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Feinleib J, Baron EL. Airway Management Education for the Nonairway Specialist. Int Anesthesiol Clin 2024; 62:8-20. [PMID: 39041794 DOI: 10.1097/aia.0000000000000448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Affiliation(s)
- Jessica Feinleib
- West Haven, Connecticut
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, and West Haven VHA/VHA National Simulation Center
| | - Elvera L Baron
- Department of Anesthesiology and Perioperative Medicine, Case Western Reserve University School of Medicine at Louis Stokes Cleveland VAMC, Cleveland, Ohio
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Wang Z, Jin Y, Zheng Y, Chen H, Feng J, Sun J. Evaluation of preoperative difficult airway prediction methods for adult patients without obvious airway abnormalities: a systematic review and meta-analysis. BMC Anesthesiol 2024; 24:242. [PMID: 39020308 PMCID: PMC11253413 DOI: 10.1186/s12871-024-02627-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 07/09/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND This systematic review aims to assist clinical decision-making in selecting appropriate preoperative prediction methods for difficult tracheal intubation by identifying and synthesizing literature on these methods in adult patients undergoing all types of surgery. METHODS A systematic review and meta-analysis were conducted following PRISMA guidelines. Comprehensive electronic searches across multiple databases were completed on March 28, 2023. Two researchers independently screened, selected studies, and extracted data. A total of 227 articles representing 526 studies were included and evaluated for bias using the QUADAS-2 tool. Meta-Disc software computed pooled sensitivity (SEN), specificity (SPC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). Heterogeneity was assessed using the Spearman correlation coefficient, Cochran's-Q, and I2 index, with meta-regression exploring sources of heterogeneity. Publication bias was evaluated using Deeks' funnel plot. RESULTS Out of 2906 articles retrieved, 227 met the inclusion criteria, encompassing a total of 686,089 patients. The review examined 11 methods for predicting difficult tracheal intubation, categorized into physical examination, multivariate scoring system, and imaging test. The modified Mallampati test (MMT) showed a SEN of 0.39 and SPC of 0.86, while the thyromental distance (TMD) had a SEN of 0.38 and SPC of 0.83. The upper lip bite test (ULBT) presented a SEN of 0.52 and SPC of 0.84. Multivariate scoring systems like LEMON and Wilson's risk score demonstrated moderate sensitivity and specificity. Imaging tests, particularly ultrasound-based methods such as the distance from the skin to the epiglottis (US-DSE), exhibited higher sensitivity (0.80) and specificity (0.77). Significant heterogeneity was identified across studies, influenced by factors such as sample size and study design. CONCLUSION No single preoperative prediction method shows clear superiority for predicting difficult tracheal intubation. The evidence supports a combined approach using multiple methods tailored to specific patient demographics and clinical contexts. Future research should focus on integrating advanced technologies like artificial intelligence and deep learning to improve predictive models. Standardizing testing procedures and establishing clear cut-off values are essential for enhancing prediction reliability and accuracy. Implementing a multi-modal predictive approach may reduce unanticipated difficult intubations, improving patient safety and outcomes.
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Affiliation(s)
- Zhichen Wang
- Department of Clinical Engineering and Material Supplies, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Qingchun Road, Hangzhou, 310003, China
| | - Yile Jin
- Department of Clinical Engineering and Material Supplies, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Qingchun Road, Hangzhou, 310003, China
| | - Yueying Zheng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31003, China
| | - Hanjian Chen
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31003, China
| | - Jingyi Feng
- Department of Clinical Engineering and Material Supplies, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Qingchun Road, Hangzhou, 310003, China
| | - Jing Sun
- Department of Clinical Engineering and Material Supplies, The First Affiliated Hospital, Zhejiang University School of Medicine, No.79 Qingchun Road, Hangzhou, 310003, China.
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Wang M, Liu Y, Qiu Y, Chen H, Liwen W, Huang D, Zhang X, Li G. Predictors of Difficult Laryngeal Exposure in Suspension Laryngoscopy: A Systematic Review and Meta-Analysis. Clin Exp Otorhinolaryngol 2024; 17:177-187. [PMID: 38659242 DOI: 10.21053/ceo.2023.00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 04/25/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVES Considerable research has been focused on independent predictors of difficult laryngeal exposure (DLE) during suspension laryngoscopy. However, previous studies have yielded inconsistent results and conclusions. Consequently, we performed a meta-analysis of the existing literature with the aim of identifying significant parameters for a standardized preoperative DLE prediction system. METHODS We systematically retrieved articles from the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, and Wanfang databases up to October 2022. Data from eligible studies were extracted and analyzed using the R programming language. The effect measures included odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous variables and mean differences (MDs) with 95% CIs for continuous variables. RESULTS The search yielded 1,574 studies, of which 18 (involving a total of 2,263 patients) were included. Pooled analysis demonstrated that patients with DLE during microsurgery tended to be male (OR, 1.73; 95% CI, 1.16-2.57); were older (MD, 5.47 years, 95% CI, 2.44-8.51 years); had a higher body mass index (BMI; MD, 1.19 kg/m2; 95% CI, 0.33-2.05 kg/m2); had a greater neck circumference (MD, 2.50 cm; 95% CI, 1.56-3.44 cm); exhibited limited mouth opening (MD, -0.52 cm; 95% CI, -0.88 to -0.15 cm); had limited neck flexibility (MD, -10.05 cm; 95% CI, -14.10 to -6.00 cm); displayed various other anatomical characteristics; and had a high modified Mallampati index (MMI) or test score (OR, 3.37; 95% CI, 2.07-5.48). CONCLUSION We conducted a comprehensive and systematic analysis of the factors relevant to DLE. Ultimately, we identified sex, age, BMI, neck circumference, MMI, inter-incisor gap, hyomental distance, thyromental distance, sternomental distance, and flexion-extension angle as factors highly correlated with DLE.
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Affiliation(s)
- Mengshu Wang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China
- Otolaryngology Major Disease Research, Key Laboratory of Hunan Province, Changsha, China
- Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
| | - Yong Liu
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China
- Otolaryngology Major Disease Research, Key Laboratory of Hunan Province, Changsha, China
- Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, China
| | - Yuanzheng Qiu
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China
- Otolaryngology Major Disease Research, Key Laboratory of Hunan Province, Changsha, China
- Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, China
| | - Huihong Chen
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China
- Otolaryngology Major Disease Research, Key Laboratory of Hunan Province, Changsha, China
- Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
| | - Wang Liwen
- Department of Hematology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Donghai Huang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China
- Otolaryngology Major Disease Research, Key Laboratory of Hunan Province, Changsha, China
- Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
| | - Xin Zhang
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China
- Otolaryngology Major Disease Research, Key Laboratory of Hunan Province, Changsha, China
- Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
- National Clinical Research Center for Geriatric Disorders (Xiangya Hospital), Changsha, China
| | - Guo Li
- Department of Otolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China
- Otolaryngology Major Disease Research, Key Laboratory of Hunan Province, Changsha, China
- Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Liu X, Flanagan C, Li G, Lei Y, Zeng L, Fang J, Guo X, McGrath S, Han Y. Identification of difficult laryngoscopy using an optimized hybrid architecture. BMC Med Res Methodol 2024; 24:4. [PMID: 38177983 PMCID: PMC10765670 DOI: 10.1186/s12874-023-02115-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 12/01/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Identification of difficult laryngoscopy is a frequent demand in cervical spondylosis clinical surgery. This work aims to develop a hybrid architecture for identifying difficult laryngoscopy based on new indexes. METHODS Initially, two new indexes for identifying difficult laryngoscopy are proposed, and their efficacy for predicting difficult laryngoscopy is compared to that of two conventional indexes. Second, a hybrid adaptive architecture with convolutional layers, spatial extraction, and a vision transformer is proposed for predicting difficult laryngoscopy. The proposed adaptive hybrid architecture is then optimized by determining the optimal location for extracting spatial information. RESULTS The test accuracy of four indexes using simple model is 0.8320. The test accuracy of optimized hybrid architecture using four indexes is 0.8482. CONCLUSION The newly proposed two indexes, the angle between the lower margins of the second and sixth cervical spines and the vertical direction, are validated to be effective for recognizing difficult laryngoscopy. In addition, the optimized hybrid architecture employing four indexes demonstrates improved efficacy in detecting difficult laryngoscopy. TRIAL REGISTRATION Ethics permission for this research was obtained from the Medical Scientific Research Ethics Committee of Peking University Third Hospital (IRB00006761-2015021) on 30 March 2015. A well-informed agreement has been received from all participants. Patients were enrolled in this research at the Chinese Clinical Trial Registry ( http://www.chictr.org.cn , identifier: ChiCTR-ROC-16008598) on 6 June 2016.
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Affiliation(s)
- XiaoXiao Liu
- College of Mathematics and Information Science, Hebei University, Baoding, China
- Electronic and Computer Engineering, University of Limerick, Limerick, Ireland
| | - Colin Flanagan
- Electronic and Computer Engineering, University of Limerick, Limerick, Ireland
| | - Gang Li
- Department of General Surgery (GL), Peking University Third Hospital, Beijing, China
| | - Yiming Lei
- Ministry of Education Engineering Research Centre on Mobile Digital Hospital Systems, School of Electronics, Peking University, Beijing, China.
| | - Liaoyuan Zeng
- School of Communications, University of Electronic Science and Technology of China, Chengdu, China
| | - Jingchao Fang
- Department of Radiology (JCF), Peking University Third Hospital, Beijing, China
| | - Xiangyang Guo
- Department of Anaesthesiology, Peking University Third Hospital, Beijing, China
| | - Sean McGrath
- Electronic and Computer Engineering, University of Limerick, Limerick, Ireland.
| | - Yongzheng Han
- Department of Anaesthesiology, Peking University Third Hospital, Beijing, China.
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Harjai M, Alam S, Rastogi S, Kumar S. Effectiveness and Validity of Preoperative Ultrasonographic Airway Assessment and Clinical Screening Tests to Predict Difficult Laryngoscopy: A Prospective, Observational Study. Cureus 2023; 15:e41933. [PMID: 37583718 PMCID: PMC10425165 DOI: 10.7759/cureus.41933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND The anticipation of a challenging airway can be demanding in emergency care settings. Due to the patient's clinical condition, executing the pre-intubation clinical screening tests during the management of the airway in an emergency situation can be sometimes troublesome. Ultrasonographic airway assessment may become a helpful tool, but no specific sonographic measurements can precisely visualize the prospect of meeting a difficult airway. Therefore, the present study aimed to verdict some correlation between preoperative sonographic airway assessment parameters and the Cormack-Lehane (CL) grading at laryngoscopic view in patients undergoing general anesthesia with endotracheal intubation. METHODS This observational study was conducted on 150 elective surgery subjects undergoing general anesthesia. The clinician in the pre-anesthetic clinic performed clinical airway and ultrasonographic airway assessments to predict difficult intubation and correlated with the CL grade viewed at laryngoscopy in the operative room during intubation. The parameters assessed were sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS In this study, the incidence of difficult intubation was 13.3%. The Mallampatti Grading (MPG) showed the maximum receiver operating characteristic (ROC) and area under the curve (AUC) among the clinical predictors, with 86.7% sensitivity. At the same time, the skin-to-hyoid distance has the maximum ROC among the sonographic parameters, and the skin-to-thyroid isthmus has the utmost sensitivity to predict difficult laryngoscopy. CONCLUSIONS Among the clinical predictors, MPG and the sonographic parameters, like the skin-to-hyoid distance and skin-to-thyroid isthmus, are favorable predictors of difficult laryngoscopy.
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Affiliation(s)
- Mamta Harjai
- Anesthesia and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Sharif Alam
- Anesthesia and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Shivani Rastogi
- Anesthesia and Critical Care Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, IND
| | - Sumit Kumar
- Anaesthesia, Hinchingbrooke Hospital, Huntingdon, GBR
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Nakazawa H, Uzawa K, Tokumine J, Lefor AK, Motoyasu A, Yorozu T. Airway ultrasound for patients anticipated to have a difficult airway: Perspective for personalized medicine. World J Clin Cases 2023; 11:1951-1962. [PMID: 36998948 PMCID: PMC10044949 DOI: 10.12998/wjcc.v11.i9.1951] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/28/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
Airway ultrasound allows for precise airway evaluation, particularly for assessing the difficult airway and the potential for front of neck access. Many studies have shown that identification of the cricothyroid membrane by airway ultrasound is more accurate than digital palpation. However, no reports to date have provided clinical evidence that ultrasound identification of the cricothyroid membrane increases the success rate of cricothyroidotomy. This is a narrative review which describes patients with difficult airways for whom airway ultrasound may have been useful for clinical decision making. The role of airway ultrasound for the evaluation of difficult airways is summarized and an approach to the use of ultrasound for airway management is proposed. The goal of this review is to present practical applications of airway ultrasound for patients predicted to have a difficult airway and who undergo cricothyroidotomy.
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Affiliation(s)
- Harumasa Nakazawa
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Kohji Uzawa
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Joho Tokumine
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke 329-0498, Tochigi, Japan
| | - Akira Motoyasu
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
| | - Tomoko Yorozu
- Department of Anesthesiology, Kyorin University School of Medicine, Mitaka 181-8611, Tokyo, Japan
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Prediction of Difficult Laryngoscopy Using Ultrasound: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:117-126. [PMID: 36519985 DOI: 10.1097/ccm.0000000000005711] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Evaluate associations between ultrasound measures and difficult laryngoscopy. DATA SOURCES MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library were searched using MeSH terms and keywords. STUDY SELECTION Studies published in English describing the use of airway ultrasound for identifying difficult laryngoscopy, with sufficient data to calculate sensitivity and specificity using 2 × 2 tables. DATA EXTRACTION We assigned the described indices of airway dimension to one of three domains based on methodology characteristics: anterior tissue thickness domain, anatomical position domain, and oral space domain. We then performed a bivariate random-effects meta-analysis, deriving pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio estimates. We assessed risks of bias using Quality Assessment of Diagnostic Accuracy Studies-2 analysis. DATA SYNTHESIS Thirty-three studies evaluating 27 unique indices were included in the meta-analysis. The ultrasound protocols of the included studies were heterogeneous. Anterior tissue thickness demonstrated a pooled sensitivity of 76% (95% CI, 71-81%), specificity of 77% (95% CI, 72-81%), and an area under the receiver operating characteristic curve (AUROC) of 0.83 (95% CI, 0.80-0.86). Anatomical position demonstrated a pooled sensitivity of 74% (95% CI, 61-84%), specificity of 86% (95% CI, 78-91%), and an AUROC of 0.87 (95% CI, 0.84-0.90). Oral space demonstrated a pooled sensitivity of 53% (95% CI, 0.36-0.69), specificity of 77% (95% CI, 0.67-0.85), and an AUROC of 0.73 (95% CI, 0.69-0.77). CONCLUSIONS Airway ultrasound metrics associate with difficult laryngoscopy in three domains: anterior tissue thickness, anatomic position, and oral space. An assessment instrument combining clinical and ultrasound assessments may be an accurate screening tool for difficult laryngoscopy.
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Ito K, Kamura A, Koshika K, Handa T, Matsuura N, Ichinohe T. Usefulness of lateral cephalometric radiography for successful blind nasal intubation: a prospective study. J Dent Anesth Pain Med 2022; 22:427-435. [PMID: 36601136 PMCID: PMC9763822 DOI: 10.17245/jdapm.2022.22.6.427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to investigate the relationship between pharyngeal morphology and the success or failure of blind nasotracheal intubation using standard lateral cephalometric radiography and to analyze the measurement items affecting the difficulty of blind nasotracheal intubation. Methods Assuming a line perpendicular to the Frankfort horizontal (FH) plane, the reference point (O) was selected 1 cm above the posterior-most end of the hard palate. A line passing through the reference point and parallel to the FH plane is defined as the X-axis, and a line passing through the reference point and perpendicular to the X-axis is defined as the Y-axis. The shortest length between the tip of the uvula and posterior pharyngeal wall (AW), shortest length between the base of the tongue and posterior pharyngeal wall (BW), and width of the glottis (CW) were measured. The midpoints of the lines representing each width are defined as points A, B, and C, and the X and Y coordinates of each point are obtained (AX, BX, CX, AY, BY, and CY). For each measurement, a t-test was performed to compare the tracheal intubation success and failure groups. A binomial logistic regression analysis was performed using clinically relevant items. Results The items significantly affecting the success rate of blind nasotracheal intubation included the difference in X coordinates at points A and C (Odds ratio, 0.714; P-value, 0.024) and the ∠ABC (Odds ratio, 1.178; P-value, 0.016). Conclusion Using binomial logistic regression analysis, we observed statistically significant differences in AX-CX and ∠ABC between the success group and the failure group.
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Affiliation(s)
- Kana Ito
- Department of Dental Anesthesiology, Tokyo Dental College, Tokyo, Japan.,Department of Oral Medicine and Hospital Dentistry, Ichikawa General Hospital, Tokyo Dental College, Tokyo, Japan
| | - Ayaka Kamura
- Department of Dental and Oral Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Kyotaro Koshika
- Department of Dental Anesthesiology, Tokyo Dental College, Tokyo, Japan
| | - Toshiyuki Handa
- Department of Dental Anesthesiology, Tokyo Dental College, Tokyo, Japan
| | - Nobuyuki Matsuura
- Department of Oral Medicine and Hospital Dentistry, Ichikawa General Hospital, Tokyo Dental College, Tokyo, Japan
| | - Tatsuya Ichinohe
- Department of Dental Anesthesiology, Tokyo Dental College, Tokyo, Japan
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Li X, An B, Jiang B, Xu S, Liu H, Zhao H. Pharynx volume derived from three-dimensional computed tomography is associated with difficult intubation in spinal deformity surgery: A retrospective cohort study. Medicine (Baltimore) 2022; 101:e31139. [PMID: 36253975 PMCID: PMC9575825 DOI: 10.1097/md.0000000000031139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Spinal abnormality surgery, including surgery for ankylosing spondylitis and idiopathic scoliosis, can present significant challenges to anesthesiologists because of the potential difficult airway. The bedside screening tests routinely used to detect difficult airways are highly variable. Pharynx volume calculated using three-dimensional (3D) computed tomography (CT) may play a role in predicting difficult airways. We conducted a retrospective cohort study on patients (aged ≥14 years) who received orthopedic surgery for ankylosing spondylitis/idiopathic scoliosis under general anesthesia. Volume of the pharynx air space was calculated through volume rendering technique by 3D reconstruction of patients' cervical spine CT. Patients were divided into 2 groups according to their pharynx volume, pharyngeal volume lower than 16 mL (n = 11) and equal or higher than 16 mL (n = 13). Pharynx volume in low volume group was 10.4 ± 3.6 mL (n = 11), and the counterpart in high volume group was 20.8 ± 5.5 mL (n = 13). The incidence of difficult intubation was significantly higher in low pharynx volume group than in high pharynx volume group (54.5% (6/11) vs 7.6% (1/13), P = .023). Bedside screening tests including modified Mallampati test, inter-incisor gap and thyromental distance, or radiological variables such as anterior neck soft tissue thickness to vocal cords were not different between the 2 groups. Smaller pharynx volume played an important role in difficult airways for patients undergoing orthopedic surgery for ankylosing spondylitis/idiopathic scoliosis.
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Affiliation(s)
- Xiaoyan Li
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
| | - Bei An
- Department of Radiology, Peking University People’s Hospital, Beijing, China
| | - Bailin Jiang
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
| | - Shuai Xu
- Department of Spinal Surgery, Peking University People’s Hospital, Beijing, China
| | - Haiying Liu
- Department of Spinal Surgery, Peking University People’s Hospital, Beijing, China
| | - Hong Zhao
- Department of Anesthesiology, Peking University People’s Hospital, Beijing, China
- *Correspondence: Hong Zhao, Department of Anesthesiology, Peking University People’s Hospital, #11 Xizhimen South Street, Beijing 100044, China (e-mail: )
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Sajayan A, Nair A, McNarry AF, Mir F, Ahmad I, El‐Boghdadly K. Analysis of a national difficult airway database. Anaesthesia 2022; 77:1081-1088. [DOI: 10.1111/anae.15820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Affiliation(s)
- A. Sajayan
- Department of Anaesthesia University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - A. Nair
- Department of Anaesthesia University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - A. F. McNarry
- Department of Anaesthesia Western General and St John's Hospitals Edinburgh UK
| | - F. Mir
- Department of Anaesthesia St Georges University Hospitals NHS Foundation Trust London UK
| | - I. Ahmad
- Department of Anaesthesia and Peri‐operative Medicine Guy's and St. Thomas' NHS Foundation Trust London UK
- King's College London London UK
| | - K. El‐Boghdadly
- Department of Anaesthesia and Peri‐operative Medicine Guy's and St. Thomas' NHS Foundation Trust London UK
- King's College London London UK
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12
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Shehata I, Diab S, Kweon J, Farrag O. The role of ultrasonography in anesthesia for bariatric surgery. Saudi J Anaesth 2022; 16:347-354. [PMID: 35898531 PMCID: PMC9311175 DOI: 10.4103/sja.sja_80_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 01/30/2022] [Accepted: 02/03/2022] [Indexed: 11/30/2022] Open
Abstract
Bariatric surgeries are effective long-term management for morbid obesity with its adverse sequelae. Anesthesia of bariatric surgeries poses unique challenges for the anesthesiologist in every step starting with vascular access till tracheal extubation. The usage of ultrasound in anesthesia is becoming more prevalent with a variety of benefits, especially in the obese population. Ultrasound is successfully used for obtaining vascular access, with more than 15 million catheters placed in the United States alone. Ultrasound can also be used to predict difficult intubation, as it can confirm the tracheal intubation and assess the gastric content to prevent pulmonary aspiration. Ultrasound is also used in the management of mechanically ventilated patients to monitor lung aeration and to identify respiratory complications during positive pressure ventilation. Moreover, intraoperative echocardiography helps to discover the pulmonary embolism and guides the fluid therapy. Finally, ultrasound can be used to perform neuraxial and fascial plane block with a less overall time of the procedures and minimal complications. The wide use of ultrasound in bariatric anesthesia reflects the learning curve of the anesthesiologists and their mounting efforts to provide safe anesthesia utilizing the updated technology. In this review, we highlight the role of ultrasonography in anesthesia of bariatric surgery and discuss the recent guidelines.
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Senol D, Ozbag D, Dedeoglu N, Cevirgen F, Toy S, Ogeturk M, Kose E. Comparison of anthropometric and conic beam computed tomography measurements of patients with and without difficult intubation risk according to modified mallampati score: New markers for difficult intubation. Niger J Clin Pract 2021; 24:1609-1615. [PMID: 34782498 DOI: 10.4103/njcp.njcp_694_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background The aim of this study was to compare the anthropometric and cone beam computed tomography (CBCT) measurements taken from risk-free and risky groups by using the modified Mallampati score (MMS). Patients and Methods A total of 176 volunteers between the ages of 18 and 65 in four different MMS classes were included in the study. The patients in classes MMS I and MMS II were accepted as risk-free and the patients in classes MMS III and MMS IV were accepted as risky for intubation. The Mann-Whitney U test was performed on the data to compare the anthropometric and radiological measurements taken from the risk-free and risky groups. A receiver operating characteristic (ROC) analysis was applied to the parameters that had a statistically significant difference. Results According to the analysis results, statistically significant differences were found in the neck circumference (NC), maximum interincisal distance (MID), thyromental distance (TMD) and sternomental distance (SMD) of the anthropometric measurements of men and women between the risk-free and risky groups (P < 0.05). In terms of CBCT measurements, the thickness of the tongue (TT), distance between the uvula and posterior wall of pharynx (U-Ph), distance between posterior nasal spine and nasopharynx (Snp-Nph) and length of the epiglottis (LE) were found to have statistically significant differences between the risk-free and risky groups of men and women (P < 0.05). Conclusion The NC, MID, TMD and SMD anthropometric measurements and TT, U-Ph, Snp-Nph and LE radiologic measurements were found to support MMS, which is one of the most widely used bedside intubation prediction tests. In addition to the inclusion of CBCT for intubation prediction, U-Ph and Snp-Nph radiologic measurements were added as difficult intubation markers.
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Affiliation(s)
- D Senol
- Department of Anatomy, Faculty of Medicine, Düzce University, Düzce, Turkey
| | - D Ozbag
- Department of Anatomy, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - N Dedeoglu
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Inönü University, Malatya, Turkey
| | - F Cevirgen
- Department of Anatomy, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - S Toy
- Department of Anatomy, Faculty of Medicine, Karabük University, Karabük, Turkey
| | - M Ogeturk
- Department of Anatomy, Faculty of Medicine, Fırat University, Elazığ, Turkey
| | - E Kose
- Department of Anatomy, Faculty of Medicine, İnönü University, Malatya, Turkey
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Sotoodehnia M, Rafiemanesh H, Mirfazaelian H, Safaie A, Baratloo A. Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis. BMC Emerg Med 2021; 21:76. [PMID: 34217221 PMCID: PMC8254992 DOI: 10.1186/s12873-021-00472-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 06/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment. Methods This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included. Results In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the “thickness of anterior neck soft tissue at the vocal cords level”. Also, “skin to epiglottis” and “anterior neck soft tissue at the hyoid bone level” were among the most common indicators examined in this area. Conclusion This systematic review showed that US can be used for predicting difficult airway. Of note, “skin thickness at the epiglottis and hyoid levels”, “the hyomental distance”, and “the hyomental distance ratio” were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.
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Affiliation(s)
- Mehran Sotoodehnia
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Rafiemanesh
- Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hadi Mirfazaelian
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Safaie
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Alireza Baratloo
- Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Ampanozi G, Franckenberg S, Schweitzer W, Thali MJ, Chatzaraki V. Prevalence of calcified epiglottis in postmortem computed tomography. Is there a correlation to failed endotracheal intubation? Dentomaxillofac Radiol 2021; 50:20200615. [PMID: 33591846 DOI: 10.1259/dmfr.20200615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Calcification of the epiglottis is a normal physiological degenerative process, although it can also be a consequence of infection or trauma. There are three possible forensically relevant consequences from epiglottic calcification: misinterpretation as foreign bodies, dysphagia as a major contributing factor to aspiration, and association with difficult intubation or a misplaced ventilation tube. It is the aim of this study (I) to inquire about the prevalence of epiglottic calcification in postmortem CT in general and (II) to investigate whether calcification of the epiglottis is linked to a higher incidence of failed endotracheal intubation. METHODS We retrospectively analysed 2930 consecutive cases in postmortem CT at the Institute of Forensic Medicine. RESULTS The prevalence of epiglottic calcification was 4.1%. Higher age and male sex are associated with an increased risk of epiglottic calcification. There was no calcification of the epiglottis in the cases with misplacement of the ventilation tube in the esophagus. CONCLUSIONS To verify the result of our study, that is, the calcification of the epiglottis is not linked to a higher incidence of failed endotracheal intubation, it might be reasonable to repeat this study with a more representative study population. The high interindividual variations of calcified epiglottis could be used for identification.
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Affiliation(s)
- Garyfalia Ampanozi
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Sabine Franckenberg
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland.,Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Wolf Schweitzer
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Michael J Thali
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Vasiliki Chatzaraki
- Department of Forensic Medicine and Imaging, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland.,Department of Radiology, Cantonal Hospital Baden, Baden, Switzerland
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Anterior neck soft tissue measurements on computed tomography to predict difficult laryngoscopy: a retrospective study. Sci Rep 2021; 11:8438. [PMID: 33875761 PMCID: PMC8055648 DOI: 10.1038/s41598-021-88076-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 04/08/2021] [Indexed: 11/20/2022] Open
Abstract
Predicting difficult laryngoscopy is an essential component of the airway management. We aimed to evaluate the use of anterior neck soft tissue measurements on computed tomography for predicting difficult laryngoscopy and to present a clear measurement protocol. In this retrospective study, 281 adult patients whose tracheas were intubated using a direct laryngoscope for thyroidectomy were enrolled. On computed tomography, the distances from the midpoint of the thyrohyoid membrane to the closest concave point of the vallecular (membrane-to-vallecula distance; dMV), and to the most distant point of the epiglottis (membrane-to-epiglottis distance; dME) were measured, respectively. The extended distances straight to the skin anterior from the dMV and dME were called the skin-to-vallecula distance (dSV) and skin-to-epiglottis distance (dSE), respectively. Difficult laryngoscopy was defined by a Cormack-Lehane grade of > 2. Difficult laryngoscopy occurred in 40 (14%) cases. Among four indices, the dMV showed the highest prediction ability for difficult laryngoscopy with an area under the receiver operating characteristic curve of 0.884 (95% confidence interval 0.841–0.919, P < 0.001). The optimal dMV cut-off value for predicting difficult laryngoscopy was 2.33 cm (sensitivity 75.0%; specificity 93.8%). The current study provides novel evidence that increased dMV is a potential predictive indicator of difficult laryngoscopy.
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Neck ultrasound to improve risk assessment for difficult tracheal intubation in the operating room: The TUBECHO case-control prospective observational pilot study. J Clin Anesth 2020; 68:110101. [PMID: 33069971 DOI: 10.1016/j.jclinane.2020.110101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/05/2020] [Accepted: 10/10/2020] [Indexed: 11/22/2022]
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Clinical versus Ultrasound Measurements of Hyomental Distance Ratio for the Prediction of Difficult Airway in Patients with and without Morbid Obesity. Diagnostics (Basel) 2020; 10:diagnostics10030140. [PMID: 32138351 PMCID: PMC7151107 DOI: 10.3390/diagnostics10030140] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose: To describe the correlation between clinically measured hyomental distance ratio (HMDRclin) and the ultrasound measurement (HMDRecho) in patients with and without morbid obesity and to compare their diagnostic accuracy for difficult airway prediction. Methods: HMDRclin and HMDRecho were recorded the day before surgery in 160 consecutive consenting patients. Laryngoscopy was performed by a skilled anesthesiologist, with grades III and IV Cormack–Lehane being considered difficult views of the glottis. Linear regression was used to assess the correlation between HMDRclin and HDMRecho and receiver operating curve analysis was used to compare the performance of the two for predicting difficult airway. Results: The linear correlation between HMDRclin and HDMRecho in patients without morbid obesity had a Pearson coefficient of 0.494, while for patients with morbid obesity this was 0.14. A slightly higher area under the curve for HMDRecho was oberved: 0.64 (5%CI 0.56–0.71) versus 0.52 (95%CI, 0.44–0.60) (p = 0.34). Conclusion: The association between HMDRclin and HDMRecho is moderate in patients without morbid obesity, but negligible in morbidly obese patients. These might be explained by difficulties in palpating anatomical structures of the airway.
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Airway sonography fails to detect difficult laryngoscopy in an adult Veteran surgical population. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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20
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Rossi M. The entropic world of the difficult airway. Minerva Anestesiol 2019; 85:454-456. [DOI: 10.23736/s0375-9393.18.13239-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Guay J, Kopp S. Ultrasonography of the airway to identify patients at risk for difficult tracheal intubation: Are we there yet? J Clin Anesth 2018; 46:112-115. [PMID: 29573624 DOI: 10.1016/j.jclinane.2018.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 01/04/2018] [Accepted: 01/07/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Joanne Guay
- University of Sherbrooke, Sherbrooke, Quebec, Canada; Teaching and Research Unit, Health Sciences, University of Quebec in Abitibi-Temiscamingue, Quebec, Canada.
| | - Sandra Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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