This is a tough one. 20 Answers – Airway and Intubation 1. This is why patients with micrognathia can be so difficult to intubate, they have an inadequately sized lower jaw, and so almost no place to displace the tongue into. Is propofol the new wonder drug for treating headaches? A useful acronym for this is LEMON. The most important aspects of it are: can you open your mouth wide enough, can you move your neck to allow better positioning and is there adequate space in the floor of the mouth into which to displace the tongue? Anaesthesia 1991;46:1005-8. Predicting an anatomically and/or physiologically challenging airway is not a straightforward task by any stretch of the imagination. Predicting difficult intubation. L – Look externally – Is the patient obese, do they have a high arched palate, a short neck, facial or neck trauma? An approach to predicting the potentially difficult airway. Reports of a modified LEMON where Mallampati is not assessed in emergency situations still affirm this tool as a good predictor of difficult airway. Contributed by. E – Evaluate the 3:3:2 rule – 3cm mouth opening, 3cm thyromental distance, 2cm between hyoid bone and thyroid notch. Br J Anaesth 1994;73:149-53. There are some existing difficult-airway prediction tools available (i.e. Combination of predictors in the “L-E-M-O-N” score showed that, as the mean “L-E-M-O-N” score of the patients increased, the likelihood of difficult visual laryngoscopy also increased. Background: Endotracheal intubation is an integral part of airway management and is key to the practice of safe anesthesia. O – Obstruction – Is there a tumour, epiglottitis, recent neck surgery? Evaluate 3-3-2 rule… O bstruction. Intubation is likely to be difficult with a Grade 2b view or worse. Some of us might find it difficult to intubate any patient whatsoever. How-ever, don’t just calculate a LEMON score without consid-ering why those particular characteristics might make the intubation or the ventilation more difficult. A case of head injury that raised a few questions, Head injury and blood thinners-When to Scan, Using Adrenaline the right way in Cardiac Resuscitation. Designing the perfect emergency department →. This is what procedures like chin lift and jaw thrust do. Airway assessment- The LEMON Score. Diagnostic predictor of diffi cult laryngoscopy: The hyomental distance ratio. Several methods exist to quickly assess the probability of success during tracheal intubation. […] 3-3-2 rule, Malempati, Obstruction of the airway, Neck Mobility. Use of the “L-E-M-O-N” score in predicting difficult intubation in Africans google_ad_height = 600; Here are some answers and a few resources for you. A previously defined clinical decision rule, the modified LEMON criteria, may provide a reliable and reproducible means of identifying difficult intubations. Multiple methods can be used to evaluate the airway and the risk of difficult intubation (eg, LEMON rule, 3-3-2, Mallampati class, McCormack and Lehane … This gestalt is usually gained following years of experience BUT it can be taught. The following are more likely found in patients with high grade views (2-4). Can J Anaesth 1994;41:372-83. The 3:3:2 Rule is part of that. Below is the approach I use. Recently at the EM Core we discussed headache and the red eye. Evaluate – The 3-3-2 rule. THE 6D METHOD. PopUp = location,'RightsLink','location=no,toolbar=no,directories=no,status=no,menubar=no,scrollbars=yes,resizable=yes,width=650,height=550'); }, Source of Support: None, Conflict of Interest: None. The L.E.M.O.N. Anesth Analg 1995; 81: 254-8. Savva D. Prediction of difficult tracheal intubation. Predicting The Difficult Airway with LEMON. Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Operative Techniques in Otolaryngology-Head and Neck Surgery. Danladi B Mshelia1, Elizabeth O Ogboli-Nwasor2, Erdoo S Isamade3 The tongue falls backwards into the hypopharynx and is responsible for obstructing the airway in most cases. The only real place to displace it into is the floor of the mouth. The 3-3-2 rule plays a crucial role in planning as a component of the LEMON scale. When intubating, we need to have adequate room, to get the laryngoscope blade in, as well as the endotracheal tube and be able to see. google_ad_width = 160; Get notified on all upcoming Conferences PLUS our Webcasts, Education Newsletters, and more! The reality is that it doesn’t change the fact that you need to secure the airway stat. The ability to predict the potentially difficult airway is useful in that it puts you in the right frame of mind, you start thinking about alternatives should you not be able to intubate. OK, so let’s look at what the LEMON Rule really tells us. Patil VU, Stehling LC, Zauder HL. google_ad_client = "pub-8451019964492775"; Araoye OM. The LEMON rule is one popular rule for assessment for difficult intubation (Table 122-2). We studied the use of “L-E-M-O-N” (Look-Evaluate-Mallampati-Obstruction-Neck mobility) scoring system to predict difficult intubation and determine the prevalence of difficult intubation among adult surgical patients. M allampati. Education . Rose DK, Cohen MM. Research The “LOOK” features had sensitivities of 99.1%, 96.6%, and 92.5% for facial trauma, large incisors, and beard or moustache, respectively, and positive predictive values of 0%. How useful is predicting really? 2020; 17(6): 63. google_color_url = "000000"; Some studies have investigated the use of LEMON in emergency and trauma situations where there is limited time for patient assessment. These patients are not elective patients, but come in in a decompensated state and need immediate assistance. is coming in late APRIL 2010 – videos of lectures on all of acute medicine. This step also involves stratifying the difficulty level of the patient's airway. Evaluate 3-3-2 Rule 3 fingers between the patient’s teeth (patient’s mouth should open adequately to permit three fingers to be placed between the upper and lower teeth) 3 fingers between the tip of the jaw and the beginning of the neck (under the chin) 2 fingers between the thyroid notch and the floor of the mandible (top of the neck) 1 Department of Anesthesia, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria2 Department of Anesthesia, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State, Nigeria3 Department of Anesthesia, University of Jos Teaching Hospital, Jos, Plateau State, Nigeria, Correspondence Address:Elizabeth O Ogboli-NwasorDepartment of Anesthesia, Ahmadu Bello University Teaching Hospital Shika, Zaria, Kaduna State NigeriaSource of Support: None, Conflict of Interest: NoneCheckDOI: 10.4103/njbcs.njbcs_25_16 function RightsLinkPopUp () { var url = ""; var location = url + "?publisherName=" + encodeURI ('Medknow') + "&publication=" + encodeURI ('NBCS') + "&title=" + encodeURI ('Use of the “L-E-M-O-N” score in predicting difficult intubation in Africans') + "&publicationDate=" + encodeURI ('Jan 1 2018 12:00AM') + "&author=" + encodeURI ('Mshelia DB, Ogboli-Nwasor EO, Isamade ES') + "&contentID=" + encodeURI ('NigerJBasicClinSci_2018_15_1_17_228359') + "&orderBeanReset=true" Care (SIAARTI Societa' Italiana Di Anestesia Analgesia Rianimazione E Terapia Intensiva) study committee on the difficult airway Difficult intubation and airway management. The primary outcome measure was to find the ability of the “LEMON” scoring system to actually predict difficult intubation, i.e., the positive predictive value of the “L-E-M-O-N” score. There has to be adequate volume at the base of the mouth to push the tongue into. This entails gathering and testing the supplies needed (endotracheal tubes, stylet, blades, handles, drugs, alternate airway methods) as well as planning for a surgical airway if orotracheal intubation ultimately fails. N – Neck mobility – Is the patient in a cervical collar, are they elderly? Creator Int. Well done! Br J Med Prac 2010;3:307. ← The BURP, the Sellick and the bimanual – which is better? The difficulty cially helpful in emergency circumstances, is the LEMON score (Table 1 and Figure 2).10-12 The higher the score, with a maximum of 10, the more need for caution. Movement of the mandible, to which the tongue is attached, moves the tongue. Be careful as most men with small jaws grow beards to hide them! I had a great case just over a... ADRENALINE AND CARDIAC RESUSCITATION How much to use, when to use it and when not to use it. The variables evaluated were gender, age, weight, height, body mass index (BMI), dentition and a variety of airway tests using the “L-E-M-O-N” scale. Br J Anaesth 1988;61:211-6. The knowledge you take into your shift DOES matter, Get access to Resus learning resources and learn about upcoming event. This review was previously posted on REBEL EM here. The LEMON rule allows us to remember to look externally and to look at those parameters that will make the intubation simple or difficult. Gupta AK, Ommid M, Nengroo S, Naqash I, Mehta A. Predictors of difficult intubation: Study in kashmiri population. [ 1] O One tool for rapid assessment is the LEMON law, … Tse JC, Rimm EB, Hussain A. google_color_bg = "FFFFFF"; Br J Anaesth 1983;55:141-4. © 2012 Farlex, Inc. Knowledge . It has been well rehashed here and here (video). Difficult intubation = LEMON. Remember in airway, the tongue is the enemy, the patient’s enemy and yours. It is a way of adding some measurable parameters to what should become a ‘gestalt’ approach, where you know or have a ‘vibe’, a feeling, call it what you will, about the relative ease or difficulty of any airway. It’s this thought process that allows you to see the big picture and not fixate. Think of the mnemonic ‘LEMON’ to determine difficulty of intubation: Look – at the anatomy – thick, short neck, high palate, narrow face, trauma, large tongue, teeth, or dentures. The LEMON method, which consists of following assessments: Look-Evaluate-Mallampati-Obstruction-Neck mobility, can be used to predict difficult intubation in the emergency setting [ 4 ], and the modified LEMON score (also called “LEON” score), which excludes the Mallampati classification from the original LEMON score, has been developed for the identification of difficult … Chicago: Year Book Medical; 1983. p. 79-80. Anesthesiology 2008;98:1269-77. “I’ve got to get the tube, I’ve got to get the tube, I’ve got to get the tube.” You try again and again and the patient starts to desaturate and now you are playing catch-up. approach is just that. Background: Evidence to predict difficult intubation remains scarce in the emergency department (ED) setting. A prospective observational study of 156 patients undergoing intubation in the emergency department found the LEMON scale evaluation accurately stratified patients according to the risk of difficult intubation. google_ad_channel ="6718441946"; The LEMON score is a tool described and validated for predicting endotracheal intubation difficulty in emergency situation[14]. google_ad_format = "160x600_as"; Background: Predicting an anatomically and/or physiologically challenging airway is not a straightforward task by any stretch of the imagination. Karkouti K, Rose DK, Ferris LE, Wigglesworth DF, Meisamai-Fard T, Lee H. Inter-observer reliability of ten tests used for predicting difficult tracheal intubation. Materials and Methods: One hundred and sixty (160) consecutive ASA I–III surgical patients between 18 and 65 years of age were recruited from October to December 2011. Can J Anaesth 1996;43:554-9. EMS Airway Clinic is a new site offering best practices in airway management and education for EMS professionals and educators, featuring: Regular articles by Charlie Eisele, Flight Paramedic, retired First Sergeant with the Maryland State Police Aviation Command, and co-founder of the Advanced Airway Course at EMS Today google_color_text = "000000"; Instead, Limited neck mobility was the only independent predictor of intubation difficulty (odds ratio, 6.15; P=0.002). Shiga T, Wajima Z, Inoue T, Sakamoto A. google_color_link = "cc6601"; If I can’t tube, I may try again, or go straight to a bougie. [ 1] O One tool for rapid assessment is the LEMON law, … Get access to Resus learning resources and learn about upcoming events SUBSCRIBE [email protected]. Emerg Med J 2005;15:99-102. Providers may avoid awake intubation for a variety of reasons, including: As described by Rich, 2005; see this table. Italian Society of Anaesthesiology Analg. google_ad_type = "text_image"; Use of SOME elements of the LEMON (look, evaluate, mallampati, obstruction, neck mobility) approach to airway assessment MAY be helpful in predicting likely laryngoscopic view (Cormack- Lehane grade) as a proxy for difficulty of intubation. Dr. Gerald Diaz @GeraldMD. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. USEFUL MNEMONICS. Is Propofol the new wonder drug for headaches? The LEMON method of predicting the potentially difficult airway is very helpful. This is all uncharted territory.... Head injury in the anticoagulated patient can be a challenge. There are some existing difficult-airway prediction tools available (i.e. Can an airway assessment score predict difficulty at intubation in the emergency department? I have a lot of questions. Difficult Laryngoscopy and Intubation (LEMON) Look externally: Use your clinical gestalt, evidence of lower facial disruption, bleeding, small mouth, agitated patient: Evaluate: Use the 3-3-2 rule: mouth open, mandible, glottis: Mallampati score: In order of increasing difficulty Class I-IV: Frerk CM. Several methods exist to quickly assess the probability of success during tracheal intubation. Predicting difficult intubation in apparently normal patients: A meta-analysis of bedside screening test performance. 2. Research methodology with statistics for health and social sciences, saw-mill, ilorin. West Afr J Med 1994;13:102-4. unconscious patient alive: In this scenario, techniques for awake intubation and difficult airway adjuncts can be used. Fiberoptic endoscopy in anesthesia. The LEMON rule  allows us to remember to look externally and to look at those parameters that will make the intubation simple or difficult. Evaluate the 3-3-2 rule: ... Can an airway assessment score predict difficulty at intubation in the emergency department? N eck Mobility. Mallampati, Gatts P, Gucino LD, Desais P, Waraksa B, Freiberger D. Wilson ME, Spiegelhaltder D, Robertson JA, Lesser P. Predicting difficult intubation. It stands for Look, Evaluate the 3-3-2 rule, Mallampati score, Obstruction, and Neck mobility … Predicting of difficult in surgical patients scheduled for general anesthesia: a prospective blind study. A common mnemonic for difficult intubation is LEMON (look external, 3-3-2 rule, Mallampati score, obstruction, neck mobility). This field is for validation purposes and should be left unchanged. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Huh J, Shin HY, Kim SH, Yoon TK, Kim DK. If unsure as to how much a cm is, just use the 3 fingers or 2 fingers approach, M – Mallampati Score – remember a Mallampati 4 is associated with a >10% chance of difficult airway. Anesthesiology 2005;103:429-37. Become a Resus Member for FREE! Results: Prevalence of difficult intubation using Cormack and Lehane score only was found to be 8.1%. 2020; © Nigerian Journal of Basic and Clinical Sciences | Published by Wolters Kluwer -, Inter-incisor distance: patient's mouth is opened adequately to allow the placement of three fingers between the upper and lower teeth, Hyomental distance: three finger breadths are used, Thyromental distance: two finger breadths are used. Merah NA, Foulkes-Crabbe DJ, Kushimo OT, Ajayi PA. Tham EJ, Gildersleve CD, Sanders LD, Mapleson WW, Vaughan RS. E valuate 3-3-2. What does difficult mean? Look externally: Remember "BONES" Beard Obesity No teeth Elderly Sleep apnea/Snoring 2. The LEMON approach for predicting the difficult airway. Anesth Analg 2009;108:544-8. Predicting The Difficult Airway with LEMON. Some (2), however, have suggested it might be challenging to apply to ED […]. photo by pig sty ave The LEMON score is a mnemonic for predicting difficult intubation. We then need to displace the tongue with the laryngoscope blade. google_color_border = "FFFFFF"; Prediction of a difficult airway can help reduce the incidence of failed or difficult intubation. West Afr J Med 2004;23:38-41. And it's FREE! The LEMON assessment (L = Look externally, E – Evaluate the 3:3:2 rule, M = Mallampati score, O = Obstruction, N = Neck mobility) was first described by Walls and Murphy in 2000 as a bedside screening tool to identify patients who might be challenging with direct laryngoscopy (DL). Emerg Med J 2005 Feb Use of this tool can reduce the chance of unexpectedly encountering a difficult airway. The difficult intubation group showed higher modified LEMON score than the non-difficult intubation group (3 [2-5] vs. 2 [1-3], respectively, P=0.017). The airway: Problems and predictions 18,500 patients. Difficult Airway Assessment - LEMON Mnemonic - Look Externally - Evaluate - Mallampati - Obstruction or Obesity - Neck Mobility #Diagnosis #CriticalCare #Difficult #Airway #Evaluation #Mnemonic #LEMON. Anesthesiology 1997;86:316-21. Prediction of difficult laryngoscopy in a population of Nigerian obstetrics patients. One of the greatest dangers in any life saving procedure is to get fixated. Approach the patient with 9 Ps. //-->. (SIAARTI Guidelines for Difficult Intubation and for Difficult Airway Management. THe LEMON rule also coined by the Walls crew is probably as good as any: L ook at head and neck. Look externally; Evaluate 3-3-2 rule; Mallampati score; Obstruction; Neck Mobility; Difficult BVM = BONES. Yamamoto K, Tsubokawa T, Shibata K, Ohmura S, Nitta S, Kobayashi T. Predicting difficult intubation with indirect laryngoscopy. Nichol HC, Zuck D. Difficult laryngoscopy: The 'anterior' larynx and the atlanto-occipital joint. SPSS version 17.0 was used for statistical analysis; and a P value <0.05 was considered significant. Recognition of the difficult airway in normal Nigerian adults (a prospective study). The LEMON factors should be assessed and may identify potential problems in endotracheal intubation Segen's Medical Dictionary. Most EMS providers have heard of the “LEMON Law” theory of assessing a patient for difficult laryngoscopy and intubation. see here for more. With the ability to predict a potentially difficult airway, you may say to yourself, I’ll try a tube and it should be in if I use all those techniques that I’ve learnt, like using an introducer in the endotracheal tube and bending the end at 35-40 degrees, getting correct positioning and even getting an assistant to open the mouth further for me by pulling the cheek further open. Ita CE, Eshiet AI, Akpan SG. I also discuss a new possible indication for awake intubation. However, whenever you see a difficult airway you should at least consider awake intubation, if only to rule it out as a potentially safer approach. Emergency Physician, Educator. Conclusion: Combination of airway predictors in the “L-E-M-O-N” scoring system significantly improves the ability to predict difficult intubation. Mnemonic: LEMON approach 1. The goal is to clear the tongue out of the way, or at least to lift it, so that we can ventilate. Many clinical assessment tools have been developed to predict a difficult airway, but insufficient evidence supports recommending any individual tool. Br J Anaesth 1992;68:32-8.,, Messenger of ANESTHESIOLOGY AND RESUSCITATION. Keywords: Africans, difficult intubation, L-E-M-O-N score,