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Intubation and Anatomy of the Airway

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Compression to the cricoid cartilage can be applied in rapid sequence induction in order to compress the esophagus to prevent aspiration in cases of regurgitation but be wary in cases of vomiting as it may cause perforation of the esophagus

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For supporting ventilation in patien t with some pathologic disease

: Upper airway obstruction

: Respiratory failure

: Loss of conciousness or a Glasgow coma scale of less then 8

For supporting ventilation durin g general anesthesia

Type of surgery

: Operative site near the airway

: Abdominal or thoracic surgery

: Prone or lateral position

: Long period of surgery

: Patient has risk of pulmonary aspiration

: Difficult mask ventilation

--- : Congenital anomalies > Pierre Robin syndrome , Down’s syndrom

e -- : Infection in airway > Retrophary

ngeal abscess, Epiglottitis : Tumor in oral cavity or larynx

Conditions that are associated with difficult intubation

Enlarge thyroid gland

trachea shift to la teral or compress

ed tracheal lumen

Condition that associated with difficult intubation (con’t)

: Maxillofacial ,cervical or laryngeal trauma : Temperomandibular joint dysfunction : Burn scar at face and neck

: Morbidly obese or pregnancy

Condition that associated with difficult intubation (con’t)

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is to identify any possible problems with

maintaining, protecting, and providing a patent

airway during anesthesia.

The evaluation is performed with the aid of a

physical examination and a review of the

patients history and previous anesthetic

records.

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1-2-3’ test is used to asses several factors that may affect decisions concerning the patient’s airway management.

‘1-2-3’ TEST COMPONENTS:

TMJ MOBILITY MOUTH OPENING

THYROMENTAL DISTANCE

1-2-3’ TEST

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FIRST COMPONENT :ISTEMPOROMANDIBULAR JOINT

(TMJ) MOBILITYIt`s used to identify and restricted

mobility of the temporomandibular joint (TMJ). Ask the patient to sit up with his head in the neutral position and open his mouth as wide as possible.The condyle should rotate forward freely such that the space created between the tragus of the ear and the mandibular condyle is approximately one fingerbreadth in width.

1-2-3’ TEST

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SECOND COMPONENT :ISMouth Opening and tongue protrusion:

Incisor gap : normal -> more than 3 cms or the patient's mouth should allow at least 2 fingers between the teeth, on the other hand, It will be difficult to insert the laryngoscope blade on less than 2 fingers

1-2-3’ TEST

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SECOND COMPONENT :ISMouth Opening and tongue protrusion:

With the patient's tongue maximally protruded, the structures visualized should include:

•The pharyngeal arches.• Uvula.• Soft palate.• Hard palate.• Tonsillar beds.• Posterior pharyngeal wall.

Technical difficulties with intubation should be anticipated when only the tongue and soft palate are visualized in a patient during this above maneuver.

1-2-3’ TEST

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SECOND COMPONENT :ISMouth Opening and tongue protrusion:

Mallampati ClassificationActually, the amount of the posterior pharynx

you can visualize is important and correlates with the difficulty of intubation. 

Visualization of the pharynx is obscured by a large tongue (relative to the size of the mouth), which also interferes with visualization of the larynx on laryngoscopy.

1-2-3’ TEST

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SECOND COMPONENT : MOUTH OPENING AND TONGUE PROTRUSION

Mallampati classification is used to predict the ease of intubation

It is determined by looking at the anatomy of the oral cavity; specifically, it is based on the visibility of the base of uvula, faucial pillars(the arches in front of and behind the tonsils) and soft palate. Some suggest that phonation is best to be used to better asses the mallampati score

Modified Mallampati Scoring is as follows:Class 1: Full visibility of tonsils, uvula and soft palateClass 2: Visibility of hard and soft palate, upper portion of tonsils and uvulaClass 3: Soft and hard palate and base of the uvula are visibleClass 4: Only Hard Palate visible

1-2-3’ TEST

Uvula

Class 3,4 -> may be difficult intubation

- grade 3,4 > risk for difficult intubation

Laryngoscopic view

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THIRD COMPONENT :ISTHE THYROMENTAL

DISTANCE :

It is measured from the lower border of the chin.

Adults who have less than 3 fingerbreadths between their mentum and thyroid notch may have either an anterior larynx or a small mandible, which will make intubation difficult.

1-2-3’ TEST

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THIRD COMPONENT :ISTHE THYROMENTAL

DISTANCE :Next, evaluate the mobility of the cervical spine.

This is performed by asking the patient to flex and extend their neck. They should be able to perform this without discomfort. Disease of the C-spine (RA, OA, previous injury or surgical fusion) may limit neck extension, which may create difficulties during attempts to intubate. This is certainly true if the atlanto-occipital joint is involved, as restriction of this joints mobility may impair one's ability to visualize the larynx.

1-2-3’ TEST