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Insights on Innovation
by Dan White

Airway Class vs. Airway Grade: Know the distinction

Understanding the difference can sometimes make all the difference

Clinicians, like paramedics who intubate patients with poor airway control, will use a few ways to describe the condition of the airway before beginning laryngoscopy, such as a Mallampati Score or Cormack-Lehane Grading. It may be easy to think that one evaluation method is like another, and use them interchangeably. It's better to know that each one provides information about the airway that is distinct from the other.

Airway Class is what you see when looking in the mouth. It’s a means of predicting difficult intubation, and is measured as a Mallampati Score based on how much room there is inside the mouth.

Airway Grade is what you see in the posterior pharynx with a laryngoscope. It is a more accurate measure of how much trouble you are going to have passing a tube, and is evaluated with a Cormack-Lehane Score.

Both are easy to do

Keeping score with ‘class’

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.

Getting good ‘grades’

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

If you see the entire glottis after positioning the laryngoscope, that is a Grade 1 Airway. If you have a partial view, that’s a Grade 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.

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.

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, which often makes it challenging to get a Mallampati Score for Airway Class before attempting intubation.

There is one important exception and that’s when we do rapid sequence intubation (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.

Remember, Class and Grade don’t always correlate. They are not interchangeable or different ways of saying the same thing.

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.

I hope that clears up any confusion about what these two different scores really mean.

About the author

Dan White, EMT-P works for Intersurgical, Inc. as the National Account Manager for EMS. Immediately prior he ran Arasan, LLC. He served as Sales & Marketing Director for Truphatek, Inc. and before that Director of Corporate Planning & Product Development for AllMed. He has been certified as a paramedic since 1978 and an EMS and ACLS instructor since 1981. Dan has designed many emergency medical products since his first, the White Pulmonary Resuscitator, including the Prolite Speedboad, Cook Needle Decompression Kit and RapTag Triage System. His more recent EMS product designs are the Arasan Ultra EMS Coat and the B2 Paramedic Helmet. To contact Dan, email

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Jeff Levy Jeff Levy Friday, April 04, 2014 5:39:36 PM Just a sidenote. There are specific anatomic structures that are defining characteristics of each of the four Mallampati scores. It is generally accepted that a MP 1 or 2 is 'predictive' of or correlates with a Cormack-Lehane grade 1 or 2 view. Additionally, it is generally accepted that a MP 3 or 4 is suggestive of a more difficult intubation with less or no glottic view. I would like to point out that comparing a MP 1 and MP 2, for example does not imply that the MP 1 will give you a grade 1 view rather than a grade 2 view, nor does a MP 2 imply that your view will be that of a grade 2 view. MP class is simply a predictor of difficulty of intubation, not of a direct correlation of glottic view grade. For me, personally (I am a CRNA and also an EMT-P), I am interested not only in MP class, but more specifically interested in thyromental distance (more of a predictor of an anterior larynx), dentition ( are the teeth loose, chipped, cracked, broken, protruding/buckteeth or even present, i.e. dentures), the degree of mouth opening and the degree of flexion and extension of the neck. I piece all of this information together to decide which blade I use for my laryngoscopy and which one is my back up. I use a Miller 2 or Mac 3 for almost ALL of my intubations. Lastly, do not forget that proper patient positioning can make or break an intubation attempt. Having the patient ALL THE WAY AT THE TOP OF THE BED, having the earlobe at the same level as the sternum (especially important with the obese as this helps align pharyngeal axes) often requires 'ramping' the patient up on multiple folded blankets. When you insert the blade, you may need to lift the head with your right hand and move the head up and down, or tilt the head back or forth. Utilize the additional manpower (or your partner or bystanders) to hold the head right where you tell them to (same technique for BURP or cricoid pressure - sometimes you need to adjust it to optimize your view and have someone hold it 'right there') and then free your right hand to pass the tube.
Rob Frazier Rob Frazier Saturday, April 05, 2014 8:28:55 PM Great points, Jeff! I also highly agree that positioning is one of the best tools we have in proper airway visualization and management. Moreover, you have some pretty valid points with regard to Cormack-Lehane grading not necessarily correlating with a specific Mallampatti view. Thanks for your input.
Dan White Dan White Sunday, April 06, 2014 10:05:27 AM Excellent points Jeff Levy.
Dan White Dan White Thursday, May 08, 2014 1:39:00 PM You have been trained right. The best anesthesiologist I ever met uses a #2 Miller on almost everybody .

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