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Tasdemir O, Kocaoglu N, Demir HF, Ugun F, Sagir O. Ultrasound-based airway assessment in obese patients as a valuable tool for predicting difficult airway: an observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844539. [PMID: 38997064 DOI: 10.1016/j.bjane.2024.844539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND Difficult airway, characterized by difficult mask ventilation and intubation, is common in obese patients undergoing surgery. The purpose of this study was to evaluate and compare the prognostic efficiency of ultrasound-measured anterior cervical soft tissue parameters as an indicator of difficult airway during anesthesia induction in obese patients. METHODS This prospective, double-blind, observational study was conducted at Balikesir University Faculty of Medicine Hospital between March 2020 and March 2022. A total of 157 patients age ≥ 18 (BMI ≥ 30 kg.m-2), without previous head and neck surgery were included in the study. Anterior cervical soft tissue measurements were performed at three levels; minimum distance between the hyoid bone and skin at the level of the hyoid bone; (DSHB), distance between the midpoint of the epiglottis and skin at the level of the thyrohyoid membrane; (DSE), distance between the anterior commissure of vocal cords and skin at the vocal cord level; (DSV). The Han scale was used to assess difficult mask ventilation and the Cormack-Lehane scale was used to assess difficult laryngoscopy. RESULTS In the difficult laryngoscopy group, the mean values of DSHB, DSE and DSV were 18.5 ± 3.5, 18.3 ± 3.8, and 18.6 ± 3.4, respectively. The AUC values for DSHB, DSE, and DSV were 0.845, 0.827, and 0.850, respectively. Anterior cervical measurements showed a better predictive value for difficult laryngoscopy compared to difficult mask ventilation. CONCLUSION Ultrasonographic measurements were predictive for difficult laryngoscopy and ventilation with better correlation in laryngoscopy.
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Affiliation(s)
- Ozan Tasdemir
- Balikesir Atatürk City Hospital, Department of Anesthesiology and Intensive Care Medicine, Altieylul, Balikesir, Türkiye
| | - Nazan Kocaoglu
- Balıkesir University Faculty of Medicine, Department of Anesthesiology and Intensive Care Medicine, Altieylul, Balikesir, Türkiye.
| | - H Fisun Demir
- Balıkesir University Faculty of Medicine, Department of Anesthesiology and Intensive Care Medicine, Altieylul, Balikesir, Türkiye
| | - Fatih Ugun
- Balıkesir University Faculty of Medicine, Department of Anesthesiology and Intensive Care Medicine, Altieylul, Balikesir, Türkiye
| | - Ozlem Sagir
- Balıkesir University Faculty of Medicine, Department of Anesthesiology and Intensive Care Medicine, Altieylul, Balikesir, Türkiye
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Sarah Jacob D, Bhat S, Vasudev Rao S. Comparison of Modified Mallampati Classification in Supine and Sitting Positions to Predict Difficult Tracheal Intubation in Diabetic Patients. Anesth Pain Med 2024; 14:e145034. [PMID: 38741898 PMCID: PMC11088840 DOI: 10.5812/aapm-145034] [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] [Received: 01/14/2024] [Revised: 03/11/2024] [Accepted: 03/25/2024] [Indexed: 05/16/2024] Open
Abstract
Background Airway management of patients with long-standing diabetes poses a major challenge for anaesthesiologists due to stiff joint syndrome affecting the atlanto-occipital joint. In certain cases requiring immobilization, the Mallampati test must often be performed in the supine position for obvious reasons. Objectives Hence, we determined the diagnostic precision (sensitivity and specificity) of the modified Mallampati test in sitting and supine positions among the diabetic population in predicting difficult tracheal intubation. Methods A single-center prospective observational study on adult diabetic patients undergoing general anesthesia and orotracheal intubation was carried out. An observer recorded the modified Mallampati in the sitting posture during the pre-anesthetic examination. The Mallampati in the supine position was determined while in the operating room, and the difficulty of intubation was noted, and diagnostic precision was calculated. The main objective was to predict a difficult airway by calculating the sensitivity, specificity, positive predictive value, and negative predictive value. Results Out of the 150 participants, Mallampati grading in a sitting position was correctly able to identify 42.5% of difficult intubation cases, whereas it was 97.5% with Mallampati in the supine position. Mallampati grading in the sitting position was able to correctly identify 89.1% of easy intubation cases, which was 63.6% with Mallampati in the supine position. The correlation of Mallampati in the supine position with CL grading was statistically significant (P < 0.001). Conclusions Among diabetic patients, the modified Mallampati test in the supine position can be considered a more accurate and sensitive predictor of difficult intubation than the sitting posture.
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Affiliation(s)
| | - Sonal Bhat
- Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Sunil Vasudev Rao
- Department of Anaesthesiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
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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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Ning L, Zhu X, Li HC, Zhou SJ, Zhang QW, Zou HY, Mao QX, Yan H. A quantitative study of airway ultrasound in predicting difficult laryngoscopy: A prospective study. Chin J Traumatol 2023; 26:351-356. [PMID: 37838578 PMCID: PMC10755766 DOI: 10.1016/j.cjtee.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 06/27/2023] [Accepted: 07/11/2023] [Indexed: 10/16/2023] Open
Abstract
PURPOSE As common clinical screening tests cannot effectively predict a difficult airway, and unanticipated difficult laryngoscopy remains a challenge for physicians. We herein used ultrasound to develop some point-of-care predictors for difficult laryngoscopy. METHODS This prospective observational study included 502 patients who underwent laryngoscopy and a detailed sonographic assessment. Patients under 18 years old, or with maxillofacial deformities or fractures, limited mouth opening, limited neck movement or history of neck surgery were excluded from the study. Laryngoscopic views of all patients were scored and grouping using the modified Cormack-Lehane (CL) scoring system. The measurements acquired comprised tongue width, the longitudinal cross-sectional area of the tongue, tongue volume, the mandible-hyoid bone distance, the hyoid bone-glottis distance, the mandible-hyoid bone-glottis angle, the skin-thyrohyoid membrane distance, the glottis-superior edge of the thyroid cartilage distance (DGTC), the skin-hyoid bone distance, and the epiglottis midway-skin distance. ANOVA and Chi-square were used to compare differences between groups. Logistic regression was used to identify risk factors for difficult laryngoscopy and it was visualized by receiver operating characteristic curves and nomogram. R version 3.6.3 and SPSS version 26.0 were used for statistical analyses. RESULTS Difficult laryngoscopy was indicated in 49 patients (CL grade Ⅲ - Ⅳ) and easy laryngoscopy in 453 patients (CL grade Ⅰ - Ⅱ). The ultrasound-measured mandible-hyoid bone-glottis angle and DGTC significantly differed between the 2 groups (p < 0.001). Difficult laryngoscopy was predicted by an area under the curve (AUC) of 0.930 with a threshold mandible-hyoid bone-glottis angle of 125.5° and by an AUC of 0.722 with a threshold DGTC of 1.22 cm. The longitudinal cross-sectional area of the tongue, tongue width, tongue volume, the mandible-hyoid distance, and the hyoid-glottis distance did not significantly differ between the groups. CONCLUSION Difficult laryngoscopy may be anticipated in patients in whom the mandible-hyoid bone-glottis angle is smaller than 125.5° or DGTC is larger than 1.22 cm.
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Affiliation(s)
- Lin Ning
- Department of Anaesthesiology, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China
| | - Xing Zhu
- Laboratory of Anaesthesia Center, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China
| | - Hong-Chao Li
- Department of Anaesthesiology, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China
| | - Shi-Jie Zhou
- Department of Anaesthesiology, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China
| | - Qi-Wei Zhang
- Department of Anaesthesiology, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China
| | - Hong-Yu Zou
- Department of Anaesthesiology, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China
| | - Qing-Xiang Mao
- Anaesthesia Center, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China
| | - Hong Yan
- Department of Anaesthesiology, Army Medical Center of PLA, Daping Hospital of Army Medical University, Chongqing, China.
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Yu Y, Cao J, Tang X, Dong Z, Xu J, Wang B, Cheng P, Wang M, Wu Y, Yao W, Jiang X. Development and validation of a screening method for difficult tracheal intubation based on geometric simulation and computer technology. BMC Anesthesiol 2023; 23:350. [PMID: 37880585 PMCID: PMC10598895 DOI: 10.1186/s12871-023-02312-9] [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: 03/19/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The anatomical characteristics of difficult airways can be analysed geometrically. This study aims to develop and validate a geometry-assisted difficult airway screening method (GADAS method) for difficult tracheal intubation. METHODS In the GADAS method, a geometric simulated model was established based on computer graphics. According to the law of deformation of the upper airway on laryngoscopy, the expected visibility of the glottis was calculated to simulate the real visibility on laryngoscopy. Validation of the new method: Approved by the Ethics Committee of Yijishan Hospital of Wannan Medical College. Adult patients who needed tracheal intubation under general anaesthesia for elective surgery were enrolled. The data of patients were input into the computer software to calculate the expected visibility of the glottis. The results of tracheal intubation were recorded by anaesthesiologists. The primary observation outcome was the screening performance of the expected visibility of the glottis for difficult tracheal intubation. RESULTS The geometric model and software of the GADAS method were successfully developed and are available for use. We successfully observed 2068 patients, of whom 56 patients had difficult intubation. The area under the receiver operating characteristic curve of low expected glottis visibility for predicting difficult laryngoscopy was 0.96 (95% confidence interval [CI]: 0.95-0.96). The sensitivity and specificity were 89.3% (95% CI: 78.1-96.0%) and 94.3% (95% CI: 93.2%-95.3), respectively. CONCLUSIONS It is feasible to screen difficult-airway patients by applying computer techniques to simulate geometric changes in the upper airway.
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Affiliation(s)
- Yue Yu
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Jingjing Cao
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xinyuan Tang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Zhiyuan Dong
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Jianling Xu
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Bin Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Pingping Cheng
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Mingfang Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Yue Wu
- Department of Anesthesiology, The First People's Hospital of Wuhu City, Wuhu, Anhui, China
| | - Weidong Yao
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China.
- Anhui Province Clinical Research Center for Critical Care Medicine (Respiratory Disease), Wannan Medical College, Wuhu, Anhui, China.
| | - Xiaogan Jiang
- Anhui Province Clinical Research Center for Critical Care Medicine (Respiratory Disease), Wannan Medical College, Wuhu, Anhui, China.
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Naftalovich R, Oydanich M, Adeola J, Eloy JD, Rodriguez-Correa D, Tewfik GL. A Prospective Cohort Study on the Respiratory Effect on Modified Mallampati Scoring. Anesthesiol Res Pract 2023; 2023:2193403. [PMID: 37663890 PMCID: PMC10469716 DOI: 10.1155/2023/2193403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/15/2023] [Accepted: 06/20/2023] [Indexed: 09/05/2023] Open
Abstract
Background Mallampati scoring is a common exam method for evaluating the oropharynx as a part of the airway assessment and for anticipation of difficult intubation. It partitions the oropharynx into 4 categories with scores of 1, 2, 3, and 4. Even though its reliability is known to be limited by confounding factors such as patient positioning, patient phonation, tongue protrusion, and examiner variability, the effect of respiration, i.e., inspiration and expiration, has not yet been formally studied. Methods Mallampati scores were collected from 100 surgical patients during both inspiration and expiration and later compared to the score obtained in the medical record, determined by a board certified anesthesiologist. Results Score deviations from the medical record reference were compared for both inspiration and expiration showing that respiration affects Mallampati scores; for some patients, the scores improved (i.e., decreased), while in others they worsened (i.e., increased). The respiratory change effect was quantified and visualized by plotting the area under the curve of the histogram of the deviations. 42% of the patients had a worsening of scores by 1 or 2 points with inspiration while 36% of the patients had a worsening of scores by 1 or 2 points with expiration. Conclusions Mallampati scoring is commonly used in evaluating the oropharynx as a part of the airway assessment and as a screening tool for difficult intubations. However, as this study points out, the respiratory cycle substantially affects the Mallampati scoring system, with significant deviations of 1 or 2 points. In a scoring system of 4 score categories, these deviations are remarkable.
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Affiliation(s)
- Rotem Naftalovich
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
- Medical Corps, U.S. Army, U.S. Army Medical Department, Fort Sam Houston, San Antonio, TX, USA
| | - Marko Oydanich
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Janet Adeola
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Jean Daniel Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - George L. Tewfik
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Chan DP, Jularbal Iii GCRM, Mapili IJR. Left Head Rotation as an Alternative to Difficult Tracheal Intubation: Randomized Open Label Clinical Trial. Interact J Med Res 2023; 12:e42500. [PMID: 37335071 PMCID: PMC10439464 DOI: 10.2196/42500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Tracheal intubation is a life-saving intervention, and optimizing the patient's head and neck position for the best glottic view is a crucial step that accelerates the procedure. The left head rotation maneuver has been recently described as an innovative alternative to the traditional sniffing position used for tracheal intubation with marked improvement in glottic visualization. OBJECTIVE This study compared the glottic view and intubating conditions in the sniffing position versus left head rotation during direct laryngoscopy. METHODS This randomized, open-label clinical trial enrolled 52 adult patients admitted to Baguio General Hospital and Medical Center from September 2020 to January 2021 for an elective surgical procedure requiring tracheal intubation under general anesthesia. Intubation was done using a 45° left head rotation in the experimental group (n=26), while the control group (n=26) was intubated using the conventional sniffing position. Glottic visualization and intubation difficulty with the two procedures were assessed using the Cormack-Lehane grade and Intubation Difficulty Scale, respectively. Successful intubation is measured by observing a capnographic waveform in the end-tidal CO2 monitor after placement of the endotracheal tube. RESULTS There was no statistically significant difference in the Cormack-Lehane grade, with 85% (n=44) of patients classified under grades 1 (n=11 and n=15) and 2 (n=11 and n=7) in the left head rotation and sniffing position groups, respectively. In addition, there were no statistically significant differences in the Intubation Difficulty Scale scores of patients intubated with left head rotation or sniffing position; 30.7% (n=8) of patients in both groups were easily intubated, while 53.8% (n=14) in left head rotation and 57.6% (n=15) in sniffing position groups were intubated with slight difficulty. Similarly, there were no significant differences between the 2 techniques in any of the 7 parameters of the Intubation Difficulty Scale, although numerically fewer patients required the application of additional lifting force (n=7, 26.9% vs n=11, 42.3%) or laryngeal pressure (n=3, 11.5% vs n=7, 26.9%) when intubated with left head rotation. The intubation success rate with left head rotation was 92.3% versus 100% in the sniffing position, but this difference was not statistically significant. CONCLUSIONS Left head rotation produces comparable laryngeal exposure and intubation ease to the conventional sniffing position. Therefore, left head rotation may be an alternative for patients who cannot be intubated in the sniffing position, especially in hospitals where advanced techniques such as video laryngoscopes and flexible bronchoscopes are unavailable, as is the case in this study. However, since our sample size was small, studies with a larger study population are warranted to establish the generalizability of our findings. In addition, we observed inadequate familiarity among anesthesiologists with the left head rotation technique, and the intubation success rate may improve as practitioners attain greater technical familiarization. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number (ISRCTN)ISRCTN23442026; https://www.isrctn.com/ISRCTN23442026.
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Affiliation(s)
- Danya P Chan
- Department of Anesthesiology, Baguio General Hospital and Medical Center, Baguio City, Philippines
| | | | - Ismael Julius R Mapili
- Department of Anesthesiology, Baguio General Hospital and Medical Center, Baguio City, Philippines
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8
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Udayakumar GS, Priya L, Narayanan V. Comparison of Ultrasound Parameters and Clinical Parameters in Airway Assessment for Prediction of Difficult Laryngoscopy and Intubation: An Observational Study. Cureus 2023; 15:e41392. [PMID: 37546081 PMCID: PMC10401488 DOI: 10.7759/cureus.41392] [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: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Background and objective The primary responsibility of the anesthesiologist is to provide adequate oxygenation and ventilation to the patient by securing the airway. Prediction of Cormack-Lehane (CL) grading preoperatively helps patients' airway management during anesthesia induction, particularly in difficult intubations. Our study aims to evaluate airway assessment modalities using ultrasound and conventional clinical screening methods for predicting difficult laryngoscopy and intubation. Materials and methods This prospective observational study was conducted on 100 patients aged between 18 and 70 years belonging to ASA classes I, II, and III scheduled for elective surgery requiring general anesthesia under endotracheal intubation was included in the study. Patients who needed rapid sequence induction and had a history of difficult intubation, obese patients with a body mass index (BMI) of more than 40, patients with notable swelling in the neck region (thyroid), pregnant patients, and patients with maxillofacial anomalies were excluded from the study. Clinical parameters such as body mass index, neck circumference, modified Mallampati grading, thyromental distance, and ultrasound parameters such as anterior neck soft tissue thickness at the level of the thyrohyoid membrane (ANS-TM) and anterior neck soft tissue thickness at the level of vocal cord (ANS-VC) were obtained preoperatively. After intubation, the CL grading was noted and categorized into two groups: easy (classes 1 and 2) and difficult (classes 3 and 4). Descriptive statistics included frequency and percentage for categorical variables and mean±standard deviation for continuous variables. The chi-square test was applied to find the relationship between easy and difficult laryngoscopy when compared with the outcome for categorical variables. A P value of less than 0.05 was considered significant throughout the study. The receiver operating characteristics curve (ROC curve) was used to determine the sensitivity and specificity to predict the outcomes. Results Ultrasound-guided measurements of ANS-TM and ANS-VC are independent predictors of difficult laryngoscopy compared with clinical screening tests. Of the two parameters, we found that ANS-TM has a better diagnostic value for predicting a difficult airway with an area under the ROC curve (AUC) of 91% compared with ANS-VC, which has an AUC of 84%. Of the clinical parameters, the modified Mallampati grading has an AUC of 81%, leading to better diagnostic value in the prediction of a difficult airway. Conclusion Our study demonstrated that ANS-TM and ANS-VC are independent predictors of a difficult airway. ANS-TM has a better correlation with CL grading. Clinical screening tests should be combined with ultrasound measurements to aid in the better prediction of difficult laryngoscopy.
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Affiliation(s)
| | - Lakshmi Priya
- Anesthesiology, Sree Balaji Medical College and Hospital, Chennai, IND
| | - Vidhya Narayanan
- Anesthesiology, Sree Balaji Medical College and Hospital, Chennai, IND
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9
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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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Li Y, Li J, Zhong L, Zeng Z. Development and Internal Validation of a Prediction Model for Difficult Laryngoscopy Using Ultrasound-Derived Factor in Comatose Patients. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1567-1576. [PMID: 36649198 DOI: 10.1002/jum.16177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/19/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The distance from skin to the hyoid bone (DSHB) and skin to the anterior commissure of vocal cords (DSAC) are reliable parameters for pre-operative airway ultrasound assessment in awake patients and can be assessed in comatose patients. This study aimed to inspect its feasibility and accuracy in predicting difficult laryngoscopy for comatose patients. METHODS A prospective cohort study included patients with a Glasgow Coma Scale (GCS) of ≤8 who underwent emergency tracheal intubation between November 2019 and August 2020. The outcome was difficult laryngoscopy and classified according to the Cormack-Lehane grading. RESULTS A total of 151 patients were included in the study. Fifty-two (34.4%) patients were categorized as having difficult laryngoscopy. The DSHB add DSAC (hereinafter referred to as the "DSBAC") was superior to either parameter alone in the predictive performance, and the optimal cut-off value was 1.90. To optimize the predictive value, DSBAC (adjusted odds ratio [OR]: 7.76; 95% confidence interval [CI]: 2.88-20.94; P < .001), GCS (adjusted OR: 1.39; 95% CI: 3.93-26.28; P = .039), mandibular retraction (adjusted OR: 8.20; 95% CI: 1.92-35.09; P = .005) and edentulous (adjusted OR: 4.23; 95% CI: 1.40-12.80; P = .011) were included in a multivariable model and constructed a nomogram. Discrimination and calibration statistics were satisfactory, with C-index above 0.80 from both model development and internal validation. CONCLUSIONS Ultrasound-derived factor, DSBAC, can be easily assessed and help predict difficult laryngoscopy among comatose patients. A simple nomogram including only four clinical items exhibited excellent discrimination performance and was useful when comatose patients underwent emergency tracheal intubation.
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Affiliation(s)
- Yueying Li
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
| | - Jingye Li
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
| | - Liping Zhong
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
| | - Zhiwen Zeng
- Department of Anesthesiology, Meizhou People's Hospital, Meizhou, China
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11
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Pradeep S, Bhar Kundu S, Nivetha C. Evaluation of neck-circumference- thyromental- distance ratio as a predictor of difficult intubation: A prospective, observational study. Indian J Anaesth 2023; 67:445-451. [PMID: 37333697 PMCID: PMC10269975 DOI: 10.4103/ija.ija_631_22] [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: 07/20/2022] [Revised: 09/11/2022] [Accepted: 03/15/2023] [Indexed: 06/20/2023] Open
Abstract
Background and Aims Preoperative identification of difficult airway and subsequent planning is of utmost importance for a patient's safety. Previous studies have identified the ratio of the neck circumference (NC) to the thyromental distance (TMD); NC/TMD as a reliable predictor of difficult intubation in obese patients. But there is a lack of studies evaluating the NC/TMD in non-obese patients. Therefore, the aim of this study was to compare the NC/TMD as a predictor of difficult intubation in both obese and non-obese patients. Methods A prospective, observational study was conducted after obtaining institutional ethics committee clearance and written and informed consent from each patient. One hundred adult patients undergoing elective surgeries under general anaesthesia with orotracheal intubation were included in this study. Difficulty in intubation was assessed using the Intubation Difficulty Scale. The NC/TMD was calculated and the predictive accuracy of NC/TMD and other established parameters in obese and non-obese patients were compared. Results Univariate logistic regression analysis showed that gender, weight, body mass index, inter-incisor gap, Mallampati classification, NC, TMD, sternomental distance, and NC/TMD had a significant association with difficult intubation. NC/TMD has a higher sensitivity, specificity, and positive and negative predictive value with better predictability in comparison to other parameters. Conclusion The NC/TMD is a reliable and better predictor of difficult intubation in both obese and non-obese patients in comparison to NC, TMD, and sternomental distance alone.
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Affiliation(s)
- S Pradeep
- Department of Anaesthesiology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Sudeshna Bhar Kundu
- Department of Anaesthesiology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - C Nivetha
- Department of Anaesthesiology, Calcutta National Medical College, Kolkata, West Bengal, India
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12
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Cho HY, Lee K, Kong HJ, Yang HL, Jung CW, Park HP, Hwang JY, Lee HC. Deep-learning model associating lateral cervical radiographic features with Cormack-Lehane grade 3 or 4 glottic view. Anaesthesia 2023; 78:64-72. [PMID: 36198200 DOI: 10.1111/anae.15874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 12/13/2022]
Abstract
Unanticipated difficult laryngoscopy is associated with serious airway-related complications. We aimed to develop and test a convolutional neural network-based deep-learning model that uses lateral cervical spine radiographs to predict Cormack-Lehane grade 3 or 4 direct laryngoscopy views of the glottis. We analysed the radiographs of 5939 thyroid surgery patients at our hospital, 253 (4%) of whom had grade 3 or 4 glottic views. We used 10 randomly sampled datasets to train a model. We compared the new model with six similar models (VGG, ResNet, Xception, ResNext, DenseNet and SENet). The Brier score (95%CI) of the new model, 0.023 (0.021-0.025), was lower ('better') than the other models: VGG, 0.034 (0.034-0.035); ResNet, 0.033 (0.033-0.035); Xception, 0.032 (0.031-0.033); ResNext, 0.033 (0.032-0.033); DenseNet, 0.030 (0.029-0.032); SENet, 0.031 (0.029-0.032), all p < 0.001. We calculated mean (95%CI) of the new model for: R2 , 0.428 (0.388-0.468); mean squared error, 0.023 (0.021-0.025); mean absolute error, 0.048 (0.046-0.049); balanced accuracy, 0.713 (0.684-0.742); and area under the receiver operating characteristic curve, 0.965 (0.962-0.969). Radiographic features around the hyoid bone, pharynx and cervical spine were associated with grade 3 and 4 glottic views.
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Affiliation(s)
- H-Y Cho
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - K Lee
- Department of Electrical Engineering and Computer Science, Daegu Gyeongbuk Institute of Science and Technology, Daegu, Republic of Korea.,Medical Big data Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - H-J Kong
- Transdisciplinary Department of Medicine and Advanced Technology, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - H-L Yang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - C-W Jung
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - H-P Park
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - J Y Hwang
- Department of Electrical Engineering and Computer Science, Daegu Gyeongbuk Institute of Science and Technology, Daegu, Republic of Korea.,Department of Interdisciplinary Studies of Artificial Intelligence, Daegu Gyeongbuk Institute of Science and Technology, Daegu, Republic of Korea
| | - H-C Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Zhang F, Xu Y, Zhou Z, Zhang H, Yang K. Critical element prediction of tracheal intubation difficulty: Automatic Mallampati classification by jointly using handcrafted and attention-based deep features. Comput Biol Med 2022; 150:106182. [PMID: 36242810 DOI: 10.1016/j.compbiomed.2022.106182] [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: 06/11/2022] [Revised: 09/14/2022] [Accepted: 10/01/2022] [Indexed: 11/20/2022]
Abstract
Preoperative assessment of the difficulty of tracheal intubation is of great importance in anesthesia practice because failed intubation can lead to severe complications and even death. The Mallampati score is widely used as a critical assessment criterion in combination with other measures to assess the difficulty of tracheal intubation. The performance of existing methods for Mallampati classification with artificial intelligence (AI) is unreliable to the extent that the current clinical judgment of the Mallampati score relies entirely on doctors' experience. In this paper, we propose a new method for automatic Mallampati classification. Our method extracts deep features that are more favorable for the Mallampati classification task by introducing an attention mechanism into the basic deep convolutional neural network (DCNN) and then further improves the classification performance by jointly using attention-based deep features with handcrafted features. We conducted experiments on a dataset consisting of 321 oral images collected online. The proposed method has a classification accuracy of 97.50%, a sensitivity of 96.52%, a specificity of 98.05%, and an F1 score of 96.52% after five-fold cross-validation. The experimental results show that our proposed method is superior to other methods, can assist doctors in determining Mallampati class objectively and accurately, and provide an essential reference element for assessing the difficulty of tracheal intubation.
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Affiliation(s)
- Fan Zhang
- Unmanned System Research Institute, Northwestern Polytechnical University, Xi'an, 710072, Shaanxi, China.
| | - Yuelei Xu
- Unmanned System Research Institute, Northwestern Polytechnical University, Xi'an, 710072, Shaanxi, China.
| | - Zhaoyun Zhou
- Department of Anesthesiology, Tai'an Central Hospital, Tai'an, 271000, Shandong, China.
| | - Han Zhang
- Department of Anesthesiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, 710054, Shaanxi, China.
| | - Ke Yang
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Kunming, 650102, Yunnan, China.
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Lazar AE, Gherghinescu MC. Airway Ultrasound for Anesthesia and in Intensive Care Patients-A Narrative Review of the Literature. J Clin Med 2022; 11:6327. [PMID: 36362555 PMCID: PMC9655924 DOI: 10.3390/jcm11216327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 12/09/2023] Open
Abstract
Ultrasound is an everyday diagnostic tool. In anesthesia and intensive care, it has a role as an adjuvant for many procedures, including the evaluation of the airway. Ultrasound airway evaluation can help predict a difficult airway, visualize the proper positioning of an intubation cannula, or evaluate the airway post-intubation. Protocols need to be established for the better integration of ultrasound in the airway evaluation, however until a consensus is reached in this respect, the ultrasound is a reliable aid in anesthesia and intensive care.
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Affiliation(s)
- Alexandra Elena Lazar
- Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science and Technology from Tirgu Mures, Gheorghe Marinescu Street no 38, 540142 Targu Mures, Mures County, Romania
| | - Mircea Constantin Gherghinescu
- Department of Surgery 1, George Emil Palade University of Medicine, Pharmacy, Science and Technology from Tirgu Mures, Gheorghe Marinescu Street no 38, 540142 Targu Mures, Mures County, Romania
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15
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Li Y, Li Y, Chen Q, Hua H, Jiao J, Zhang L, Chen L, Huang S. The effect of first trimester body mass index on the changes in the upper lip bite test classification before and after delivery: A prospective observational study. Front Med (Lausanne) 2022; 9:969862. [PMID: 36186764 PMCID: PMC9515353 DOI: 10.3389/fmed.2022.969862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe difficult airway (DA) assessment and management of pregnant woman has always brought specific challenges. The aim of this study was to investigate the effect of labor on the airway by assessing changes in the upper lip bite test (ULBT) classes and to explore its correlation with the first trimester's body mass index (BMI).MethodsAccording to the BMI of the first trimester, 354 full-term women were divided into low BMI group, normal BMI group and high BMI group. The ULBT class and pregnancy outcome were recorded and compared at early labor, after delivery, and 48 h after delivery.ResultsThe ULBT class was increased in 75(21.1%) patients after delivery. Compared to the normal BMI group, the high BMI group had a higher probability of increasing (34.8 vs. 17.5%; P = 0.002). The number of women with ULBT class 2–3 increased to 157, which was 1.48 times that of early labor. The number of women with ULBT class 3 increased from 4 to 16, of which 7 (53.8%) were from the high BMI group. Binary logistic regression analysis showed that first trimester's BMI was associated with a significant increase in ULBT class after delivery (adjusted odds ratio [aOR] = 2.13 [0.91–4.98], P = 0.02). The ULBT classes of the three groups tended to return to their initial level 48 h after delivery (P > 0.05).ConclusionLabor results in an approximately one-fifth increase in ULBT class. Being overweight or obese in the first trimester is associated with an increased risk of DA during labor.Trial registrationThis study was registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn) on September 26, 2020. Registration number ChiCTR2000038643.
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CM A, Rao SS, K R, R V, KN V, T S D. The Ratio of Height to Thyromental Distance (RHTMD) and Height to Sternomental Distance (RHSMD) as the Predictive Tests for Difficult Tracheal Intubation. Cureus 2022; 14:e28734. [PMID: 36211089 PMCID: PMC9528921 DOI: 10.7759/cureus.28734] [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: 08/13/2022] [Accepted: 09/03/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Pre-operative evaluation is a cornerstone in identifying patients with a risk of difficulty in intubation. Thyromental distance (TMD) is the most commonly used predictor of difficult intubation. However, it’s not a reliable indicator of difficulty during intubation because it differs with patients’ body & size proportion. The present study was done for the evaluation of the ratio of height to thyromental distance (RHTMD) and ratio of height to sternomental distance (RHSMD) as difficult airway predictors. Methods: Data was taken from 400 consecutive patients posted for the need for anesthesia with intubation during surgery. Preoperatively examination of RHTMD and RHSMD was done. Difficulty during intubation has been explained in this current study with Cormack and Lehane grade 3 or 4. The positive and negative predictive values, as well as sensitivity and specificity of individual tests, were calculated as per the recognized formula. Results: The study enrolled 400 patients, which include a maximum number of participants (138 [34.5%]) from the 41-50 year age group. On analyzing RHTMD and RHSMD, the former was found to have a better predictive value than RHSMD (p=0.001). RHTMD & RHSMD was found to have 62.5% & 37.50% sensitivity, respectively. RHTMD was found to have better specificity, positive & negative predictive values, and accuracy than RHSMD. Conclusion: RHTMD was observed to have superior precision in anticipating difficulty in intubation compared to RHSMD.
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Kar S, Senapati LK, Samanta P, Satapathy GC. Predictive Value of Modified Mallampati Test and Upper Lip Bite Test Concerning Cormack and Lehane's Laryngoscopy Grading in the Anticipation of Difficult Intubation: A Cross-Sectional Study at a Tertiary Care Hospital, Bhubaneswar, India. Cureus 2022; 14:e28754. [PMID: 36211112 PMCID: PMC9529291 DOI: 10.7759/cureus.28754] [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] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background and objective Many tests are at hand to predict difficult intubation preoperatively to prevent morbidity and mortality of unanticipated difficult intubation. The present study was conducted to evaluate and compare the efficacy of the modified Mallampati test (MMT) and upper lip bite test (ULBT) to foresee difficult intubation. Materials and methods After obtaining written informed consent, this prospective comparative observational study was conducted on 225 patients scheduled for elective surgery under general endotracheal anesthesia. Preoperative MMT and ULBT were performed. MMT Grade III, IV, and ULBT Grade IV were regarded as predictors of difficult intubation. The laryngoscopic view was graded as per Cormack and Lehane's laryngoscopic grading after induction of anesthesia by an experienced anesthesiologist ignorant of preoperative airway evaluation. Patients with Cormack and Lehane Class III and IV were regarded as difficult intubation. Sensitivity, specificity, and positive and negative predictive values of MMT and ULBT were computed. Agreement between two tests with the Cormack Lehane test was determined by the Kappa coefficient. Results In our research, the occurrence of difficult intubation was found to be 10.2% (23 cases of difficult intubation out of 225 patients). In our analysis, we found the sensitivity (95.5% vs. 95.4%), specificity (54.8% vs 50.0%), positive predictive value (91.6% vs 93.1%), and negative predictive value (39.1% vs 39.1%) were almost comparable between modified Mallampati test and upper lip bite test. Kappa coefficient for the upper lip bite test (0.492) was slightly higher as compared to modified Mallampati scoring (0.454), but both the values are highly statistically significant (p-value <0.001). Conclusion Both the upper lip bite test and modified Mallampati test are comparable with each other and since the upper lip bite test is easy to perform bedside test we recommend it to be used alone or in collaboration with other tests in assessing difficult airways.
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Peeceeyen S A, Balakrishnan R, Thomas R. Comparison of acromio axillary sternal notch index, thyromental height test, and modified mallampati test in preanesthetic prediction of difficult laryngoscopy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Assessment of predictors for difficult intubation and laryngoscopy in adult elective surgical patients at Tikur Anbessa Specialized Hospital, Ethiopia: A cross-sectional study. Ann Med Surg (Lond) 2022; 77:103682. [PMID: 35638080 PMCID: PMC9142645 DOI: 10.1016/j.amsu.2022.103682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background General anesthesia is not without morbidity. One of the well-known life-threatening events associated with general anesthesia is difficult airway which can happen during induction of anesthesia while attempting to insert the endotracheal tube with the aid of a laryngoscope. Difficult intubation, inadequate ventilation, and esophageal intubation are the principal causes of death or brain damage related to airway manipulation. Objective The main objective of this study was to assess the magnitude and predictors for difficult laryngoscopy and intubation among surgical patients who underwent elective surgery under general anesthesia with endotracheal intubation at Tikur Anbessa Specialized Hospital from February 1 to March 30, 2019. Materials &method An institutional based cross sectional study was conducted from February 1 to March 30, 2019 on patients who underwent elective surgery under general anesthesia with endotracheal intubation. Data on socio-demographic characteristics, preanesthetic airway assessment and laryngoscopic view were collected. Data were analyzed by SPSS Version 20.0. Chi- square test, binary logistic regression and multivariate analysis were performed. Tables and texts were used to present data. A p value less than 0.05 was considered as statistically significant. Results The magnitude of difficult laryngoscopy, difficult intubation, and failed intubation were 12.2%, 6.1%, and 0.67%, respectively. Upper Lip Bite Test (ULBT) had a higher sensitivity (90.2%) and negative predictive value of 85.3%. Mallampati had a sensitivity of 45.8% and negative predictive value of 86% in predicting difficult laryngoscopy. Mallampati grade, thyromental distance and ratio of height to thyromental distance (HRTMD) have also showed greater sensitivity (69.6%, 58.3% and 47.8%, respectively) when compared to other tests in predicting difficult intubation. Mallampati class, upper lip bite test (ULBT) and inter-incisor distance (IID) are independent predictors for difficult laryngoscopy (p < 0.05). Furthermore, Mallampati class, Thyromental distance and ratio of height to thyromental distance (HRTMD) are identified as independent predictors of difficult intubation (p < 0.001). Conclusion and recommendation: Mallampati class, Thyromental distance and Ratio of height to Thyromental distance (HRTMD) can predict the probability of difficult endotracheal intubation in adult patients. Whereas, Mallampati class and upper lip bite test (ULBT) predicts higher probability for difficult laryngoscopy. The magnitude of difficult laryngoscopy and intubation were 12.2% and 6.1%, respectively. Mallampati class, TMD and HRTMD were predictors of difficult intubation. Upper Lip Bite Test had a higher sensitivity to predict difficult laryngoscopy. Mallampati class, Upper Lip Bite Test and IID predicts difficult laryngoscopy.
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Charoenkoop P, Luetrakool P, Puttapornpattana T, Sangdee N. Anesthesiology trainees performing flexible scope intubation in spontaneously breathing patients in the left lateral position and the supine position: a prospective randomized trial. BMC Anesthesiol 2022; 22:93. [PMID: 35366811 PMCID: PMC8976386 DOI: 10.1186/s12871-022-01636-2] [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: 01/20/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background Flexible scope intubation is an important airway management skill that requires hands-on training in a real airway. We compared flexible scope intubation by trainees between patients in the left lateral and supine positions. Methods Forty patients aged 20 to 80 years with American Society of Anesthesiologists physical status class I to III were scheduled for elective surgery under general endotracheal anesthesia in Ramathibodi Hospital from February 2020 to June 2020. Patients were randomly assigned to be intubated in one of two positions: supine (Group S) or left lateral (Group L). Trainees performed flexible scope intubation in sedated patients under the supervision of an attending anesthesiologist. Intubation success, time to successful intubation, number of attempts, airway adjustment maneuvers, and hemodynamic changes were compared between groups. Results Patient characteristics did not differ between groups except for Mallampati airway classification. The rate of successful intubation on the first attempt and intubation time did not significantly differ between groups. The proportion of patients who required a jaw thrust during intubation was significantly lower in Group L (10.5% vs. 85%; P < 0.01). Blood pressure and oxygen saturation declined in both groups after intubation. The relative risk of desaturation in patients in the left lateral position compared with the supine position was 0.44 (0.1649–1.1978). Conclusion The rate of successful flexible scope intubation on the first attempt and intubation time did not differ between the groups. The proportion of patients who required a jaw thrust maneuver was significantly lower in patients in the left lateral position. Trial registration https://www.thaiclinicaltrials.org/ (TCTR20200208001) on 08/02/2020.
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Jayaraj AK, Siddiqui N, Abdelghany SMO, Balki M. Management of difficult and failed intubation in the general surgical population: a historical cohort study in a tertiary care centre. Can J Anaesth 2022; 69:427-437. [PMID: 34907502 DOI: 10.1007/s12630-021-02161-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The objective of this study was to describe the incidence, management, and complications of difficult and failed endotracheal intubation in a general surgical population. METHODS This historical cohort study included all cases of difficult endotracheal intubation in general surgical patients at Mount Sinai Hospital (Toronto, ON, Canada) from 1 January 2011 to 31 December 2017. Patient charts and electronic records were reviewed to collect data on airway management and complications. Endotracheal intubation was graded as "difficult" if more than two attempts with direct laryngoscopy or if additional equipment for second or subsequent attempts was required, and "failed" if it could not be achieved despite the attempts. The primary outcome was the incidence of difficult and failed intubation. The secondary outcomes were complications, difficult airway parameters, mask ventilation, number of intubation attempts, and rescue devices including the eventually successful method. RESULTS We identified 111 cases of difficult intubation (0.26%) and 14 cases of failed intubation (0.03%) in 42,805 surgical cases requiring endotracheal intubation over the seven-year period. The incidence was highest in 2012 (0.36%) and lowest in 2017 (0.13%). Difficulty was anticipated in 84 (76%) patients. The median (range) number of intubation attempts was 2 (2-5). Videolaryngoscopy was the eventually successful method in those with unsuccessful first attempt direct laryngoscopy (n = 91) and videolaryngoscopy (n = 17) in 71% and 77% cases, respectively. Intubation failed in 14 patients, three of whom required a surgical airway because the lungs could not be ventilated. Poor visualization of the glottis (93%) and airway bleeding (36%) were the leading causes of failed intubation. Desaturation was seen in 8%, airway bleeding in 7%, and airway edema in 6% of cases of difficult intubation. CONCLUSION The incidences of difficult and failed intubations in our study were 2.6 and 0.3 per 1,000 surgeries requiring laryngoscopies, respectively, with a decrease over time. Videolaryngoscopy showed a high success rate as a rescue device.
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Affiliation(s)
- Ashok Kumar Jayaraj
- Advanced Airway Management, Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Naveed Siddiqui
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Mrinalini Balki
- Department of Anesthesiology and Pain Medicine, Department of Obstetrics & Gynaecology, and Department of Physiology, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Room 7-405, Toronto, ON, M5G 1X5, Canada.
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.
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Wang B, Yao W, Xue Q, Wang M, Xu J, Chen Y, Zhang Y. Nomograms for predicting difficult airway based on ultrasound assessment. BMC Anesthesiol 2022; 22:23. [PMID: 35026991 PMCID: PMC8756724 DOI: 10.1186/s12871-022-01567-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/07/2022] [Indexed: 12/08/2022] Open
Abstract
Background Accurate prediction of the difficult airway (DA) could help to prevent catastrophic consequences in emergency resuscitation, intensive care, and general anesthesia. Until now, there is no nomogram prediction model for DA based on ultrasound assessment. In this study, we aimed to develop a predictive model for difficult tracheal intubation (DTI) and difficult laryngoscopy (DL) using nomogram based on ultrasound measurement. We hypothesized that nomogram could utilize multivariate data to predict DTI and DL. Methods A prospective observational DA study was designed. This study included 2254 patients underwent tracheal intubation. Common and airway ultrasound indicators were used for the prediction, including thyromental distance (TMD), modified Mallampati test (MMT) score, upper lip bite test (ULBT) score temporomandibular joint (TMJ) mobility and tongue thickness (TT). Univariate and the Akaike information criterion (AIC) stepwise logistic regression were used to identify independent predictors of DTI and DL. Nomograms were constructed to predict DL and DTL based on the AIC stepwise analysis results. Receiver operating characteristic (ROC) curves were used to evaluate the accuracy of the nomograms. Results Among the 2254 patients enrolled in this study, 142 (6.30%) patients had DL and 51 (2.26%) patients had DTI. After AIC stepwise analysis, ULBT, MMT, sex, TMJ, age, BMI, TMD, IID, and TT were integrated for DL nomogram; ULBT, TMJ, age, IID, TT were integrated for DTI nomogram. The areas under the ROC curves were 0.933 [95% confidence interval (CI), 0.912–0.954] and 0.974 (95% CI, 0.954–0.995) for DL and DTI, respectively. Conclusion Nomograms based on airway ultrasonography could be a reliable tool in predicting DA. Trial registration Chinese Clinical Trial Registry (No. ChiCTR-RCS-14004539), registered on 13th April 2014. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01567-y.
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Affiliation(s)
- Bin Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China.,Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, China
| | - Weidong Yao
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, China
| | - Qi Xue
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China
| | - Mingfang Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, China
| | - Jianling Xu
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, China
| | - Yongquan Chen
- Department of Anesthesiology, The First Affiliated Hospital of Wannan Medical College, Yijishan Hospital, Wuhu, China
| | - Ye Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, 678# Furong Road, Hefei, Anhui Province, China.
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23
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Mehrotra S, Rana V, Asthana V, Raghuvanshi S. Radiological versus traditional parameters for airway assessment: A comparison. Anesth Essays Res 2022; 16:109-114. [PMID: 36249134 PMCID: PMC9558665 DOI: 10.4103/aer.aer_28_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/28/2022] [Accepted: 05/06/2022] [Indexed: 11/04/2022] Open
Abstract
Background: Aim: Settings and Design: Materials and Methods: Statistical Analysis Used: Results: Conclusion:
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24
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Chatterjee A, Maheshwari VS, Mahanty PR, Nag DS, Shukla R. A Prospective, Comparative Study to Evaluate the Diagnostic Accuracy of Mallampati Grading in Supine and Sitting Positions for Prediction of Difficult Airway. Cureus 2021; 13:e18465. [PMID: 34754631 PMCID: PMC8569641 DOI: 10.7759/cureus.18465] [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] [Accepted: 10/03/2021] [Indexed: 11/21/2022] Open
Abstract
Background & aim Difficult airway is a major concern for all anaesthesiologists because failure to secure airway could lead to devastating complications or may increase morbidity and mortality. Airway assessment, therefore, is of paramount importance and anticipating a difficult airway prior to anesthetic administration, could help us in better preparation as well as avoidance of life-threatening complications. There are various tests available to assess the airway, out of which, modified Mallampati test (MLPT) is one of the common, easy and reliable methods to predict difficult airway. Mallampati test, usually is done with patient in sitting position. However, in certain group of patients in whom sitting position is not possible (suspected cervical spine injury, pelvic injury, patients in shock, etc.), the Mallampati test can be done in supine position. Few studies were available which concluded that Mallampati test in supine position was not only reliable but also superior to sitting position, whereas, few other studies contradicted this opinion. We, therefore, wanted to address this issue and tried to find out whether Mallampati test in supine position could offer better diagnostic accuracy or not. Materials & methods Mallampati test (MLPT) in sitting position was done in 100 patients initially in preoperative period and subsequently in supine position inside operating room prior to induction of anesthesia. During laryngoscopy, Cormack-Lehane (CL) grading was noted in all patients. Correlation of Mallampati test in sitting and supine position with Cormack-Lehane grading was obtained. A receiver operating characteristics (ROC) analysis was done to determine the area under the curve, the sensitivity and the specificity. Positive predictive value (PPV) and negative predictive value (NPV) were also calculated to analyse the diagnostic accuracy of Mallampati score (MLPT) in sitting and supine position. Results A toal of 22.2% of patients had difficult intubation (CL grade 3) although MLPT of these patients in sitting position anticipated a non-difficult airway (MLPT 1 and 2) and there was no significant correlation between MLPT grade in sitting position with the Cormack-Lehane grade. In comparison to sitting position, MLPT in supine position had significant correlation with the Cormack-Lehane grading and all patients with supine MLPT 1 and 2 (non-difficult airway) had easy intubation (CL grade 1 and 2). ROC analysis also showed that MLPT grade in supine position had superior correlation and better diagnostic accuracy than MLPT in sitting position for assessment of airway as indicated by higher sensitivity and better positive as well as negative predictive values. Conclusion Mallampati test done in supine position has far greater sensitivity and is superior in predicting difficult intubation as compared to MLPT done in conventional sitting position.
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Affiliation(s)
| | | | | | | | - Rajiv Shukla
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
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25
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Castillo-Escario Y, Kumru H, Ferrer-Lluis I, Vidal J, Jané R. Detection of Sleep-Disordered Breathing in Patients with Spinal Cord Injury Using a Smartphone. SENSORS 2021; 21:s21217182. [PMID: 34770489 PMCID: PMC8587662 DOI: 10.3390/s21217182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/20/2021] [Accepted: 10/27/2021] [Indexed: 01/10/2023]
Abstract
Patients with spinal cord injury (SCI) have an increased risk of sleep-disordered breathing (SDB), which can lead to serious comorbidities and impact patients’ recovery and quality of life. However, sleep tests are rarely performed on SCI patients, given their multiple health needs and the cost and complexity of diagnostic equipment. The objective of this study was to use a novel smartphone system as a simple non-invasive tool to monitor SDB in SCI patients. We recorded pulse oximetry, acoustic, and accelerometer data using a smartphone during overnight tests in 19 SCI patients and 19 able-bodied controls. Then, we analyzed these signals with automatic algorithms to detect desaturation, apnea, and hypopnea events and monitor sleep position. The apnea–hypopnea index (AHI) was significantly higher in SCI patients than controls (25 ± 15 vs. 9 ± 7, p < 0.001). We found that 63% of SCI patients had moderate-to-severe SDB (AHI ≥ 15) in contrast to 21% of control subjects. Most SCI patients slept predominantly in supine position, but an increased occurrence of events in supine position was only observed for eight patients. This study highlights the problem of SDB in SCI and provides simple cost-effective sleep monitoring tools to facilitate the detection, understanding, and management of SDB in SCI patients.
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Affiliation(s)
- Yolanda Castillo-Escario
- Institute for Bioengineering of Catalonia (IBEC), Barcelona Institute of Science and Technology (BIST), 08028 Barcelona, Spain; (I.F.-L.); (R.J.)
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya-Barcelona Tech (UPC), 08028 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
- Correspondence: (Y.C.-E.); (H.K.)
| | - Hatice Kumru
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació, 08916 Badalona, Spain;
- Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, 08916 Badalona, Spain
- Correspondence: (Y.C.-E.); (H.K.)
| | - Ignasi Ferrer-Lluis
- Institute for Bioengineering of Catalonia (IBEC), Barcelona Institute of Science and Technology (BIST), 08028 Barcelona, Spain; (I.F.-L.); (R.J.)
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya-Barcelona Tech (UPC), 08028 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
| | - Joan Vidal
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació, 08916 Badalona, Spain;
- Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
- Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, 08916 Badalona, Spain
| | - Raimon Jané
- Institute for Bioengineering of Catalonia (IBEC), Barcelona Institute of Science and Technology (BIST), 08028 Barcelona, Spain; (I.F.-L.); (R.J.)
- Department of Automatic Control (ESAII), Universitat Politècnica de Catalunya-Barcelona Tech (UPC), 08028 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
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Bindu HM, Dogra N, Makkar JK, Bhatia N, Meena S, Gupta R. Limited condylar mobility by ultrasonography predicts difficult direct laryngoscopy in morbidly obese patients: An observational study. Indian J Anaesth 2021; 65:612-618. [PMID: 34584285 PMCID: PMC8445208 DOI: 10.4103/ija.ija_1508_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/04/2021] [Accepted: 08/02/2021] [Indexed: 12/25/2022] Open
Abstract
Background and Aims Unpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially in morbidly obese patients. The present study aimed to determine the efficacy of different sonographic measures as predictors of difficult laryngoscopy in morbidly obese patients undergoing elective surgery. Methods This observational study evaluated 70 morbidly obese adult patients (body mass index >35 kg/m2) undergoing elective surgery under general anaesthesia with tracheal intubation. Pre-operative clinical and ultrasonographic variables (anterior condylar translation, tongue thickness, hyomental distance and oral cavity height) associated with difficult direct laryngoscopy ([Cormack Lehane (CL) grade>2]) were analysed. The primary outcome was to determine the efficacy of the above-mentioned sonographic measures as predictors of difficult laryngoscopy (CL grade >2). The secondary outcome compared ultrasonographic predictors with clinical predictors in morbidly obese patients for determining difficult direct laryngoscopy. Results Amongst the primary outcome measures, limited condylar mobility (anterior condylar translation <9.25 mm) [odds ratio (OR) 0.3, confidence interval (CI):1.04-1.22;P<0.001;area under curve (AUC):0.8] and increased tongue thickness >5.85 cm [OR: 3.2, CI: 1.05-10; P < 0.04; AUC: 0.73] were two independent sonographic predictors for difficult direct laryngoscopy by multivariate logistic regression and receiver operating characteristic curve analyses in morbidly obese patients. The secondary outcome suggested that as compared to clinical predictors such as Mallampati grade and thyromental distance, ultrasonographic variables such as tongue thickness and limited condylar mobility (sensitivity: 56.4%, 70.9%, 66.7% and 93.3%, respectively) better predicted difficult direct laryngoscopy in morbidly obese patients. Conclusion Limited condylar mobility and increased tongue thickness are independent sonographic predictors of difficult direct laryngoscopy in morbidly obese patients.
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Affiliation(s)
- Harika M Bindu
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Neeti Dogra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | - Nidhi Bhatia
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Shyam Meena
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, PGIMER, Chandigarh, India
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27
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Lin HY, Tzeng IS, Hsieh YL, Kao MC, Huang YC. Submental Ultrasound Is Effective in Predicting Difficult Mask Ventilation but Not in Difficult Laryngoscopy. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:2243-2249. [PMID: 34020847 DOI: 10.1016/j.ultrasmedbio.2021.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/21/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
The goal of this study was to determine the utility of submental ultrasound parameters in distinguishing difficult airway management from easy airway management. Forty-one adult patients who underwent elective surgery under general anesthesia with endotracheal intubation from March to December 2018 were included. We used submental ultrasound to measure tongue base thickness (TBT) in the midsagittal plane and the distance between lingual arteries (DLA) in the transverse dimension. The primary outcome was difficult laryngoscopy, and the secondary outcome was difficult mask ventilation. Receiver operating characteristic curve analysis and logistic regression revealed no correlation between difficult laryngoscopy and SMUS measurements. Nevertheless, patients with difficult mask ventilation had significantly higher TBT (p = 0.009) and longer DLA (p = 0.010). After adjustment of confounding factors, increased TBT (>69.6 mm) was the sole independent predictor of difficult mask ventilation. The results indicated that SMUS is effective in predicting difficult mask ventilation but not difficult laryngoscopy.
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Affiliation(s)
- Han-Yu Lin
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - I-Shiang Tzeng
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Yung-Lin Hsieh
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ming-Chang Kao
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yun-Chen Huang
- College of Medicine, Tzu Chi University, Hualien, Taiwan; Department of Otolaryngology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan.
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28
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Pearce AC, Duggan LV, El-Boghdadly K. Making the grade: has Cormack and Lehane grading stood the test of time? Anaesthesia 2021; 76:705-709. [PMID: 33799315 DOI: 10.1111/anae.15446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 12/16/2022]
Affiliation(s)
- A C Pearce
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - L V Duggan
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - 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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Zhou Y, Han Y, Li Z, Zhao Y, Yang N, Liu T, Li M, Wang J, Guo X, Xu M. Preoperative X-ray C 2C 6AR is applicable for prediction of difficult laryngoscopy in patients with cervical spondylosis. BMC Anesthesiol 2021; 21:111. [PMID: 33845783 PMCID: PMC8040201 DOI: 10.1186/s12871-021-01335-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 04/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway management is one of the most important techniques in anesthesia practice and inappropriate airway management is related with airway injury, brain hypoxia, and even death. The patients with cervical spondylosis are often confronted with difficult laryngoscopy who are more prone to appear difficult airway, so it is important to figure out valuable predictors of difficult laryngoscopy in these patients. METHODS We randomly enrolled 270 patients undergoing elective cervical spine surgery and analyzed the cervical mobility data in predicting difficult laryngoscopy. The preoperative X-ray radiological indicators were measured by an attending radiologist. Cormack-Lehane scales were assessed during intubation, and patients with a class III or IV view were assigned to the difficult laryngoscopy group. RESULTS Univariate analysis showed that the hyomental distance (HMD, the distance between the hyoid bone and the tip of the chin) and the hyomental distance ratio (HMDR, the ratio between HMD in the extension position and the one in the neutral position) might not be suitable indicators in patients with cervical spondylosis. Binary multivariate logistic regression (backward-Wald) analyses identified two independent correlative factors from the cervical mobility indicators that correlated best as a predictor of difficult laryngoscopy: modified Mallampati test (MMT) and C2C6AR (the ratio of the angle between a line passing through the bottom of the second cervical vertebra and a line passing through the bottom of the sixth cervical vertebra in the extension position and the one in the neutral position). The odds ratio (OR) and 95 % CI were 2.292(1.093-4.803) and 0.493 (0.306-0.793), respectively. C2C6AR exhibited the largest area under the curve (0.714; 95 % CI 0.633-0.794). CONCLUSIONS C2C6AR based on preoperative X-ray images may be the most accurate predictor of cervical mobility indicators for difficult laryngoscopy in patients with cervical spondylosis. TRIAL REGISTRATION The study was registered at the Chinese Clinical Trial Registry ( http://www.chictr.org.cn ; identifier: ChiCTR-ROC-16,008,598) on June 6, 2016.
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Affiliation(s)
- Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China
| | - Yuqing Zhao
- Department of Radiology, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Ning Yang
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China
| | - Taotao Liu
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China
| | - Min Li
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China
| | - Jun Wang
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China.
| | - Mao Xu
- Department of Anesthesiology, Peking University Third Hospital, Peking University Health Science Center, 49 North Garden Road, Haidian District, Beijing, P.R. China.
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Mahmoud M, Hasanin AM, Mostafa M, Alhamade F, Abdelhamid B, Elsherbeeny M. Evaluation of super-obesity and super-super-obesity as risk factors for difficult intubation in patients undergoing bariatric surgery. Surg Obes Relat Dis 2021; 17:1279-1285. [PMID: 33941481 DOI: 10.1016/j.soard.2021.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/13/2020] [Accepted: 03/31/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Super-obesity is a serious disorder which requires bariatric surgery. The association of super-obesity and difficult intubation was not adequately established. OBJECTIVES To determine if super-obesity and super-super-obesity are associated with difficult intubation or not. SETTING University Hospital. METHODS A cohort of obese patients scheduled for bariatric surgery was prospectively recruited. Super-obesity and super-super-obesity were defined as body mass index ≥50 kg/m2 and 60 kg/m2, respectively. Intubation difficulty was assessed by 2 methods: (1) intubation difficulty scale; (2) number of intubation attempts. Risk factors for difficult intubation were recorded. Univariate and multivariate analysis for risk factors for difficult intubation and difficult mask ventilation were performed. RESULTS A total of 658 patients were enrolled in the study including 205 (31%) super-obese and 52 (8%) super-super-obese patients. Ninety-nine (15%) patients required more than 1 intubation attempt, while 215 (33%) patients had intubation difficulty scale ≥5. Ninety-four (14.4%) patients had mask ventilation of moderate difficulty, while only 2 (.3%) patients needed 2-person ventilation. The independent risk factors for difficult intubation using the two stated definitions were STOP-Bang and Mallampati score values. The independent risk factors for mask ventilation of moderate difficulty were STOP-Bang score, Mallampati score, and limited neck extension. CONCLUSION Within obese patients, neither super-obesity nor super-super-obesity was associated with difficult intubation or difficult mask ventilation. High STOP-Bang and Mallampati score are the independent factors for difficult intubation.
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Affiliation(s)
- Mohamed Mahmoud
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Ahmed M Hasanin
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt.
| | - Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Fatema Alhamade
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Bassant Abdelhamid
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
| | - Mona Elsherbeeny
- Department of Anesthesia and Critical Care Medicine, Cairo University, Cairo, Egypt
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Rhee SH, Yun HJ, Kim J, Karm MH, Ryoo SH, Kim HJ, Seo KS. Risk factors affecting the difficulty of fiberoptic nasotracheal intubation. J Dent Anesth Pain Med 2020; 20:293-301. [PMID: 33195807 PMCID: PMC7644361 DOI: 10.17245/jdapm.2020.20.5.293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/16/2020] [Accepted: 10/23/2020] [Indexed: 11/15/2022] Open
Abstract
Background The success rate of intubation under direct laryngoscopy is greatly influenced by laryngoscopic grade using the Cormack-Lehane classification. However, it is not known whether grade under direct laryngoscopy can also affects the success rate of nasotracheal intubation using a fiberoptic bronchoscpe, so this study investigated the same. In addition, we investigated other factors that influence the success rate of fiberoptic nasotracheal intubation (FNI). Methods FNI was performed by 18 anesthesiology residents under general anesthesia in patients over 15 years of age who underwent elective oral and maxillofacial operations. In all patients, the Mallampati grade was measured. Laryngeal view grade under direct laryngoscopy, and the degree of secretion and bleeding in the oral cavity was measured and divided into 3 grades. The time required for successful FNI was measured. If the intubation time was > 5 minutes, it was evaluated as a failure and the airway was managed by another method. The failure rate was evaluated using appropriate statistical method. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were also measured. Results A total of 650 patients were included in the study, and the failure rate of FNI was 4.5%. The patient's sex, age, height, weight, Mallampati, and laryngoscopic view grade did not affect the success rate of FNI (P > 0.05). BMI, the number of FNI performed by residents (P = 0.03), secretion (P < 0.001), and bleeding (P < 0.001) grades influenced the success rate. The AUCs of bleeding and secretion were 0.864 and 0.798, respectively, but the AUC of BMI, the number of FNI performed by residents, Mallampati, and laryngoscopic view grade were 0.527, 0.616, 0.614, and 0.544, respectively. Conclusion Unlike in intubation under direct laryngoscopy, in the case of FNI, oral secretion and nasal bleeding had a significant effect on FNI difficulty than Mallampati grade or Laryngeal view grade.
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Affiliation(s)
- Seung-Hyun Rhee
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Korea
| | - Hye Joo Yun
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jieun Kim
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Korea
| | - Seung-Hwa Ryoo
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Korea
| | - Hyun Jeong Kim
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Korea
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Korea
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Agarwal R, Jain G, Agarwal A, Govil N. Effectiveness of four ultrasonographic parameters as predictors of difficult intubation in patients without anticipated difficult airway. Korean J Anesthesiol 2020; 74:134-141. [PMID: 32536044 PMCID: PMC8024205 DOI: 10.4097/kja.20114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/08/2020] [Indexed: 12/04/2022] Open
Abstract
Background Predicting difficult intubation (DI) is a key challenge, as no single clinical predictor is sufficiently valid to predict the outcome. We evaluated the effectiveness of four upper airway ultrasonographic parameters in predicting DI. The validity of the models using combinations of ultrasonography-based parameters was also investigated. Methods This prospective, observational, double-blinded cohort trial enrolled 1,043 surgical patients classified as American Society of Anesthesiologists physical status I–III without anticipated difficult airway. Preoperatively, their tongue thickness (TT), invisibility of hyoid bone (VH), and anterior neck soft tissue thickness from the skin to thyrohyoid membrane (ST) and hyoid bone (SH) were measured by sublingual and submandibular ultrasonography. The logistic regression, Youden index, and receiver operator characteristic analysis results were reported. Results Overall, 58 (5.6%) patients were classified as DI. The TT, SH, ST, and VH had accuracies of 78.4%, 85.0%, 84.7%, and 84.9%, respectively. The optimal values of TT, SH, and ST for predicting DI were > 5.8 cm (sensitivity: 84.5%, specificity: 78.1%, AUC: 0.880), > 1.4 cm (sensitivity: 81%, specificity: 85.2%, AUC: 0.898) and > 2.4 cm (sensitivity: 75.9%, specificity: 85.2%, AUC: 0.885) respectively. VH had a sensitivity and specificity of 72.4% and 85.6% (AUC: 0.790). The AUC values of the five models (with combinations of three or four parameters) ranged from 0.975–0.992. ST and VH had a significant impact on the individual models. Conclusions SH had the best accuracy. Individual parameters showed limited validity. The model including all four parameters offered the best diagnostic value.
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Affiliation(s)
- Rishabh Agarwal
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Gaurav Jain
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Ankit Agarwal
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
| | - Nishith Govil
- Department of Anesthesiology, All India Institute of Medical Sciences, Rishikesh, India
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Ultrasonography for predicting a difficult laryngoscopy. Getting closer. J Clin Monit Comput 2020; 35:269-277. [PMID: 31993893 DOI: 10.1007/s10877-020-00467-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/21/2020] [Indexed: 12/24/2022]
Abstract
Our objective was to evaluate the usefulness of five ultrasound measurements to predict a difficult laryngoscopy (DL). Prospective observational study. 50 patients underwent scheduled surgery under general anesthesia with orotracheal intubation with classical laryngoscopy at the University Hospital of Jaén (Spain). Sociodemographic variables, classic preintubation screening tests and ultrasound measurements of the neck soft tissue from skin to hyoid (DSH), epiglottis (DSE) and glottis (DSG) were obtained, as well as two measurements derived from the above: DSH + DSE and DSE - DSG. The relationship between a DL and ultrasound measurements was evaluated using t student test. The ROC Curve was used to establish the diagnostic accuracy of ultrasound measurements to discriminate a DL and logistic regression was used to establish a cut-off point. Multivariate analysis was performed to assess the impact of these measures in clinical practice. Patients with DL showed greater thickness of DSE (2.9 ± 0.46 cm vs 2.32 ± 0.54 cm; p = 0.001), DSH + DSE (4.25 ± 0.45 cm vs 3.62 ± 0.77 cm; p = 0.001) and DSE - DSG (1.83 ± 0.54 cm vs 1.24 ± 0.46 cm; p = 0.001) than those with an easy laryngoscopy. DSE and DSE - DSG had the highest diagnostic accuracy for DL with an area under the ROC curve of 0.79 [95%IC 0.66-0.92] and 0.82 [95%IC 0.68-0.96], respectively. It was established that DSE ≥ 3 cm, could predict a DL with a positive predictive value (PPV) of 69.23% [95%CI 40.3-98.2], and DSE - DSG ≥ 1.9 cm would do so with a PPV of 78.57% [95%CI 53.31-100%]. The multivariate analysis endorsed that DSE and DSE - DSG combined with classic tests (the Modified Mallampati score, the thyromental distance and the upper lip bite test) improved the preoperative detection of a DL. The inclusion of DSE and DSE - DSG in a multivariate model with classic parameters may offer the anesthesiologist better information for detecting a DL preoperatively.
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Koundal V, Rana S, Thakur R, Chauhan V, Ekke S, Kumar M. The usefulness of point of care ultrasound (POCUS) in preanaesthetic airway assessment. Indian J Anaesth 2019; 63:1022-1028. [PMID: 31879427 PMCID: PMC6921326 DOI: 10.4103/ija.ija_492_19] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/01/2019] [Accepted: 10/23/2019] [Indexed: 01/28/2023] Open
Abstract
Background and Aims: Point of care ultrasound has the potential to become reliable airway assessment tool by accurate prediction of difficult laryngoscopy. We aimed to determine the feasibility of ultrasound in preoperative airway assessment. Methods: This prospective, observational study was conducted on 200 patients requiring general anaesthesia and tracheal intubation. The thickness of anterior soft tissue neck at the level of hyoid bone (DSHB), epiglottis (DSEM), and Pre-E/E-VC[depth of the pre-epiglottic space (Pre-E)/distance from the epiglottis to the midpoint of the distance between the vocal cords (E-VC)] were measured sonographically. The hyomental distance ratio (HMDR) was measured utilising distances with head in neutral and extended position. The primary outcome was the efficacy of the parameters in predicting difficult laryngoscopy[Cormack Lehane 3,4]. The secondary outcome was to correlate the parameters to CL grading. Results: Utilising receiver operating curves, cutoff value of HMDR for predicting difficult laryngoscopy was ≤1.0870 with sensitivity of 65%, specificity of 77%. The cutoff value, sensitivity andspecificity for Pre-E/E-VC were ≥1.785, 82.8% and 83.8%., respectively. The cutoff value of DSHB was ≥0.99 with sensitivity of 48% and specificity of 82%. The cutoff, sensitivity and specificity for DSEM were ≥1.615, 89.7%, and 64.8%, respectively. There was moderate positive correlations of DSHB, DSEM, and Pre-E/E-VC (r = 0.551 and 0.701, 0.787: P = 0.00), whereas moderate negative correlation observed with HMDR (r = -.0671: P = 0.00). Conclusion: The strong positive correlation of Pre-E/E-VC, DSEM, and moderate negative correlation of HMDR makes these ultrasound parameters reliable predictors for difficult laryngoscopy.
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Affiliation(s)
- Vishal Koundal
- Department of Anesthesia, CH Dehra, Dr Rajendra Prasad Medical Govt. College, Kangra at Tanda, Himachal Pradesh, India
| | - Shelly Rana
- Department of Anesthesia, Dr Rajendra Prasad Medical Govt. College, Kangra at Tanda, Himachal Pradesh, India
| | - Ravinder Thakur
- Department of Anesthesia, Dr Rajendra Prasad Medical Govt. College, Kangra at Tanda, Himachal Pradesh, India
| | - Vrinda Chauhan
- Department of Anesthesia, Dr Rajendra Prasad Medical Govt. College, Kangra at Tanda, Himachal Pradesh, India
| | - Sony Ekke
- Department of Anesthesia, Dr Rajendra Prasad Medical Govt. College, Kangra at Tanda, Himachal Pradesh, India
| | - Manuj Kumar
- Department of Anesthesia, Dr Rajendra Prasad Medical Govt. College, Kangra at Tanda, Himachal Pradesh, India
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Mao Z, Zhang N, Cui Y. A clinical prediction rule to identify difficult intubation in children with Robin sequence requiring mandibular distraction osteogenesis based on craniofacial CT measures. BMC Anesthesiol 2019; 19:215. [PMID: 31752712 PMCID: PMC6868728 DOI: 10.1186/s12871-019-0889-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway management is challenging in children with Robin sequence (RS) requiring mandibular distraction osteogenesis (MDO). We derived and validated a prediction rule to identify difficult intubation before MDO for children with RS based on craniofacial computed tomography (CT) images. METHOD This was a retrospective study of 69 children with RS requiring MDO from November 2016 to June 2018. Multiple CT imaging parameters and baseline characteristic (sex, age, gestational age, body mass index [BMI]) were compared between children with normal and difficult intubation according to Cormack-Lehane classification. A clinical prediction rule was established to identify difficult intubation using group differences in CT parameters (eleven distances, six angles, one section cross-sectional area, and three segment volumes) and clinicodemographic characteristics. Predictive accuracy was evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS The overall incidence of difficult intubation was 56.52%, and there was no significant difference in sex ratio, age, weight, height, BMI, or gestational age between groups. The distance between the root of the tongue and posterior pharyngeal wall was significantly shorter, the bilateral mandibular angle shallower, and the cross-sectional area at the epiglottis tip smaller in the difficult intubation group. A clinical prediction rule based on airway cross-sectional area at the tip of the epiglottis was established. Area > 36.97 mm2 predicted difficult intubation while area < 36.97 mm2 predicted normal intubation with 100% sensitivity, 62.5% specificity, 78.6% positive predictive value, and 100% negative predictive value (area under the ROC curve = 0.8125). CONCLUSION Computed tomography measures can objectively evaluate upper airway morphology in patients with RS for prediction of difficult intubation. If validated in a larger series, the measures identified could be incorporated into airway assessment tools to guide treatment decisions. This was a retrospective study and was granted permission to access and use these medical records by the ethics committee of Guangzhou Women and Children's Medical Center. TRIALS REGISTRATION Registration No. ChiCTR1800018252, NaZhang, Sept 7 2018.
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Affiliation(s)
- Zhe Mao
- Guangzhou Women and Children's Medical Center, No 9, Jinsui Road, Guangzhou, 510623, Guangdong, China
| | - Na Zhang
- Guangzhou Women and Children's Medical Center, No 9, Jinsui Road, Guangzhou, 510623, Guangdong, China
| | - Yingqiu Cui
- Guangzhou Women and Children's Medical Center, No 9, Jinsui Road, Guangzhou, 510623, Guangdong, China.
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Abstract
Understanding how to assess, secure, and manage an airway can save a patient's life in an emergent situation. This article briefly describes the basics of airway management in the acute care setting.
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Dada OF, Faponle AF, Adenekan AT. Description and comparison of the performance of the upper lip bite test, the ratio of height to thyromental distance and other methods of preoperative airway assessment in a Nigerian population – a pilot study. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2019. [DOI: 10.36303/sajaa.2019.25.5.a1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background: The ability to reliably predict difficult intubation can prevent airway related adverse outcomes. The upper lip bite test (ULBT) and ratio of height to thyromental distance (RHTMD) are airway predictive tests that have been evaluated in Caucasian populations with promising results. This study determined the test performance of the ULBT and RHTMD and compared with commonly employed predictive tests (modified Mallampati [MMT], thyromental distance [TMD] and inter-incisor gap [IIG]) in adult Nigerians.
Methods: This was a cross-sectional study. Two hundred and sixteen consecutive, consenting ASA I-III patients presenting for surgery and planned for general anaesthesia with endotracheal intubation over a six month period in our teaching hospital, had all five airway assessment tests (ULBT, RHTMD, MMT, TMD and IIG) assessed preoperatively. The Cormack and Lehane grading was used to determine easy or difficult visualisation of the larynx (EVL or DVL). Sensitivity, specificity, predictive values and likelihood ratios of the tests were determined.
Results: The sensitivities, specificities, positive and negative predictive values and positive and negative likelihood ratios respectively for the tests were: ULBT (11.8%, 99.0%, 50.0%, 92.9%, 11.71 and 0.89), RHTMD (35.3%, 92.5%, 28.6%, 94.4%, 4.68 and 0.70), TMD (29.4%, 97.5%, 50.0%, 94.2%, 11.71 and 0.72), MMT (52.9%, 86.4%, 25.0%, 95.6%, 3.90 and 0.54), and IIG (11.8%, 97.0%, 25.0%, 92.8%, 3.90 and 0.91).
Conclusion: The modified Mallampati test had the highest sensitivity in this study, however all the tests evaluated showed only low to moderate sensitivity. The ULBT and RHTMD had low sensitivities in this population. However, based on the high positive likelihood ratios of the ULBT and the TMD, whenever positive, these tests do show a high probability of DVL and these two tests would probably perform similarly in this population. Anthropometric differences may account for differences in performance of preoperative airway assessment tests in various populations.
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Affiliation(s)
- OF Dada
- Obafemi Awolowo University Teaching Hospitals Complex
| | - AF Faponle
- Obafemi Awolowo University Teaching Hospitals Complex
| | - AT Adenekan
- Obafemi Awolowo University Teaching Hospitals Complex
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Green SM, Roback MG. Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation? Ann Emerg Med 2019; 74:251-259. [DOI: 10.1016/j.annemergmed.2018.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
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Yoon HK, Lee HC, Oh H, Jun K, Park HP. Postoperative sore throat and subglottic injury after McGrath® MAC videolaryngoscopic intubation with versus without a stylet in patients with a high Mallampati score: a randomized controlled trial. BMC Anesthesiol 2019; 19:137. [PMID: 31366325 PMCID: PMC6668117 DOI: 10.1186/s12871-019-0811-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/25/2019] [Indexed: 11/24/2022] Open
Abstract
Background A tracheal tube stylet can be used to assist successful tracheal intubation, especially during videolaryngoscopic intubation because videolaryngoscopes with a Macintosh-type blade such as McGrath® MAC videolaryngoscope have more acute angle than conventional Macintosh laryngoscope. However, the use of a stylet during tracheal intubation can raise concerns about stylet-induced postoperative airway complications, such as sore throat, subglottic injury, and hoarseness. In this study, we compared the incidence of postoperative airway complications after McGrath® MAC videolaryngoscopic intubation with versus without a stylet in patients with a high Mallampati score. Methods In 104 patients with Mallampati score III or IV and who were scheduled for lumbar or thoracic spine surgery, McGrath® MAC videolaryngoscopic intubation was performed either with a stylet (group S, n = 52) or without a stylet (group N, n = 52). The primary outcome measure was the incidences of sore throat evaluated at 1 and 24 h postoperatively. Secondary outcome measures were the incidences of subglottic injury and postoperative hoarseness. Results The incidence of CL grade III in group S and N was 3.8 and 5.8%, respectively. No patient showed CL grade IV. The incidences of sore throat at 1 (26.9 vs 19.2%, P = 0.485) and 24 h (17.3 vs 13.5%, P = 0.786, respectively) postoperatively were not significantly different between the group S and N. However, the incidence of subglottic injury was significantly higher in the group S, compared with the group N (65.4 vs 42.3%, P = 0.030). The incidence of postoperative hoarseness did not differ significantly between the two groups. Conclusions The use of a stylet during McGrath® MAC videolaryngoscopic intubation did not have a significant impact on the incidence of postoperative sore throat in patients with a high Mallampati score. Avoiding the use of a stylet during intubation with McGrath® MAC videolaryngoscope may reduce the incidence of subglottic injury in such patients. Trial registration Clinical Research Information Service (identifier: KCT0002427, date of registration: June 12, 2017).
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Affiliation(s)
- Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hyongmin Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Kwanghoon Jun
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hee-Pyoung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Han Y, Fang J, Zhang H, Xu M, Guo X. Anterior neck soft tissue thickness for airway evaluation measured by MRI in patients with cervical spondylosis: prospective cohort study. BMJ Open 2019; 9:e029987. [PMID: 31147371 PMCID: PMC6549676 DOI: 10.1136/bmjopen-2019-029987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Anterior neck soft tissue thickness, usually measured by ultrasound, is increasingly being investigated to predict difficult laryngoscopy, but the results have not been validated. Considering the conflicting measurement data, different measuring body positions and lack of a standard ultrasound procedure, we used MRI to verify the efficacy of these popular ultrasonographic parameters. DESIGN Prospective cohort study. SETTING A tertiary hospital in Beijing, China. METHODS We enrolled 315 adult patients who underwent cervical spinal surgery in Peking University Third Hospital from April to October 2016. We analysed MRI data to predict difficult laryngoscopy. Cormack-Lehane scales were assessed during intubation, and patients with a class III or IV view were assigned to the difficult laryngoscopy group. RESULTS Univariate analysis showed that male sex (p<0.01), older age (p=0.03) and body weight (p=0.02) were associated with difficult laryngoscopy. MRI data consisted of five common ultrasonographic variables used to predict difficult laryngoscopy, but none was a valuable predictor: skin to hyoid (p=0.18), skin to midpoint of epiglottis (p=0.72), skin to thyroid cartilage at the level of the vocal cords (p=0.10), skin to vocal cords (p=0.44) or skin to anterior to the trachea at the level of suprasternal notch (p=0.92). Adjusted by sex, age and body weight, none of the five MRI indicators had predictive value (p>0.05). CONCLUSION The five most commonly studied ultrasonographic indicators of anterior soft tissue thickness appeared unreliable to predict difficult laryngoscopy in patients with cervical spondylosis. Further study is needed to validate the most valuable indicator to predict difficult laryngoscopy. TRIAL REGISTRATION NUMBER ChiCTRROC-16008598; Pre-results.
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Affiliation(s)
- Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Jingchao Fang
- Radiology, Peking University Third Hospital, Beijing, China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Mao Xu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
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Lundstrøm LH, Rosenstock CV, Wetterslev J, Nørskov AK. The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients. Anaesthesia 2019; 74:1267-1276. [PMID: 31106851 DOI: 10.1111/anae.14701] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2019] [Indexed: 12/01/2022]
Abstract
Facemask ventilation is an essential part of airway management. Correctly predicting difficulties in facemask ventilation may reduce the risk of morbidity and mortality among patients at risk. We aimed to develop and evaluate a weighted risk score for predicting difficult facemask ventilation during anaesthesia. We analysed a cohort of 46,804 adult patients who were assessed pre-operatively airway for 13 predictors of difficult airway management and subsequently underwent facemask ventilation during general anaesthesia. We developed the Difficult Facemask (DIFFMASK) score in two consecutive steps: first, a multivariate regression analysis was performed; and second, the regression coefficients of the adjusted regression model were converted into a clinically applicable weighted point score. The predictive accuracy of the DIFFMASK score was evaluated by assessment of receiver operating characteristic curves. The prevalence of difficult facemask ventilation was 1.06% (95%CI 0.97-1.16). Following conversion of regression coefficients into 0, 1, 2 or 3 points, the cumulated DIFFMASK score ranged from 0 to 18 points and the area under the receiver operating characteristic curve was 0.82. The Youden index indicated a sum score ≥ 5 as an optimal cut-off value for prediction of difficult facemask ventilation giving a sensitivity of 85% and specificity of 59%. The DIFFMASK score indicated that a score of 6-10 points represents a population of patients who may require heightened attention when facemask ventilation is planned, compared with those patients who are obviously at a high- or low risk of difficulties. The DIFFMASK score may be useful in a clinical context but external, prospective validation is needed.
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Affiliation(s)
- L H Lundstrøm
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerød, Denmark
| | - C V Rosenstock
- Department of Anaesthesiology and Intensive Care, Nordsjaellands Hospital, Hillerød, Denmark
| | - J Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - A K Nørskov
- Department of Anaesthesiology and Intensive care, Nordsjaellands Hospital, Hillerød, Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Abstract
Abstract
An airway manager’s primary objective is to provide a path to oxygenation. This can be achieved by means of a facemask, a supraglottic airway, or a tracheal tube. If one method fails, an alternative approach may avert hypoxia. We cannot always predict the difficulties with each of the methods, but these difficulties may be overcome by an alternative technique. Each unsuccessful attempt to maintain oxygenation is time lost and may incrementally increase the risk of hypoxia, trauma, and airway obstruction necessitating a surgical airway. We should strive to optimize each effort. Differentiation between failed laryngoscopy and failed intubation is important because the solutions differ. Failed facemask ventilation may be easily managed with an supraglottic airway or alternatively tracheal intubation. When alveolar ventilation cannot be achieved by facemask, supraglottic airway, or tracheal intubation, every anesthesiologist should be prepared to perform an emergency surgical airway to avert disaster.
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Affiliation(s)
- Richard M. Cooper
- From the Department of Anesthesia, Faculty of Medicine, University of Toronto and University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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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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Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H. Bedside tests for predicting difficult airways: an abridged Cochrane diagnostic test accuracy systematic review. Anaesthesia 2019; 74:915-928. [DOI: 10.1111/anae.14608] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 12/13/2022]
Affiliation(s)
- D. Roth
- Emergency Medicine Medical University of Vienna Austria
| | - N. L. Pace
- Department of Anesthesiology University of Utah Salt Lake City UT USA
| | - A. Lee
- Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong Shatin Hong Kong
- Hong Kong Branch of The Chinese Cochrane Centre The Jockey Club School of Public Health and Primary Care The Chinese University of Hong Kong Shatin Hong Kong
| | - K. Hovhannisyan
- Clinical Health Promotion Centre Faculty of Medicine Lund University MalmöSweden
| | - A. M. Warenits
- Department of Emergency Medicine Medical University of Vienna Austria
| | - J. Arrich
- Department of Emergency Medicine Medical University of Vienna Austria
| | - H. Herkner
- Department of Emergency Medicine Medical University of Vienna Austria
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Kim JC, Ki Y, Kim J, Ahn SW. Ethnic considerations in the upper lip bite test: the reliability and validity of the upper lip bite test in predicting difficult laryngoscopy in Koreans. BMC Anesthesiol 2019; 19:9. [PMID: 30630419 PMCID: PMC6329147 DOI: 10.1186/s12871-018-0675-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several methods have been used to predict difficult tracheal intubation. Among recently suggested methods, the upper lip bite test (ULBT) could serve as a good predictor. Soft tissue and skeletal hard tissue profiles are affected by many factors including ethnicity. We aimed to assess the clinical utility of the ULBT in Koreans while considering ethnic differences. METHODS Three-hundred-forty-four Korean patients undergoing general anesthesia with orotracheal intubation were included. Preoperatively, we recorded the patient's Modified Mallampati (MMT) classification, ULBT ratings, and the Cormack-Lehane grade. RESULTS The area under the receiver operating characteristic (ROC) curve (AUC) was lower for the ULBT than the MMT (95% confidence interval: 0.0697-0.191, p < 0.0001). The ULBT showed high accuracy (73.83%) and specificity (98.04%). On the other hand, the ULBT showed significantly lower sensitivity (4.49%). Only nine of 344 Korean patients could not bite their upper lip; among them, only three presented a difficult laryngoscopic view. CONCLUSIONS One factor related to the low sensitivity is the low incidence of a grade III ULBT in Koreans. In Asians, the scarcity of a grade III ULBT is explainable as a result of anteriorly displaced temporomandibular joints and redundant lip soft tissues. Despite its high specificity, the low sensitivity and AUC of the ULBT mean that the test results should be interpreted cautiously in Koreans. Ethnic differences should be considered when evaluating parameters related to soft tissues such as the ULBT. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01908218, Date of registration JUL 2013.
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Affiliation(s)
- Jong Chan Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Yumin Ki
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - Jihee Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea
| | - So Woon Ahn
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13496, South Korea.
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Panjiar P, Kochhar A, Bhat KM, Bhat MA. Comparison of thyromental height test with ratio of height to thyromental distance, thyromental distance, and modified Mallampati test in predicting difficult laryngoscopy: A prospective study. J Anaesthesiol Clin Pharmacol 2019; 35:390-395. [PMID: 31543591 PMCID: PMC6748003 DOI: 10.4103/joacp.joacp_276_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Preoperative airway assessment to predict patients with difficult laryngoscopy is always crucial for anesthesiologists. Several predictive tests have been studied by various authors in quest of finding the best airway predictor. Recently, a new airway predictor, thyromental height test (TMHT) has been reported to have good predictive value in assessing difficult airway. We conducted this study with primary aim to evaluate the diagnostic accuracy of TMHT and to compare it with other established airway predictors, such as ratio of height to thyromental distance (RHTMD), thyromental distance (TMD), and modified Mallampati test (MMT) for predicting difficult laryngoscopy. Material and Methods This prospective, observational study was conducted in 550 patients of either sex aged >18 years scheduled for elective surgery under general anesthesia. The patients' airway was assessed preoperatively by two anesthetists. Standard anesthetic protocol was followed in all the patients. The laryngoscopic view was graded according to Cormack-Lehane scale. The receiver operating characteristic (ROC) curve was used to calculate the ideal cut off values for TMHT and RHTMD. Standard formulae were used to calculate validity indexes. Results The incidence of difficult laryngoscopy was 10%. The cut-off value for TMHT and RHTMD were 5.1 cm and 19.5, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TMHT were 78.18%, 93.94%, 58.90%, and 97.48%, respectively. The highest sensitivity, PPV, and NPV were observed with TMHT as compared with RHTMD, TMD, and MMT (P < 0.0001). Conclusions TMHT is the best predictive test with highest accuracy and odds ratio for predicting difficult airway out of all predictive tests evaluated.
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Affiliation(s)
- Pratibha Panjiar
- Department of Anesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Anjali Kochhar
- Department of Anesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Kharat M Bhat
- Department of Anesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
| | - Mudassir A Bhat
- Department of Anesthesiology and Critical Care, Hamdard Institute of Medical Sciences and Research, New Delhi, India
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Yabuki S, Iwaoka S, Murakami M, Miura H. Reliability of the thyromental height test for prediction of difficult visualisation of the larynx: A prospective external validation. Indian J Anaesth 2019; 63:270-276. [PMID: 31000890 PMCID: PMC6460976 DOI: 10.4103/ija.ija_852_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and Aims: Thyromental height (TMH) has been reported to be useful for prediction of difficult visualisation of the larynx (DVL), defined as Cormack--Lehane (C&L) grade III or IV. The aim of this study was to compare the diagnostic accuracy of the TMH test for DVL with that of other clinically used tests in Japanese patients. Methods: Six hundred and nine surgical patients undergoing endotracheal intubation under general anaesthesia were enrolled in this prospective observational study. TMH, thyromental distance (TMD), and Samsoon and Young's modified Mallampati (MMT) tests were performed in all patients. The C&L grades for the laryngoscopic view with and without external backward, upward, rightward pressure (BURP) were determined by designated airway assessors. The cutoff value for the TMH test was calculated using receiver-operating characteristic (ROC) curve analysis. The sensitivity, specificity, positive predictive value, accuracy, positive likelihood ratio, and area under the ROC curve (AUROC) for each predictive test were calculated and compared. Results: ROC curve analysis indicated that 54 mm is the optimal cutoff value for the TMH test. However, both this value and the conventional cutoff value of 50 mm, which has been reported as having good diagnostic accuracy in the literature, had poor diagnostic accuracy. The AUROC for the TMH test was 0.631 without BURP and 0.592 with BURP; these values were not superior to those for the TMD test or MMT. Conclusion: The TMH test is not a good predictor of DVL in Japanese patients.
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Affiliation(s)
- Shizuha Yabuki
- Department of Anesthesiology, Tohoku Kosai Hospital, 2-3-11 Kokubun-cho, Aoba-ku, Sendai, Japan
| | - Satoka Iwaoka
- Department of Anesthesiology, Tohoku Kosai Hospital, 2-3-11 Kokubun-cho, Aoba-ku, Sendai, Japan
| | - Mamoru Murakami
- Department of Anesthesiology, Tohoku Kosai Hospital, 2-3-11 Kokubun-cho, Aoba-ku, Sendai, Japan
| | - Hiroko Miura
- Department of Anesthesiology, Tohoku Kosai Hospital, 2-3-11 Kokubun-cho, Aoba-ku, Sendai, Japan
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Wang JM, Ma EL, Wu QP, Tian M, Sun YY, Lin J, Peng L, Xu Q, Wei W, Tan H, Yang C, Li XQ, Zuo YX, Liu J. Effectiveness and Safety of a Novel Approach for Management of Patients with Potential Difficult Mask Ventilation and Tracheal Intubation: A Multi-center Randomized Trial. Chin Med J (Engl) 2018. [PMID: 29521283 PMCID: PMC5865306 DOI: 10.4103/0366-6999.226897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Patients with potential difficult mask ventilation (DV) and difficult intubation (DI) are often managed with awake intubation, which can be stressful for patients and anesthesiologists. This prospective randomized study evaluated a new approach, fast difficult airway evaluation (FDAE). We hypothesized that the FDAE approach would reduce the need for awake intubation. Methods: After obtaining informed consent, 302 patients with potential DV/DI undergoing elective surgeries were randomly assigned to the FDAE group (Group E) and the control group (Group C). In Group E, patients were gradually sedated, and adequacy of manual mask ventilation during spontaneous breathing was assessed at various sedation levels. Awake intubation was applied in those with inadequate mask ventilation. In Group C, DI was evaluated under local anesthesia. However, the care team could intubate under general anesthesia if the vocal cords were visible. The primary outcome was the rate of awake intubations in both groups and the induction efficiency assessed by the induction time. The secondary outcome was the incidence of serious complications. Results: The rate of awake intubation was significantly lower in Group E than that in Group C (5.81% vs. 36.05%, χ2 = 42.3, P < 0.001). The induction time was much shorter in Group E than in Group C (11.85 ± 4.82 min vs. 18.71 ± 7.85 min, t = 5.39, P < 0.001). There was no significant difference in the incidence of intubation related complications between the two groups. Patients in Group E had a much lower incidence of recall (9.68% vs. 44.90%, χ2 = 47.68, P < 0.001) of the induction process and higher satisfaction levels than patients in Group C (t = 15.36, P < 0.001). Conclusions: The FDAE significantly reduces the need for awake intubation and improves the efficiency of the intubation process without comprising safety in patients with potential difficult mask ventilation and DI. Trial Registration: No. ChiCTR-TRC-11001418; http://www.gctr.org/cn/proj/show.aspx?proj=1562.
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Affiliation(s)
- Ji-Ming Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Er-Li Ma
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qing-Ping Wu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, China
| | - Ming Tian
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yan-Yan Sun
- Department of Anesthesiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710000, China
| | - Jing Lin
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Liang Peng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qiang Xu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, China
| | - Wei Wei
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Hong Tan
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Cen Yang
- Department of Anesthesiology, Xijing Hospital, The Fourth Military Medical University, Xi'an, Shaanxi 710000, China
| | - Xiao-Qiang Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yun-Xia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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[Update Mallampati : Theoretical and practical knowledge of European anesthetists on basic evaluation of airways]. Anaesthesist 2018; 67:738-744. [PMID: 30171286 DOI: 10.1007/s00101-018-0481-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/10/2018] [Accepted: 08/10/2018] [Indexed: 10/28/2022]
Abstract
In 1985 Mallampati et al. published a non-invasive score for the evaluation of airways (Mallampati grading scale, MGS), which originally consisted of only three different classes and has been modified several times. At present it is mostly used in the version of Samsoon and Young consisting of four different classes. Class I: soft palate, fauces, uvula, palatopharyngeal arch visible, class II: soft palate, fauces, uvula visible, class III: soft palate, base of the uvula visible and class IV: soft palate not visible. Nevertheless, other versions of MGS still exist, each having different values for sensitivity and specification. The current opinion is therefore that MGS is no longer useful as a stand-alone predictor but in combination with others it is still part of today's most relevant guidelines, such as those of the American Society of Anesthesiologists (ASA), the UK's Difficult Airway Society (DAS), the European Society of Anaesthesiology (ESA) and the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and must therefore be known by anesthetists. Even in times of sophisticated tools for airway management, the procedure remains a high risk, so every anesthetist has to be prepared for and well trained in management of known and unexpected difficult airways. Evaluation of the patient's airway is a part of modern airway management to prevent problems and reduce risk of hypoxia during the procedure. The theoretical knowledge and practical skills of European anesthetists were evaluated at two international congresses, the German Anesthesia Congress (DAC) and Euroanaesthesia 2014. The DAC is an annual meeting of German speaking anesthetists, hosted by the DGAI. The Euroanaesthesia is the annual European pendant hosted by the ESA. Participation was voluntary and only physicians were allowed to take part. Theory was evaluated by a questionnaire containing open and closed questions for MGS that had to be answered by every participant alone. Apart from theory, a practical evaluation was performed. Every participant had to classify the MGS of a human airway model. The model was identical on both congresses. According to the original publication a checklist containing the factors essential for the correct performance was filled out by a supervising experienced anesthetist. During DAC 2014 n = 267 physicians participated in the study, 22 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part. A total of 245 data sets were evaluated. During Euroanaesthesia 2014 n = 298 physicians participated in the study, 68 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part and 230 data sets were evaluated. At the DAC the mean age (± SD) was 44.5 ± 9.5 years, 157 (64.1%) were male and 88 (35.9%) were female. Working experience was trainee anesthetist in 16.7% and other participants were experienced anesthetists. At the ESA the mean age (± SD) was 42.4 ± 9.5 years, 133 (57.8%) were male and 97 (42.2%) female. Trainee anesthetists were 15.2%, the rest were experienced anesthetists. The DAC participants knew Mallampati classes 1 (65%) and 4 (45%) better than 2 and 3 and there was no relevant differences to the ESA (close to 30% knew the classes 1-4 here). Classification of the airway model was correct in 62% and 67% at DAC and ESA, respectively. Most participants performed the practical evaluation correctly except the sitting position of the model. In agreement with earlier studies, these results show the lack of knowledge in evaluation of airways according to current guidelines of all relevant societies. This is likely to increase preventable risks for patients as unexpected difficult airway management increases the risk for hypoxia and intubation damage.
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Ieropoulos P, Tassoudis V, Ntafoulis N, Mimitou I, Vretzakis G, Tzovaras G, Zacharoulis D, Karanikolas M. Do Difficult Airway Techniques Predispose Obese Patients to Bronchospasm? Turk J Anaesthesiol Reanim 2018; 46:292-296. [PMID: 30140536 DOI: 10.5152/tjar.2018.02328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 02/06/2018] [Indexed: 02/03/2023] Open
Abstract
Objective The existing evidence separately correlates morbid obesity with difficult intubation and bronchospasm. However, there is a lack of data on whether anaesthesia provider manipulations during difficult intubation contribute to an increased ratio of bronchospasm in these patients. Methods This is a retrospective analysis of data prospectively taken from 50 morbidly obese patients involved in a previously published study. A possible difficult intubation was preoperatively investigated by recording the following specific physical examination indices: Mallampati and Cormack-Lehane (CL) classifications, cervical spine mobility (CSM), thyromental distance (Td) and patients' ability to open their mouth (mouth opening). Bronchospasm was clinically detected by auscultation and confirmed by measuring peak airway pressures during mechanical ventilation. The Kruskal-Wallis H test was used for data analysis, followed by the Mann-Whitney U test as applicable. Results Different physical examination prognostic indices, including Mallampati and CL scales (p<0.001; the CSM excluded -p=0.790), showed that they are related to difficult intubation. Bronchospasm not attributable to difficult intubation was observed in six obese patients. Conclusion Patients with morbid obesity constitute an increased relative risk group as far as difficult intubation is concerned, particularly if preoperative findings support a relationship between the two variables examined. In our study, difficult intubation and the concomitant use of special equipment and manipulations did not contribute to an increased rate of bronchospasm in obese patients, but in view of the lack of data, a large number of more sophisticated studies are required to elucidate such an assumption.
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Affiliation(s)
| | - Vassilios Tassoudis
- Department of Anesthesiology, University Hospital of Larissa, Larissa, Greece
| | - Nick Ntafoulis
- Department of Anesthesiology, General Hospital of Larissa, Larissa, Greece
| | - Ioanna Mimitou
- Department of Anesthesiology, "Gennimatas" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - George Vretzakis
- Department of Anesthesiology, University Hospital of Larissa, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
| | | | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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