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ASA Physical Status (ASA-PS) Grading

The American Society of Anesthesiologists Physical Status classification grades a patient's preoperative systemic health. It communicates perioperative risk and helps in planning anaesthetic care. It is not, by itself, a measure of operative difficulty or a complete predictor of outcome.

Grade	Definition	Typical examples
ASA I	Normal healthy patient	Healthy, non-smoker, minimal/no alcohol use
ASA II	Mild systemic disease without substantive functional limitation	Controlled hypertension or diabetes, current smoker, pregnancy, BMI 30-39.9 kg/m², mild asthma
ASA III	Severe systemic disease with substantive functional limitation	Poorly controlled hypertension/diabetes, COPD, morbid obesity (BMI ≥40), dialysis-dependent ESRD, previous MI or stroke more than 3 months ago
ASA IV	Severe systemic disease that is a constant threat to life	Recent MI/CVA/TIA, ongoing ischaemia, decompensated heart failure, severe valve disease, sepsis, shock, ARDS, severe reduction in ejection fraction
ASA V	Moribund patient not expected to survive without the operation	Ruptured abdominal aortic aneurysm, massive trauma, intracranial bleed with mass effect, perforated viscus with severe physiological derangement
ASA VI	Declared brain-dead patient undergoing organ retrieval for donation	Brain-dead organ donor

Emergency modifier: E

Add E to the grade if delay in treatment would significantly increase the threat to life or a body part.

Examples:

ASA I E: otherwise healthy patient needing emergency appendicectomy.
ASA IV E: septic shock requiring emergency laparotomy.

Key points

ASA-PS is assigned after pre-anaesthetic assessment, based mainly on the patient's comorbidities and functional impact.
Higher ASA class generally correlates with a higher rate of perioperative complications and mortality.
The grade does not indicate the complexity of surgery, airway difficulty, or whether the procedure is elective versus emergency. Emergency status is shown separately with E.

Source: Schwartz's Principles of Surgery, 11th ed., p. 2061. The ASA official classification statement provides the current definitions and example conditions.

23 page short note on ASA grade

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ASA Physical Status (ASA-PS) Classification

Introduction

The American Society of Anesthesiologists Physical Status (ASA-PS) Classification System is a grading system used during pre-anaesthetic assessment to describe a patient’s overall physical condition and severity of systemic disease. It helps communicate the patient’s comorbidities, estimate perioperative risk, guide anaesthetic planning, and provide a uniform language among clinicians.

It was introduced by the American Society of Anesthesiologists in 1941 and has since been revised. The patient is assigned one of six classes, from ASA I to ASA VI. The suffix “E” is added when surgery is performed as an emergency.

ASA Grades

ASA grade	Definition	Examples
ASA I	A normal healthy patient	Healthy non-smoker, no significant medical illness, minimal or no alcohol intake
ASA II	A patient with mild systemic disease	Well-controlled hypertension or diabetes, current smoker, social alcohol use, uncomplicated pregnancy, mild asthma, obesity with BMI 30-39.9 kg/m²
ASA III	A patient with severe systemic disease causing substantive functional limitation	Poorly controlled hypertension or diabetes, COPD, morbid obesity with BMI ≥40 kg/m², stable angina, dialysis-dependent chronic kidney disease, history of MI or stroke more than 3 months previously
ASA IV	A patient with severe systemic disease that is a constant threat to life	Recent MI, stroke or TIA within 3 months, ongoing myocardial ischaemia, decompensated heart failure, severe valvular heart disease, septic shock, ARDS, severe reduction in ejection fraction
ASA V	A moribund patient who is not expected to survive without the operation	Ruptured abdominal aortic aneurysm, massive trauma, intracranial haemorrhage with mass effect, perforated viscus with shock, ischaemic bowel with multiorgan dysfunction
ASA VI	A declared brain-dead patient whose organs are being removed for donor purposes	Brain-dead organ donor for organ retrieval

Emergency Modifier: “E”

The suffix E is attached to the ASA grade when an emergency procedure is required.

An emergency is a condition in which delaying treatment would lead to a significant increase in threat to the patient’s life or a body part.

Examples:

ASA I E: Healthy patient with acute appendicitis requiring emergency appendicectomy.
ASA III E: Patient with COPD and poorly controlled diabetes requiring emergency laparotomy.
ASA IV E: Patient in septic shock undergoing emergency surgery for perforation peritonitis.
ASA V E: Patient with ruptured abdominal aortic aneurysm requiring immediate repair.

Importance and Uses

Risk assessment:
Higher ASA grade is associated with increased perioperative morbidity and mortality.
Anaesthetic planning:
It helps the anaesthetist decide the appropriate type of anaesthesia, monitoring, postoperative observation, and need for intensive care.
Communication:
It provides a common, simple description of the patient’s preoperative status to surgeons, anaesthetists, and other team members.
Audit and research:
ASA grade is commonly used in surgical audits, outcome studies, and comparison of patient populations.
Resource planning:
Patients with ASA III or higher may require invasive monitoring, optimisation before surgery, blood products, ICU care, or postoperative high-dependency monitoring.

Limitations

ASA-PS is based primarily on the patient’s systemic illness, not on the complexity or magnitude of surgery.
It does not assess difficult airway, anticipated blood loss, surgical duration, or technical difficulty of the procedure.
Assignment may vary between clinicians, especially in borderline cases.
It should not be used as the only predictor of postoperative outcome. Age, urgency, type of surgery, functional capacity, nutritional status, and intraoperative events also influence risk.
Final grading is a clinical decision of the anaesthetist after assessing the patient.

Conclusion

ASA-PS classification is an important part of preoperative evaluation. It grades patients from ASA I, a healthy patient, to ASA VI, a brain-dead organ donor. The emergency suffix E indicates that delay in surgery would endanger life or limb. Although it is useful for communicating comorbidity and estimating perioperative risk, it should always be interpreted along with the nature and urgency of surgery and the patient’s full clinical condition.

Source: Schwartz’s Principles of Surgery, 11th ed., p. 2061. The current examples align with the ASA classification guidance.

3 page short note on ASA grade

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ASA Physical Status (ASA-PS) Grading

Introduction

The American Society of Anesthesiologists Physical Status (ASA-PS) Classification System is a simple method of grading the physical condition of a patient before administration of anaesthesia and surgery. It categorizes patients according to the presence and severity of systemic disease.

It is widely used in preoperative assessment to:

Communicate the patient’s general health and comorbidities.
Assist in anaesthetic planning and perioperative preparation.
Estimate the likelihood of perioperative complications.
Help decide the need for optimisation, invasive monitoring, high-dependency care, or ICU admission.
Provide a common standard for audit, research, and documentation.

ASA-PS grades range from ASA I to ASA VI. An additional suffix, E, is added for emergency procedures.

Important: ASA grade reflects the patient’s preoperative physical status, not the magnitude or technical difficulty of surgery.

ASA Physical Status Grades

Grade	Definition	Examples
ASA I	Normal healthy patient	Healthy non-smoker, no systemic illness, minimal/no alcohol consumption
ASA II	Patient with mild systemic disease	Controlled hypertension, controlled diabetes, mild asthma, current smoker, social alcohol use, uncomplicated pregnancy, BMI 30-39.9 kg/m²
ASA III	Patient with severe systemic disease with substantive functional limitation	Poorly controlled diabetes or hypertension, COPD, morbid obesity, stable angina, dialysis-dependent chronic kidney disease, prior MI or stroke more than 3 months earlier
ASA IV	Patient with severe systemic disease that is a constant threat to life	Recent MI/CVA/TIA, active myocardial ischaemia, severe cardiac failure, severe valve disease, sepsis, shock, ARDS, severe reduction in ejection fraction
ASA V	Moribund patient not expected to survive without the operation	Ruptured aortic aneurysm, massive trauma, intracranial bleed with mass effect, bowel ischaemia with multiorgan dysfunction
ASA VI	Declared brain-dead patient whose organs are being removed for donation	Brain-dead organ donor

ASA I: Normal Healthy Patient

Definition: A patient with no systemic disease.

These patients are generally fit, have normal functional capacity, and do not have clinically important medical illness.

Examples

Healthy young adult for hernia repair.
Healthy non-smoker presenting for elective appendicectomy after recovery from acute illness.
Patient with isolated local surgical disease, such as an uncomplicated lipoma, without any relevant systemic illness.

Points to remember

A healthy person with no medical disease is ASA I.
The type of surgery alone does not increase the ASA class.
Advanced age alone does not necessarily make a patient ASA II or III. It is the associated systemic illness and functional state that determine the grade.

ASA II: Mild Systemic Disease

Definition: A patient with mild systemic disease that does not cause substantive functional limitation.

The patient has a medical condition, but it is usually well controlled and does not significantly limit everyday activity.

Examples

Well-controlled hypertension.
Controlled diabetes mellitus without end-organ damage.
Mild, well-controlled asthma.
Current smoker.
Social alcohol consumption.
Uncomplicated pregnancy.
Obesity with BMI 30-39.9 kg/m².
Mild anaemia.
Stable hypothyroidism on treatment.

Example

A 45-year-old patient with well-controlled hypertension on one drug, normal exercise tolerance, and planned elective cholecystectomy is ASA II.

Key distinction

ASA II disease is mild and controlled. The patient has no major limitation in normal daily activities.

ASA III: Severe Systemic Disease

Definition: A patient with severe systemic disease causing substantive functional limitation, but which is not an immediate constant threat to life.

These patients have significant disease that may affect anaesthetic management and increase postoperative complications.

Examples

Poorly controlled hypertension.
Poorly controlled diabetes mellitus.
Diabetes with end-organ damage, such as nephropathy or neuropathy.
COPD with exercise limitation.
Morbid obesity, BMI ≥40 kg/m².
Stable angina.
Previous MI, stroke, or TIA more than 3 months previously.
Chronic kidney disease requiring regular dialysis.
Compensated cirrhosis.
Pacemaker in situ with stable cardiac condition.

Example

A patient with COPD who develops breathlessness while walking short distances, but is stable on treatment and is posted for surgery, is ASA III.

Significance

ASA III patients require careful preoperative optimisation. Anaesthetic plans may include:

Better control of hypertension, diabetes, lung disease, or heart failure.
Assessment of functional capacity.
Appropriate investigations such as ECG, echocardiography, pulmonary function tests, or renal function tests when indicated.
Planning for enhanced postoperative monitoring.

ASA IV: Severe Systemic Disease That Is a Constant Threat to Life

Definition: A patient with severe systemic illness that poses a continuing threat to life.

The disease is poorly controlled, unstable, or associated with major organ dysfunction. Even without surgery, the patient is at high risk.

Examples

Recent myocardial infarction, stroke, or TIA within 3 months.
Ongoing myocardial ischaemia.
Decompensated congestive cardiac failure.
Severe valvular heart disease.
Severe reduction in left ventricular ejection fraction.
Sepsis or septic shock.
Disseminated intravascular coagulation.
Acute respiratory distress syndrome.
ESRD not receiving regular dialysis.
Uncompensated cirrhosis.
Severe respiratory distress.

Example

A patient with severe heart failure who is breathless at rest and requires urgent surgery for intestinal obstruction is ASA IV.

Significance

ASA IV patients have a high perioperative risk. They may need:

Optimisation or resuscitation before surgery, if time allows.
Invasive arterial blood-pressure monitoring.
Central venous access or advanced haemodynamic monitoring in selected cases.
Postoperative ventilatory support.
Admission to ICU or high-dependency unit.

ASA V: Moribund Patient

Definition: A moribund patient who is not expected to survive without the operation.

The patient has a life-threatening condition, and surgery is required as a life-saving measure.

Examples

Ruptured abdominal or thoracic aortic aneurysm.
Massive trauma with shock.
Massive intracranial haemorrhage with raised intracranial pressure and mass effect.
Intestinal ischaemia with severe cardiac disease or multiorgan dysfunction.
Perforation peritonitis with profound septic shock.
Severe ruptured ectopic pregnancy with haemorrhagic shock.

Example

A patient in shock due to a ruptured abdominal aortic aneurysm who needs immediate surgery is ASA V E.

Significance

The prognosis is poor even with surgical intervention. Resuscitation and surgery often proceed simultaneously because delaying surgery may be fatal.

ASA VI: Brain-dead Organ Donor

Definition: A declared brain-dead patient whose organs are being removed for donor purposes.

Example

A brain-dead patient undergoing organ retrieval for kidney, liver, heart, or lung donation is classified as ASA VI.

This grade does not apply to a critically ill patient with poor neurological function who has not been formally declared brain-dead.

Emergency Modifier: ASA “E”

The suffix E denotes an emergency operation. It is added after the numerical ASA grade.

An emergency exists when delay in treatment would lead to a significant increase in the threat to the patient’s life or a body part.

Examples

Classification	Clinical example
ASA I E	Healthy patient requiring urgent appendicectomy for acute appendicitis
ASA II E	Patient with controlled hypertension requiring emergency surgery for fracture with vascular compromise
ASA III E	Patient with COPD and chronic kidney disease requiring emergency laparotomy
ASA IV E	Patient with septic shock from perforation peritonitis undergoing emergency surgery
ASA V E	Patient with ruptured abdominal aortic aneurysm requiring immediate repair

The emergency suffix indicates urgency of surgery, whereas the ASA number indicates severity of the patient’s systemic illness.

Clinical Importance of ASA Grading

1. Assessment of perioperative risk

With increasing ASA grade, the risk of perioperative morbidity and mortality rises. Patients in ASA III, IV, and V have greater risk of cardiovascular, respiratory, renal, and infectious complications.

2. Anaesthetic planning

The grade helps plan:

Choice of general, regional, or local anaesthesia.
Need for preoperative optimisation.
Requirement for blood products and vascular access.
Need for invasive monitoring.
Need for postoperative observation in HDU or ICU.

3. Communication

ASA grade provides a quick and standard description of the patient’s systemic health to surgeons, anaesthetists, nurses, and intensivists.

4. Audit and research

It is commonly used to compare outcomes among surgical patients and to adjust for preoperative risk in clinical studies.

Limitations of ASA Classification

Although useful, ASA grading has limitations:

It does not measure the complexity or duration of surgery.
It does not indicate anticipated blood loss.
It does not predict airway difficulty.
It does not include all risk factors, such as age, nutrition, frailty, functional capacity, or type of procedure.
There may be variation between clinicians in assigning grades, particularly between ASA II and III.
It should not be used as the sole predictor of postoperative outcome.

Thus, ASA grade must be interpreted along with clinical examination, investigations, functional status, urgency and magnitude of surgery, and the expected physiological stress of the procedure.

Conclusion

ASA-PS grading is an essential component of preanaesthetic evaluation. It classifies patients from ASA I, a healthy patient, to ASA VI, a brain-dead organ donor, based on systemic disease severity. The E modifier is used for emergencies. It is useful for risk communication and perioperative planning, but it is not a complete measure of surgical or anaesthetic risk.

Source: Schwartz’s Principles of Surgery, 11th ed., p. 2061. Current examples are consistent with the ASA physical-status guidance.

3 page short note on mpg grading

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Modified Mallampati Grading (MPG)

Introduction

Modified Mallampati grading (MPG) is a simple bedside test used during pre-anaesthetic airway assessment. It estimates the amount of visible oropharyngeal space and helps identify patients who may have difficult direct laryngoscopy or tracheal intubation.

The principle is that a relatively large tongue or reduced oral-pharyngeal space obscures pharyngeal structures. As fewer structures are visible, the likelihood of difficult laryngoscopy generally increases.

MPG is a screening test, not a definitive test. It should always be interpreted together with other airway findings.

Technique of Examination

The examination should be done as follows:

Patient is seated upright.
Head is kept in the neutral position.
The patient opens the mouth as widely as possible.
The tongue is protruded maximally.
The patient should not phonate or say “ah,” because phonation elevates the soft palate and can produce a falsely favourable grade.
The examiner observes the visible structures in the oral cavity and oropharynx.

The visible structures assessed are:

Hard palate
Soft palate
Faucial pillars
Uvula
Tonsillar fauces

Modified Mallampati Grades

Grade	Structures visible	Interpretation
Grade I	Soft palate, fauces, entire uvula and tonsillar pillars	Good oropharyngeal view, usually easy laryngoscopy
Grade II	Soft palate, fauces and uvula, but pillars are not visible	Usually adequate airway view
Grade III	Soft palate and base of uvula only	Reduced oropharyngeal space, possible difficult laryngoscopy
Grade IV	Hard palate only; soft palate not visible	Markedly reduced oropharyngeal space, higher likelihood of difficult laryngoscopy/intubation

Easy mnemonic: PUSH

The structures become progressively hidden from Grade I to IV:

Grade I: P U S H
Pillars, Uvula, Soft palate, Hard palate visible.
Grade II: U S H
Uvula, soft palate and hard palate visible.
Grade III: S H
Soft palate and hard palate visible.
Grade IV: H
Hard palate only visible.

Grade 0

An additional category, Mallampati Grade 0, is sometimes described.

Grade 0

Part or whole of the epiglottis is visible when the mouth is opened and tongue is protruded.
It suggests a very favourable laryngeal view and is usually associated with easy intubation.

Grade 0 is not included in the routine four-grade modified Mallampati classification.

Clinical Significance

Modified Mallampati grading is used to predict a potentially difficult airway before induction of anaesthesia.

Interpretation

Grades I and II: Usually associated with easier laryngoscopy and intubation.
Grades III and IV: Associated with increased likelihood of difficult laryngoscopy, difficult glottic visualization, and difficult intubation.

However, a Grade III or IV view does not prove that intubation will be difficult. Similarly, a Grade I or II view does not guarantee an easy intubation.

A high Mallampati grade may occur in patients with:

Large tongue
Obesity
Obstructive sleep apnoea
Reduced oral cavity volume
Craniofacial abnormalities
Restricted neck movement
Pregnancy-related airway oedema
Tonsillar enlargement or upper airway masses

Use in Pre-Anaesthetic Airway Assessment

MPG is useful because it is:

Quick
Non-invasive
Inexpensive
Easy to perform
Easily documented
Repeatable in awake cooperative patients

It is part of the routine airway assessment before general anaesthesia, especially when endotracheal intubation may be required.

A patient with Grade III or IV should alert the anaesthetist to prepare for a potentially difficult airway. This may include availability of:

Videolaryngoscope
Bougie or stylet
Supraglottic airway device
Fibre-optic intubation equipment
Skilled assistance
Emergency front-of-neck airway equipment

Limitations of Modified Mallampati Grading

Mallampati grading should not be used alone to predict difficult intubation. Its predictive accuracy is limited because difficult intubation depends on many anatomical and clinical factors.

Important limitations include:

Inter-observer variation
The grade may differ between examiners.
Patient cooperation is required
It may be difficult to assess in infants, uncooperative patients, patients with altered consciousness, facial trauma, or severe pain.
Technique affects the grade
Head position, tongue protrusion, phonation, and degree of mouth opening can alter the observed grade.
It assesses only oropharyngeal view
It does not assess neck movement, laryngeal position, mandibular size, mouth opening, or subglottic pathology.
Poor standalone prediction
A high grade raises suspicion but cannot accurately predict difficult laryngoscopy in every patient. Miller’s Anesthesia notes that the modified Mallampati classification alone is insufficient for accurate prediction of difficult intubation, but it is useful when combined with other predictors.

Other Predictors of Difficult Airway

Mallampati grade should be combined with a full airway assessment.

Assessment	Abnormal finding suggesting difficulty
Mouth opening	Inter-incisor distance <3 cm
Thyromental distance	<6-6.5 cm
Sternomental distance	Reduced distance
Neck movement	Restricted flexion or extension
Mandible	Micrognathia, retrognathia, receding chin
Upper lip bite test	Inability to bite upper lip with lower incisors
Dentition	Prominent upper incisors, loose teeth
Neck circumference	Increased circumference, especially with obesity
History	Previous difficult intubation, OSA, stridor, head-and-neck surgery or radiation

A structured approach may use the LEMON mnemonic:

L - Look externally for difficult-airway features
E - Evaluate the 3-3-2 rule
M - Mallampati grading
O - Obstruction
N - Neck mobility

Difference Between Mallampati and Cormack-Lehane Grading

This is a frequent examination question.

Modified Mallampati grading	Cormack-Lehane grading
Done before induction of anaesthesia	Done during direct laryngoscopy
Patient is awake and sitting	Patient is anaesthetised
Assesses visible oral and pharyngeal structures	Assesses laryngeal view and glottic visibility
Predicts possible difficulty	Describes actual laryngoscopic view
Grades I-IV	Grades I-IV, with modified subdivisions in some systems

Thus, Mallampati is a preoperative airway screening test, whereas Cormack-Lehane grading is an intraoperative laryngoscopic grading system.

Practical Points

Record the Mallampati grade during every pre-anaesthetic airway examination.
Use the modified four-grade system in routine clinical practice.
Perform the test with the patient sitting, mouth fully open, tongue protruded, and without phonation.
Grade III or IV should prompt detailed airway assessment and preparation for difficult airway management.
Never rely solely on MPG to decide that an airway will be easy or difficult.
A history of previous difficult intubation is often more important than Mallampati grade alone.

Conclusion

Modified Mallampati grading is a quick, widely used method of assessing the oropharyngeal view before anaesthesia. It ranges from Grade I, where the soft palate, uvula, and pillars are visible, to Grade IV, where only the hard palate is visible. Grades III and IV indicate reduced oropharyngeal space and may predict difficult laryngoscopy or intubation. However, it must be combined with mouth opening, thyromental distance, neck mobility, body habitus, airway history, and other predictors for safe airway planning.

The clinical Mallampati review similarly emphasizes using Mallampati score alongside other bedside airway assessments rather than in isolation.

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mkdir -p "/tmp/workspace/mallampati-pdf/src" "/tmp/workspace/mallampati-pdf/output" "/tmp/workspace/mallampati-pdf/assets" && python -c "import urllib.request; urllib.request.urlretrieve('https://cdn.orris.care/cdss_images/fea8ce6055b8ac28f9434ab33bd7ca920eec76f8b1147cdba5d1e4baa2309af8.png','/tmp/workspace/mallampati-pdf/assets/mallampati_source.png')"

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from reportlab.pdfbase.pdfmetrics import stringWidth
from reportlab.lib.utils import ImageReader
from PIL import Image as PILImage
from pathlib import Path

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story += [P('What is assessed?', 'H1x'), bullet('<b>Oropharyngeal visibility:</b> soft palate, uvula, fauces and tonsillar pillars.'), bullet('<b>Relative tongue size:</b> a large tongue may obscure pharyngeal structures.'), bullet('<b>Risk signal:</b> Classes III and IV prompt a more detailed airway evaluation and preparation.'), Spacer(1,5)]
box=Table([[P('<b>Exam point:</b> Mallampati grading is performed in the awake patient before induction. It should not be confused with Cormack-Lehane grading, which describes the laryngeal view during laryngoscopy.', 'Boxx')]],colWidths=[16.15*cm])
box.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,-1),lightblue),('BOX',(0,0),(-1,-1),.8,blue),('LEFTPADDING',(0,0),(-1,-1),9),('RIGHTPADDING',(0,0),(-1,-1),9),('TOPPADDING',(0,0),(-1,-1),7),('BOTTOMPADDING',(0,0),(-1,-1),7)]))
story += [box, PageBreak()]

# PAGE 2
story += [P('The modified Mallampati classes', 'H1x'), P('The number of visible structures decreases progressively from Class I to Class IV.', 'Bodyx')]
data=[[P('<b>Class</b>','Smallx'),P('<b>Structures visible</b>','Smallx'),P('<b>Usual implication</b>','Smallx')],
[P('<b>I</b>','Bodyx'),P('Soft palate, fauces, entire uvula and tonsillar pillars.','Bodyx'),P('Favourable oropharyngeal view; laryngoscopy is usually easier.','Bodyx')],
[P('<b>II</b>','Bodyx'),P('Soft palate, fauces and uvula; pillars are not seen.','Bodyx'),P('Usually an adequate view; assess with other airway findings.','Bodyx')],
[P('<b>III</b>','Bodyx'),P('Soft palate and base of the uvula only.','Bodyx'),P('Reduced oropharyngeal space; possible difficult laryngoscopy.','Bodyx')],
[P('<b>IV</b>','Bodyx'),P('Hard palate only; soft palate is not visible.','Bodyx'),P('Marked crowding; greater likelihood of difficult laryngoscopy/intubation.','Bodyx')]]
t=Table(data,colWidths=[1.55*cm,7.5*cm,7.1*cm], repeatRows=1)
t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,0),navy),('TEXTCOLOR',(0,0),(-1,0),colors.white),('GRID',(0,0),(-1,-1),.4,line),('VALIGN',(0,0),(-1,-1),'TOP'),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,lightblue]),('LEFTPADDING',(0,0),(-1,-1),6),('RIGHTPADDING',(0,0),(-1,-1),6),('TOPPADDING',(0,0),(-1,-1),6),('BOTTOMPADDING',(0,0),(-1,-1),6)]))
story += [t, Spacer(1,9)]
# source image
if IMG.exists():
    pil=PILImage.open(IMG); w,h=pil.size
    im=Image(str(IMG), width=15.0*cm, height=15.0*cm*h/w)
    cap=Table([[im]],colWidths=[16.15*cm]); cap.setStyle(TableStyle([('ALIGN',(0,0),(-1,-1),'CENTER'),('VALIGN',(0,0),(-1,-1),'MIDDLE'),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),2)]))
    story += [cap, P('<i>Figure: Modified Mallampati classes I-IV. Structures visible diminish as the class increases.</i>', 'Smallx'), Spacer(1,5)]
story += [P('Helpful mnemonic: PUSH', 'H2x'), P('<b>Class I:</b> <b>P</b>illars + <b>U</b>vula + <b>S</b>oft palate + <b>H</b>ard palate. &nbsp;&nbsp; <b>Class II:</b> U-S-H. &nbsp;&nbsp; <b>Class III:</b> S-H. &nbsp;&nbsp; <b>Class IV:</b> H only.', 'Bodyx')]
story += [P('Class 0', 'H2x'), P('Occasionally, a <b>Class 0</b> is recorded when any part of the epiglottis is visible on mouth opening and tongue protrusion. It is uncommon and generally represents a favourable view; it is not part of the routine four-class system.', 'Bodyx'), PageBreak()]

# PAGE 3
story += [P('Clinical use, limitations and interpretation', 'H1x')]
story += [P('A Class III or IV result should lead to a complete airway assessment and preparation for a potentially difficult airway. It does <b>not</b> establish that intubation will be difficult, and Classes I-II do not guarantee easy intubation.', 'Bodyx')]
story += [P('Use Mallampati grading with other predictors', 'H2x')]
data=[[P('<b>Assessment</b>','Smallx'),P('<b>Concerning finding</b>','Smallx')],
[P('Mouth opening','Bodyx'),P('Reduced inter-incisor distance, particularly <3 cm.','Bodyx')],
[P('Thyromental distance','Bodyx'),P('Short distance, commonly <6-6.5 cm.','Bodyx')],
[P('Neck movement','Bodyx'),P('Restricted flexion/extension or inability to attain sniffing position.','Bodyx')],
[P('Jaw and teeth','Bodyx'),P('Micrognathia, retrognathia, prominent upper incisors, poor mandibular protrusion.','Bodyx')],
[P('Neck/body habitus','Bodyx'),P('Short thick neck, obesity, increased neck circumference.','Bodyx')],
[P('History','Bodyx'),P('Previous difficult airway, obstructive sleep apnoea, head/neck mass, trauma, surgery or radiotherapy.','Bodyx')]]
t=Table(data,colWidths=[5.2*cm,10.95*cm],repeatRows=1)
t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,0),navy),('TEXTCOLOR',(0,0),(-1,0),colors.white),('GRID',(0,0),(-1,-1),.4,line),('VALIGN',(0,0),(-1,-1),'TOP'),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,lightblue]),('LEFTPADDING',(0,0),(-1,-1),6),('RIGHTPADDING',(0,0),(-1,-1),6),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)]))
story += [t, Spacer(1,7)]
story += [P('Limitations', 'H2x'), bullet('Technique, patient position, degree of tongue protrusion and phonation influence the observed class.'), bullet('There is inter-observer variation, particularly at the boundary between Classes II and III.'), bullet('It cannot assess all contributors to difficult airway management, such as laryngeal position, cervical spine mobility, or ability to ventilate by mask.'), bullet('Used alone, it has limited accuracy for predicting difficult intubation. It is most useful as one component of a multivariable airway assessment.'), Spacer(1,2)]
story += [P('Mallampati versus Cormack-Lehane', 'H2x')]
comp=[[P('<b>Modified Mallampati</b>','Smallx'),P('<b>Cormack-Lehane</b>','Smallx')], [P('Preoperative bedside screen in an awake patient.','Bodyx'),P('Laryngoscopic view assessed after induction.','Bodyx')], [P('Based on visible oral-pharyngeal structures.','Bodyx'),P('Based on visibility of the glottis at laryngoscopy.','Bodyx')], [P('Predicts possible difficulty.','Bodyx'),P('Describes the actual laryngeal view.','Bodyx')]]
t=Table(comp,colWidths=[8.075*cm,8.075*cm])
t.setStyle(TableStyle([('BACKGROUND',(0,0),(-1,0),navy),('TEXTCOLOR',(0,0),(-1,0),colors.white),('GRID',(0,0),(-1,-1),.4,line),('VALIGN',(0,0),(-1,-1),'TOP'),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,lightblue]),('LEFTPADDING',(0,0),(-1,-1),6),('RIGHTPADDING',(0,0),(-1,-1),6),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)]))
story += [t, Spacer(1,6)]
story += [P('Take-home points', 'H2x'), P('<b>Perform correctly:</b> sitting, head neutral, mouth wide open, tongue maximally protruded, no phonation. <b>Remember:</b> I-II are generally reassuring; III-IV require heightened preparedness. <b>Never use MPG in isolation</b> to declare an airway easy or difficult.', 'Bodyx')]
story += [P('References', 'H2x'), P('Miller’s Anesthesia, 10th ed., airway physical examination section, pp. 5847-5848. <br/>Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. <i>Anaesthesia</i>. 1987;42:487-490. <br/>Expert consensus on difficult airway assessment. <i>PMC10432292</i>.', 'Smallx')]

doc.build(story, onFirstPage=header_footer, onLaterPages=header_footer)
print(OUT)

Running Command

python "/tmp/workspace/mallampati-pdf/src/create_pdf.py" && python -c "from pypdf import PdfReader; p='/tmp/workspace/mallampati-pdf/output/Modified_Mallampati_Grading_3_Page_Note.pdf'; r=PdfReader(p); print('pages=',len(r.pages)); print('sizes=',__import__('os').path.getsize(p)); [print('PAGE',i+1, (page.extract_text() or '')[:250].replace('\\n',' | ')) for i,page in enumerate(r.pages)]"

Modified Mallampati Grading 3 Page Note

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