Gorovitz & Borten, P.C.
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Framingham, Massachusetts
Tel: (781) 890-9095
Difficult Intubation
Endotracheal intubation is one of the earliest skills that anesthesiologists learn
during their training period.  Difficult intubation occurs relatively commonly in
association with general anesthesia.

A difficult intubation can be anticipated in a number of circumstances including a
previous history of difficulty with intubation, syndromes known to be associated
with difficulty to intubate, and some patho-anatomical states involving the head
and neck region (known as short neck, characterized by a limited range of motion).

The intent of the airway history is to detect medical, surgical, and anesthetic
factors that may indicate the presence of a difficult airway. Examination of
previous anesthetic records, if available in a timely manner, may yield useful
information about airway management.

An airway physical examination should be conducted, whenever feasible, before
the initiation of anesthetic care and airway management in all patients. The intent
of this examination is to detect physical characteristics (risk factors) that may
indicate the presence of a difficult airway, thereby placing the patient at a greater
chance of a dangerous outcome.

The risk factors identified are as follows:  weight; head and neck movement; jaw
movement (mandibular protrusion, inter-incisor gap); prominent maxillary teeth
(‘‘buck teeth’’); receding mandible (lower jaw) Mallampati and colleagues
described clinical signs to predict difficult intubation in 1983: The patient sits
upright, head in the neutral position. The mouth is opened as widely as possible
and the tongue is maximally protruded, without phonating. The observer sits
opposite at eye level and inspects the pharyngeal structures. The airway is
classified according to the structures seen. Mallampati et al described three
grades, but the commonly used assessment consists of four grades as modified
by Samsoon and Young. The four grades are as follows:

•        (I) soft palate, fauces, uvula, pillars;
•        (II) soft palate, fauces, uvula;
•        (III) soft palate, base of uvula;
•        (IV) soft palate not visible at all.
It should be noted that a class I view nearly always predicts easy intubation and a
class IV view a difficult intubation. Intermediate classes (II and III) are associated
with a wide range of degrees of difficulty with intubation.


The most common remediable cause of unpredicted difficulty with intubation
occurs in the setting of inadequate preoperative assessment.

In February of 2013, the American Society of Anesthesiologists  published
updated Practice Guidelines for Management of the Difficult Airway summarized
by a Task Force on Management of the Difficult Airway. The Task Force on the
management of the difficult airway recommended that all anesthesiologists should
have a preformed strategy for intubation of the difficult airway. A preplanned pre-
induction strategy includes the consideration of various interventions designed to
facilitate intubation should a difficult airway occur.

Awake intubation when difficult intubation is suspected is the method of choice to
prevent complications. When endotracheal intubation is planned in an awake
state under topical anaesthesia, a combination of premedicant drugs is used to
allay anxiety, provide a clear and dry airway, and prevent aspiration of gastric

If you believe that you or your loved one have been injured as a result of an
anesthesiologist’s error that was diagnosable, avoidable and/or preventable, you
may have a valid cause of action. The injury may be the result of a medical
provider's mistake in handling your anesthesia needs and the result of medical
negligence. Dr. Borten is an experienced trial attorney and also has over 35 years
of experience as a physician/surgeon to fully evaluate the merits of your potential
case. Allow the medical malpractice attorneys at Gorovitz & Borten help you
assert your rights and get the compensation you deserve.
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