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LETTERS TO THE EDITOR

Evaluating a Patient’s Airway

Center for Pain Management, West Hempstead, NY

To the Editor:

The article by Khan et al. (1) attempts to give us a new way of evaluating a patient’s airway that is both clinically useful to the practitioner as well as descriptively accurate in communicating the most about the airway to others with the least explanation, a great help to both clinician and researcher. A quick bite of the upper lip certainly is easy to perform in the cooperative patient and the results readily communicated. In trying their method, I quickly found a potential problem not addressed in their paper, the edentulous patient and one with oversized caps. I think it would be better to view this bedside test as an adjunct to the clinical examination of the entire airway. I do not believe it can replace the Mallampati Classification, as there are sufficient numbers of patients that would be disqualified for evaluation based on their lack of dentition.

Reference

1. Khan ZH, Kashfi A, Ebrahimkhani B. A comparison of the Upper Lip Bite Test (a simple new technique) with the Mallampati Classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg 2003; 96: 595–9.[Abstract/Free Full Text]

Response

Department of Anesthesiology/Neurosurgery, Imam Khomeini Hospital, Tehran, Iran

In Response:

While the Mallampati Classification (1) which has prevailed as the only single and reliable test in predicting difficult airway for the past two decades is important, we believe that the Upper Lip Bite Test (ULBT) (2) is undoubtedly a distinct improvement.

Dr. Herschman’s question of edentulous patients whom our new technique—the ULBT—did not encompass is correct. We excluded the edentulous patients from our study, as appears in the "Methods" section. We may add that the test was not designed to incorporate those devoid of dentition because of the inherent difficulty of this class of population to take a bite—which of course is the cardinal and standing feature of the ULBT.

In our approach to the edentulous patients who form a significant proportion of our patients in today’s statistics, the principal author and innovator (Z.H.K.) of ULBT has further introduced his next new technique, the Upper Lip Catch Test (ULCT) in predicting difficulty in endotracheal intubation in edentulous patients to accommodate the aforementioned class for airway assessment. In conducting the ULCT in edentulous patients, we propose the following criteria for classification:

Class Zero (0): the lower lip gliding or rolling over the upper lip reaching as high as the rhinion or else positioning itself at any point above midway between the vermilion line and the rhinion (Figs. 1A and 2A).

Class I: the lower lip catching the upper lip, between a point 2 mm above the vermilion line and the point midway between the vermilion line and the rhinion (Figs. 1B and 2B).

Class II: the lower lip catches the upper lip at the level of the vermilion line or positioning itself just above it (2 mm) (Figs. 1C and 2C).

Class III: the lower lip just caresses the upper lip but falls short of obliterating the vermilion line (Figs. 1D and 2D).

View larger version (14K): [in this window] [in a new window]      Figure 1. Schematic frontal view of ULCT. A, Class 0; the lower lip rolling over the upper lip advancing as high as the rhinion or else positioning itself at any point above midway between the vermilion line and the rhinion. Note that the lower lip rolling over the upper lip exhibiting wrinkles and folds of senility, and the area above the chin contracted giving a goose pimple appearance. B, Class I; the lower lip catching the upper lip, between a point 2 mm above the vermilion line and the point midway between the vermilion line and the rhinion. C, Class II; the lower lip catching the upper lip at the level of the vermilion line or positioning itself just above it (2 mm). D, Class III; the lower lip just caresses the upper lip unable to make further advancement and falls short of vanishing the vermilion line.

View larger version (9K): [in this window] [in a new window]      Figure. 2. Schematic lateral view of ULCT. Dotted area depicts the mucosa of the upper lip. A, Class 0; the lower lip rolling over the upper lip advancing as high as the rhinion or else stationing itself at any point above midway between the vermilion line and the rhinion. B, Class I; the lower lip catching the upper lip, between a point 2 mm above the vermilion line and the point midway between the vermilion line and the rhinion. C, Class II; the lower lip catching the upper lip at the level of the vermilion line or positioning itself just above it (2 mm). D, Class III; the lower lip just caressing the upper lip but fails to obliterate the vermilion line.

It might be argued that this technique might impart stress on this senescent population, but we are of the opinion and the conviction that its inherent and potential benefits are beyond proportions, making its use not only prudent, but also lifesaving for those unidentified cases of difficult intubation who lack dentition.

Patients with oversized caps on the other hand can be tested and assessed with our ULBT, and we feel that the ULBT has the inherent potential to address this issue.

References

1. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429–34.[ISI][Medline]
2. Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the Upper Lip Bite Test (a simple new technique) with modified Mallampati Classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg 2003; 96: 595–9.

This article has been cited by other articles:

				L. H. J. Eberhart, C. Arndt, T. Cierpka, J. Schwanekamp, H. Wulf, and C. Putzke The Reliability and Validity of the Upper Lip Bite Test Compared with the Mallampati Classification to Predict Difficult Laryngoscopy: An External Prospective Evaluation Anesth. Analg., July 1, 2005; 101(1): 284 - 289. [Abstract] [Full Text] [PDF]

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999