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Modified Mallampati Classification the Modified Mallampati Classification Stratifies Predicted Difficulty of Endotracheal Intubation Based on Anatomic Features

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Modified Mallampati Classification the Modified Mallampati Classification Stratifies Predicted Difficulty of Endotracheal Intubation Based on Anatomic Features CalculatedPOWERED BY Decisions Clinical Decision Support for Pediatric Emergency Medicine Practice Subscribers Modified Mallampati Classification The Modified Mallampati Classification stratifies predicted difficulty of endotracheal intubation based on anatomic features. Click the thumbnail above to access the calculator. Consider strategies to improve ease of intuba- About the Score tion in patients with a predicted difficult airway The modified Mallampati classification predicts (class III-IV) (eg, video-assisted laryngoscopy, awake difficult airway in patients requiring endotracheal intubation). For patients with identified or anticipat- intubation. The tool is simple to use at the ed difficult airways, consider involving other airway bedside, can be performed in < 1 minute, and has specialists early and identify alternatives to endo- good accuracy (area under the summary receiver tracheal intubation such as laryngeal mask airway, operating characteristic curve, 0.83) at predicting bougie-guided intubation, or other adjuncts. Before difficult airway (eg, difficult laryngoscopy, difficult starting the procedure in any intubation, especially intubation, or difficult ventilation). (Lee 2006) in an emergency setting, determine the “plan B” The original Mallampati classification had 3 and “plan C” to be followed if initial attempts fail. classes of visualization, but a fourth was added later by Samsoon and Young (1987) and shown to have Evidence Appraisal greater predictive value. The latter version of the The Mallampati score was initially developed for classification is most commonly used today. While the operating room setting. Multiple large studies the modified Mallampati classification is usually de- involving tens of thousands of patients have shown termined with the patient sitting up, a prospective a reliable association between a higher Mallampati cohort study suggested that evaluating the patient score (class III or IV) and difficult laryngoscopy and supine may better predict difficult intubation (area intubation. under the receiver operating characteristic curve, Despite this, the Mallampati score does have 0.82 supine vs 0.7 while sitting) (Hanouz 2018). A its detractors. In a 2019 paper, Green and Roback class 0 has been proposed by Ezri et al (1998) to argued that despite the high association seen with denote “extremely easy” intubation, but evidence higher Mallampati class and difficult intubation, the supporting its accuracy is limited to case reports. sensitivity of the score is rather low, which is subop- A low score may predict easy laryngoscopy and timal for a screening test. They advocated for the intubation, but does not guarantee it. While a high use of the Mallampati score in the context of the score should prompt caution, a low score is not total clinical picture. Furthermore, in the emergency intended to provide reassurance. setting, a patient with a failing airway or respiratory effort requiring intubation will still require intuba- CALCULATOR REVIEW AUTHORS tion, regardless of the Mallampati score. Although a higher Mallampati score may prompt an earlier Derek Tam, MD, MPH call to anesthesia or other specialties for assistance, Department of Pediatrics, Rady Children's Hospital, San its application in the emergent setting (emergency Diego, CA department, intensive care unit) may be limited, as the score was initially developed and has primarily Christopher Tainter, MD, RDMS been validated in the operating room setting. Division of Critical Care and Department of Emergency Medicine, University of California, San Diego, San Diego, CA CD1 October 2020 ∙ www.ebmedicine.net Instructions Additional References To use the modified Mallampati classification, • Ezri T, Cohen I, Geva D, et al. Pharyngoscopic views. Anesth position the patient seated upright and direct the Analg. 1998;87(3):748 patient to open mouth and protrude tongue fully. DOI: https://doi.org/10.1097/00000539-199809000-00065 • O'Leary AM, Sandison MR, Roberts KW. History of anes- Use the Calculator Now thesia; Mallampati revisited: 20 years on. Can J Anaesth. Click here to access the Modified Mallampati Clas- 2008;55(4):250-251. DOI: https://doi.org/10.1007/bf03021512 sification on MDCalc. • Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an up- Calculator Creator dated report by the American Society of Anesthesiologists Seshagiri R. Mallampati, MD Task Force on Management of the Difficult Airway. Anesthe- Click here to read more about Dr. Mallampati. siology. 2013;118(2):251-270. DOI: https://doi.org/10.1097/ALN.0b013e31827773b2 • Hanouz JL, Bonnet V, Buléon C, et al. Comparison of the References Mallampati classification in sitting and supine position to Original/Primary Reference predict difficult tracheal intubation: a prospective obser- • Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to vational cohort study. Anesth Analg. 2018;126(1):161-169. predict difficult tracheal intubation: a prospective study. Can DOI: https://doi.org/10.1213/ane.0000000000002108 Anaesth Soc J. 1985;32(4):429-434. • Green SM, Roback MG. Is the Mallampati score useful for DOI: https://doi.org/10.1007/bf03011357 emergency department airway management or procedural • Samsoon GL, Young JR. Difficult tracheal intubation: a retro- sedation? Ann Emerg Med. 2019;74(2):251-259. spective study. Anaesthesia. 1987;42(5):487-490. DOI: https://doi.org/10.1016/j.annemergmed.2018.12.021 DOI: https://doi.org/10.1111/j.1365-2044.1987.tb04039.x Validation References Copyright © MDCalc • Reprinted with permission. • Lee A, Fan LT, Gin T,et al. A systematic review (meta-anal- ysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesth Analg. 2006;102(6):1867-1878. DOI: https://doi.org/10.1213/01.ane.0000217211.12232.55 This edition of Calculated Decisions, powered by MDCalc, is published as a supplement to Pediatric Emergency Medicine Practice as an exclusive benefit to subscribers. Calculated Decisions is the result of a collaboration between EB Contact EB Medicine: Contact MD Aware: Medicine, publisher of Pediatric Emergency Medicine Practice, Phone: 1-800-249-5770 MDCalc and MD Aware, developer of MDCalc. Both companies are or 678-366-7933 Phone: 646-543-8380 3475 Holcomb Bridge Rd 12 East 20th Street dedicated to providing evidence-based clinical decision- Suite 100 5th Floor making support for emergency medicine clinicians. Peachtree Corners, GA 30092 New York, NY 10003 Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine (475 Holcomb Bridge Rd, Suite 100, Peachtree Corners, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2020 EB Medicine. All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only and may not be copied in whole or part or redistributed in any way without the publisher’s prior written permission. CD2 October 2020 ∙ www.ebmedicine.net.
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