A Comprehensive and Analytical Review of the Airway Pathology, Assessment, and Management
,
Abstract
The human airway has since long remained a subject of debate and controversies; thus, to arrive at a subtle and acceptable solution, airway assessment tests, innovative techniques, and devices have been introduced to solve the enigma. Although human endeavors have made significant advances since time immemorial, the difficult airway still poses a major challenge even in the best of hands and the best centers.
[1] Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology. 1990; 72(5):828-33.
[2] Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011; 106(5):617-31.
[3] Pahor AL. Ear, nose and throat in Ancient Egypt. J Laryngol Otol. 1992; 106(9):773-9.
[4] Stock CR. What is past is prologue: a short history of the development of tracheostomy. Ear Nose Throat J. 1987; 66(4):166-9.
[5] Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med. 2008; 34(2):222-8.
[6] Ferlito A, Rinaldo A, Shaha AR, Bradley PJ. Percutaneous tracheotomy. Acta Otolaryngol. 2003; 123(9):1008-12.
[7] Golzari SEJ, Khan ZH, Ghabili K, Hosseinzadeh H, Soleimanpour H, Azarfarin R, et al. Contributions of Medieval Islamic physicians to the history of tracheostomy. Anesth Analg. 2013; 116(5):1123-32.
[8] Ezri T, Evron S, Hadad H, Roth Y. [Tracheostomy and endotracheal intubation: a short history]. Harefuah. 2005; 144(12):891-3, 908.
[9] Macewen W. General Observations on the Introduction of Tracheal Tubes by the Mouth, Instead of Performing Tracheotomy or Laryngotomy. Br Med J. 1880; 2(1021):122-4.
[10] Westhorpe R. O'Dwyer's tubes. Anaesth Intensive Care. 1991; 19(2):157.
[11] Thierbach A. Franz Kuhn, his contribution to anaesthesia and emergency medicine. Resuscitation. 2001; 48(3):193-7.
[12] Alberti PW. The history of laryngology: a centennial celebration. Otolaryngol Head Neck Surg. 1996; 114(3):345-54.
[13] Miller RA. A new laryngoscope. Anesthesiology. 1941; 2(3):317-20.
[14] Macintosh RR. A new laryngoscope. Lancet. 1943; 241(6233):205.
[15] Bannister F, Macbeth R. Direct laryngoscopy and tracheal intubation. Lancet. 1944; 244(6325):651-4.
[16] Adnet F, Borron SW, Lapostolle F, Lapandry C. The three axis alignment theory and the “sniffing position”: perpetuation of an anatomic myth?. Anesthesiology. 1999; 91(6):1964.
[17] Khan ZH. Cancer, Psychotherapy and the Airway. In: Mehdipour P, editor. Cancer Genetics and Psychotherapy. Springer, Cham; 2017.
[18] Yotakis J, Davris S, Kontozoglou T, Adamopoulos G. Evaluation of risk factors for stomal recurrence after total laryngectomy. Clin Otolaryngol Allied Sci. 1996; 21(2):135-8.
[19] Narula AA, Sheppard IJ, West K, Bradley PJ. Is emergency laryngectomy a waste of time? Am J Otolaryngol. 1993; 14(1):21-3.
[20] Pelton JJ, Ratner IA. A technique of airway management in children with obstructed airway due to tumor. Ann Thorac Surg. 1989; 48(2):301-2.
[21] Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987; 42(5):487-90.
[22] Savva D. Prediction of difficult tracheal intubation. Br J Anaesth. 1994; 73(2):149-53.
[23] Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth. 1988; 61(2):211-6.
[24] Chou HC, Wu TL. Thyromental distance--shouldn't we redefine its role in the prediction of difficult laryngoscopy? Acta Anaesthesiol Scand. 1998; 42(1):136-7.
[25] Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003; 97(2):595-600.
[26] Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg. 2003; 96(2):595-9.
[27] Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022; 136(1):31-81.
[28] Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018; 5(5):CD008874.
[29] Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope. Anesth Analg. 2008; 106(5):1495-500.
[30] Khan ZH, Mofrad MK, Arbabi S, Javid MJ, Makarem J. Upper lip bite test as a predictor of difficult mask ventilation: a prospective study. Middle East J Anaesthesiol. 2009; 20(3):377-82.
[31] Khan ZH, Mohammadi M, Rasouli MR, Farrokhnia F, Khan RH. The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study. Anesth Analg. 2009; 109(3):822-4.
[32] Khan ZH, Maleki A, Makarem J, Mohammadi M, Khan RH, Zandieh A. A comparison of the upper lip bite test with hyomental/thyrosternal distances and mandible length in predicting difficulty in intubation: A prospective study. Indian J Anaesth. 2011; 55(1):43-6.
[33] Khan ZH, Gharabaghian M, Nilli F, Ghiamat M, Mohammadi M. Easy endotracheal intubation of a patient suffering from both Cushing's and Nelson's syndromes predicted by the upper lip bite test despite a Mallampati Class 4 airway. Anesth Analg. 2007; 105(3):786-7.
[34] Khan ZH. Airway Assessment: A Critical Appraisal. In: Khan Z, editor. Airway Management. Springer, Cham; 2014.
[35] Lundstrom LH, Vester-Andeason M, Moller AM, Charuluxananan S, L'hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177,088 patients. Br J Anaesth. 2011; 107(5):659-67.
[36] Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A, Sasaki C. Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg. 2011; 112(3):602-7.
[37] Ahmad I, Keane O, Muldoon S. Enhancing airway assessment of patients with head and neck pathology using virtual endoscopy. Indian J Anaesth. 2017; 61(10):782-6.
[38] Yao W, Wang B. Can tongue thickness measured by ultrasonography predict difficult tracheal intubation? Br J Anaesth. 2017; 118(4):601-9.
[39] Carsetti A, Sorbello M, Adrario E, Donati A, Falcetta S. Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis. Anesth Analg. 2022; 134(4):740-50.
[40] Sustić A. Role of ultrasound in the airway management of critically ill patients. Crit Care Med. 2007; 35(5 Suppl):S173-7.
[41] Nicholls SE, Sweeney TW, Ferre RM, Strout TD. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. Am J Emerg Med. 2008; 26(8):852-6.
[42] De Jong A, Casey JD, Myatra SN. Focus on noninvasive respiratory support before and after mechanical ventilation in patients with acute respiratory failure. Intensive Care Med. 2020; 46(7):1460-3.
[43] Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012; 59(3):165-75.e1.
[44] Khan ZH. Airtraq or the Macintosh Laryngoscope: Looking for the Elusive Elixir. Arch Anesth Crit Care. 2023; 9(3):188-9.
[45] Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, et al. Learning curves of the Glidescope, the McGrath and the Airtraq laryngoscopes: a manikin study. Eur J Anaesthesiol. 2009; 26(7):554-8.
[46] Cattano D, Panicucci E, Paolicchi A, Forfori F, Giunta F, et al. Risk factors assessment of the difficult airway: an italian survey of 1956 patients. Anesth Analg. 2004; 99(6):1774-9.
[47] Tse JC, Rimm EB, Hussain A. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia: a prospective blind study. Anesth Analg. 1995; 81(2):254-8.
[48] Merah NA, Wong DT, Ffoulkes-Crabbe DJ, Kushimo OT, Bode CO. Modified Mallampati test, thyromental distance and inter-incisor gap are the best predictors of difficult laryngoscopy in West Africans. Can J Anaesth. 2005; 52(3):291-6.
[49] Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005; 103(2):429-37.
[50] Khan ZH, Eskandari S, Yekaninejad MS. A comparison of the Mallampati test in supine and upright positions with and without phonation in predicting difficult laryngoscopy and intubation: A prospective study. J Anaesthesiol Clin Pharmacol. 2015; 31(2):207-11.
[51] Yentis SM. Predicting difficult intubation--worthwhile exercise or pointless ritual? Anaesthesia. 2002; 57(2):105-9.
[52] Krobbuaban B, Diregpoke S, Kumkeaw S, Tanomsat M. The predictive value of the height ratio and thyromental distance: four predictive tests for difficult laryngoscopy. Anesth Analg. 2005; 101(5):1542-5.
[53] Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology. 1997; 87(6):1290-7.
[54] Janssens M, Lamy M. Airway Difficulty Score (ADS): a new score to predict difficulty in airway management. Eur J Anaesthesiol.
[55] Naguib M, Scamman FL, O'Sullivan C, Aker J, Ross AF, Kosmach S, et al. Predictive performance of three multivariate difficult tracheal intubation models: a double-blind, case-controlled study. Anesth Analg. 2006; 102(3):818-24.
[56] el-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg. 1996; 82(6):1197-204.
[57] Arné J, Descoins P, Fusciardi J, Ingrand P, Ferrier B, Boudigues D, et al. Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index. Br J Anaesth. 1998; 80(2):140-6.
[58] Benumof JL. Definition and incidence of difficult airway. Airway management: principles and practice. 1996:121-5.
[59] Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth. 1994; 41(5 Pt 1):372-83.
[60] Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984; 39(11):1105-11.
[2] Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011; 106(5):617-31.
[3] Pahor AL. Ear, nose and throat in Ancient Egypt. J Laryngol Otol. 1992; 106(9):773-9.
[4] Stock CR. What is past is prologue: a short history of the development of tracheostomy. Ear Nose Throat J. 1987; 66(4):166-9.
[5] Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med. 2008; 34(2):222-8.
[6] Ferlito A, Rinaldo A, Shaha AR, Bradley PJ. Percutaneous tracheotomy. Acta Otolaryngol. 2003; 123(9):1008-12.
[7] Golzari SEJ, Khan ZH, Ghabili K, Hosseinzadeh H, Soleimanpour H, Azarfarin R, et al. Contributions of Medieval Islamic physicians to the history of tracheostomy. Anesth Analg. 2013; 116(5):1123-32.
[8] Ezri T, Evron S, Hadad H, Roth Y. [Tracheostomy and endotracheal intubation: a short history]. Harefuah. 2005; 144(12):891-3, 908.
[9] Macewen W. General Observations on the Introduction of Tracheal Tubes by the Mouth, Instead of Performing Tracheotomy or Laryngotomy. Br Med J. 1880; 2(1021):122-4.
[10] Westhorpe R. O'Dwyer's tubes. Anaesth Intensive Care. 1991; 19(2):157.
[11] Thierbach A. Franz Kuhn, his contribution to anaesthesia and emergency medicine. Resuscitation. 2001; 48(3):193-7.
[12] Alberti PW. The history of laryngology: a centennial celebration. Otolaryngol Head Neck Surg. 1996; 114(3):345-54.
[13] Miller RA. A new laryngoscope. Anesthesiology. 1941; 2(3):317-20.
[14] Macintosh RR. A new laryngoscope. Lancet. 1943; 241(6233):205.
[15] Bannister F, Macbeth R. Direct laryngoscopy and tracheal intubation. Lancet. 1944; 244(6325):651-4.
[16] Adnet F, Borron SW, Lapostolle F, Lapandry C. The three axis alignment theory and the “sniffing position”: perpetuation of an anatomic myth?. Anesthesiology. 1999; 91(6):1964.
[17] Khan ZH. Cancer, Psychotherapy and the Airway. In: Mehdipour P, editor. Cancer Genetics and Psychotherapy. Springer, Cham; 2017.
[18] Yotakis J, Davris S, Kontozoglou T, Adamopoulos G. Evaluation of risk factors for stomal recurrence after total laryngectomy. Clin Otolaryngol Allied Sci. 1996; 21(2):135-8.
[19] Narula AA, Sheppard IJ, West K, Bradley PJ. Is emergency laryngectomy a waste of time? Am J Otolaryngol. 1993; 14(1):21-3.
[20] Pelton JJ, Ratner IA. A technique of airway management in children with obstructed airway due to tumor. Ann Thorac Surg. 1989; 48(2):301-2.
[21] Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987; 42(5):487-90.
[22] Savva D. Prediction of difficult tracheal intubation. Br J Anaesth. 1994; 73(2):149-53.
[23] Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth. 1988; 61(2):211-6.
[24] Chou HC, Wu TL. Thyromental distance--shouldn't we redefine its role in the prediction of difficult laryngoscopy? Acta Anaesthesiol Scand. 1998; 42(1):136-7.
[25] Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003; 97(2):595-600.
[26] Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg. 2003; 96(2):595-9.
[27] Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022; 136(1):31-81.
[28] Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018; 5(5):CD008874.
[29] Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope. Anesth Analg. 2008; 106(5):1495-500.
[30] Khan ZH, Mofrad MK, Arbabi S, Javid MJ, Makarem J. Upper lip bite test as a predictor of difficult mask ventilation: a prospective study. Middle East J Anaesthesiol. 2009; 20(3):377-82.
[31] Khan ZH, Mohammadi M, Rasouli MR, Farrokhnia F, Khan RH. The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study. Anesth Analg. 2009; 109(3):822-4.
[32] Khan ZH, Maleki A, Makarem J, Mohammadi M, Khan RH, Zandieh A. A comparison of the upper lip bite test with hyomental/thyrosternal distances and mandible length in predicting difficulty in intubation: A prospective study. Indian J Anaesth. 2011; 55(1):43-6.
[33] Khan ZH, Gharabaghian M, Nilli F, Ghiamat M, Mohammadi M. Easy endotracheal intubation of a patient suffering from both Cushing's and Nelson's syndromes predicted by the upper lip bite test despite a Mallampati Class 4 airway. Anesth Analg. 2007; 105(3):786-7.
[34] Khan ZH. Airway Assessment: A Critical Appraisal. In: Khan Z, editor. Airway Management. Springer, Cham; 2014.
[35] Lundstrom LH, Vester-Andeason M, Moller AM, Charuluxananan S, L'hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177,088 patients. Br J Anaesth. 2011; 107(5):659-67.
[36] Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A, Sasaki C. Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg. 2011; 112(3):602-7.
[37] Ahmad I, Keane O, Muldoon S. Enhancing airway assessment of patients with head and neck pathology using virtual endoscopy. Indian J Anaesth. 2017; 61(10):782-6.
[38] Yao W, Wang B. Can tongue thickness measured by ultrasonography predict difficult tracheal intubation? Br J Anaesth. 2017; 118(4):601-9.
[39] Carsetti A, Sorbello M, Adrario E, Donati A, Falcetta S. Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis. Anesth Analg. 2022; 134(4):740-50.
[40] Sustić A. Role of ultrasound in the airway management of critically ill patients. Crit Care Med. 2007; 35(5 Suppl):S173-7.
[41] Nicholls SE, Sweeney TW, Ferre RM, Strout TD. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. Am J Emerg Med. 2008; 26(8):852-6.
[42] De Jong A, Casey JD, Myatra SN. Focus on noninvasive respiratory support before and after mechanical ventilation in patients with acute respiratory failure. Intensive Care Med. 2020; 46(7):1460-3.
[43] Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012; 59(3):165-75.e1.
[44] Khan ZH. Airtraq or the Macintosh Laryngoscope: Looking for the Elusive Elixir. Arch Anesth Crit Care. 2023; 9(3):188-9.
[45] Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, et al. Learning curves of the Glidescope, the McGrath and the Airtraq laryngoscopes: a manikin study. Eur J Anaesthesiol. 2009; 26(7):554-8.
[46] Cattano D, Panicucci E, Paolicchi A, Forfori F, Giunta F, et al. Risk factors assessment of the difficult airway: an italian survey of 1956 patients. Anesth Analg. 2004; 99(6):1774-9.
[47] Tse JC, Rimm EB, Hussain A. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia: a prospective blind study. Anesth Analg. 1995; 81(2):254-8.
[48] Merah NA, Wong DT, Ffoulkes-Crabbe DJ, Kushimo OT, Bode CO. Modified Mallampati test, thyromental distance and inter-incisor gap are the best predictors of difficult laryngoscopy in West Africans. Can J Anaesth. 2005; 52(3):291-6.
[49] Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005; 103(2):429-37.
[50] Khan ZH, Eskandari S, Yekaninejad MS. A comparison of the Mallampati test in supine and upright positions with and without phonation in predicting difficult laryngoscopy and intubation: A prospective study. J Anaesthesiol Clin Pharmacol. 2015; 31(2):207-11.
[51] Yentis SM. Predicting difficult intubation--worthwhile exercise or pointless ritual? Anaesthesia. 2002; 57(2):105-9.
[52] Krobbuaban B, Diregpoke S, Kumkeaw S, Tanomsat M. The predictive value of the height ratio and thyromental distance: four predictive tests for difficult laryngoscopy. Anesth Analg. 2005; 101(5):1542-5.
[53] Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology. 1997; 87(6):1290-7.
[54] Janssens M, Lamy M. Airway Difficulty Score (ADS): a new score to predict difficulty in airway management. Eur J Anaesthesiol.
[55] Naguib M, Scamman FL, O'Sullivan C, Aker J, Ross AF, Kosmach S, et al. Predictive performance of three multivariate difficult tracheal intubation models: a double-blind, case-controlled study. Anesth Analg. 2006; 102(3):818-24.
[56] el-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth Analg. 1996; 82(6):1197-204.
[57] Arné J, Descoins P, Fusciardi J, Ingrand P, Ferrier B, Boudigues D, et al. Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index. Br J Anaesth. 1998; 80(2):140-6.
[58] Benumof JL. Definition and incidence of difficult airway. Airway management: principles and practice. 1996:121-5.
[59] Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth. 1994; 41(5 Pt 1):372-83.
[60] Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984; 39(11):1105-11.
| Files | ||
| Issue | Vol 12 No 4 (2026): Jul-Aug |
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| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/aacc.v12i4.21802 | |
| Keywords | ||
| Difficult airway Assessment tests Devices Techniques Management strategies Tracheostomy | ||
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How to Cite
1.
Khan ZH, Khan RH. A Comprehensive and Analytical Review of the Airway Pathology, Assessment, and Management. Arch Anesth & Crit Care. 2026;12(4):427-434.
