Airway Assessment

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It is essential to understand that abnormalities of the anterior and/or posterior columns may have effects on the middle column. Accentuated airway curvatures from posterior column abnormalities may reduce airway patency by encroachment of the curves towards the posterior pharyngeal wall. Anterior column abnormalities displacing the primary curve posteriorly can further limit the diameter of the airway conduit. Pathology involving the middle column is typically the most concerning due to our infrequent exposure to these problems, the difficulty in assessment and the dynamic airway changes that occur with anaesthesia. THE NEXT STEP: APPLICATION OF THE “TWO CURVES AND THREE COLUMNS” An anatomical airway model for direct laryngoscopy must be logical and clinically applicable. Its usefulness is limited unless every airway can be appropriately assessed with reference to the model. This is one of the strengths of the two-curve theory. Airway assessment and management are inseparable processes. First we must define the problem. The next step is determining the solution. The application of this model allows the operator to rationally appraise problems likely to be encountered during direct laryngoscopy. Careful consideration is necessary to determine the optimal method of safely securing an airway given a single or multiple simultaneous pathologies. Appropriate airway equipment and manoeuvres employed to combat anterior, middle and posterior column abnormalities will be comprehensively discussed in Part 4. ACKNOWLEDGEMENTS The authors thank Dr Phil Allen and Professor David A Scott for their assistance with the preparation of this article. ONLINE RESOURCES Revising our approach to airway assessment (Greenland, K. 25 minutes): www.youtube.com/watch?v=y4-F-usCCFk Reinventing our approach to direct laryngoscopy (Greenland, K. 25 minutes): www.youtube.com/watch?v=el2-3bdAuug REFERENCES 1. Banister F, Macbeth R. Direct laryngoscopy and tracheal intubation. Lancet 1944; 244: pp. 651-654, 2. Magill IW. Endotracheal anaesthesia. American Journal of Surgery 1936; 34: pp. 450-455. 3. Adnet F, Borron SW, Lapostolle F, Lapandry C. The three-axis alignment theory and the “sniffing position”: perpetuation of an anatomic myth? Anesthesiology 1999; 91: pp. 1964–1665. 4. Adnet F, Borron SW, Dumas JL, Lapostolle F, Cupa M, Lapandry C. Study of the “sniffing position” by magnetic resonance imaging. Anesthesiology 2001; 94: pp. 83-6. 5. Adnet F, Baillard C, Borron SW, Denantes C, Lefebvre L, Galinski M, et al. Randomised study comparing the “sniffing position” with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology 2001; 95: pp. 836-41. 6. Adnet F. A reconsideration of three axes alignment theory and sniffing position. Anesthesiology 2002; 97: pp. 754. 46 Airway Assessment
7. Chou HC, Wu TL. A reconsideration of three axes alignment theory and sniffing position. Anesthesiology 2002; 97: pp. 753-754. 8. El-Orbany M, Woehlck H, Salem MR. Head and neck position for direct laryngoscopy. Anesthesia and Analgesia 2011; 113(1): pp. 103-9. 9. Greenland KB. The sniffing and extension-extension position: the need to develop the clinical relevance. Anaesthesia 2008; 63: pp. 1013-1014. 10. Greenland KB, Edwards MJ, Hutton NJ, Challis VJ, Irwin MG, Sleigh JW. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications. British Journal of Anaesthesia 2010; 105(5): pp. 683-90. 11. Marks RRD, Hancock R, Charters P. An analysis of laryngoscope blade shape and design: new criteria for laryngoscopic evaluation. Canadian Journal of Anaesthesia 1993; 40: pp. 262-70. 12. Greenland KB. A proposed model for direct laryngoscopy and tracheal intubation. Anaesthesia 2008; 63: pp. 156-161. 13. Greenland KB. Airway assessment based on a three-column model of direct laryngoscopy. Anaesthesia and Intensive Care 2010; 38: pp. 14-19. 14. Arné J, Descoins P, Fusciardi J, Ingrand P, Ferrier B, Boudigues D, Ariés J. Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical and multivariate risk index. British Journal of Anaesthesia 1998; 80: pp. 140-146. 15. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology 2005; 103: pp. 429-37. 16. Horton WA, Fahy L, Charters P. Defining a standard intubating position using “angle finder”. British Journal of Anaesthesia 1989; 62: pp. 6-12. 17. Greenland KB, Edwards MJ, Hutton NJ. External auditory meatus-sternal notch relationship in adults in the sniffing position: a magnetic resonance imaging study. British Journal of Anaesthesia 2010; 104(2): pp. 268-269. 18. Benumof JL. Comparison of intubating positions: the end point for position should be measured. Anesthesiology 2002; 97: p. 750. 19. Collins J, Lemmens H, Brodsky J, Brock-Utne J, Levitan R. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obesity Surgery 2004; 14: pp. 1171-1175. 20. Khan ZH, Kashfi A, 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. Anesthesia and Analgesia 2003; 96: pp. 595-599. 21. Myneni N, O’Leary AM, Sandison M, Roberts K. Evaluation of the upper lip bite test in predicting difficult laryngoscopy. Journal of Clinical Anaesthesia 2010; 22(3): pp. 174-8. 22. Sharwood-Smith GH. Difficulty in intubation. Calcified stylo-hyoid ligament. Anaesthesia 1976; 31: pp. 508-510. 23. Walls RD, Timmis DP, Finucane BT. Difficult intubation associated with calcified stylohyoid ligament. Anaesthesia and Intensive Care 1990; 18: pp. 110-112. 47 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 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: It is postulated that any reduction
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,

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