CLINICAL CASE

76-YEAR-OLD MAN PRESENTS FOR ENDOSCOPIC VOCAL CORD

INJECTIONS. HE UNDERWENT GENERAL ANESTHESIA MANY
YEARS
AGO WITHOUT ANY KNOWN PROBLEMS. THE OLD RECORDS ARE
UNAVAILABLE. HE HAS LIMITED TRANSLATION OF THE
TEMPOROMANDIBULAR JOINT. OTHERWISE, HIS AIRWAY
EXAMINATION IS WITHIN NORMAL LIMITS.

By Virginia Fernandez Paulino.

1. WHAT ARE THE

PREDICTORS OF
DIFFICULT MASK
VENTILATION?

Difficult facemask ventilation occurs when a practitioner

cannot provide sufficient gas exchange because of
inadequate mask seal, large volume leaks, or excessive
resistance to the ingress or egress of gas
One of the most important predictors of a difficult airway is
a history of a difficult airway.

Risk factors for difficult mask ventilation include a full

beard, a massive jaw, edentulousness, skin sensitivity
(burns, epidermolysis bullosa, fresh skin grafts), facial
dressings, obesity, age .55 years, and a history of snoring.
Other criteria that suggest the possibility of difficult
facemask ventilation include a large tongue,heavy jaw
muscles, a history of obstructive sleep apnea, poor atlantooccipital extension, some types of pharyngealpathology,
facial burns, and facial deformities.

Criteria for Dificult mask

Ventilation

Inability for one anesthesia professional to

maintain oxygen saturation >92%

Independent risk factors for

Dificult mask Ventilation odds
ratio

Significant gas leak around face mask

Need for 4 L/min gas low (or use of fresh gas

low button more than twice)

Change of operator required

Presence of a beard 3.18

Body mass index >26 ng/m2 2.75

No chest movement

Two-handed mask ventilation needed

Lack of teeth 2.28

Age >55 yrs 2.26

History of snoring 1.84

2. DISCUSS THE RISK

FACTORS FOR DIFFICULT
INTUBATION.

SNIFFING POSITION
Inability to assume the sniffing position is a
predictor of difficult intubation. Examples of
problems that prevent the sniffing position includes:
cervical vertebral arthritis,
cervical ankylosing spondylitis
unstable cervical
Fractures
protruding cervical disks
atlantoaxial subluxation,
cervical fusions, cervical collars, and halo frames.
Morbidly obese patients sometimes have posterior
neck fat pads that prevent atlanto-occipital
extension.

MOUTH OPENING
The adequacy of mouth opening is assessed by
measuring the interincisor distance. An
interincisor distance of 3 cm provides sufficient
space for intubation. This corresponds
approximately to the width of two fingerbreadths.
Factors that interfere with mouth opening
include:
Masseter muscle spasm
TMJ dysfunction
and various integumentary ailments, such as
burn scar contractures and progressive systemic
sclerosis

TONGUE

DENTITION
Poor dentition is at risk
for damage as the
mouth is opened and as
the laryngoscope blade
is introduced.
Prominent maxillary
incisors complicate
laryngoscopy in another
way. They protrude into
the mouth and block
the line of sight to the
larynx.

Usually, a normal-size tongue fits easily into

a normal-size mandibular space, whereas a
large tongue would fit poorly.

After filling the space, a large tongue still

occupies some of the oropharyngeal airway
causing obstruction.

MALLAMPATI SCORE
Mallampati proposed a classification system
(Mallampati score) to correlate the oropharyngeal
space with the predicted ease of direct laryngoscopy
and tracheal intubation.
With the observer at eye level, the patient holds the
head in a neutral position, opens
the mouth maximally, and protrudes the tongue
without phonating.
Class I: The soft palate, fauces, uvula, and tonsillar
pillars are visible.
Class II: The soft palate, fauces, and uvula are
visible.
Class III: The soft palate and base of the uvula are
visible.
Class IV: The soft palate is not visible.

CORMACK AND LEHANE

SCORE
The Cormack and Lehane score classifies
laryngoscopic view
Grade I: Most of the glottis is visible.
Grade II: Only the posterior portion of the glottis
is visible.
Grade III: The epiglottis, but no part of the
glottis, can be seen.
Grade IV: No airway structures are visualized.

PREDICTORS OF DIFFICULT INTUBATION

3. ARE THE RISK FACTORS FOR

DIFFICULT INTUBATION
RELIABLE
PREDICTORS OF DIFFICULT
INTUBATION?

No single factor reliably predicts

difficult intubation. The likelihood of a
difficult intubation increases when
multiple predictors are present in a
patient at the same time.

4. HOW IS AN ANTICIPATED
DIFFICULT INTUBATION
APPROACHED?

Anticipated difficult intubations with proven or

suspected difficult mask ventilation are best
approached with the patient awake and
spontaneously breathing.
In the absence of local nasal pathology, flexible
fiberoptic nasotracheal intubation is generally less
difficult than the oral route.
Blind techniques, retraction blades, and
fiberscopes are commonly employed. Friable
tumors, abscesses, and impending obstructive
airway tumors often require awake tracheostomy.

5.DESCRIBE THE MANAGEMENT OPTIONS

FOR A PATIENT
WHO, AFTER INDUCTION OF ANESTHESIA,
UNEXPECTEDLY
CANNOT BE INTUBATED WITH A MACINTOSH
BLADE; THE
PATIENT HAS A GOOD MASK AIRWAY.

Difficulty with the Macintosh blade often arises when

its tip fails to elevate the hyoid bone, which indirectly
raises the epiglottis. Often, a straight blade elevates a
floppy epiglottis when curved blades fail todo so.
Difficulty with the straight blade frequently comes from
impacting on teeth.
Various stylets may be used. The hollow stylet,
gummed elastic bougie, or similar devices should be
available in all anesthetizing locations.
If a flexible fiberoptic laryngoscopy is not planned,
blind spontaneously breathing nasotracheal intubation
is an alternative offering a good chance of success.

OPTIONS FOR FAILED TRADITIONAL

TRACHEAL INTUBATION UNDER GENERAL
ANESTHESIA

Click icon to add picture

After
exhausting
ones personal
repertoire of
techniques,
simply
repeating
methods that
have already
failed

seems to have
little chance of
success.

6. AFTER INDUCTION OF
ANESTHESIA, VENTILATION BY
FACEMASK AND INTUBATION
ARE IMPOSSIBLE; WHAT
MANEUVERS MAY HELP?

Several treatment options exist. Of the oral

techniques, worldwide experience is greatest with
laryngeal masks of various designs.
Laryngeal masks are available in adult and
pediatric sizes. The mask works well in 90%98%
of cases. This 2%10% failure rate is far greater
than the incidence of inability to ventilate and
intubate. Nevertheless, the LM has been
successfully used for airway management in
elective surgery as well as in cases of predicted
and unanticipated difficult intubation.

Of the more invasive techniques, cricothyroid

puncture and transtracheal ventilation are well
described.
Transtracheal jet ventilation is the administration
of oxygen under high pressure through a needle
placed in the cricothyroid membrane into the
trachea.
Cricothyrotomy is almost always performed under
emergent circumstances. This technique involves
the placement of breathing tube through the
cricothyroid membrane.

7. HOW IS SUCCESSFUL
TRACHEAL INTUBATION
VERIFIED?

The most reliable method of confirming successful

tracheal intubation is by direct laryngoscopy with a
traditional rigid laryngoscope and visualizing the
tracheal tube between the vocal cords.
Two other methods of confirmation, expired carbon
dioxide detection and esophageal indicator bulb
inflation, are slightly less reliable.
Careful auscultation for the presence of bilateral breath
sounds and the absence of gastric gurgling while
ventilating through the TT and chest radiography, are
less reliable methods.
Even though it is confirmed that the tube is in the
trachea, it may not be correctly positioned.

8. AFTER A DIFFICULT
INTUBATION, HOW IS
POSTOPERATIVE
EXTUBATION MANAGED?

Repeated instrumentation during intubation and

surgical manipulation independently and additively
contribute to tongue base and laryngeal swelling.
Airway edema may culminate in respiratory
obstruction after extubation.
Patients at risk for edema are best managed with
prolonged tracheal intubation or tracheostomy. After
edema has resolved, a trial of extubation or
decannulation can be considered.
Before extubating a potentially edematous airway,
theETT cuff is deflated, and gas escaping around the
tube is sought. The presence of escaping gas is
encouraging but hardly pathognomonic of airway
patency. Patients at substantial risk for reintubation
can be extubated over a stylet.

REFERENCES
Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th
ed. St. Louis,MO: Elsevier Saunders Company;
2014: 431-433
Butterworth JF, Mackey DC, Wasnick JD.
Morgan & Mikhail's Clinical Anesthesiology. 5th
ed. New York, NY: McGraw-Hill; 2013: 330
Longnecker DE, Newman MF, Brown DL, Zapol
WM. Anesthesiology. 2nd ed. New York: McGrawHill; 2012: 560.