1. Topics in Airway Management: Intelligent Airway Evaluation Donald M. Voltz, MD Assistant Professor of Anesthesiology Case Western Reserve University / University Hospitals of Cleveland 3 November 2004

3. What we focus on and our mental models determine what we see.

5. What is Intelligence?

6. Intelligence = Behavior

7. Turing Test

8. Intelligence = Prediction

9. Is There Such a Thing as an Unexpected Difficult Intubation?

10. What is the Problem?

11. “More than 85% of respiratory- related closed claims involve a brain-damaged or dead patient.” Jonathan Benumof, MD

13. Incidence of Difficult Intubation Successful with multiple attempts Successful, many attempts, many people Unsuccessful Can not ventilate or intubate 100-1800/10,000 (1-18%) 100-400/10,000 (1-4%) 5-35/10,000 (0.05-.35%) 0.01-2/10,000 (0.0001-0.02%)

15. What do we want to Predict?

16. Cormack-Lehane Classifications

24. Airway Prediction Models

25. Mallenpatti Classification Neck Range of Motion Thyromental/Thyrosternal Distance Upper Lip Bite Test Multivariate Analysis

26. Mallinpatti Classification

28. Upper Lip Bite Test

29. Table 1. Relationship Between the Results of Two Predicting Tests and Laryngoscopy Grades in 300 Patients I and IIIII and IV Predicting test Modified Mallampati Classes I and II1893 Classes III and IV9414 Upper lip bite Classes I and II2514 Class III3213 Laryngoscopic view

31. Airway Evaluation Mouth (4) Oral Cavity (3) Neck (4)

32. Airway Evaluation - Mouth Length of Upper Incisors Relationship of Maxillary Incisors to Mandibular Incisors Ability to Prognath the Mandible Interincisor Distance

33. Airway Evaluation – Oral Cavity Visibility of the Uvula Shape of the Palate Compliance of the Mandibular Space

34. Airway Evaluation - Neck Thyromental/Thyrosternal Distance Length of the Neck Thickness of the Neck Range of Motion of the Head and Neck

36. Approaching the Difficult Airway Algorithm William H. Rosenblatt, M.D. Yale University School of Medicine

37. Is Airway Management Required?

38. Do you predict difficult direct laryngoscopy?

40. Will superlarngeal ventilation be possible?

41. Predictors of Difficult Mask Ventilation Age greater than 55 years Body mass index greater than 26 kg/m 2 History of snoring Edentulous Presence of facial hair

42. Is the patient at an increased risk of aspiration?

43. Will the patient tolerate a judgment error?

45. Problems with Prediction Methods

46. Future of Airway Prediction

47. References Rosenblatt, W.H. Decision making in airway evaluation. ASA Refresher Course in Anesthesiology, V. 32, 2004. Benumof, J.L. Airway Management, pp. 121- 158, 1996. ASA Task Force on Airway Management. Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway, Anesthesiology, 98(5), 1269-1277.