The Difference Between Airway Class and Airway Grade

Airway Class is what you see looking in the mouth; Airway Grade is what you see with a laryngoscope. Class is determined looking in the mouth, Grade is what you see looking in the posterior pharynx.

Airway Class is a means of predicting difficult intubation; Grade is a more accurate measure of how much trouble you are going to have passing a tube.

Class is measured in Mallampati Score; Grade is measured in Cormack-Lehane Score. Both are easy to do.

Ask the patient to open their mouth wide and protrude their tongue. If you see a lot of room and can visualize the soft palate, uvula, the faucial pillars (the arches over the tonsils), and soft palate that is a Mallampati Class 1.

If you see only see the soft palate, uvula, and faucial pillars, that’s a Class 2. If you only see a little room, usually just the soft palate and base of the uvula, that’s a Class 3. If all you see is the tongue and hard palate that’s a Class 4.

Mallampati is for predicting how much trouble you might have intubating, if the patient is a Mallampati Class 3 or 4, get ready for a challenge.

Have all your equipment prepared before attempting including your back up airway devices. You might be well served to go straight to a video-laryngoscope on your  first attempt if you have one. Don’t wait for a failure, prepare for it.

Cormack-Lehane Grading is done with a laryngoscope. It is what you see when performing direct laryngoscopy. It is a more accurate way of predicting the actual difficulty of putting a tube in. It is also used to document how tough the airway really is.

It too is easy to do. When you scope the patient if you see the entire glottis that is a Grade 1 Airway. If you have a partial view, that’s a 2. If you can only see the epiglottis, that’s a Grade 3. If you cannot see the epiglottis, that’s a grade 4 or very difficult.

In EMS most patients that we intubate are unconscious and/or non-breathing. That makes it tough to have them open their mouth for us. This translates into challenges getting a Mallampati Score before we attempt intubation in many situations.

There is one important exception and that’s when we do RSI. Medics should always assess Mallampati before pushing the syringe plunger. Take an extra few seconds to know what you are getting into before you jump off the deep end.

I hope that clears up confusion about what these two different scores really mean. They are not interchangeable or different ways of saying the same thing. Sometimes they don’t correlate.

A Mallampati Class 1 is not always a Cormack-Lehane Grade 1 airway. Neither is a Mallampati Class 4 always a nearly impossible intubation, it just flags you to consider the possibility early enough to be ready for it.


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About Dan White

I'm a retired Paramedic and EMS Instructor with 35 years EMS and emergency medical product experience. I love canoes, cars and EMS. I write about EMS Technology on the Paramedic Blog, the Insights on Innovation column for, on and I work for Intersurgical, Inc. managing EMS sales and distribution. I can be reached directly at 573-240-0002. Follow me @Paradan on Twitter
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2 Responses to The Difference Between Airway Class and Airway Grade

  1. It is important to note that Mallampati class and CL grade often do not correlate. It is possible to have a Grade 1 CL with a Mallampati 1 and vice versa. Mallampati is a good assessment though. At a minimum it gives the operator the affirmation that (A) the mouth can be opened and (B) and approximation of possible difficulty.

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