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 , 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 such as , 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 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 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

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