAMINING THE FOUNDATIONS OF AIRWAY ASSESSMENT AND MANAGEMENT In airway assessment, the discovery of abnormal signs and symptoms often leads to the presumption of the “difficult airway”. The determination of an abnormality during the assessment phase is only the first step towards a working diagnosis. Unless we understand the fundamentals of airway anatomy, laryngoscopy and intubation, evaluation of an airway is fruitless. With the advent of supraglottic airway devices, more intuitive video laryngoscopes and other developments in airway equipment, airway management is becoming easier. This trend could lead to the incorrect assumption that airway assessment is less important. This is far from the truth. There is a disconnect between assessment and its application. There is a divergence in teaching between pattern recognition and conceptual understanding. This article presents an anatomical foundation for successful direct laryngoscopy and tracheal intubation and a model for structured airway assessment. I) THE TWO-CURVE THEORY In 1944, Banister and Macbeth explored the anatomical basis of direct laryngoscopy via the description of the “three-axis alignment theory” 1 . The three-axis theory was a refinement of Magill’s formal description of the “sniffing position” as the preferred intubating position 2 . Although contentious, the theory has been a mainstay of airway teaching 3-8 . A novel anatomical airway concept was first proposed in 2008 9 . A Bézier spline, consisting of primary (oro-pharyngeal) and secondary (pharyngo-glotto-tracheal) curves, serves as the foundation of the anatomical model (Figure 1) 10 . The inflection point of these curves occurs in the laryngeal vestibule – the space from the epiglottis to the glottis 10 . Successful direct laryngoscopy requires alignment of the primary curve and laryngeal vestibule with the line of sight 10,11 . Intubation of the trachea is facilitated by alignment of the secondary curve and laryngeal vestibule 10 . Figure 1. The airway passage is divided into two curves (primary and secondary). The meeting point of these curves occurs in the laryngeal vestibule 10 . 37 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 and 30: fibreoptic intubation has a finite
Page 31 and 32: 8. Practice guidelines for manageme
Page 33 and 34: 46. Samsoon GL, and Young JR. Diffi
Page 35: 86. Komatsu R, et al. Ultrasound qu
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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