3-3-2 rule - stat pearls

Regla 3-3-2 para intubación

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.
3-3-2 Rule
Authors
Sandeep Sharma; Rotem Friede.
Affiliations
Baptist Regional Medical Center
Mercy Catholic Medical Center
Last Update: March 8, 2019.
Introduction
The airway is one of the most important components in the body to be protected regardless of why a patient is in a
hospital, whether for outpatient surgery or admission to the (ICU) intensive care unit for observation and therapy. For
this reason, when a physician considers intubation, it is essential that they evaluate the risk of failure to intubate and
optimize variables for success. One percent to 3% of the patient population that requires endotracheal intubation has
difficult airways. Recognizing these patients is crucial as it allows the clinician to prepare accordingly to minimize
complications. The 3-3-2 rule is an assessment tool for the prediction of difficult intubations in the unexpected
difficult airway.[1][2][3]
According to the American Society of Anesthesiologists, intubation is determined to be difficult to secure when an
appropriately trained and experienced anesthesiologist requires more than 3 attempts or longer than 10 minutes for
successful endotracheal intubation. Similarly, ventilation is determined to be difficult when a trained clinician is
unable to maintain an oxygen saturation of more than 90% when a facemask is being used for ventilation, and 100%
FIO2 is used for oxygenation.
The airway should be managed in a very time-sensitive way as poor oxygenation or ventilation can lead to hypoxic
and hypercapnic abnormalities. This can be detrimental at the cellular level. Hypoxic brain injury can lead to
permanent neuronal injury and acidosis due to hypoxia and hypercapnia which together can lead to cardiac arrest or
death.
Function
The 3:3:2 rule functions to estimate whether the anatomy of the neck will allow for appropriate opening of the throat
and larynx. It serves to roughly estimate if the alignment of the openings for direct visualization of the larynx is
possible given anatomical findings.[3]
3: A measurement of 3 fingers between the upper and lower teeth of the open mouth of a patient indicates the ease of
access to the airway through the oral opening. A typical patient can open their mouth sufficiently to permit 3 of their
fingers to be placed between the incisors. Adequate mouth opening facilitates both insertions of the laryngoscope and
obtaining a direct view of the glottis.
3: A measurement of 3 fingers from the anterior tip of the mandible to the anterior neck provides an estimate of the
volume of the submandibular space. A typical patient can place three fingers on the floor of the mandible between the
mental angle and the neck near the hyoid bone. Normally this distance should measure close to 7 cm. If this distance
is shorter than 3 finger widths, the laryngeal axis will be at a more acute angle with the pharyngeal axis, indicating
that alignment of the oral opening to the pharyngeal opening will be difficult. It also indicates that there will be less
space to displace the tongue within the throat. The rule has limitations as the distance can vary according to height
and ethnicity. For this reason, an alternative in the form of a ratio of height to thyromental distance (RHTMD) has
been suggested.
1 2
1
2

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2: A measurement of 2 fingers between the floor of the mandible to the thyroid notch on the anterior neck identifies
the location of the larynx relative to the base of the tongue. A typical patient can place two fingers in the superior
laryngeal notch. If the larynx is too high in the neck, measuring less than 2 fingers, direct laryngoscopy will be
difficult and possibly impossible. This is because the angle between the base of the tongue to the larynx is too acute to
be negotiated for direct visualization of the larynx easily.
A likely indication of difficult intubation is present if the inter-incisor or hyoid-mental distance is less than three
fingers or the hyoid-thyroid cartilage distance is less than two fingers. Depending on the patient population, a difficult
intubation is reported in 1.5% to 13% of patients. When combined with the Mallampati score in evaluating an
airway, the positive predictive value for determining a difficult airway increases.
Additional estimations to be considered in preparing for intubation of a patient should include:
Assessment of atlanto-occipital extension is performed by asking the patient to look at the floor and the wall after
fully flexing and fixing the neck. Flexion movement of the cervical spine is assessed by asking the patient to touch
the manubrium sterni with the chin. If successful, this indicates that the flexion and extension range of motion is
sufficient to help in aligning the oral pharyngeal and laryngeal axis in a straight line, thus indicating easier
intubation.
A combined assessment of the mandibular space with the 3:3:2 rule and atlanto-occipital extension will further
determine how easily the laryngeal and pharyngeal axis will fall in line with the atlantoaxial joint during extension of
the neck.
The Warning sign of delicate is performed by placing the index finger of each hand, one submental, under the chin,
and the other under the inferior occipital prominence with the head in the neutral position. The patient is then asked to
fully extend their head and neck. If the submental finger is seen to be higher than the inferior occipital prominence
finger, there should be no difficulty with intubation. If the finger on the inferior occipital prominence is still higher
than the submental finger, a difficult airway should be anticipated.
Prayer sign is positive when the patient cannot approximate the palmar surfaces of the phalangeal joints while
pressing the hands together. This is seen in advanced diabetes and has a very high positive predictive value for
cervical spine immobility and thus difficult endotracheal intubation.
Clinical Significance
Recognizing that patient’s airway will be difficult allows the clinician to plan for and minimize the risks of airway-
related morbidity. 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. The 3:3:2 rule plays a crucial role in planning as a component of the LEMON scale. [4] LEMON stands
for:
L: Look externally
Look for external indicators of difficult endotracheal intubation. Which can include the abnormal shape of the face,
extreme cachexia, poor dentition, edentulous mouth, morbid obesity, high arching palate, short neck, large front teeth,
surgical scar indicating previous tracheostomy scar, indicating patient might have tracheomalacia, narrow mouth,
face, or neck pathology.
E: Evaluate
This is where the 3:3:2 rule is important. It is the estimated measurement of 3 separate distances on the patient using
the examiner's fingers.
3: Measurement of the Inter-incisor space, which should be greater than three fingers distance between the upper and
lower teeth of the open mouth of a patient.

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1.
3: Measurement of the hyoid-mental distance, which should be greater than three fingers from the anterior tip of the
mandible to the anterior neck on the hyoid bone.
2: Measurement of the hyoid-thyroid cartilage distance, which should be greater than two fingers between the floor of
the mandible at the hyoid bone to the thyroid notch on the anterior neck.
M: Mallampati Scoring
Mallampati scoring is a system based on the anatomy of mouth and the view of various anatomical structures when
one opens his or her mouth as wide as possible. The scoring is done in a sitting position and cannot be performed in
an emergency situation. A class I score is interpreted as easy, and class IV is the most difficult.[5][6][7]
Class I: Structures visualized- soft palate, uvula, fauces, anterior and posterior pillars
Class II: Structures visualized- soft palate fauces and uvula
Class III: Structures visualized- soft palate and the base of the uvula
Class IV: Soft palate is not visible
O: Obstruction
One should assess if the airway could be obstructed with the foreign body, abscess, tumor, soft tissue swelling such as
in a burn victim or expanding hematoma in a trauma patient.
N: Neck Mobility
In alert and awake patients, see if the patient can place their chin on their chest and how far backward are they able to
tilt their head. Decreased neck mobility is a negative predictor of intubation complication.
Other Issues
Pearls
It is essential to anticipate when a difficult airway may occur. Many patients that otherwise appear normal/easy
to intubate may prove difficult. The 3:3:2 rule can help to anticipate complications.
The 3:3:2 rule is useful, but its significance is greater when combined with the Mallampati score.
The 3:3:2 rule along with other estimations does not play a role in emergent intubations.
Enhancing Healthcare Team Outcomes
The airway is one of the most important components in the body to be protected regardless of why a patient is in
a hospital, whether for outpatient surgery or admission to the (ICU) intensive care unit for observation and
therapy. For this reason, when a physician considers intubation, it is essential that they evaluate the risk of failure to
intubate and optimize variables for success. Besides anesthesiologists, physicians in many specialties and nurse
anesthetists, as well as the clinical pharmacist, are often called upon to assist in the preparation and intubation of a
patient, but they should be fully aware of the 3-3-2 rule. Failure to intubate on a timely basis is a very common cause
of cardiac arrest. In view of this, an anesthesiologist should always be consulted if a difficult airway is anticipated.
Sometimes, oral intubation may not be possible and an emergent tracheostomy may be required.[8][9][10]
Questions
To access free multiple choice questions on this topic, click here.
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