USC Anesthesia Sub-I
Supervised skill

Airway skills

Assess, describe what you see, keep the team informed. You practice under direct supervision — the team directs every attempt and any rescue.

Assessment Standard practice

History: prior anesthesia records (view grade, device, any “difficult airway” letter) · OSA/snoring/CPAP · head & neck surgery or radiation · C-spine disease (RA, ankylosing spondylitis, fusion) · dentition (loose teeth, crowns, dentures) · reflux · recent URI.

ExamHowConcerning
Modified MallampatiSitting, head neutral, mouth open fully, tongue out, no phonation; examiner at eye levelClass III–IV
Mouth openingInter-incisor distance< 3 cm (< 3 fingers)
Thyromental distanceNeck extended, chin tip to thyroid notch< 6 cm (≈ < 3 fingers)
3-3-2 rule3 fingers mouth · 3 hyoid–chin · 2 hyoid–thyroid notchFewer fingers
Upper lip bite testCan the lower incisors bite the upper lip?Class III (can’t reach the lip)
NeckExtension range; circumferenceLimited; > 40 cm
FaceBeard, edentulous, facial traumaPoor mask seal

Mallampati classes

Figure: Mallampati classification — Jmarchn, CC BY-SA 3.0, via Wikimedia Commons.

  1. Class I — soft palate, fauces, uvula and pillars visible
  2. Class II — soft palate, fauces, uvula
  3. Class III — soft palate and base of the uvula
  4. Class IV — hard palate only; soft palate not visible

Figure panels run left→right, top→bottom from Class I to IV (modified Samsoon–Young scale). Mallampati is an awake exam of the oral cavity — different from the laryngeal view you get with a laryngoscope.

Difficulty mnemonics

MnemonicPredicts difficulty withComponents
LEMONLaryngoscopyLook externally · Evaluate 3-3-2 · Mallampati · Obstruction/obesity · Neck mobility
MOANSBag-mask ventilationMask seal (beard) · Obesity/obstruction · Age > 55 · No teeth · Stiff lungs/snoring
RODSSupraglottic airwayRestricted mouth opening · Obstruction · Disrupted airway · Stiff lungs or C-spine
SHORTFront-of-neck accessSurgery/scar · Hematoma · Obesity · Radiation · Tumor

Anatomy

Sagittal view: oral cavity → oropharynx → epiglottis → glottis/vocal folds → trachea. The esophagus lies posterior to the larynx.

Figure: Mouth and pharynx — BruceBlaus (Blausen.com staff, 2014, Medical gallery of Blausen Medical, WikiJournal of Medicine 1(2), doi:10.15347/wjm/2014.010), CC BY 3.0, via Wikimedia Commons. Resized and converted to WebP.

The laryngoscopic view

Through a laryngoscope, anterior is at the top: tongue base and vallecula, then the epiglottis, then the glottis as an inverted “V” of white vocal folds, with the arytenoids posterior. The esophagus sits behind the arytenoids.

Laryngoscopic view, labeled (schematic) ANTERIOR POSTERIOR 1 2 3 4 5 6 7
  1. 1Vallecula — Mac blade tip sits here
  2. 2Epiglottis
  3. 3Vocal fold (true cord)
  4. 4Glottic opening → trachea
  5. 5Arytenoid cartilage
  6. 6Interarytenoid notch (posterior)
  7. 7Esophagus — posterior, never the target

Cormack–Lehane grades

Cormack–Lehane grades I–IV (schematic) Grade I Full view of the glottis Grade II Posterior glottis only Grade III Epiglottis only Grade IV No epiglottis or glottis
  • Grade 1 full glottis · 2 partial (modified: 2a part of the cords, 2b arytenoids only) · 3 epiglottis only (3a liftable / 3b adherent) · 4 no epiglottis.
  • POGO (percent of glottic opening seen, 0–100%) is handy with video laryngoscopy. A great screen view doesn’t guarantee easy tube delivery.

Original schematic diagrams made for this guide.

Devices

Macintosh (curved) blades: tip goes in the vallecula; lift along the handle to indirectly raise the epiglottis.

Figure: Macintosh Blades — Sasata, CC BY 3.0, via Wikimedia Commons. Converted to WebP; metadata removed.

Miller (straight) blades: tip lifts the epiglottis directly — useful for a floppy epiglottis or anterior larynx.

Figure: Laryngoscopes – Miller blades — DiverDave, CC BY 3.0, via Wikimedia Commons. Resized and converted to WebP.

What you’ll use at LA General: disposable Polaris MAC 4 on a DispoLED handle.
Supraglottic airways: classic LMA with an inflatable cuff (left) vs. i-gel with a non-inflatable gel cuff (right). Follow the specific product’s instructions.

Figure: Masques laryngés – LMA Unique et i-gel — CYP3A42D6, CC BY-SA 4.0, via Wikimedia Commons. Resized and converted to WebP.

DeviceStudent pearls
Video laryngoscopeWatch the tube enter the mouth, then switch to the screen. Hyperangulated blades need a stylet bent to match.
BougieFeel the “clicks” over tracheal rings; railroad the tube over it, rotating 90° counter-clockwise.
Oral airwaySize: corner of the mouth to the angle of the jaw.
Nasal airwaySize: nare to tragus. Avoid with basilar skull fracture or coagulopathy.

The endotracheal tube

Endotracheal tube anatomy 262422201816 15 mm connector Pilot balloon + valve (syringe here) Depth markings (cm at the teeth) Cuff Murphy eye Bevel Stylet — tip stays inside, short of the cuff/tip Radiopaque line runs the length of the tube

Supervised sequence

  • Position: sniffing (neck flexed, head extended); ramped in obesity — ear level with the sternal notch.
  • Pre-oxygenate: tight seal, 3 min tidal breathing or 8 vital-capacity breaths; head-up helps; target end-tidal O₂ ≥ 0.9 if displayed.
  • Mask ventilation — C-E grip: thumb and index finger make a “C” on the mask; middle, ring and little fingers make an “E” lifting the mandible. Two hands + jaw thrust + oral airway if difficult.
  • Laryngoscopy: enter right, sweep the tongue left, lift along the handle. External laryngeal manipulation (BURP) if the team directs.
  • RSI concepts (for discussion): pre-oxygenation, induction + rapid paralytic, minimal/gentle mask ventilation; cricoid pressure is debated. The team decides based on aspiration risk.

What to say — practice aloud

  1. 1. Brief the team

    Agree on your role, the primary and backup device, the oxygenation plan, and exactly when you hand over.

    “What would you like me to attempt, and when should I hand over?”

  2. 2. Prepare & oxygenate

    Position (sniffing, or ramped in obesity), suction on, checked equipment, tight mask seal. Follow the team’s pre-oxygenation plan.

    “Suction’s working, the backup is here. I’m having trouble with the seal — can you help?”

  3. 3. Describe the view

    Enter on the right, sweep the tongue left, find the epiglottis first, then the glottic landmarks. Lift along the handle — never lever on the teeth.

    “I see the epiglottis… I see arytenoids but not the cords.”

  4. 4. Report progress

    Advance only under the agreed view and direct supervision. Stop for resistance, loss of view or a handover request.

    “The tube is meeting resistance — I’m stopping.”

  5. 5. Confirm & hand over

    Hold the tube while the team checks sustained waveform ETCO₂ and clinical signs. Report an absent or equivocal trace immediately.

    “Tube passed through the cords — I’m holding it. Do we have a CO₂ trace?”

Confirming placement

See the capnography patterns →

Difficult-airway guidelines

ASA 2022 (Apfelbaum et al.) and LA General policy govern practice here. The UK DAS 2025 guideline (Ahmad et al., BJA 2026) is a clear teaching framework:

  • Continuous oxygen delivery throughout
  • Maximize first-attempt success
  • Confirm ventilation with waveform capnography
  • Progress through Plan A (intubation) → B (supraglottic airway) → C (face-mask) → D (front-of-neck airway)
  • Multidisciplinary teamwork
ASA 2022 guideline DAS 2025 algorithms

This is education, not an emergency algorithm. In a real airway emergency the supervising team leads.

Name the landmark

Use the labeled view above. Tap your answer.

Pimp questions

Pimp question 1
Mallampati vs Cormack–Lehane — what’s the difference?
Answer
Mallampati is an awake bedside exam of the oral cavity; Cormack–Lehane grades the laryngeal view during laryngoscopy.
Pimp question 2
Where does the tip of a Mac blade go? A Miller?
Answer
Mac: into the vallecula (indirect epiglottis lift). Miller: under the epiglottis, lifting it directly.
Pimp question 3
Best confirmation of tracheal intubation?
Answer
Sustained waveform ETCO₂ over several breaths, with clinical signs.
Pimp question 4
Why ramp an obese patient?
Answer
Aligns the airway axes (ear to sternal notch) and improves pre-oxygenation and apnea time.
Pimp question 5
Which way do you rotate the tube when railroading over a bougie, and why?
Answer
90° counter-clockwise so the bevel doesn’t catch on the right arytenoid.
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