Airway management

Question 1

What components of the physical examination are important in airway evaluation during the preoperative assessment?

Answer 1

➜ Inspection of the patient’s physical appearance noting:
- Morbid obesity,
- Frailty,
- Mental status.

➜ Inspection of the face and neck for anything suggestive of a difficult airway:
- Short neck,
- Inability to fully flex and/or extend the neck,
- Large neck circumference (>42 cm),
- Evidence of prior operations (especially tracheostomy),
- Abnormal neck masses (including but not limited to tumor, goiter, hematoma, abscess, or edema).

➜ Mouth:
- Small mouth opening (interincisor distance <3 cm);
- Large tongue;
- Micrognathia;
- Short thyromental distance (<3 finger breadths);
- Mallampati score of III or IV;
- Inability to bite the upper lip.

➜ Dentition:
- Document teeth that are chipped, missing, or loose;
- Elective case and high risk for tooth dislodgement: see a dentist for extraction before the case;
- Loose or removable dental appliances: removed before anesthesia (can impede airway management or pose an aspiration risk);
- Edentulous: direct laryngoscopy and intubation may be easier, but mask ventilation may prove more challenging.

Question 1

What components of the patient history are important in airway evaluation during the preoperative assessment?

Answer 1

◉ Ask the patient about prior anesthetics
- May provide important information that could alert the practitioner to have additional personnel or airway management equipment immediately available.

◉ Previous anesthetic records (if available)
➜ Can provide information about airway management problems in the past including:
- Mask ventilation;
- Intubation;
- Special airway techniques or equipment required for successful airway management.

◉ Inquire about previous medical interventions or trauma that may have implications on airway management
- Cervical spine injury or surgery;
- History of tracheostomy;
- Head and neck surgery;
- Head and neck radiation treatment;
- Congenital craniofacial abnormalities;
- Predisposition to atlantoaxial instability (e.g., rheumatoid arthritis, achondroplasia, Down syndrome).