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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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Giraldo-Gutiérrez DS, Ruíz-Villa JO, Rincón-Valenzuela DA, Feliciano-Alfonso JE. Multivariable prediction models for difficult direct laryngoscopy: Systematic review and literature metasynthesis. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:88-101. [PMID: 35210196 DOI: 10.1016/j.redare.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 11/09/2020] [Indexed: 06/14/2023]
Abstract
CONTEXT The difficult airway is an important scenario in anaesthesia due to the impact of its potential complications, and the difficulty in predicting its presence in current clinical practice. METHODS Systematic review of articles in English and Spanish retrieved from MEDLINE (Ovid), LILACS and EMBASE up to March 2018. The search strategy was defined by the authors. The reviewers uploaded the studies to specially designed tables in order to qualitatively analyse the results of each paper. RESULTS A total of 3602 studies were identified. Thirty-four of these were included in the qualitative review. The most commonly used definition of difficulty was the Cormack-Lehane 3 or 4 classification, with a weighted mean incidence of 7.23%. The most relevant finding was the methodological weaknesses in obtaining these scales. CONCLUSIONS Available prediction models show limited discrimination, and weaknesses were detected in the methodology used to develop these prediction rules.
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Affiliation(s)
- D S Giraldo-Gutiérrez
- Especialista en Anestesiología y Reanimación, Universidad Nacional de Colombia, Bogotá, Colombia.
| | - J O Ruíz-Villa
- Especialista en Anestesiología y Reanimación, Universidad Nacional de Colombia, Bogotá, Colombia
| | - D A Rincón-Valenzuela
- Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia; Departamento de Salas de Cirugía, Clínica Universitaria Colombia (Clínica Colsanitas, Keralty), Bogotá, Colombia
| | - J E Feliciano-Alfonso
- Departamento de Medicina Interna, Universidad Nacional de Colombia, Bogotá, Colombia
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Affiliation(s)
- Samir Kendale
- Department of Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Tavolara TE, Gurcan MN, Segal S, Niazi MKK. Identification of difficult to intubate patients from frontal face images using an ensemble of deep learning models. Comput Biol Med 2021; 136:104737. [PMID: 34391000 DOI: 10.1016/j.compbiomed.2021.104737] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/27/2022]
Abstract
Failure to identify difficult intubation is the leading cause of anesthesia-related death and morbidity. Despite preoperative airway assessment, 75-93% of difficult intubations are unanticipated, and airway examination methods underperform, with sensitivities of 20-62% and specificities of 82-97%. To overcome these impediments, we aim to develop a deep learning model to identify difficult to intubate patients using frontal face images. We proposed an ensemble of convolutional neural networks which leverages a database of celebrity facial images to learn robust features of multiple face regions. This ensemble extracts features from patient images (n = 152) which are subsequently classified by a respective ensemble of attention-based multiple instance learning models. Through majority voting, a patient is classified as difficult or easy to intubate. Whereas two conventional bedside tests resulted in AUCs of 0.6042 and 0.4661, the proposed method resulted in an AUC of 0.7105 using a cohort of 76 difficult and 76 easy to intubate patients. Generic features yielded AUCs of 0.4654-0.6278. The proposed model can operate at high sensitivity and low specificity (0.9079 and 0.4474) or low sensitivity and high specificity (0.3684 and 0.9605). The proposed ensembled model outperforms conventional bedside tests and generic features. Side facial images may improve the performance of the proposed model. The proposed method significantly surpasses conventional bedside tests and deep learning methods. We expect our model will play an important role in developing deep learning methods where frontal face features play an important role.
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Affiliation(s)
- Thomas E Tavolara
- Center for Biomedical Informatics, Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | - Metin N Gurcan
- Center for Biomedical Informatics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Scott Segal
- Dept. of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - M K K Niazi
- Center for Biomedical Informatics, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Giraldo-Gutiérrez DS, Ruíz-Villa JO, Rincón-Valenzuela DA, Feliciano-Alfonso JE. Multivariable prediction models for difficult direct laryngoscopy: Systematic review and literature metasynthesis. ACTA ACUST UNITED AC 2021:S0034-9356(21)00056-6. [PMID: 34154822 DOI: 10.1016/j.redar.2020.11.017] [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: 03/17/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 10/21/2022]
Abstract
CONTEXT The difficult airway is an important scenario in anaesthesia due to the impact of its potential complications, and the difficulty in predicting its presence in current clinical practice. METHODS Systematic review of articles in English and Spanish retrieved from MEDLINE (Ovid), LILACS and Embase up to March 2018. The search strategy was defined by the authors. The reviewers uploaded the studies to specially designed tables in order to qualitatively analyse the results of each paper. RESULTS A total of 3602 studies were identified. Thirty-four of these were included in the qualitative review. The most commonly used definition of difficulty was the Cormack-Lehane3 or 4 classification, with a weighted mean incidence of 7.23%. The most relevant finding was the methodological weaknesses in obtaining these scales. CONCLUSIONS Available prediction models show limited discrimination, and weaknesses were detected in the methodology used to develop these prediction rules.
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Affiliation(s)
- D S Giraldo-Gutiérrez
- Especialista en Anestesiología y Reanimación, Universidad Nacional de Colombia, Bogotá, Colombia.
| | - J O Ruíz-Villa
- Especialista en Anestesiología y Reanimación, Universidad Nacional de Colombia, Bogotá, Colombia
| | - D A Rincón-Valenzuela
- Facultad de Medicina, Universidad Nacional de Colombia, Bogotá, Colombia; Departamento de Salas de Cirugía, Clínica Universitaria Colombia (Clínica Colsanitas, Keralty), Bogotá, Colombia
| | - J E Feliciano-Alfonso
- Departamento de Medicina Interna, Universidad Nacional de Colombia, Bogotá, Colombia
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Effectiveness of simplified predictive intubation difficulty score and thyromental height in head and neck surgeries: an observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33187687 PMCID: PMC9373095 DOI: 10.1016/j.bjane.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background and objectives In this study, we aimed to investigate the predictive value of different airway assessment tools, including parts of the Simplified Predictive Intubation Difficulty Score (SPIDS), the SPIDS itself and the Thyromental Height Test (TMHT), in intubations defined as difficult by the Intubation Difficulty Score (IDS) in a group of patients who have head and neck pathologies. Methods One hundred fifty-three patients who underwent head and neck surgeries were included in the study. The Modified Mallampati Test (MMT) result, Thyromental Distance (TMD), Ratio of the Height/Thyromental Distance (RHTMD), TMHT, maximum range of head and neck motion and mouth opening were measured. The SPIDSs were calculated, and the IDSs were determined. Results A total of 25.4% of the patients had difficult intubations. SPIDS scores >10 had 86.27% sensitivity, 71.57% specificity and 91.2% Negative Predictive Value (NPV). The results of the Receiver Operating Curve (ROC) analysis for the airway screening tests and SPIDS revealed that the SPIDS had the highest area under the curve; however, it was statistically similar to other tests, except for the MMT. Conclusions The current study demonstrates the practical use of the SPIDS in predicting intubation difficulty in patients with head and neck pathologies. The performance of the SPIDS in predicting airway difficulty was found to be as efficient as those of the other tests evaluated in this study. The SPIDS may be considered a comprehensive, detailed tool for predicting airway difficulty.
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Selvi O, Kahraman ST, Tulgar S, Senturk O, Serifsoy TE, Thomas D, Cinar AS, Ozer Z. [Effectiveness of simplified predictive intubation difficulty score and thyromental height in head and neck surgeries: an observational study]. Rev Bras Anestesiol 2020; 70:595-604. [PMID: 33187687 DOI: 10.1016/j.bjan.2020.06.005] [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: 01/08/2019] [Revised: 06/01/2020] [Accepted: 06/07/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In this study, we aimed to investigate the predictive value of different airway assessment tools, including parts of the Simplified Predictive Intubation Difficulty Score (SPIDS), the SPIDS itself and the Thyromental Height Test (TMHT), in intubations defined as difficult by the Intubation Difficulty Score (IDS) in a group of patients who have head and neck pathologies. METHODS One hundred fifty-three patients who underwent head and neck surgeries were included in the study. The Modified Mallampati Test (MMT) result, Thyromental Distance (TMD), Ratio of the Height/Thyromental Distance (RHTMD), TMHT, maximum range of head and neck motion, and mouth opening were measured. The SPIDSs were calculated, and the IDSs were determined. RESULTS A total of 25.4% of the patients had difficult intubations. SPIDS scores > 10 had 86.27% sensitivity, 71.57% specificity and 91.2% Negative Predictive Value (NPV). The results of the Receiver Operating Curve (ROC) analysis for the airway screening tests and SPIDS revealed that the SPIDS had the highest area under the curve; however, it was statistically similar to other tests, except for the MMT. CONCLUSIONS The current study demonstrates the practical use of the SPIDS in predicting intubation difficulty in patients with head and neck pathologies. The performance of the SPIDS in predicting airway difficulty was found to be as efficient as those of the other tests evaluated in this study. The SPIDS may be considered a comprehensive, detailed tool for predicting airway difficulty.
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Affiliation(s)
- Onur Selvi
- Maltepe University Faculty of Medicine, Istambu, Turquia.
| | | | - Serkan Tulgar
- Maltepe University Faculty of Medicine, Istambu, Turquia
| | - Ozgur Senturk
- Maltepe University Faculty of Medicine, Istambu, Turquia
| | | | - David Thomas
- Maltepe University Faculty of Medicine, Istambu, Turquia
| | - Ayse Surhan Cinar
- Sisli Hamidiye Etfal Training and Research Hospital, Istambu, Turquia
| | - Zeliha Ozer
- Maltepe University Faculty of Medicine, Istambu, Turquia
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Patient-specific and hyper-realistic phantom for an intubation simulator with a replaceable difficult airway of a toddler using 3D printing. Sci Rep 2020; 10:10631. [PMID: 32606342 PMCID: PMC7326915 DOI: 10.1038/s41598-020-67575-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/09/2020] [Indexed: 12/29/2022] Open
Abstract
Difficult tracheal intubation is the third most common respiratory-related adverse co-morbid episode and can lead to death or brain damage. Since difficult tracheal intubation is less frequent, trainees have fewer opportunities to perform difficult tracheal intubation; this leads to the need to practice with a hyper-realistic intubation simulator. However, conventional simulators are expensive, relatively stiffer than the human airway, and have a lack of diversity in terms of disease variations and anatomic reproducibility. Therefore, we proposed the development of a patient-specific and hyper-realistic difficult tracheal intubation simulator using three-dimensional printing technology and silicone moulding and to test the feasibility of patient-specific and hyper-realistic difficult intubation simulation using 3D phantom for the trainee. This difficult tracheal intubation phantom can provide a realistic simulation experience of managing various difficult tracheal intubation cases to trainees, which could minimise unexpected tissue damage before anaesthesia. To achieve a more realistic simulation, a patient-specific phantom was fabricated to mimic human tissue with realistic mouth opening and accurate difficult airway shape. This has great potential for the medical education and training field.
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Liaskou C, Vouzounerakis E, Trikoupi A, Staikou C. [Evaluation of bedside tests and proposal of a model for predicting difficult laryngoscopy: an observational prospective study]. Rev Bras Anestesiol 2020; 70:125-133. [PMID: 32482358 DOI: 10.1016/j.bjan.2020.02.007] [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: 08/14/2019] [Revised: 01/29/2020] [Accepted: 02/08/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The prediction of difficult laryngoscopy is based on tests that assess anatomic characteristics of face and neck. We aimed to identify the most accurate tests and propose a multivariate predictive model. METHODS This prospective observational study included 1134 patients. Thyromental Distance (TMD), Sternomental Distance (STMD), Ratio of Height-to-Thyromental Distance (R-H/TMD), Neck Circumference (NC), Ratio of Neck Circumference-to-Thyromental Distance (R-NC/TMD), Hyomental Distance with head in Neutral Position (HMD-NP) and at Maximal Extension (HMD-HE), Ratio of Hyomental Distance at Maximal head extension-to-hyomental distance in neutral position (R-HMD), Mallampati Class (MLC), Upper Lip Bite Test (ULBT), Mouth Opening (MO) and Head Extension (HE) were assessed preoperatively. A Cormack-Lehane Grade ≥ 3 was defined as Difficult Laryngoscopy. Sensitivity, specificity, positive and negative predictive values were assessed for all tests. Multivariate analysis with logistic regression was used to create the predictive models. RESULTS A model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed high prognostic accuracy; x2(5)=109.12, p <0.001, AUC=0.86, p <0.001). Its sensitivity, specificity and negative predictive value were 82.3%, 74.8% and 97.4%, respectively. A second model including two measurements not requiring patient's cooperation (R-NC/TMD and HMD-HE) exhibited good prognostic performance; x2(2)=63.5, p <0.001, AUC=0.77, p <0.001. Among single tests, HE had the highest sensitivity (78.5%) and negative predictive value (96%). CONCLUSIONS A five-variable model incorporating MLC, ULBT, HE, HMD-HE and R-NC/TMD showed satisfyingly high predictive value for difficult laryngoscopy. A model including R-NC/TMD and HMD-HE could be useful in incapable patients. The most accurate single predictor was HE.
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Affiliation(s)
- Chara Liaskou
- General Hospital of Rethymnon, Department of Anesthesiology, Rethymnon, Greece.
| | - Eleftherios Vouzounerakis
- Aristotle University of Thessaloniki, Medical School, General Practice & Health Policies Lab, Primary Health Care, Thessaloniki, Greece
| | - Anastasia Trikoupi
- George Papanikolaou General Hospital, Department of Anesthesiology, Thessaloniki, Greece
| | - Chryssoula Staikou
- National and Kapodistrian University of Athens, Aretaieion Hospital, Medical School, Department of Anesthesiology, Athens, Greece
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Carvalho CC, Silva DM, de Carvalho Junior AD, Santos Neto JM, Rio BR, Neto CN, Orange FA. Pre‐operative voice evaluation as a hypothetical predictor of difficult laryngoscopy. Anaesthesia 2019; 74:1147-1152. [DOI: 10.1111/anae.14732] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2019] [Indexed: 12/12/2022]
Affiliation(s)
- C. C. Carvalho
- Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) Recife Pernambuco Brazil
| | - D. M. Silva
- Hospital das Clínicas de Pernambuco Recife Pernambuco Brazil
| | | | | | - B. R. Rio
- Hospital das Clínicas de Pernambuco Recife Pernambuco Brazil
| | - C. N. Neto
- Instituto Dante Pazzanese de Cardiologia São Paulo Brazil
| | - F. A. Orange
- Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) Recife Pernambuco Brazil
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Moustafa MA, El-Metainy S, Mahar K, Mahmoud Abdel-magied E. Defining difficult laryngoscopy findings by using multiple parameters: A machine learning approach. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2017.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
| | | | - Khaled Mahar
- Arab Academy for Science and Technology, Alexandria, Egypt
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Law JA, Duggan LV. The airway assessment has come of age—or has it? Anaesthesia 2019; 74:834-838. [DOI: 10.1111/anae.14658] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 12/17/2022]
Affiliation(s)
- J. A. Law
- Department of Anesthesia, Pain Management and Peri‐operative Medicine Dalhousie University Halifax NSCanada
| | - L. V. Duggan
- Department of Anesthesiology University of British Columbia Vancouver BC Canada
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Payne E, Ragheb J, Jewell ES, Huang BP, Bailey AM, Fritsch LM, Engoren M. Are physician assistant and patient airway assessments reliable compared to anesthesiologist assessments in detecting difficult airways in general surgical patients? Perioper Med (Lond) 2017; 6:20. [PMID: 29201360 PMCID: PMC5700753 DOI: 10.1186/s13741-017-0077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background Airway management remains one of the most important responsibilities of anesthesiologists. Prediction of difficult airway allows time for proper selection of equipment, technique, and personnel experienced in managing patients with difficult airway. Face to face preoperative anesthesia interviews are difficult to conduct as they necessitate patients traveling to the clinics, and, in practice, are usually conducted in the morning of the procedure by the anesthesiologist, when identification of predictors of difficult intubation may lead to schedule delays or case cancelations. We hypothesized that an airway assessment tool could be used by patients or physician assistants to accurately assess their airways. Methods We administered an airway assessment tool, which had been constructed in consultation with a psychometrician and revised after non-medical layperson feedback, to 215 patients presenting to the preoperative clinic for evaluation. Separately, patients had the airway exam performed by a physician assistant and an anesthesiologist. Agreement was compared using kappa. Results We found good agreement between observers only on "can you put three fingers in your mouth?" (three-way kappa = .733, p < 0.001) and poor agreement on Mallampati classification (three-way kappa = .195, p < 0.001) and "Can you fit three fingers between your chin and your Adam's Apple?" (three-way kappa = .216, p < 0.001). The agreements for the other questions were mostly fair. Agreements between patients and anesthesiologists were similar to those between physician assistants and anesthesiologists. Conclusions Neither the patients' self-assessments nor the physician assistants' assessments were adequate to substitute for the anesthesiologists' airway assessments.
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Affiliation(s)
- Erin Payne
- Department of Anesthesiology, University of Michigan, 4383 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5861 USA
| | - Jacqueline Ragheb
- Department of Anesthesiology, University of Michigan, 4383 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5861 USA
| | - Elizabeth S Jewell
- Department of Anesthesiology, University of Michigan, 4383 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5861 USA
| | - Betsy P Huang
- Department of Anesthesiology, University of Michigan, 4383 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5861 USA
| | - Angela M Bailey
- Department of Anesthesiology, University of Michigan, 4383 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5861 USA
| | - Laura M Fritsch
- Department of Anesthesiology, University of Michigan, 4383 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5861 USA
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, 4383 Cardiovascular Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5861 USA
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Aqil M, Khan MU, Mansoor S, Mansoor S, Khokhar RS, Narejo AS. Incidence and severity of postoperative sore throat: a randomized comparison of Glidescope with Macintosh laryngoscope. BMC Anesthesiol 2017; 17:127. [PMID: 28899338 PMCID: PMC5596501 DOI: 10.1186/s12871-017-0421-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 09/05/2017] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Postoperative sore throat (POST) is a common problem following endotracheal (ET) intubation during general anesthesia. The objective was to compare the incidence and severity of POST during routine intubation with Glidescope (GL) and Macintosh laryngoscope (MCL). METHODS One hundred forty adult patients ASA I and II with normal airway, scheduled to undergo elective surgery under GA requiring ET intubation were enrolled in this prospective randomized study and were randomly divided in two groups, GL and MCL. Incidence and severity of POST was evaluated at 0, 6, 12 and 24 h after surgery. RESULTS At 0 h, the incidence of POST was more in MCL than GL (n = 41 v.s n = 22, P = 0.001), and also at 6 h after surgery (n = 37 v.s n = 23, P = 0.017). Severity of POST was more at 0, 6 and 12 h after surgery in MCL (P < 0.001, P = 0.001, P = 0.004 respectively). CONCLUSIONS Routine use of GL for ET tube placement results in reduction in the incidence and severity of POST compared to MCL. TRIAL REGISRATION ClinicalTrials.gov NCT02848365 . Retrospectively Registered (Date of registration: July, 2016).
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Affiliation(s)
- Mansoor Aqil
- Department of Anesthesiology, King Saud University Medical City, P.O Box 7805, Riyadh, 11472, Saudi Arabia.
| | - Mueen Ullah Khan
- Department of Anesthesiology, King Saud University Medical City, P.O Box 7805, Riyadh, 11472, Saudi Arabia
| | - Saara Mansoor
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Saad Mansoor
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Rashid Saeed Khokhar
- Department of Anesthesiology, King Saud University Medical City, P.O Box 7805, Riyadh, 11472, Saudi Arabia
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L'Hermite J, Wira O, Castelli C, de La Coussaye JE, Ripart J, Cuvillon P. Tracheal extubation with suction vs. positive pressure during emergence from general anaesthesia in adults: A randomised controlled trial. Anaesth Crit Care Pain Med 2017; 37:147-153. [PMID: 28882741 DOI: 10.1016/j.accpm.2017.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/30/2017] [Accepted: 07/11/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND After general anaesthesia (GA) in adults, the optimal tracheal extubation technique (positive pressure or suctioning) remains debated. The primary endpoint of this study was to assess the effects of these techniques on onset time of desaturation (SpO2<92%). METHODS Sixty-nine patients with a body mass index<30 scheduled for elective orthopaedic surgery were allocated to positive pressure (PP) or suctioning (SUC) group. GA was standardised with propofol and remifentanil via target-controlled infusion. A morphine bolus of 0.15mg/kg was administered 20-30mins before the end of surgery. The effect of extubation technique on onset time of desaturation (T92) was assessed during the first 10mins after extubation during the spontaneous air breathing. Secondary endpoints included: frequency of desaturation, respiratory complications, need to use oxygen therapy and SpO2 at the end of the first hour while breathing in air (ClinicalTrials.gov identifier: NCT01323049). RESULTS Baseline patient characteristics and intraoperative management data for the 68 patients included had no relevant clinical difference between groups. T92 (sec) after tracheal extubation was 214 (168) vs. 248 (148) in the PP and SUC groups, respectively (P=0.44). In the PP and SUC groups, 50 and 43% reached a SpO2<92% within the first 10mins after extubation respectively (P=0.73). There were no statistically significant differences between groups for any secondary endpoints. CONCLUSIONS Positive pressure extubation as compared with suctioning extubation did not seem to delay onset time of desaturation after GA in standard weight adult patients.
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Affiliation(s)
- Joël L'Hermite
- Faculté de médecine, université Montpellier I, place du Pr-Debré, 30029 Nîmes cedex 9, France; Division of Anaesthesia Intensive Care Pain and Emergency, University Hospital of Nîmes, place du Pr-Debré, 30029 Nîmes cedex 9, France.
| | - Olivier Wira
- Faculté de médecine, université Montpellier I, place du Pr-Debré, 30029 Nîmes cedex 9, France; Division of Anaesthesia Intensive Care Pain and Emergency, University Hospital of Nîmes, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Chritel Castelli
- Department of Biostatistics and Clinical Epidemiology, Nimes University Hospital, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Jean-Emmanuel de La Coussaye
- Faculté de médecine, université Montpellier I, place du Pr-Debré, 30029 Nîmes cedex 9, France; Division of Anaesthesia Intensive Care Pain and Emergency, University Hospital of Nîmes, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Jacques Ripart
- Faculté de médecine, université Montpellier I, place du Pr-Debré, 30029 Nîmes cedex 9, France; Division of Anaesthesia Intensive Care Pain and Emergency, University Hospital of Nîmes, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Philippe Cuvillon
- Faculté de médecine, université Montpellier I, place du Pr-Debré, 30029 Nîmes cedex 9, France; Division of Anaesthesia Intensive Care Pain and Emergency, University Hospital of Nîmes, place du Pr-Debré, 30029 Nîmes cedex 9, France
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Abstract
PURPOSE To investigate the characteristics of difficult intubation and identify novel efficient predictors in patients with acromegaly. METHODS Patients with either untreated acromegaly or non-functional pituitary adenomas were enrolled. Patients with acromegaly underwent hormone assays, upper airway computed tomography and magnetic resonance imaging examinations and preoperative overnight polysomnography. The modified Mallampati classification, mouth opening, neck circumference, and neck extension were assessed, and the Cormack-Lehane grades and the time of tracheal intubation were recorded. RESULTS Patients with acromegaly had a higher incidence of difficult intubation (62.5%). The time of tracheal intubation was prolonged, the neck circumference was enlarged, and the neck extension was confined. In patients with acromegaly and difficult intubation, the insulin-like growth factor 1 levels and apnea/hypoxia index were significantly higher compared to patients without difficult intubation (1115.40 ± 253.73 vs. 791.67 ± 206.62 ng/ml, P = 0.020; 22.17 ± 23.25 vs. 2.47 ± 2.84, P = 0.026, respectively). The bilateral regression analysis revealed that high levels of insulin-like growth factor 1 were an independent risk factor for developing difficult intubation (p = 0.042, Exp B = 1.006). The modified Mallampati classification was positively correlated with apnea/hypoxia index and could be calculated using the following logarithmic equation: MMC = 0.2982 * ln (AHI) + 2.1836. CONCLUSIONS In patients with acromegaly, neck movement is confined, the time of tracheal intubation is prolonged, and the neck circumference is enlarged, and these patients suffer from an increased incidence of difficult intubation (62.5%) during anesthesia induction. The apnea/hypoxia index and insulin-like growth factor 1 levels are both increased in acromegalic patients with difficult intubation, and elevated insulin-like growth factor 1 levels are an independent risk factor of difficult intubation in acromegalic patients.
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Affiliation(s)
- Yu Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
- China Pituitary Disease Registry Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Lijian Pei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Zhuhua Zhang
- Department of Radiography, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
- China Pituitary Disease Registry Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
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Lundstrøm LH, Duez CHV, Nørskov AK, Rosenstock CV, Thomsen JL, Møller AM, Strande S, Wetterslev J. Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents. Cochrane Database Syst Rev 2017; 5:CD009237. [PMID: 28513831 PMCID: PMC6481744 DOI: 10.1002/14651858.cd009237.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tracheal intubation during induction of general anaesthesia is a vital procedure performed to secure a patient's airway. Several studies have identified difficult tracheal intubation (DTI) or failed tracheal intubation as one of the major contributors to anaesthesia-related mortality and morbidity. Use of neuromuscular blocking agents (NMBA) to facilitate tracheal intubation is a widely accepted practice. However, because of adverse effects, NMBA may be undesirable. Cohort studies have indicated that avoiding NMBA is an independent risk factor for difficult and failed tracheal intubation. However, no systematic review of randomized trials has evaluated conditions for tracheal intubation, possible adverse effects, and postoperative discomfort. OBJECTIVES To evaluate the effects of avoiding neuromuscular blocking agents (NMBA) versus using NMBA on difficult tracheal intubation (DTI) for adults and adolescents allocated to tracheal intubation with direct laryngoscopy. To look at various outcomes, conduct subgroup and sensitivity analyses, examine the role of bias, and apply trial sequential analysis (TSA) to examine the level of available evidence for this intervention. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, LILACS, advanced Google, CINAHL, and the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and www.centerwatch.com, up to January 2017. We checked the reference lists of included trials and reviews to look for unidentified trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared the effects of avoiding versus using NMBA in participants 14 years of age or older. DATA COLLECTION AND ANALYSIS Two review authors extracted data independently. We conducted random-effects and fixed-effect meta-analyses and calculated risk ratios (RRs) and their 95% confidence intervals (CIs). We used published data and data obtained by contacting trial authors. To minimize the risk of systematic error, we assessed the risk of bias of included trials. To reduce the risk of random errors caused by sparse data and repetitive updating of cumulative meta-analyses, we applied TSA. MAIN RESULTS We identified 34 RCTs with 3565 participants that met our inclusion criteria. All trials reported on conditions for tracheal intubation; seven trials with 846 participants described 'events of upper airway discomfort or injury', and 13 trials with 1308 participants reported on direct laryngoscopy. All trials used a parallel design. We identified 18 dose-finding studies that included more interventions or control groups or both. All trials except three included only American Society of Anesthesiologists (ASA) class I and II participants, 25 trials excluded participants with anticipated DTI, and obesity or overweight was an excluding factor in 13 studies. Eighteen trials used suxamethonium, and 18 trials used non-depolarizing NMBA.Trials with an overall low risk of bias reported significantly increased risk of DTI with no use of NMBA (random-effects model) (RR 13.27, 95% CI 8.19 to 21.49; P < 0.00001; 508 participants; four trials; number needed to treat for an additional harmful outcome (NNTH) = 1.9, I2 = 0%, D2 = 0%, GRADE = moderate). The TSA-adjusted CI for the RR was 1.85 to 95.04. Inclusion of all trials resulted in confirmation of results and of significantly increased risk of DTI when an NMBA was avoided (random-effects model) (RR 5.00, 95% CI 3.49 to 7.15; P < 0.00001; 3565 participants; 34 trials; NNTH = 6.3, I2 = 70%, D2 = 82%, GRADE = low). Again the cumulative z-curve crossed the TSA monitoring boundary, demonstrating harmful effects of avoiding NMBA on the proportion of DTI with minimal risk of random error. We categorized only one trial reporting on upper airway discomfort or injury as having overall low risk of bias. Inclusion of all trials revealed significant risk of upper airway discomfort or injury when an NMBA was avoided (random-effects model) (RR 1.37, 95% CI 1.09 to 1.74; P = 0.008; 846 participants; seven trials; NNTH = 9.1, I2 = 13%, GRADE = moderate). The TSA-adjusted CI for the RR was 1.00 to 1.85. None of these trials reported mortality. In terms of our secondary outcome 'difficult laryngoscopy', we categorized only one trial as having overall low risk of bias. All trials avoiding NMBA were significantly associated with difficult laryngoscopy (random-effects model) (RR 2.54, 95% CI 1.53 to 4.21; P = 0.0003; 1308 participants; 13 trials; NNTH = 25.6, I2 = 0%, D2= 0%, GRADE = low); however, TSA showed that only 6% of the information size required to detect or reject a 20% relative risk reduction (RRR) was accrued, and the trial sequential monitoring boundary was not crossed. AUTHORS' CONCLUSIONS This review supports that use of an NMBA may create the best conditions for tracheal intubation and may reduce the risk of upper airway discomfort or injury following tracheal intubation. Study results were characterized by indirectness, heterogeneity, and high or uncertain risk of bias concerning our primary outcome describing difficult tracheal intubation. Therefore, we categorized the GRADE classification of quality of evidence as moderate to low. In light of defined outcomes of individual included trials, our primary outcomes may not reflect a situation that many clinicians consider to be an actual difficult tracheal intubation by which the patient's life or health may be threatened.
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Affiliation(s)
- Lars H Lundstrøm
- Nordsjællands HospitalDepartment of AnaesthesiologyHillerødDenmark3400
| | | | - Anders K Nørskov
- Nordsjællands HospitalDepartment of AnaesthesiologyHillerødDenmark3400
| | | | - Jakob L Thomsen
- Herlev Hospital, University of CopenhagenDepartment of AnaesthesiologyHerlevDenmark
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of CopenhagenThe Cochrane Anaesthesia, Critical and Emergency Care GroupHerlev RingvejHerlevDenmark2730
| | - Søren Strande
- Gentofte HospitalDepartment of Anaesthesiology and Intensive CareKildegårdsvej 28HellerupCopenhagenDenmark2900
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Torres K, Błoński M, Pietrzyk Ł, Piasecka-Twaróg M, Maciejewski R, Torres A. Usefulness and diagnostic value of the NEMA parameter combined with other selected bedside tests for prediction of difficult intubation. J Clin Anesth 2017; 37:132-135. [DOI: 10.1016/j.jclinane.2016.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 10/24/2016] [Accepted: 11/30/2016] [Indexed: 11/25/2022]
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Selvi O, Kahraman T, Senturk O, Tulgar S, Serifsoy E, Ozer Z. Evaluation of the reliability of preoperative descriptive airway assessment tests in prediction of the Cormack-Lehane score: A prospective randomized clinical study. J Clin Anesth 2016; 36:21-26. [PMID: 28183567 DOI: 10.1016/j.jclinane.2016.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 08/14/2016] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE In this study we investigated and compared the predictive values of different airway assessments tests including thyromental height measurement test, which has been recently suggested, in difficult laryngoscopy (Cormack and Lehane [C-L] scores 3 and 4). In addition, we compared the effectiveness of methods and C-L scores, by IDS, in terms of predicting difficult intubation. DESIGN Prospective, blinded study. SETTING Maltepe University. PATIENTS Four hundred fifty-one patients selected randomly who underwent general anesthesia. INTERVENTIONS In this study we compared predictive value of thyromental height measurement test (TMH), which has been recently suggested, modified Mallampati test (MMT), upper lip bite test (ULBT), and thyromental distance measurement test (TMD) in difficult laryngoscopy. Final C-L scores were compared with intubation difficulty scale (IDS) in terms of predicting difficult intubation. MEASUREMENTS Patient's American Society of Anesthesiology score, age and weight were recorded. TMH, TMD, MMT, ULBT, IDS and C-L scores were measured and determined. MAIN RESULTS The optimal cut-off point for TMH for predicting difficult laryngoscopy was 43.5 mm and for TMD was 82.06 mm. Use of TMH <43.5 with MMT has the highest sensitivity for predicting difficult intubation (78.38) with 75.36% specificity and 97.50% negative predictive value. TMH showed sensitivity of 91.89% and specificity 52.17% at 50 mm cut-off value. In the comparison of the area under the receiver operating characteristic curve values, none of the tests came forth individually or in combination with MMT test. CONCLUSIONS The present study demonstrates the practicality of TMH as a digitalized test however the clinical benefits of TMH in daily medical practice are drawn into question. The additional variable of race may have had some bearing on this and further studies, larger in patient sample size, may need to use different methodology concerning age-, sex-, and race-dependent variables in evaluating these tests.
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Affiliation(s)
- Onur Selvi
- Department of Anesthesiology & Reanimation, Maltepe University Faculty of Medicine, Feyzullah cad. No 39 Maltepe, Istanbul, Turkey.
| | - Tugce Kahraman
- Department of Anesthesiology & Reanimation, Maltepe University Faculty of Medicine, Feyzullah cad. No 39 Maltepe, Istanbul, Turkey
| | - Ozgur Senturk
- Department of Anesthesiology & Reanimation, Maltepe University Faculty of Medicine, Feyzullah cad. No 39 Maltepe, Istanbul, Turkey
| | - Serkan Tulgar
- Department of Anesthesiology & Reanimation, Maltepe University Faculty of Medicine, Feyzullah cad. No 39 Maltepe, Istanbul, Turkey
| | - Ercan Serifsoy
- Department of Anesthesiology & Reanimation, Maltepe University Faculty of Medicine, Feyzullah cad. No 39 Maltepe, Istanbul, Turkey
| | - Zeliha Ozer
- Department of Anesthesiology & Reanimation, Maltepe University Faculty of Medicine, Feyzullah cad. No 39 Maltepe, Istanbul, Turkey
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20
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A validation study of the intubation difficulty scale for obese patients. J Clin Anesth 2016; 33:86-91. [DOI: 10.1016/j.jclinane.2016.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 07/27/2015] [Accepted: 03/05/2016] [Indexed: 11/21/2022]
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Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016; 122:1101-7. [PMID: 26866753 DOI: 10.1213/ane.0000000000001184] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Based on the data from elective surgical patients, positioning patients in a back-up head-elevated position for preoxygenation and tracheal intubation can improve patient safety. However, data specific to the emergent setting are lacking. We hypothesized that back-up head-elevated positioning would be associated with a decrease in complications related to tracheal intubation in the emergency room environment. METHODS This retrospective study was approved by the University of Washington Human Subjects Division (Seattle, WA). Eligible patients included all adults undergoing emergent tracheal intubation outside of the operating room by the anesthesiology-based airway service at 2 university-affiliated teaching hospitals. All intubations were through direct laryngoscopy for an indication other than full cardiopulmonary arrest. Patient characteristics and details of the intubation procedure were derived from the medical record. The primary study endpoint was the occurrence of a composite of any intubation-related complication: difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration. Multivariable logistic regression was used to estimate the odds of the primary endpoint in the supine versus back-up head-elevated positions with adjustment for a priori-defined potential confounders (body mass index and a difficult intubation prediction score [Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score]). RESULTS Five hundred twenty-eight patients were analyzed. Overall, at least 1 intubation-related complication occurred in 76 of 336 (22.6%) patients managed in the supine position compared with 18 of 192 (9.3%) patients managed in the back-up head-elevated position. After adjusting for body mass index and the Mallampati, obstructive sleep Apnea, Cervical mobility, mouth Opening, Coma, severe Hypoxemia, and intubation by a non-Anesthesiologist score, the odds of encountering the primary endpoint during an emergency tracheal intubation in a back-up head-elevated position was 0.47 (95% confidence interval, 0.26-0.83; P = 0.01). CONCLUSIONS Placing patients in a back-up head-elevated position, compared with supine position, during emergency tracheal intubation was associated with a reduced odds of airway-related complications.
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Affiliation(s)
- Nita Khandelwal
- From the *Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington; †Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; and ‡Division of Emergency Medicine, University of Washington, Seattle, Washington
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Nørskov A, Wetterslev J, Rosenstock C, Afshari A, Astrup G, Jakobsen J, Thomsen J, Bøttger M, Ellekvist M, Schousboe B, Horn A, Jørgensen B, Lorentzen K, Madsen M, Knudsen J, Thisted B, Estrup S, Mieritz H, Klesse T, Martinussen H, Vedel A, Maaløe R, Bøsling K, Kirkegaard P, Ibáñez C, Aleksandraviciute G, Hansen L, Mantoni T, Lundstrøm L. Effects of using the simplified airway risk index vs usual airway assessment on unanticipated difficult tracheal intubation - a cluster randomized trial with 64,273 participants. Br J Anaesth 2016; 116:680-9. [DOI: 10.1093/bja/aew057] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2016] [Indexed: 11/14/2022] Open
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Corso RM, Cattano D, Buccioli M, Carretta E, Maitan S. [Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway]. Rev Bras Anestesiol 2016; 66:298-303. [PMID: 26993411 DOI: 10.1016/j.bjan.2016.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 09/03/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. METHODS We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. RESULTS A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). CONCLUSIONS This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety.
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Affiliation(s)
- Ruggero M Corso
- Setor de Emergência, Anestesia e Tratamento Intensivo, G.B. Morgagni-Pierantoni Hospital, Forlì, Itália.
| | - Davide Cattano
- Departamento de Anestesiologia, The University of Texas Medical School at Houston, Houston, EUA
| | - Matteo Buccioli
- Setor de Emergência, Anestesia e Tratamento Intensivo, G.B. Morgagni-Pierantoni Hospital, Forlì, Itália
| | - Elisa Carretta
- Departamento de Bioestatística e Ensaios Clínicos, Institute Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Itália
| | - Stefano Maitan
- Setor de Emergência, Anestesia e Tratamento Intensivo, G.B. Morgagni-Pierantoni Hospital, Forlì, Itália
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Abstract
It is wise to plan and prepare for the unexpected difficult airway. Although it is essential to take a history and examine every patient prior to airway management, preoperative anticipation of a difficult airway occurs in only 50% of patients subsequently found to have a difficult airway. Bedside screening tests lack accuracy. The modified Mallampati test and the measurement of thyromental distance are unreliable for prediction of difficult tracheal intubation. Knowledge of risk factors for various airway management techniques may help when devising an airway management plan.
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Affiliation(s)
- Paul Baker
- Department of Anaesthesiology, University of Auckland, Level 12, Room 081, Auckland Support Building 599, Park Road, Grafton, Private Bag 92019, Auckland 1142, New Zealand.
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Prospective validation of the modified LEMON criteria to predict difficult intubation in the ED. Am J Emerg Med 2015; 33:1492-6. [PMID: 26166379 DOI: 10.1016/j.ajem.2015.06.038] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evidence to predict difficult intubation remains scarce in the emergency department (ED) setting. A previously defined clinical decision rule, the modified LEMON criteria, may provide a reliable and reproducible means of identifying difficult intubations. We aimed to prospectively evaluate the external validity of the modified LEMON criteria in the EDs. METHODS We conducted a 13-center prospective observational study, the second Japanese Emergency Airway Network study. We prospectively collected data on all patients undergoing intubations in the ED from February 2012 through September 2014. The primary outcomes were sensitivity, specificity, and predictive values of the modified LEMON criteria for predicting difficult intubation (≥2 attempts by emergency attending physicians or anesthesiologists). RESULTS The database recorded a total of 4034 encounters (capture rate, 96%) in the EDs. Of these, 3313 patients (84%) underwent the intubation attempt with a direct laryngoscope and 610 patients (16%) with a video laryngoscope. The proportion of difficult intubation was 5.4% (95% confidence interval [CI], 4.7%-6.2%) in the direct laryngoscope group and 7.4% (95% CI, 5.6%-9.7%) in the video laryngoscope group. The sensitivity was 85.7% (95% CI, 79.3%-90.4%) with direct laryngoscope and 94.9% (95% CI, 83.5%-98.6%) with video laryngoscope. The specificity was 47.6% (95% CI, 47.2%-47.9%) and 40.3% (95% CI, 39.4%-40.6%), respectively. The negative predictive value was 98.2% (95% CI, 97.5%-98.8%) and 99.0% (95% CI, 96.6%-99.7%), respectively. CONCLUSIONS In this multicenter prospective study, we found a high sensitivity and a negative predictive value of the modified LEMON criteria for predicting difficult intubation. The modified LEMON might assist ED providers in better identifying difficult intubations.
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Patnaik R, Baidya DK, Maitra S. Unanticipated difficult intubation in a patient with juvenile Paget disease. J Clin Anesth 2015; 27:427-8. [PMID: 25962331 DOI: 10.1016/j.jclinane.2015.03.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Rupali Patnaik
- Junior ResidentDepartment of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Dalim K Baidya
- Assistant ProfessorDepartment of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Souvik Maitra
- Senior ResidentDepartment of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
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Shailaja S, Nichelle SM, Shetty AK, Hegde BR. Comparing ease of intubation in obese and lean patients using intubation difficulty scale. Anesth Essays Res 2015; 8:168-74. [PMID: 25886221 PMCID: PMC4173612 DOI: 10.4103/0259-1162.134493] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Difficult tracheal intubation contributes to significant morbidity and mortality during induction of anesthesia. There are divided opinions regarding ease of intubation in obese patients. Moreover, the definition of difficult intubation is not uniform; hence we have use the Intubation Difficulty Scale (IDS) to find the incidence of difficult intubation in obese patients. Aims: The primary aim of the following study is to find out the incidence of difficult intubation in obese and lean patients using IDS and secondary aim is to assess the performance of bedside screening tests to predict difficult intubation, mask ventilation and laryngoscopy in obese and lean patients. Materials and Methods: A prospective, observational cohort study of 200 patients requiring general anesthesia were categorized into 100 each based on body mass index (BMI) into lean (BMI <25 kg/m2) and obese (BMI ≥25 kg/m2) groups. IDS score ≥5 was termed as difficult intubation. Pre-operative airway assessment included Mallampati score, mouth opening, neck circumference (NC), upper lip bite test, thyromental distance, sternomental distance (SMD) and head neck mobility. Patients having difficulty in mask ventilation and laryngoscopy was recorded. Results: Over all in 200 patients the incidence of difficult intubation was 9%. Obese patients were slightly more difficult to intubate than lean (11% vs. 7%, P = 0.049). Age >40 years, NC >35 cm, SMD <12.5 cm and restricted head neck mobility were factors which were associated with IDS ≥5. Multivariate analysis revealed SMD <12.5 cm to predict difficult intubation in obese patients. Obese patients were difficult to mask ventilate (6% vs. 1%, P = 0.043). There was no difference regarding grading of laryngoscopy between the two groups. Conclusion: Obese patients are difficult to mask ventilate and intubate. During intubation of obese patients who is more than 40 years age and SMD <12.5 cm, it is preferable to have a second skilled anesthesiologist.
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Affiliation(s)
- S Shailaja
- Department of Anaesthesiology, Father Muller Medical College, Mangalore, Karnataka, India
| | - S M Nichelle
- Department of Anaesthesiology, Father Muller Medical College, Mangalore, Karnataka, India
| | - A Kishan Shetty
- Department of Anaesthesiology, Father Muller Medical College, Mangalore, Karnataka, India
| | - B Radhesh Hegde
- Department of Anaesthesiology, Father Muller Medical College, Mangalore, Karnataka, India
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Application of process improvement principles to increase the frequency of complete airway management documentation. Anesthesiology 2015; 121:1166-74. [PMID: 25299742 DOI: 10.1097/aln.0000000000000480] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Process improvement in healthcare delivery settings can be difficult, even when there is consensus among clinicians about a clinical practice or desired outcome. Airway management is a medical intervention fundamental to the delivery of anesthesia care. Like other medical interventions, a detailed description of the management methods should be documented. Despite this expectation, airway documentation is often insufficient. The authors hypothesized that formal adoption of process improvement methods could be used to increase the rate of "complete" airway management documentation. METHODS The authors defined a set of criteria as a local practice standard of "complete" airway management documentation. The authors then employed selected process improvement methodologies over 13 months in three iterative and escalating phases to increase the percentage of records with complete documentation. The criteria were applied retrospectively to determine the baseline frequency of complete records, and prospectively to measure the impact of process improvements efforts over the three phases of implementation. RESULTS Immediately before the initial intervention, a retrospective review of 23,011 general anesthesia cases over 6 months showed that 13.2% of patient records included complete documentation. At the conclusion of the 13-month improvement effort, documentation improved to a completion rate of 91.6% (P<0.0001). During the subsequent 21 months, the completion rate was sustained at an average of 90.7% (SD, 0.9%) across 82,571 general anesthetic records. CONCLUSION Systematic application of process improvement methodologies can improve airway documentation and may be similarly effective in improving other areas of anesthesia clinical practice.
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Corso RM, Cattano D, Buccioli M, Carretta E, Maitan S. Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway. Braz J Anesthesiol 2014; 66:298-303. [PMID: 27108828 DOI: 10.1016/j.bjane.2014.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. METHODS We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. RESULTS A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). CONCLUSIONS This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety.
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Affiliation(s)
- Ruggero M Corso
- Department of Emergency, Anaesthesia and Intensive Care Section, "G.B. Morgagni-Pierantoni" Hospital, Forlì, Italy.
| | - Davide Cattano
- Department of Anesthesiology, The University of Texas Medical School at Houston, Houston, USA
| | - Matteo Buccioli
- Department of Emergency, Anaesthesia and Intensive Care Section, "G.B. Morgagni-Pierantoni" Hospital, Forlì, Italy
| | - Elisa Carretta
- Biostatistics and Clinical Trials Unit, Institute Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Stefano Maitan
- Department of Emergency, Anaesthesia and Intensive Care Section, "G.B. Morgagni-Pierantoni" Hospital, Forlì, Italy
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Honarmand A, Safavi M, Ansari N. A comparison of between hyomental distance ratios, ratio of height to thyromental, modified Mallamapati classification test and upper lip bite test in predicting difficult laryngoscopy of patients undergoing general anesthesia. Adv Biomed Res 2014; 3:166. [PMID: 25221769 PMCID: PMC4162034 DOI: 10.4103/2277-9175.139130] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 05/01/2013] [Indexed: 11/23/2022] Open
Abstract
Background: Failed intubation is imperative source of anesthetic interrelated patient's mortality. The aim of this present study was to compare the ability to predict difficult visualization of the larynx from the following pre-operative airway predictive indices, in isolation and combination: Modified Mallampati test (MMT), the ratio of height to thyromental distance (RHTMD), hyomental distance ratios (HMDR), and the upper-lip-bite test (ULBT). Materials and Methods: We collected data on 525 consecutive patients scheduled for elective surgery under general anesthesia requiring endotracheal intubation and then evaluated all four factors before surgery. A skilled anesthesiologist, not imparted of the noted pre-operative airway assessment, did the laryngoscopy and rating (as per Cormack and Lehane's classification). Sensitivity, specificity, and positive predictive value for every airway predictor in isolation and in combination were established. Results: The most sensitive of the single tests was ULBT with a sensitivity of 90.2%. The hyomental distance extreme of head extension was the least sensitive of the single tests with a sensitivity of 56.9. The HMDR had sensitivity 86.3%. The ULBT had the highest negative predictive value: And the area under a receiver-operating characteristic curve (AUC of ROC curve) among single predictors. The AUC of ROC curve for ULBT, HMDR and RHTMD was significantly more than for MMT (P < 0.05). No significant difference was noted in the AUC of ROC curve for ULBT, HMDR, and RHTMD (P > 0.05). Conclusion: The HMDR is comparable with RHTMD and ULBT for prediction of difficult laryngoscopy in the general population, but was significantly more than for MMT.
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Affiliation(s)
- Azim Honarmand
- Departments of Anesthesia, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Safavi
- Departments of Anesthesia, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Narges Ansari
- Departments of Anesthesia, Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Knudsen K, Högman M, Larsson A, Nilsson U. The Best Method to Predict Easy Intubation: A Quasi-Experimental Pilot Study. J Perianesth Nurs 2014; 29:292-7. [DOI: 10.1016/j.jopan.2013.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 05/17/2013] [Accepted: 05/20/2013] [Indexed: 10/25/2022]
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Patel B, Khandekar R, Diwan R, Shah A. Validation of modified Mallampati test with addition of thyromental distance and sternomental distance to predict difficult endotracheal intubation in adults. Indian J Anaesth 2014; 58:171-5. [PMID: 24963182 PMCID: PMC4050934 DOI: 10.4103/0019-5049.130821] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Aims: Intubation is often a challenge for anaesthesiologists. Many parameters assist to predict difficult intubation. The present study was undertaken to assess the validity of different parameters in predicting difficult intubation for general anaesthesia (GA) in adults and effect of combining the parameters on the validity. Methods: The anaesthesiologist assessed oropharynx of 135 adult patients. Modified Mallampati test (MMT) was used and the thyromental distance (TMD) and sternomental distances (SMD) for each of the patients were also measured. The Cormack and Lehane laryngoscopic grading was assessed following laryngoscopy. The validity parameters such as sensitivity, specificity, false positive and negatives values, positive and negative predictive values were calculated. The effect of combining different measurements on the validity was also studied. Univariate analysis was performed using the parametric method. Results: The study group comprised of 135 patients. The sensitivity and specificity of MMT were 28.6% and 93%, respectively. The TMD (<6.5 CM) had sensitivity and specificity of 100% and 75.8%, respectively. The SMD (<12.5 CM) had sensitivity and specificity of 91% and 92.7%, respectively. Combination of MMT grading and TMD and SMD measurements increased the validity (sensitivity of 100% and specificity of 92.7%). Conclusion: MMT had high specificity. The validity of combination of MMT, SMD and TMD as compared to MMT alone was very high in predicting difficult intubation in adult patients. All parameters should be used in assessing an adult patient for surgery under GA.
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Affiliation(s)
- Bhavdip Patel
- Department of Anesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Rajiv Khandekar
- Department of Anesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Rashesh Diwan
- Department of Anesthesia, SAL Hospital, Ahmedabad, Gujarat, India
| | - Ashok Shah
- Department of Anesthesia, SAL Hospital, Ahmedabad, Gujarat, India
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The importance of subjective facial appearance on the ability of anesthesiologists to predict difficult intubation. Anesth Analg 2014; 118:419-427. [PMID: 24361845 DOI: 10.1213/ane.0000000000000012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Previously we demonstrated that a computer algorithm based on bedside airway examinations and facial photographs accurately classified easy and difficult airways. The extent of the ability of anesthesiologists to perform the same task is unknown. We hypothesized that providing photographs would add to the predictive ability of anesthesiologists over that achieved when provided only with the Mallampati (MP) score and the thyromental distance (TMD). We further hypothesized that human observers would implicitly bias their predictions toward more sensitive determination of difficult airways, rather than more specific determination of easy airways. METHODS Residents, fellows, and attending anesthesiologists with varying levels of experience (N = 160) were presented with MP and TMD information from 80 Caucasian men subjects. The same subjects' data, accompanied by 3 facial photographs in head-on and right and left profiles, were also presented. Anesthesiologists classified the airways as easy or difficult according to specified criteria ("easy" defined as a single attempt with a Macintosh 3 blade resulting in a grade 1 laryngoscopic view; "difficult" defined as >1 attempt by an operator with at least 12 months anesthesia experience, grade 3 or 4 laryngoscopic view, need for a second operator, or nonelective use of an alternative airway device). Accuracy, sensitivity, and specificity were calculated for each anesthesiologist. We further developed a cost function to quantify a relative bias toward avoiding an unexpectedly difficult intubation versus overpreparing for an easy intubation. RESULTS One hundred sixty respondents completed the study. Presenting photographs improved respondents' sensitivity and accuracy in classifying airways, though specificity decreased slightly. Overall accuracy when given photographs was 61.6% (95% confidence interval, 60.8%-62.4%), which was significantly lower than the computer's performance of 87.5% (t test, P < 0.0001). Presentation of photographs, compared with MP and TMD alone, caused anesthesiologists to change their prediction from easy to difficult more frequently if the patients were obese (weight or body mass index), despite not having data on weight or height available. The cost function demonstrated that anesthesiologists strongly preferred to enhance sensitivity (detecting difficult airways) as compared with specificity (detecting easy airways), with a ratio of 6.5:1 (95% confidence interval, 4.9:1-8.4:1). CONCLUSIONS Anesthesiologists can derive useful information from facial appearance that enhances the prediction of a difficult airway over that achieved when presented with MP and TMD data alone. Anesthesiologists implicitly bias their predictions toward detection of difficult airways, compared with the true incidence of difficult airways, at the expense of accuracy and specificity. This behavior may be rational for cognitive tasks in which the costs of failure are strongly asymmetric.
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Cattano D, Killoran PV, Iannucci D, Maddukuri V, Altamirano AV, Sridhar S, Seitan C, Chen Z, Hagberg CA. Anticipation of the difficult airway: preoperative airway assessment, an educational and quality improvement tool. Br J Anaesth 2013; 111:276-85. [PMID: 23471752 PMCID: PMC3711391 DOI: 10.1093/bja/aet029] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Assessment of the potentially difficult airway (DA) is a critical aspect of resident education. We investigated the impact of a new assessment form on airway prediction and management by anaesthesia residents. We hypothesized that residents would demonstrate improvement in evaluation of DAs over the study duration. METHODS After IRB approval, anaesthesia residents were randomized into two groups: control (existing form) and experimental (new form). Data were collected prospectively from August 2008 to May 2010 on all non-obstetric adult patients undergoing non-emergent surgery. RESULTS Eight thousand three hundred and sixty-four independent preoperative assessments were collected and 8075 were analysed. The experimental group had the higher completion rate than the control group (94.3% vs 84.3%, P=0.001). DA prediction was higher for the control group (71.2%) compared with the experimental group (69.1%; P=0.032). A significant improvement in prediction rates was found over time for the experimental group (likelihood estimate=0.00068, P=0.031). CONCLUSIONS The use of a comprehensive airway assessment did not improve resident ability to predict a DA in an academic, tertiary-based hospital, anaesthesiology residency training programme.
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Affiliation(s)
- D Cattano
- Department of Anesthesiology, University of Texas Health Science Center Medical School at Houston, 6431 Fannin Street, Houston, TX 77030, USA.
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Steelman VM, Graling PR. Top 10 Patient Safety Issues: What More Can We Do? AORN J 2013; 97:679-98, quiz 699-701. [DOI: 10.1016/j.aorn.2013.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
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Ghamande SA, Arroliga AC, Ciceri DP. Let’s Make Endotracheal Intubation in the Intensive Care Unit Safe. Am J Respir Crit Care Med 2013; 187:789-90. [DOI: 10.1164/rccm.201301-0099ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, Allaouchiche B, Paugam-Burtz C, Constantin JM, Lefrant JY, Leone M, Papazian L, Asehnoune K, Maziers N, Azoulay E, Pradel G, Jung B, Jaber S. Early Identification of Patients at Risk for Difficult Intubation in the Intensive Care Unit. Am J Respir Crit Care Med 2013; 187:832-9. [DOI: 10.1164/rccm.201210-1851oc] [Citation(s) in RCA: 215] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Nasotracheal intubation with the McGrath videolaryngoscope in patients with difficult airway. Eur J Anaesthesiol 2011; 28:673-4. [PMID: 21730864 DOI: 10.1097/eja.0b013e328348ee0c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L'hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. Br J Anaesth 2011; 107:659-67. [PMID: 21948956 DOI: 10.1093/bja/aer292] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The modified Mallampati score is used to predict difficult tracheal intubation. We have conducted a meta-analysis of published studies to evaluate the Mallampati score as a prognostic test. A total of 55 studies involving 177 088 patients were included after comprehensive electronic and manual searches. The pooled estimates from the meta-analyses were calculated based on a random-effects model and a summary receiver operating curve. Meta-regression analyses were performed to explore sources of possible heterogeneity between the studies. The summary receiver operating curve demonstrated an area under the curve of 0.75. The pooled odds ratio for a difficult intubation with a modified Mallampati score of III or IV was 5.89 [95% confidence interval (CI), 4.74-7.32]. The pooled estimates of the specificity and sensitivity were 0.91 (CI, 0.91-0.91) and 0.35 (CI, 0.34-0.36), respectively. The pooled positive and negative likelihood ratios were 4.13 (CI, 3.60-4.66) and 0.70 (CI, 0.65-0.75), respectively. The meta-analyses had statistical and clinical heterogeneity ranging from 87.2% to 99.4%. Meta-regression analyses did not identify any significant explanation of the heterogeneity. We conclude that the prognostic value of the modified Mallampati score was worse than that estimated by previous meta-analyses. Our assessment shows that the modified Mallampati score is inadequate as a stand-alone test of a difficult laryngoscopy or tracheal intubation, but it may well be a part of a multivariate model for the prediction of a difficult tracheal intubation.
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Affiliation(s)
- L H Lundstrøm
- Department of Anaesthesia and Intensive Care, Herlev Hospital, Copenhagen University Hospital, Herlev, Denmark
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Lundstrøm LH, Strande S, Møller AM, Wetterslev J. Use versus avoidance of neuromuscular blocking agent for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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A simplified risk score to predict difficult intubation: development and prospective evaluation in 3763 patients. Eur J Anaesthesiol 2011; 27:935-40. [PMID: 20299983 DOI: 10.1097/eja.0b013e328338883c] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Despite the presence of numerous preoperative tests to predict a difficult airway, there is no reliable bedside method. The aim of this study was to create and verify a simplified risk model with an acceptable discriminating power. METHODS A total of 3763 patients from two university hospitals were screened for potential risk factors for difficult intubation, defined as needing additional technical or human resources, more than three attempts or duration more than 10 min. A random sample (n = 2509) was subjected to multivariate stepwise logistic regression analysis, and the most powerful independent risk factors were used to build a simplified model that was applied to a validation dataset (n = 1254). RESULTS The following factors (odds ratio) were associated with a difficult intubation: presence of upper front teeth (3.61), history of difficult intubation (2.88), any Mallampati status different from '1' (2.55) or equal to '4' (1.91) and mouth opening less than 4 cm (1.80). The discriminating power of the score was 0.72 (95% confidence interval 0.63-0.81). The likelihood for a difficult intubation increases continuously from 0 (when no risk factor is present) to 2, 4, 8 and 17%, when one, two, three and more than three factors are present. CONCLUSION The new simplified multivariate risk score for difficult intubation may prove to be useful in clinical practice for predicting a difficult airway. Presence of upper front teeth, a history of difficult intubation, any Mallampati status different from '1' and equal to '4' and mouth opening less than 4 cm are independent risk factors for difficult endotracheal intubation. With each of these risk factors, the likelihood increases from 0 (when no risk factor is present) to 17% (when four or five factors are present).
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Lee A, Herkner H, Hovhannisyan K, Pace NL. Airway physical examination tests for detection of difficult airway management in apparently normal patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Anna Lee
- The Chinese University of Hong Kong; Department of Anaesthesia and Intensive Care; Prince of Wales Hospital Shatin New Territories Hong Kong
| | - Harald Herkner
- Medical University of Vienna; Department of Emergency Medicine; Vienna General Hospital; Währinger Gürtel 18-20 / 6D Vienna Austria 1090
| | - Karen Hovhannisyan
- Rigshospitalet; The Cochrane Anaesthesia Review Group; Blegdamsvej 9, Afsnit 3342, rum 52 Copenhagen Denmark 2100
| | - Nathan Leon Pace
- University of Utah; Department of Anesthesiology; 3C444 SOM 30 North 1900 East Salt Lake City UT USA 84132-2304
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