Grading of direct laryngoscopy A survey of current practice

Abstract

Summary Laryngoscopy .The inspection of previous anaesthetic records is an important part of pre-anaesthetic assessment. The appearance of laryngeal structures at previous direct laryngoscopy, as well as information about tracheal intubation, is particularly helpful, not least because prediction of ease of intubation from the pre-operative physical examination can be unreliable. Although many anaesthetists use the numerical grading system of Cormack and Lehane [l] to record appearances at direct laryngoscopy, it became apparent to the authors that there might be uncertainty about it, which may be of clinical importance. The following survey was carried out to assess the prevalence of usage of this numerical grading system by practising anaesthetists and to assess their knowledge of the system. allowed to alter earlier answers using information gained from subsequent questions, except if they had obviously misinterpreted a previous question.For question 4(a), the interviewees were shown a diagram of the appearances at a 'normal' laryngoscopy, with a good view of all laryngeal structures (Fig. 1). The vocal cords, arytenoid cartilages and epiglottis were specifically pointed out to familiarise interviewees with the Methodr One hundred and twenty anaesthetists from three regional health authorities were interviewed directly by the authors, using the questionnaire shown ( Table 1). Forty anaesthetists were interviewed in each region, of whom 10 were from each grade (senior house officer, registrar, senior registrar and consultant). Anaesthetists were selected for interview only if their preferences regarding recording of laryngoscopic appearances were unknown to the interviewer.The questions were simultaneously shown to and read out to the interviewee and the response recorded. Questions were asked in the order shown and interviewees were not

The effects of single‐handed and bimanual cricoid pressure on the view at laryngoscopy

“…These laryngoscopies (grade 2b in the scoring system proposed above) would be more likely to cause difficulty than grade 2a laryngoscopies and yet both types would be included in the same group (grade 2) using the widely used system described by Cormack & Lehane which employs four grades [8]. Routine use of the Cormack & Lehane classification has been the subject of recent criticism and the need for an improvement in the description of laryngoscopic findings has been suggested [9]. The original Wilson system defined grade 2 as 'only half the cords visible' and grade 3 as 'only the arytenoids visible' [6], whereas the modification proposed in the present study may be more useful, since it avoids the requirement for estimating the proportion of the cords that is unseen.…”

Predicting difficult intubation – worthwhile exercise or pointless ritual?

“…Many studies have used the Cormack & Lehane classi®cation despite the fact that it was never designed for this purpose, and despite it being shown that anaesthetists don't always know what it means [21]; in addition, several textbooks add to the confusion by describing grade 3 as a partial view of the glottic opening (it was originally de®ned as only the epiglottis visible). Attempts to improve on the classi®cation's usefulness [17,19] don't solve the problem of one person's grade 3 being another's grade 2b, or the possibility that intubation might be dif®cult because of awkward teeth or inability to pass the tube despite a good view.…”

The view from the top. Is it worth recording for posterity?

“…Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is accepted as part of a treatment bundle for selected patients with severe acute respiratory distress syndrome (ARDS) [1,2]. Though there have been many comparisons of VV-ECMO and conventional management [3][4][5], decision-making for referrals to severe respiratory failure centres (SRFC) has not been examined. In this issue of the journal, Gillon et al report a retrospective analysis of decision-making for patients referred to a SRFC in central London [6].…”