Ultrasound to Predict Difficult Airway

Upper airway ultrasound is a valuable, non-invasive, simple, and portable point of care tool
for evaluation of the airway, even in the presence of anatomic distortion caused by pathology
or trauma. The ultrasound technology is being increasingly adopted in modern anesthesiology
practice. As early as in 1984, some authors have recommended its use to guide venous
cannulation, because it shortens procedural times, reduces the number of failed puncture
attempts, and minimizes complications. On the other hand, ultrasound-guided techniques are
considered the gold standard for peripheral nerve blocks.

As ultrasound becomes more widespread, it is important to for anesthesiologists to be aware
of the expanding applications of this technology. Current and potential future applications
of ultrasound in anesthesiology are wide and include regional anesthesia, neuraxial and
chronic pain procedures, vascular access, airway assessment, lung ultrasound, ultrasound
neuro-monitoring, gastric ultrasound, focused transthoracic echography, trans-esophageal
echocardiography and vascular Doppler flow assessment. The major disadvantage is
inter-observer variability, and the fact that it requires is a unique skill that requires
continuing training and experience to master the technology. In order to be successful with
this technique, it is important to develop a thorough understanding of the sonoanatomy. The
normal or abnormal structures need to be imaged and interpreted before any intervention.

Airway management is one of the most important tasks for anesthesiologists. Access to the
airway should be safe, fast and efficient. Appropriate planning is crucial to avoid morbidity
and mortality when difficulty is anticipated. Inability to maintain airway ventilation is a
life-threatening situation that may warrant emergent surgical access to prevent devastating
consequences. A thorough assessment of the airway is recommended to predict difficulty.
Multiple clinical predictors have been used in clinical practice; however, most of them are
associated with low predictive values. In consequence, a comprehensive airway examination
that incorporates both quantitative and qualitative tests increases the probability of
predicting difficult intubation. Regardless of the method of airway evaluation, it is
important to acknowledge that clinical airway assessment is not fully accurate and can
produce both false-negative and false-positive results.

There is a growing academic interest in the ability of ultrasound to determine airway size to
estimate appropriate endotracheal tube size. Ultrasound enables us to identify important
sonoanatomy of the upper airway including thyroid cartilage, epiglottis, cricoid cartilage,
cricothyroid membrane, tracheal cartilages, and esophagus. Transverse and parasagittal views
can help diagnose supraglottic, glottic and infraglottic airway conditions and aid the
anesthesiologist in airway management. Ultrasonography has brought a paradigm shift in the
practice of airway management. With increasing awareness, portability, accessibility and
further sophistication in technology, it is likely to find a place in routine airway
management.