Modified Mallampati Classification

Why Use

Simple to use at the bedside, can be performed in less than a minute, and has good accuracy (AUC 0.83, Lee 2006 ) at predicting difficult airway (difficult laryngoscopy, difficult intubation, or difficult ventilation).

When to Use

Patients requiring endotracheal intubation.

Formula

Pearls / Pitfalls

The original Mallampati Classification had three classes of visualization, but a fourth was later added by Samsoon and Young (1987) and shown to have greater predictive value, and is the version most commonly used today. While the Mallampati Classification is usually determined with the patient sitting up, a recent prospective cohort study suggests that evaluating the patient supine may better predict difficult intubation (AUC 0.82 supine over 0.7 while sitting, Hanouz 2018 ). A class 0 has been proposed by Ezri et al (1998) to denote “extremely easy” intubation, but evidence supporting its accuracy is limited to case reports. A low score may predict easy laryngoscopy and intubation, but it does not guarantee it. While a high score should prompt caution, a low score is not intended to provide reassurance.

Management

For airways anticipated or identified to be difficult, consider involving other airway specialists early, and identify alternatives to endotracheal intubation such as laryngeal mask airway, bougie-guided intubation, or other adjuncts.

Critical Actions

In any intubation, especially in an emergency setting, determine the “Plan B” and “Plan C” if initial attempts fail before starting the procedure, whenever possible.

Advice

Consider strategies to improve ease of intubation in patients with a predicted difficult airway (class III-IV), e.g. video-assisted laryngoscopy, awake intubation.