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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Frances 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, Martín LJR, Leis CC, Ramírez SE, Orgeira JMF, Lima MJV, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Executive Summary of the 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. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2024:S2173-5735(24)00061-9. [PMID: 38797374 DOI: 10.1016/j.otoeng.2024.05.001] [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: 09/06/2023] [Accepted: 03/08/2024] [Indexed: 05/29/2024]
Abstract
The Airway section of the 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) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.
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Affiliation(s)
- Manuel Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, Spain.
| | - José Alfonso Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Teresa López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Rubén Casans-Frances
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - José Carlos Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Vicente Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | | | | | | | | | | | | | - Javier García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain; Presidente de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Spain
| | | | | | | | | | | | | | - Miguel Mayo-Yáñez
- Department of Otorhinolaryngology - Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, Galicia, Spain
| | - Pablo Parente-Arias
- Department of Otorhinolaryngology - Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, Galicia, Spain; Department of Otorhinolaryngology, Universidade de Santiago de Compostela, Galicia, Spain
| | - Jon Alexander Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Spain; Presidente de la Comisión de Tumores de la OSI Donostialdea, Spain
| | - Manuel Bernal-Sprekelsen
- Department of Otorhinolaryngology, University of Barcelona, Barcelona, Spain; Department of Otorhinolaryngology, Hospital Clinic Barcelona, Spain; Presidente de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC), Spain
| | - Pedro Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
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García-García F, Lee DJ, Mendoza-Garcés FJ, García-Gutiérrez S. Reliable prediction of difficult airway for tracheal intubation from patient preoperative photographs by machine learning methods. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 248:108118. [PMID: 38489935 DOI: 10.1016/j.cmpb.2024.108118] [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: 10/30/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Estimating the risk of a difficult tracheal intubation should help clinicians in better anaesthesia planning, to maximize patient safety. Routine bedside screenings suffer from low sensitivity. OBJECTIVE To develop and evaluate machine learning (ML) and deep learning (DL) algorithms for the reliable prediction of intubation risk, using information about airway morphology. METHODS Observational, prospective cohort study enrolling n=623 patients who underwent tracheal intubation: 53/623 difficult cases (prevalence 8.51%). First, we used our previously validated deep convolutional neural network (DCNN) to extract 2D image coordinates for 27 + 13 relevant anatomical landmarks in two preoperative photos (frontal and lateral views). Here we propose a method to determine the 3D pose of the camera with respect to the patient and to obtain the 3D world coordinates of these landmarks. Then we compute a novel set of dM=59 morphological features (distances, areas, angles and ratios), engineered with our anaesthesiologists to characterize each individual's airway anatomy towards prediction. Subsequently, here we propose four ad hoc ML pipelines for difficult intubation prognosis, each with four stages: feature scaling, imputation, resampling for imbalanced learning, and binary classification (Logistic Regression, Support Vector Machines, Random Forests and eXtreme Gradient Boosting). These compound ML pipelines were fed with the dM=59 morphological features, alongside dD=7 demographic variables. Here we trained them with automatic hyperparameter tuning (Bayesian search) and probability calibration (Platt scaling). In addition, we developed an ad hoc multi-input DCNN to estimate the intubation risk directly from each pair of photographs, i.e. without any intermediate morphological description. Performance was evaluated using optimal Bayesian decision theory. It was compared against experts' judgement and against state-of-the-art methods (three clinical formulae, four ML, four DL models). RESULTS Our four ad hoc ML pipelines with engineered morphological features achieved similar discrimination capabilities: median AUCs between 0.746 and 0.766. They significantly outperformed both expert judgement and all state-of-the-art methods (highest AUC at 0.716). Conversely, our multi-input DCNN yielded low performance due to overfitting. This same behaviour occurred for the state-of-the-art DL algorithms. Overall, the best method was our XGB pipeline, with the fewest false negatives at the optimal Bayesian decision threshold. CONCLUSIONS We proposed and validated ML models to assist clinicians in anaesthesia planning, providing a reliable calibrated estimate of airway intubation risk, which outperformed expert assessments and state-of-the-art methods. Our novel set of engineered features succeeded in providing informative descriptions for prognosis.
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Affiliation(s)
| | - Dae-Jin Lee
- School of Science & Technology, IE University - Madrid (Madrid), Spain.
| | - Francisco J Mendoza-Garcés
- Galdakao-Usansolo University Hospital, Anaesthesia & Resuscitation Service - Galdakao (Basque Country), Spain.
| | - Susana García-Gutiérrez
- Galdakao-Usansolo University Hospital, Research Unit - Galdakao (Basque Country), Spain; Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS) - Madrid (Madrid), Spain.
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Crístian de Carvalho C, Iliff HA, Santos Neto JM, Potter T, Alves MB, Blake L, El-Boghdadly K. Effectiveness of preoxygenation strategies: a systematic review and network meta-analysis. Br J Anaesth 2024:S0007-0912(24)00130-2. [PMID: 38599916 DOI: 10.1016/j.bja.2024.02.028] [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: 10/22/2023] [Revised: 01/29/2024] [Accepted: 02/18/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Preoxygenation is universally recommended before induction of general anaesthesia to prolong safe apnoea time. The optimal technique for preoxygenation is unclear. We conducted a systematic review to determine the preoxygenation technique associated with the greatest effectiveness in adult patients having general anaesthesia. METHODS We searched six databases for randomised controlled trials of patients aged ≥16 yr, receiving general anaesthesia in any setting and comparing different preoxygenation techniques and methods. Our primary effectiveness outcome was safe apnoea time, and secondary outcomes included incidence of arterial oxygen desaturation; lowest SpO2 during airway management; time to end-tidal oxygen concentration of 90%; and [Formula: see text] and [Formula: see text] at the end of preoxygenation. We assessed the quality of evidence according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) recommendations. RESULTS We included 52 studies of 3914 patients. High-flow nasal oxygen with patients in a head-up position was most likely to be associated with a prolonged safe apnoea time when compared with other strategies, with a mean difference (95% credible interval) of 291 (138-456) s and 203 (79-343) s compared with preoxygenation with a facemask in the supine and head-up positions, respectively. Subgroup analysis of studies without apnoeic oxygenation also showed high-flow nasal oxygen in the head-up position as the highest ranked technique, with a statistically significantly delayed mean difference (95% credible interval) safe apnoea time compared with facemask in supine and head-up positions of 222 (63-378) s and 139 (15-262) s, respectively. High-flow nasal oxygen was also the highest ranked technique for increased [Formula: see text] at the end of preoxygenation. However, the incidence of arterial desaturation was less likely to occur when a facemask with pressure support was used compared with other techniques, and [Formula: see text] was most likely to be lowest when preoxygenation took place with patients deep breathing in a supine position. CONCLUSIONS Preoxygenation of adults before induction of general anaesthesia was most effective in terms of safe apnoea time when performed with high-flow nasal oxygen with patients in the head-up position in comparison with facemask alone. Also, high-flow nasal oxygen in the head-up position is likely to be the most effective technique to prolong safe apnoea time among those evaluated. Clinicians should consider this technique and patient position in routine practice. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42022326046.
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Affiliation(s)
| | - Helen A Iliff
- Department of Anaesthesia, The Grange University Hospital, Cwmbran, UK
| | | | - Thomas Potter
- Department of Anaesthesia and Perioperative Medicine, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Max B Alves
- Hospital Universitário Onofre Lopes, Natal, Brazil
| | - Lindsay Blake
- University of Arkansas for Medical Sciences Library, Little Rock, AR, USA
| | - Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Medicine, Guy's and St. Thomas' NHS Foundation Trust, London, UK; King's College London, London, UK. https://twitter.com/@elboghdadly
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Xia M, Jin C, Zheng Y, Wang J, Zhao M, Cao S, Xu T, Pei B, Irwin MG, Lin Z, Jiang H. Deep learning-based facial analysis for predicting difficult videolaryngoscopy: a feasibility study. Anaesthesia 2024; 79:399-409. [PMID: 38093485 DOI: 10.1111/anae.16194] [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] [Accepted: 11/03/2023] [Indexed: 03/07/2024]
Abstract
While videolaryngoscopy has resulted in better overall success rates of tracheal intubation, airway assessment is still an important prerequisite for safe airway management. This study aimed to create an artificial intelligence model to identify difficult videolaryngoscopy using a neural network. Baseline characteristics, medical history, bedside examination and seven facial images were included as predictor variables. ResNet-18 was introduced to recognise images and extract features. Different machine learning algorithms were utilised to develop predictive models. A videolaryngoscopy view of Cormack-Lehane grade of 1 or 2 was classified as 'non-difficult', while grade 3 or 4 was classified as 'difficult'. A total of 5849 patients were included, of whom 5335 had non-difficult and 514 had difficult videolaryngoscopy. The facial model (only including facial images) using the Light Gradient Boosting Machine algorithm showed the highest area under the curve (95%CI) of 0.779 (0.733-0.825) with a sensitivity (95%CI) of 0.757 (0.650-0.845) and specificity (95%CI) of 0.721 (0.626-0.794) in the test set. Compared with bedside examination and multivariate scores (El-Ganzouri and Wilson), the facial model had significantly higher predictive performance (p < 0.001). Artificial intelligence-based facial analysis is a feasible technique for predicting difficulty during videolaryngoscopy, and the model developed using neural networks has higher predictive performance than traditional methods.
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Affiliation(s)
- M Xia
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - C Jin
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Y Zheng
- State Key Laboratory of Ocean Engineering, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - J Wang
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - M Zhao
- State Key Laboratory of Ocean Engineering, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - S Cao
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - T Xu
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - B Pei
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Hong Kong
| | - Z Lin
- State Key Laboratory of Ocean Engineering, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - H Jiang
- Department of Anaesthesiology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Frances 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:S2341-1929(24)00021-0. [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] [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 factor, 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
| | | | - 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-Frances
- 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 Poliècnic 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 Elena, Valdemoro, 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; Presidente de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR)
| | | | | | - C Camacho Leis
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, 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)
| | - 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)
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Poliècnic La Fe, Valencia, Spain
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Chang MG, Berra L, Bittner EA. Bedside Ultrasound: The Silent Guardian for Upper Airway Assessment and Management. Semin Ultrasound CT MR 2024; 45:46-57. [PMID: 38056793 DOI: 10.1053/j.sult.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Ultrasound evaluation of the upper airway has emerged as an essential instrument for clinicians, offering real-time assessment that can help to guide interventions and improve patient outcomes. This review aims to provide health care providers with a practical approach to performing ultrasound evaluation of the upper airway, covering basic physics relevant to upper airway ultrasound, the identification of key anatomical structures, and elucidating its various clinical applications, such as prediction of difficult airway, confirmation of endotracheal intubation, and guidance for surgical airway procedures and airway blocks. We also discuss evidence-based training programs, limitations, and future directions of ultrasound imaging of the upper airway.
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Affiliation(s)
- Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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7
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Qu Y, Tian Y, Fang J, Tian Y, Han D, Ren L, Xu N, Wang C, Guo X, Wang S, Han Y. Preoperative radiological indicators for prediction of difficult laryngoscopy in patients with atlantoaxial dislocation. Heliyon 2024; 10:e23435. [PMID: 38148803 PMCID: PMC10750185 DOI: 10.1016/j.heliyon.2023.e23435] [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: 06/08/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 12/28/2023] Open
Abstract
Background Difficult airway remains a great challenge in patients with atlantoaxial dislocation (AAD). Preoperative evaluation and reliable prediction are required to facilitate the airway management. We aimed to screen out reliable radiological indicators for prediction of difficult laryngoscopy in patients with AAD. Methods A retrospective nested case-control study within a single center longitudinal AAD cohort was conducted to investigate the radiological indicators. All the patients with difficult laryngoscopy from 2010 to 2021 were enrolled as the difficult laryngoscopy group. Others in the cohort without difficult laryngoscopy were randomly selected as the non-difficult laryngoscopy group by individually matching with the same gender, same surgery year, and similar age (±5 years) at a ratio of 6:1. Radiological data on preoperative lateral X-ray images between the two groups were compared. Bivariate logistic regression model was applied to screen out the independent predictive indicators and calculate the odds ratios of indicators associated with difficult laryngoscopy. Receiver operating characteristic curve and area under the curve (AUC) were used to describe the discrimination ability of indicators. Results A total of 154 patients were finally analyzed in this study. Twenty-two patients with difficult laryngoscopy and matched with 132 controls. Four radiological parameters showed significant difference between the two groups. Among which, ΔC1C2D (the difference of the distance between atlas and axis in the neutral and extension position), owned the largest AUC. Conclusions ΔC1C2D could be a valuable radiologic predictor for difficult laryngoscopy in patients with AAD.
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Affiliation(s)
- Yinyin Qu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Yang Tian
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Jingchao Fang
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Yinglun Tian
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Dengyang Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Linyu Ren
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Nanfang Xu
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Chao Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Shenglin Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China
| | - Yongzheng Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
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8
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Goh QY, Lie SA, Tan Z, Tan PYB, Ng SY, Abdullah HR. Time to intubation with McGrath ™ videolaryngoscope versus direct laryngoscope in powered air-purifying respirator: a randomised controlled trial. Singapore Med J 2024; 65:2-8. [PMID: 34688229 PMCID: PMC10863731 DOI: 10.11622/smedj.2021165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/07/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION During the coronavirus disease 2019 (COVID-19) pandemic, multiple guidelines have recommended videolaryngoscope (VL) for tracheal intubation. However, there is no evidence that VL reduces time to tracheal intubation, and this is important for COVID-19 patients with respiratory failure. METHODS To simulate intubation of COVID-19 patients, we randomly assigned 28 elective surgical patients to be intubated with either McGrath™ MAC VL or direct laryngoscope (DL) by specialist anaesthetists who donned 3M™ Jupiter™ powered air-purifying respirators (PAPR) and N95 masks. The primary outcome was time to intubation. RESULTS The median time to intubation was 61 s (interquartile range [IQR] 37-63 s) and 41.5 s (IQR 37-56 s) in the VL and DL groups, respectively ( P = 0.35). The closest mean distance between the anaesthetist and patient during intubation was 21.6 ± 4.8 cm and 17.6 ± 5.3 cm in the VL and DL groups, respectively ( P = 0.045). There were no significant differences in the median intubation difficulty scale scores, proportion of successful intubations at the first laryngoscopic attempt and proportion of intubations requiring adjuncts. All the patients underwent successful intubation with no adverse event. CONCLUSION There was no significant difference in the time to intubation of elective surgical patients with either McGrath™ VL or DL by specialist anaesthetists who donned PAPR and N95 masks. The distance between the anaesthetist and patient was significantly greater with VL. When resources are limited or disrupted during a pandemic, DL could be a viable alternative to VL for specialist anaesthetists.
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Affiliation(s)
- Qing Yuan Goh
- Division of Anaesthesiology and Perioperative Medicine, Department of Surgical Intensive Care, Singapore General Hospital, Singapore
| | - Sui An Lie
- Division of Anaesthesiology and Perioperative Medicine, Department of Surgical Intensive Care, Singapore General Hospital, Singapore
| | - Zihui Tan
- Division of Anaesthesiology and Perioperative Medicine, Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Pei Yi Brenda Tan
- Division of Anaesthesiology and Perioperative Medicine, Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Shin Yi Ng
- Division of Anaesthesiology and Perioperative Medicine, Department of Surgical Intensive Care, Singapore General Hospital, Singapore
| | - Hairil Rizal Abdullah
- Division of Anaesthesiology and Perioperative Medicine, Department of Anaesthesiology, Singapore General Hospital, Singapore
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9
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Richa F, El-Hage C, Chalhoub V, Yazbeck P. Prediction of difficult laryngoscopy and/or intubation among morbidly obese patients: Upper lip bite test versus modified Mallampati classification. J Perioper Pract 2023:17504589231206903. [PMID: 38112112 DOI: 10.1177/17504589231206903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
INTRODUCTION We aim to compare the upper lip bite test with the modified Mallampati test as predictors of difficult laryngoscopy and/or difficult intubation among morbidly obese patients. METHODS A total of 500 morbidly obese patients (body mass index > 40 kg/m2) undergoing general anaesthesia with tracheal intubation are included in this prospective single-blinded observational clinical study. The preoperative airway assessment is obtained by the modified Mallampati test and upper lip bite test. The difficulty of laryngoscopy is assessed by an experienced anaesthetist in patients adequately anaesthetised and fully relaxed. The view is classified according to Cormack and Lehane's classification. Modified Mallampati test III or IV and upper lip bite test III are considered positive tests. Difficult laryngoscopy is defined as Cormack and Lehane's classification III and IV, whereas difficult endotracheal intubation is defined as an intubation difficulty scale ⩾ 5. RESULTS The incidences of Cormack and Lehane's classification III and IV and intubation difficulty scale ⩾ 5 are 9.4% and 11.8% respectively. The specificity, positive predictive value and accuracy are higher with the upper lip bite test. The combination of the upper lip bite test and the modified Mallampati test improved these measures. The likelihood ratio + was significantly higher for the upper lip bite test (6.35 and 9.47) than for the modified Mallampati test (3.21 and 3.16). CONCLUSION The upper lip bite test is a test with high sensitivity, specificity, negative predictive value and accuracy making it a favourable test for identifying easy and difficult intubations and laryngoscopies in morbidly obese patients.
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Affiliation(s)
- Freda Richa
- Department of Anaesthesia, Critical Care and Pain Management, Hotel-Dieu de France Hospital, Beirut, Lebanon
- Saint-Joseph University Medical School, Beirut, Lebanon
| | - Christine El-Hage
- Department of Anaesthesia, Critical Care and Pain Management, Hotel-Dieu de France Hospital, Beirut, Lebanon
- Saint-Joseph University Medical School, Beirut, Lebanon
| | - Viviane Chalhoub
- Department of Anaesthesia, Critical Care and Pain Management, Hotel-Dieu de France Hospital, Beirut, Lebanon
- Saint-Joseph University Medical School, Beirut, Lebanon
| | - Patricia Yazbeck
- Department of Anaesthesia, Critical Care and Pain Management, Hotel-Dieu de France Hospital, Beirut, Lebanon
- Saint-Joseph University Medical School, Beirut, Lebanon
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Fuchs-Buder T, Brull SJ, Fagerlund MJ, Renew JR, Cammu G, Murphy GS, Warlé M, Vested M, Fülesdi B, Nemes R, Columb MO, Damian D, Davis PJ, Iwasaki H, Eriksson LI. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision. Acta Anaesthesiol Scand 2023; 67:994-1017. [PMID: 37345870 DOI: 10.1111/aas.14279] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.
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Affiliation(s)
- Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care & Perioperative Medicine, University Hospital Nancy, Nancy, France
| | - Sorin J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Guy Cammu
- Department of Anesthesiology, Critical Care and Emergency Medicine, Aalst, Belgium
| | - Glenn S Murphy
- Department of Anesthesiology, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - Michiel Warlé
- Department of Surgery, Radbound University Medical Center, Nijmegen, The Netherlands
| | - Matias Vested
- Department of Anesthesia Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Reka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Malachy O Columb
- Anaesthesia & Intensive Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniela Damian
- Anesthesiology and Perioperative Medicine, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Peter J Davis
- Anesthesia and Pediatrics, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Hajime Iwasaki
- Department of Anesthesiology and Crtical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Lars I Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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11
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de Carvalho CC, da Silva DM, Leite MS, de Andrade LB. Upper airway angle and glottic height: a prospective cohort to evaluate two new features for airway prediction. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:570-577. [PMID: 35569581 PMCID: PMC10533972 DOI: 10.1016/j.bjane.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 04/26/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Predicting difficult direct laryngoscopies remains challenging and improvements are needed in preoperative airway assessment. We conceived two new tests (the upper airway angle and the glottic height) and assessed their association with difficult direct laryngoscopies as well as their predictive performance. METHODS A prospective cohort was conducted with 211 patients undergoing general anesthesia for surgical procedures. We assessed the association between difficult laryngoscopies and modified Mallampati Test (MMT), Upper Lip Bite Test (ULBT), Mandibular Length (ML), Neck Circumference (NC), Mouth Opening (MO), Sternomental Distance (SMD), Thyromental Distance (TMD), Upper Airway Angle (UAA), and Glottic Height (GH). We also estimated their predictive values. RESULTS Difficult laryngoscopy was presented by 12 patients (5.7%). Six tests were significantly associated with difficult laryngoscopies and their area under the ROC curve, and 95% CIs were as follows: UAA = 88.82 (81.86-95.78); GH = 86.43 (72.67-100); ML = 83.75 (72.77-94.74); NC = 79.17 (64.98-93.36); MO = 65.58 (45.13-86.02); and MMT = 77.89 (68.37-87.41). CONCLUSION We have found two new features (the UAA and the GH) to be significantly associated with the occurrence of difficult direct laryngoscopies. They also presented the best predictive performance amongst the nine evaluated tests in our cohort of patients. We cannot ensure, however, these tests to be superior to other regularly used bedside tests based on our estimated 95% CIs.
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Affiliation(s)
- Clístenes Crístian de Carvalho
- Instituto de Medicina Integra Professor Fernando Figueira, Recife, PE, Brazil; Universidade Federal de Campina Grande, Departamento de Cirurgia, Campina Grande, PA, Brazil.
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12
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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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Saikia P, Saikia R, Mazumder S, Das O. Evaluation of ratio of height to thyromental distance as a predictor of difficult visualization of larynx: A prospective observational single center study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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14
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García-García F, Lee DJ, Mendoza-Garcés FJ, Irigoyen-Miró S, Legarreta-Olabarrieta MJ, García-Gutiérrez S, Arostegui I. Automated location of orofacial landmarks to characterize airway morphology in anaesthesia via deep convolutional neural networks. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 232:107428. [PMID: 36870169 DOI: 10.1016/j.cmpb.2023.107428] [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: 04/13/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND A reliable anticipation of a difficult airway may notably enhance safety during anaesthesia. In current practice, clinicians use bedside screenings by manual measurements of patients' morphology. OBJECTIVE To develop and evaluate algorithms for the automated extraction of orofacial landmarks, which characterize airway morphology. METHODS We defined 27 frontal + 13 lateral landmarks. We collected n=317 pairs of pre-surgery photos from patients undergoing general anaesthesia (140 females, 177 males). As ground truth reference for supervised learning, landmarks were independently annotated by two anaesthesiologists. We trained two ad-hoc deep convolutional neural network architectures based on InceptionResNetV2 (IRNet) and MobileNetV2 (MNet), to predict simultaneously: (a) whether each landmark is visible or not (occluded, out of frame), (b) its 2D-coordinates (x,y). We implemented successive stages of transfer learning, combined with data augmentation. We added custom top layers on top of these networks, whose weights were fully tuned for our application. Performance in landmark extraction was evaluated by 10-fold cross-validation (CV) and compared against 5 state-of-the-art deformable models. RESULTS With annotators' consensus as the 'gold standard', our IRNet-based network performed comparably to humans in the frontal view: median CV loss L=1.277·10-3, inter-quartile range (IQR) [1.001, 1.660]; versus median 1.360, IQR [1.172, 1.651], and median 1.352, IQR [1.172, 1.619], for each annotator against consensus, respectively. MNet yielded slightly worse results: median 1.471, IQR [1.139, 1.982]. In the lateral view, both networks attained performances statistically poorer than humans: median CV loss L=2.141·10-3, IQR [1.676, 2.915], and median 2.611, IQR [1.898, 3.535], respectively; versus median 1.507, IQR [1.188, 1.988], and median 1.442, IQR [1.147, 2.010] for both annotators. However, standardized effect sizes in CV loss were small: 0.0322 and 0.0235 (non-significant) for IRNet, 0.1431 and 0.1518 (p<0.05) for MNet; therefore quantitatively similar to humans. The best performing state-of-the-art model (a deformable regularized Supervised Descent Method, SDM) behaved comparably to our DCNNs in the frontal scenario, but notoriously worse in the lateral view. CONCLUSIONS We successfully trained two DCNN models for the recognition of 27 + 13 orofacial landmarks pertaining to the airway. Using transfer learning and data augmentation, they were able to generalize without overfitting, reaching expert-like performances in CV. Our IRNet-based methodology achieved a satisfactory identification and location of landmarks: particularly in the frontal view, at the level of anaesthesiologists. In the lateral view, its performance decayed, although with a non-significant effect size. Independent authors had also reported lower lateral performances; as certain landmarks may not be clear salient points, even for a trained human eye.
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Affiliation(s)
| | - Dae-Jin Lee
- Basque Center for Applied Mathematics (BCAM) - Bilbao, Basque Country, Spain; IE University, School of Science and Technology - Madrid, Madrid, Spain.
| | - Francisco J Mendoza-Garcés
- Galdakao-Usansolo University Hospital, Anaesthesia & Resuscitation Service - Galdakao, Basque Country, Spain.
| | - Sofía Irigoyen-Miró
- Galdakao-Usansolo University Hospital, Anaesthesia & Resuscitation Service - Galdakao, Basque Country, Spain.
| | | | | | - Inmaculada Arostegui
- Basque Center for Applied Mathematics (BCAM) - Bilbao, Basque Country, Spain; University of the Basque Country (UPV/EHU), Department of Mathematics - Leioa, Basque Country, Spain.
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15
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Li WX, Wang DD, Li X, Li WX, Han Y, Cai YR. Risk factors for difficult mask ventilation and difficult intubation among patients undergoing pharyngeal and laryngeal surgery. Heliyon 2023; 9:e14408. [PMID: 36938445 PMCID: PMC10018552 DOI: 10.1016/j.heliyon.2023.e14408] [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: 09/07/2022] [Revised: 02/20/2023] [Accepted: 03/03/2023] [Indexed: 03/08/2023] Open
Abstract
Background The prediction of difficult mask ventilation (DMV) and difficult intubation (DI) are key questions in anesthesia fields. DMV or DI related to pharyngeal and laryngeal diseases are a special kind of difficult airways. However, there is a lack of risk factors for prediction. Methods This study retrospectively collected data from patients who were admitted to the Eye & ENT Hospital of Fudan University from May 2014 to May 2018 and underwent laryngopharyngeal surgery under general anesthesia. Results A total of 126 patients were included. Twenty patients suffered from DMV. Preoperative laryngeal obstruction classification (OR = 7.46, 95% CI: 2.56-21.76, P < 0.001) and airway patency after sevoflurane inhalation (OR = 10.96, 95% CI: 2.70-44.43, p = 0.001) were independently associated with DMV. Seventy-six patients could be intubated at the first attempt. Preoperative laryngeal obstruction grade (OR = 0.28, 95% CI: 0.13-0.62, P = 0.002), neoplasm size (OR = 0.43, 95% CI: 0.22-0.82, P = 0.011), and airway patency after sevoflurane inhalation (OR = 0.14, 95% CI: 0.05-0.36, P < 0.001) were independently associated with first-attempt successful intubation. Conclusion Among patients with pharyngeal and laryngeal diseases, the degree of laryngeal obstruction before the operation and the degree of airway obstruction after inhaling sevoflurane are the risk factors of DMV. The degree of laryngeal obstruction before the operation, airway obstruction after inhaling sevoflurane, and the neoplasm size are the risk factors of DI.
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Affiliation(s)
| | | | | | | | - Yuan Han
- Corresponding author. Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Xuhui District 200031, Shanghai, China.
| | - Yi-Rong Cai
- Corresponding author. Department of Anesthesiology, Eye & ENT Hospital, Fudan University, Xuhui District 200031, Shanghai, China.
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Bicalho GP, Bessa RC, Cruvinel MGC, Carneiro FS, Castilho JB, Castro CHV. A prospective validation and comparison of three multivariate models for prediction of difficult intubation in adult patients. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:153-158. [PMID: 34411628 PMCID: PMC10068536 DOI: 10.1016/j.bjane.2021.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Several bedside clinical tests have been proposed to predict difficult tracheal intubation. Unfortunately, when used alone, these tests show less than ideal prediction performance. Some multivariate tests have been proposed considering that the combination of some criteria could lead to better prediction performance. The goal of our research was to compare three previously described multivariate models in a group of adult patients undergoing general anesthesia. METHODS This study included 220 patients scheduled for elective surgery under general anesthesia. A standardized airway evaluation which included modified Mallampati class (MM), thyromental distance (TMD), mouth opening distance (MOD), head and neck movement (HNM), and jaw protrusion capacity was performed before anesthesia. Multivariate models described by El-Ganzouri et al., Naguib et al., and Langeron et al. were calculated using the airway data. After anesthesia induction, an anesthesiologist performed the laryngoscopic classification and tracheal intubation. The sensitivity, specificity, and receiver operating characteristic (ROC) curves of the models were calculated. RESULTS The overall incidence of difficult laryngoscopic view (DLV) was 12.7%. The area under curve (AUC) for the Langeron, Naguib, and El-Ganzouri models were 0.834, 0.805, and 0.752, respectively, (Langeron...>...El-Ganzouri, p...=...0.004; Langeron...=...Naguib, p...=...0.278; Naguib...=...El-Ganzouri, p...=...0.101). The sensitivities were 85.7%, 67.9%, and 35.7% for the Langeron, Naguib, and El-Ganzouri models, respectively. CONCLUSION The Langeron model had higher overall prediction performance than that of the El-Ganzouri model. Additionally, the Langeron score had higher sensitivity than the Naguib and El-Ganzouri scores, and therefore yielded a lower incidence of false negatives.
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Affiliation(s)
- Gustavo P Bicalho
- Hospital Lifecenter, Departamento de Anestesiologia, Belo Horizonte, MG, Brazil.
| | - Roberto C Bessa
- Hospital Lifecenter, Departamento de Anestesiologia, Belo Horizonte, MG, Brazil
| | | | - Fabiano S Carneiro
- Hospital Lifecenter, Departamento de Anestesiologia, Belo Horizonte, MG, Brazil
| | - Jayme B Castilho
- Hospital Lifecenter, Departamento de Anestesiologia, Belo Horizonte, MG, Brazil
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Bastami Z, Sheikhpour R, Razzaghi P, Ramazani A, Gharaghani S. Proteochemometrics modeling for prediction of the interactions between caspase isoforms and their inhibitors. Mol Divers 2023; 27:249-261. [PMID: 35438428 DOI: 10.1007/s11030-022-10425-5] [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: 01/25/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022]
Abstract
Caspases (cysteine-aspartic proteases) play critical roles in inflammation and the programming of cell death in the form of necroptosis, apoptosis, and pyroptosis. The name of these enzymes has been chosen in accordance with their cysteine protease activity. They act as cysteines in nucleophilically active sites to attack and cleave target proteins in the aspartic acid and amino acid C-terminal. Based on the substrate's structure and the specificity, the physiological activity of caspases is divided. However, in apoptosis, the division of caspases into initiating caspases (caspase 2, 8, 9, and 10) and executive caspases (caspase 3, 6, and 7) is essential. The present study aimed to perform Proteochemometrics Modeling to generalize the data on caspases, which could predict ligand and protein interactions. In this study, we employed protein and ligand descriptors. Moreover, protein descriptors were computed using the Protr R package, while PADEL-Descriptor was employed for the computation of ligand descriptors. In addition, NCA (Neighborhood Component Analyses) was used for descriptor selection, and SVR, decision tree, and ensemble methods were utilized for the proteochemometrics modeling. This study shows that the ensemble model demonstrates superior performance compared with other models in terms of R2, Q2, and RMSE criteria.
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Affiliation(s)
- Zahra Bastami
- Department of Bioinformatics, Kish International Campus, University of Tehran, Kish, Iran.,Laboratory of Bioinformatics and Drug Design (LBD), Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran
| | - Razieh Sheikhpour
- Department of Computer Engineering, Faculty of Engineering, Ardakan University, P.O. Box 184, Ardakan, Iran
| | - Parvin Razzaghi
- Department of Computer Science and Information Technology, Institute for Advanced Studies in Basic Sciences (IASBS), Zanjan, Iran
| | - Ali Ramazani
- Cancer Gene Therapy Research Center, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Sajjad Gharaghani
- Laboratory of Bioinformatics and Drug Design (LBD), Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran.
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Römer T, Büttner C, Ossowski R, Mutlak H, Muellenbach RM. Atemwegsmanagement in der Intensivmedizin – Schritt für Schritt. Pneumologie 2023; 77:37-46. [PMID: 36716795 DOI: 10.1055/a-1906-6984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Fonseca D, Graça MI, Salgueirinho C, Pereira H. Physiologically difficult airway: How to approach the difficulty beyond anatomy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Vasconcelos Pereira A, Simões AV, Rego L, Pereira JG. New technologies in airway management: A review. Medicine (Baltimore) 2022; 101:e32084. [PMID: 36482552 PMCID: PMC9726337 DOI: 10.1097/md.0000000000032084] [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] [Indexed: 12/13/2022] Open
Abstract
The evolution of medical knowledge and technological growth have contributed to the development of different techniques and devices for airway management. These appear to play a role in optimizing the number of attempts and overall success, ultimately reducing the negative consequences of airway manipulation. In this literature review, we highlight the recent evidence regarding new technologies applied to airway management. Before intubation, every patient should have an individualized structured airway management plan. Technology can help with both airway evaluation and tracheal intubation. Point-of-care cervical ultrasound and artificial intelligence models with automated facial analysis have been used to predict difficult airways. Various devices can be used in airway management. This includes a robotic video endoscope that guides intubation based on real image recognition, a laryngeal mask with a non-inflatable cuff that tries to reduce local complications, video laryngeal masks that are able to confirm the correct position and facilitate intubation, Viescope™, a videolaryngoscope developed for combat medicine with a unique circular blade, a system that uses cervical transillumination for glottis identification in difficult airways and Vivasight SL™ tracheal tube, which has a high-resolution camera at its tip guaranteeing visual assurance of tube position as well as guiding bronchial blocker position. To conclude, we detailed the challenges in airway management outside the operating room as well as described suction-assisted laryngoscopy and airway decontamination technique for contaminated airways. Further research in the clinical setting is recommended to better support the use of these technologies.
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Affiliation(s)
- Ana Vasconcelos Pereira
- Anesthesiology Department, Hospital de Vila Franca de Xira, Vila Franca DE Xira, Portugal
- * Correspondence: Ana Vasconcelos Pereira, Department of Anesthesiology, Hospital Vila Franca de Xira, Estrada Carlos Lima Costa Nº 2, Povos 2600-009 - Vila Franca DE Xira, Portugal (e-mail: )
| | - André Vicente Simões
- Intensive Care Department, Hospital de Vila Franca de Xira, Vila Franca DE Xira, Portugal
| | - Luísa Rego
- Anesthesiology Department, Hospital de Vila Franca de Xira, Vila Franca DE Xira, Portugal
| | - João Gonçalves Pereira
- Intensive Care Department, Hospital de Vila Franca de Xira, Vila Franca DE Xira, Portugal
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The value of multiparameter combinations for predicting difficult airways by ultrasound. BMC Anesthesiol 2022; 22:311. [PMID: 36199026 PMCID: PMC9533522 DOI: 10.1186/s12871-022-01840-0] [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: 04/08/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
Background Based on the upper airway anatomy and joint function parameters examined by ultrasound, a multiparameter ultrasound model for difficult airway assessment (ultrasound model) was established, and we evaluated its ability to predict difficult airways. Methods A prospective case-cohort study of difficult airway prediction in adult patients undergoing elective surgery with endotracheal intubation under general anesthesia, and ultrasound phantom examination for difficult airway assessment before anesthesia, including hyomental distance, tongue thickness, mandibular condylar mobility, mouth opening, thyromental distance, and modified Mallampati tests, was performed. Receiver operating characteristic (ROC) curve analysis was used to evaluate the effectiveness of the ultrasound model and conventional airway assessment methods in predicting difficult airways. Results We successfully enrolled 1000 patients, including 51 with difficult laryngoscopy (DL) and 26 with difficult tracheal intubation (DTI). The area under the ROC curve (AUC) for the ultrasound model to predict DL was 0.84 (95% confidence interval [CI]: 0.82–0.87), and the sensitivity and specificity were 0.75 (95% CI: 0.60–0.86) and 0.82 (95% CI: 0.79–0.84), respectively. The AUC for predicting DTI was 0.89 (95% CI: 0.87–0.91), and the sensitivity and specificity were 0.85 (95% CI: 0.65–0.96) and 0.81 (95% CI: 0.78–0.83), respectively. Compared with mouth opening, thyromental distance, and modified Mallampati tests, the ultrasound model predicted a greater AUC for DL (P < 0.05). Compared with mouth opening and modified Mallampati tests, the ultrasound model predicted a greater AUC for DTI (P < 0.05). Conclusions The ultrasound model has good predictive performance for difficult airways. Trial registration This study is registered on chictr.org.cn (ChiCTR-ROC-17013258); principal investigator: Jianling Xu; registration date: 06/11/2017). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01840-0.
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Bouzid K, Ketata S, Zouche I, Keskes M, Fourati M, Kammoun A, Moncef S, Karoui A. Ultrasonography predicts difficult airway management: A prospective double blinded study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Non-invasive ventilation for preoxygenation before general anesthesia: a systematic review and meta-analysis of randomized controlled trials. BMC Anesthesiol 2022; 22:306. [PMID: 36180822 PMCID: PMC9524013 DOI: 10.1186/s12871-022-01842-y] [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: 01/06/2022] [Accepted: 09/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background and objectives Preoxygenation is crucial for providing sufficient oxygen reservoir to a patient before intubation and enables the extension of the period between breathing termination and critical desaturation (safe apnoea time). Conventionally, face mask ventilation is used for preoxygenation. Non-invasive ventilation is a new preoxygenation method. The study objective was to compare the outcomes of non-invasive ventilation and face mask ventilation for preoxygenation. Method PubMed, Embase, Cochrane Library, and the ClinicalTrials.gov registry were searched for eligible studies published from database inception to September 2021. Individual effect sizes were standardized, and a meta-analysis was conducted using random effects models to calculate the pooled effect size. Inclusion criteria were randomised controlled trials of comparing the outcomes of non-invasive ventilation or face mask ventilation for preoxygenation in patients scheduled for surgeries. The primary outcome was safe apnea time, and the secondary outcomes were post-operative complications, number of patients who achieved the expired O2 fraction (FeO2) after 3 min of preoxygenation, minimal SpO2 during tracheal intubation, partial pressure of oxygen in the arterial blood (PaO2) and partial pressure of carbon dioxide (PaCO2) after preoxygenation, and PaO2 and PaCO2 after tracheal intubation. Results 13 trials were eligible for inclusion in this study. Significant differences were observed in safe apnoea time, number of patients who achieved FeO2 90% after preoxygenation for 3 min, and PaO2 and PaCO2 after preoxygenation and tracheal intubation. Only in the non-obese subgroup, no significant difference was observed in safe apnoea time (mean difference: 125.38, 95% confidence interval: − 12.26 to 263.03). Conclusion Non-invasive ventilation appeared to be more effective than conventional methods for preoxygenation. We recommend non-invasive ventilation based on our results. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01842-y.
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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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Use of the Thyromental Height Test for Prediction of Difficult Laryngoscopy: A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:jcm11164906. [PMID: 36013145 PMCID: PMC9409656 DOI: 10.3390/jcm11164906] [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: 07/01/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/17/2022] Open
Abstract
The thyromental height test (TMHT) has been proposed as a novel single clinical test for predicting difficult laryngoscopy (DL), though consequent studies have put forward various estimates when verifying its reliability. This systematic review and meta-analysis aimed to provide a comprehensive evaluation of the predictive value of TMHT for DL. A computerized search of CNKI, CQVIP, EBSCO, PubMed, SinoMed, and Wanfang Data was conducted on 1 June 2022. Prospective cohort studies reporting diagnostic properties of TMHT in relation to Cormack and Lehane grading in patients aged more than 16 years, either sex, scheduled for surgery under general anesthesia, requiring tracheal intubation with direct laryngoscopy were included in this analysis. Data was extracted or calculated, and meta-analysis was done by the Stata MIDAS module. A total of 23 studies with 5896 patients were included in this analysis. Summary estimates of all included studies are as follows: sensitivity 74% (95% CI, 68-79%); specificity 88% (95% CI, 81-92%); diagnostic odd ratio, 20 (95% CI, 10-40); positive likelihood ratio, 5.9 (95% CI, 3.6-9.6); and negative likelihood ratio, 0.30 (95% CI, 0.23-0.39). Summary sensitivity and specificity for studies with a prespecified threshold were 82% (95% CI, 71-89%) and 94% (95% CI, 87-98%), respectively. The estimated area under curve (AUC) was 85% (95% CI, 81-88%). There was no significant threshold effect but significant heterogeneity in both sensitivity and specificity. Heterogeneity in sensitivity became insignificant after removing two outliers of sensitivity analysis. It is concluded that THMT has an overall optimal predictive value for DL in adult patients with diverse ethnicity and various risk factors, displaying better predictive values in a large patient population comparing to other recent reported bedside assessments and a previous meta-analysis. As significant heterogeneity brought by un-standardized application of external laryngeal manipulations in the included studies may have biased the results of this meta-analysis, the actual predictive value of TMHT for DL still awaits further studies with good designs and large sample sizes for better determination.
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Sajayan A, Nair A, McNarry AF, Mir F, Ahmad I, El‐Boghdadly K. Analysis of a national difficult airway database. Anaesthesia 2022; 77:1081-1088. [DOI: 10.1111/anae.15820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 12/30/2022]
Affiliation(s)
- A. Sajayan
- Department of Anaesthesia University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - A. Nair
- Department of Anaesthesia University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - A. F. McNarry
- Department of Anaesthesia Western General and St John's Hospitals Edinburgh UK
| | - F. Mir
- Department of Anaesthesia St Georges University Hospitals NHS Foundation Trust London UK
| | - I. Ahmad
- Department of Anaesthesia and Peri‐operative Medicine Guy's and St. Thomas' NHS Foundation Trust London UK
- King's College London London UK
| | - K. El‐Boghdadly
- Department of Anaesthesia and Peri‐operative Medicine Guy's and St. Thomas' NHS Foundation Trust London UK
- King's College London London UK
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Savatmongkorngul S, Pitakwong P, Sricharoen P, Yuksen C, Jenpanitpong C, Watcharakitpaisan S. Difficult Laryngoscopy Prediction Score for Intubation in Emergency Departments: A Retrospective Cohort Study. Open Access Emerg Med 2022; 14:311-322. [PMID: 35791372 PMCID: PMC9250787 DOI: 10.2147/oaem.s372768] [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: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Difficult laryngoscopy is associated with difficult intubation, an increasing number of endotracheal intubation attempts, and adverse events. Clinical prediction of difficult airways in an emergency setting was limited in sensitivity and specificity. This study developed a new model for predicting difficult laryngoscopy in the emergency department. Methods This retrospective cohort study was conducted using an exploratory model at the Emergency Medicine of Ramathibodi Hospital. The study was conducted from June 2018 to July 2020. The eligibility criteria were an age of ≥15 years who undergo intubation in the emergency department. Difficult laryngoscopy was defined as a Cormack-Lehane grade 3 and above. The predictive model and score were developed by multivariable logistic regression analysis. Results A total of 617 patients met the eligibility criteria; 83 (13.45%) had difficult laryngoscopy. Five independent factors were predictive of difficult laryngoscopy. Significant factors were M: limited mouth opening, O: presence of obstructed airway, N: poor neck mobility, T: large tongue, and H: short hypo-mental distance. The difficult laryngoscopy score had an accuracy of 89%. A score of >4 increased the likelihood ratio of difficult laryngoscopy by 7.62 times. Conclusion The MONTH Difficult Laryngoscopy Score of >4 was associated with difficult laryngoscopy.
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Affiliation(s)
- Sorravit Savatmongkorngul
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panrikan Pitakwong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pungkava Sricharoen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sorawich Watcharakitpaisan
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Butler K, Winters M. The Physiologically Difficult Intubation. Emerg Med Clin North Am 2022; 40:615-627. [DOI: 10.1016/j.emc.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lee SY, Hong DK, Kim CJ, Chung MY, Lee S, Chae MS. Association between Successful Palpation of the Cricothyroid Membrane and the 3-3-2 Rule for Predicting Difficult Airway in Female Patients Undergoing Non-Neck Surgery: A Prospective Observational Cohort Study. J Clin Med 2022; 11:jcm11092316. [PMID: 35566446 PMCID: PMC9103161 DOI: 10.3390/jcm11092316] [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: 02/25/2022] [Revised: 04/12/2022] [Accepted: 04/20/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Prediction of difficult airway is important for airway management in patients undergoing surgery. The assessment of airway structures and establishment of protective airway strategies are essential to improve patient safety. However, the association between successful palpation of the cricothyroid membrane and airway predictions has not been fully elucidated in patients undergoing surgery. We investigated this in female patients undergoing non-neck surgery. Methods: A total of 68 female patients were enrolled in this prospective observational cohort study between January 2021 and June 2021 at Eunpyeong St. Mary’s Hospital, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea. Exclusion criteria were male patients and those with neck pathology or neck surgery. The assessment of difficult airway was performed before the induction of anesthesia and was defined by one of the following conditions: inter-incisor distance < 3 fingerbreadths, hyoid-to-mental distance < 3 fingerbreadths, and thyroid-to-hyoid distance < 2 fingerbreadths (the “3-3-2 rule”). The accuracy of palpable identification of the cricothyroid membrane was confirmed by ultrasonography (US). The patients were divided into the non-difficult airway (NDA) group (n = 30) and the difficult airway (DA) group (n = 30). Results: The two groups were comparable in terms of age, but the DA group had higher body mass index (BMI). In airway assessment, 9 patients showed inter-incisor distance < 3 fingerbreadths, 3 patients showed hyoid-to-mental distance < 3 fingerbreadths, and 24 patients showed thyroid-to-hyoid distance < 2 fingerbreadths in the DA group. The rate of successful palpation of the cricothyroid membrane was higher in the patients without than in those with difficult airway variables. Conclusions: Patients with a positive 3-3-2 rule showed a poor palpability of cricothyroid membrane.
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Affiliation(s)
- So Yeon Lee
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Da Kyung Hong
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Chang Jae Kim
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Mee Young Chung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.Y.L.); (D.K.H.); (C.J.K.); (M.Y.C.)
| | - Sanghoon Lee
- Department of Anesthesiology and Pain Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Korea
- Correspondence: ; Tel.: +82-2-2258-6150; Fax: +82-2-537-1951
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Tsai YCM, Russotto V, Parotto M. Predicting the Difficult Airway: How Useful Are Preoperative Airway Tests? CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00525-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rosenblatt WH, Yanez ND. A Decision Tree Approach to Airway Management Pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg 2022; 134:910-915. [PMID: 35171880 PMCID: PMC8986631 DOI: 10.1213/ane.0000000000005930] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The American Society of Anesthesiologists’ (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist’s choice of pathway in the ASA’s Difficult Airway Algorithm. The tool prompts the anesthesiologist to consider the risk of difficulty with laryngoscopy (direct or indirect) and tracheal intubation, facemask or supraglottic ventilation, gastric contents aspiration, and rapid oxyhemoglobin desaturation. For every airway management event, the approach integrates the anesthesiologist’s unique combination of experience, expertise, patient anatomy and disease, equipment availability, and other contextual conditions into the decision process. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation. The decision tree tool is anticipated to improve communication between anesthesiologists and others by clearly identifying those factors of concern and how decision-making is affected by those concerns.
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Affiliation(s)
- William H Rosenblatt
- From the Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
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Khan M, Siddiqui AS, Raza SA, Samad K. Incidence and Predictors of Difficult Mask Ventilation in High-Risk Adult Population Scheduled for Elective Surgery: A Prospective Observational Study. Cureus 2022; 14:e22002. [PMID: 35282531 PMCID: PMC8906503 DOI: 10.7759/cureus.22002] [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: 02/06/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Mask ventilation is one of the key components in the management of airway during general anaesthesia, particularly when laryngoscopy is challenging. Adequate mask ventilation provides anaesthesiologists a safe time in case of unanticipated or anticipated difficult airway situations. The aim of this study was to determine the incidence of difficult bag-mask ventilation and intubation in patients having three or more predictors for difficult mask ventilation (DMV) in adult patients scheduled for elective surgery under anaesthesia. Methods A total of 294 patients requiring endotracheal intubation for elective surgical procedure having three or more risk factors were evaluated for the presence of difficulty in bag-mask ventilation and intubation by the anaesthesiologist. Chi-square test or Fisher's exact test and a multivariable stepwise logistic regression model were performed to identify predictors of DMV. Crude and adjusted odds ratio with 95% confidence interval were reported. Results In this study, the average age of the patients was 53.59±13.32 years with a 2:1 male-to-female ratio. DMV and difficult intubation (DI) were observed in 31.6% and 3% of patients, respectively. Multivariate analysis identified history of snoring, BMI (>35 kg/m2), presence of beard and Mallampati III or IV as independent predictors for DMV. Patients with multiple factors (≥3 factors) had a threefold (OR=2.57) increased risk of difficulty in mask ventilation and a nearly fivefold (OR=4.63) increased risk of difficulty with intubation. Conclusion In our study, the incidence of DMV was observed in 93 (31.6%) patients and DI was found in 9 (3%) patients. A simple DMV risk score may help to predict DMV better, potentially improving safety during difficult airway management, decreasing morbidity and mortality associated with it.
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Farzan B, Farzan N, Vahabi S. Airway Management: Difficulty of Intubation and Range of Movement of the Thyroid Cartilage. J Perianesth Nurs 2022; 37:184-187. [PMID: 35033430 DOI: 10.1016/j.jopan.2021.01.007] [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: 11/29/2020] [Revised: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Difficult endotracheal intubation has been associated with a number of anatomic factors. According to our experience, the range of movement of thyroid cartilage can be used as a useful test to determine the difficulty in endotracheal intubation. The aim of this study was to evaluate the association between the range of movement of thyroid cartilage and difficulty in intubation. DESIGN Cross-sectional study. METHODS This study was carried out on 400 patients at (Shohada Ashayer Hospital, Khorramabad). After obtaining consent letters from the patients who were between 18 and 60 years of age, the patients underwent general anesthesia. The participants were evaluated by Mallampati and other evaluating tests. The range of movement of thyroid cartilage from the midline was measured and recorded. FINDINGS There were significant correlation between the range of movement of thyroid cartilage and thyromental distance. In addition, in patients with Cormack-Lehane class 1, the mean range of movement of thyroid cartilage was significantly more than the patients with Cormack-Lehane class 3 and 4. CONCLUSIONS The outcomes of our study indicate that the range of movement of thyroid cartilage can be used for predication of difficult intubation. However, further randomized trials should be conducted in this regard.
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Affiliation(s)
- Behrouz Farzan
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Nina Farzan
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
| | - Sepideh Vahabi
- Department of Anesthesiology, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran.
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Carsetti A, Sorbello M, Adrario E, Donati A, Falcetta S. Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis. Anesth Analg 2021; 134:740-750. [PMID: 34914641 PMCID: PMC8903216 DOI: 10.1213/ane.0000000000005839] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in anesthesia practice. The aim of this systematic review and meta-analysis was to evaluate whether preoperative airway ultrasound can predict difficult direct laryngoscopy in adult patients undergoing elective surgery under general anesthesia.
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Affiliation(s)
- Andrea Carsetti
- From the Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico San Marco University HospitalCatania, Italy
| | - Erica Adrario
- From the Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Abele Donati
- From the Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Stefano Falcetta
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
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de Carvalho CC, da Silva DM, Lemos VM, Dos Santos TGB, Agra IC, Pinto GM, Ramos IB, Costa YSC, Santos Neto JM. Videolaryngoscopy vs. direct Macintosh laryngoscopy in tracheal intubation in adults: a ranking systematic review and network meta-analysis. Anaesthesia 2021; 77:326-338. [PMID: 34855986 DOI: 10.1111/anae.15626] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 12/22/2022]
Abstract
Videolaryngoscopes are thought to improve glottic view and facilitate tracheal intubation compared with the Macintosh direct laryngoscope. However, we currently do not know which one would be the best choice in most patients undergoing anaesthesia. We designed this systematic review with network meta-analyses to rank the different videolaryngoscopes and the Macintosh direct laryngoscope. We conducted searches in PubMed and a further five databases on 11 January 2021. We included randomised clinical trials with patients aged ≥16 years, comparing different videolaryngoscopes, or videolaryngoscopes with the Macintosh direct laryngoscope for the outcomes: failed intubation; failed first intubation attempt; failed intubation within two attempts; difficult intubation; percentage of glottic opening seen; difficult laryngoscopy; and time needed for intubation. We assessed the quality of evidence according to GRADE recommendations and included 179 studies in the meta-analyses. The C-MAC and C-MAC D-Blade were top ranked for avoiding failed intubation, but we did not find statistically significant differences between any two distinct videolaryngoscopes for this outcome. Further, the C-MAC D-Blade performed significantly better than the C-MAC Macintosh blade for difficult laryngoscopy. We found statistically significant differences between the laryngoscopes for time to intubation, but these differences were not considered clinically relevant. The evidence was judged as of low or very low quality overall. In conclusion, different videolaryngoscopes have differential intubation performance and some may be currently preferred among the available devices. Furthermore, videolaryngoscopes and the Macintosh direct laryngoscope may be considered clinically equivalent for the time taken for tracheal intubation. However, despite the rankings from our analyses, the current available evidence is not sufficient to ensure significant superiority of one device or a small set of them over the others for our intubation-related outcomes.
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Affiliation(s)
- C C de Carvalho
- Department of Surgery, Universidade Federal de Campina Grande, Campina Grande, Brazil
| | - D M da Silva
- Support and Therapeutic Diagnosis Division, Anaesthesiology and Post-Anaesthetic Care Unit, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, Brazil
| | - V M Lemos
- Support and Therapeutic Diagnosis Division, Anaesthesiology and Post-Anaesthetic Care Unit, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, Brazil
| | - T G B Dos Santos
- Support and Therapeutic Diagnosis Division, Anaesthesiology and Post-Anaesthetic Care Unit, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, Brazil
| | - I C Agra
- Centro de Ciências Biológicas e da Saúde, Universidade Federal de Campina Grande, Campina Grande, Brazil
| | - G M Pinto
- Centro de Ciências Biológicas e da Saúde, Universidade Federal de Campina Grande, Campina Grande, Brazil
| | - I B Ramos
- Centro de Ciências Biológicas e da Saúde, Universidade Federal de Campina Grande, Campina Grande, Brazil
| | - Y S C Costa
- Centro de Ciências Biológicas e da Saúde, Universidade Federal de Campina Grande, Campina Grande, Brazil
| | - J M Santos Neto
- Support and Therapeutic Diagnosis Division, Anaesthesiology and Post-Anaesthetic Care Unit, Hospital das Clínicas da Universidade Federal de Pernambuco, Recife, Brazil
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Khidr AM, El Tahan MR. Difficult lung separation. An insight into the challenges faced during COVID-19 pandemic. Saudi J Anaesth 2021; 15:300-311. [PMID: 34764837 PMCID: PMC8579506 DOI: 10.4103/sja.sja_1086_20] [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: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 11/29/2022] Open
Abstract
Difficult lung isolation or separation in patients undergoing thoracic surgery using one-lung ventilation might be attributed to upper airway difficulty or abnormal anatomy of the lower airway. Additionally, adequate deflation of the surgical lung can impair surgical exposure. The coronavirus disease 2019 (COVID-19) has a harmful consequence for both patients and anesthesiologists. Management of patients with difficult lung isolation can be challenging during the COVID-19 pandemic. Careful planning and preparation, preoperative routine testing, protective personal equipment, standard safety measures, proper preoxygenation, and individualize the patients care are required for successful lung separation. A systematic approach for management of difficult lung separation is centered around securing the airway and providing adequate ventilation using either a blocker or double-lumen tube. Several measures are described to expedite lung collapse.
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Affiliation(s)
- Alaa M Khidr
- Department of Anesthesiology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
| | - Mohamed R El Tahan
- Department of Anesthesiology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khobar, Saudi Arabia
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de Carvalho CC, da Silva DM, Leite MS, de Orange FA. Is Mallampati classification a good screening test? A prospective cohort evaluating the predictive values of Mallampati test at different thresholds. Braz J Anesthesiol 2021; 72:736-741. [PMID: 34624375 PMCID: PMC9660002 DOI: 10.1016/j.bjane.2021.09.008] [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: 03/23/2020] [Revised: 08/22/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is currently some discussion over the actual usefulness of performing preoperative upper airway assessment to predict difficult airways. In this field, modified Mallampati test (MMT) is a widespread tool used for prediction of difficult airways showing only a feeble predictive performance as a diagnostic test. We therefore aimed at evaluating if MMT test would perform better when used as a screening test rather than diagnostic. METHODS An accuracy prospective study was conducted with 570 patients undergoing general anesthesia for surgical procedures. We collected preoperatively data on sex, age, weight, height, body mass index (BMI), ASA physical status, and MMT. The main outcome was difficult laryngoscopy defined as Cormack and Lahane classes 3 or 4. Bivariate analyses were performed to build three different predictive models with their ROC curves. RESULTS Difficult laryngoscopy was reported in 36 patients (6.32%). Sex, ASA physical status, and MMT were associated with difficult laryngoscopy, while body mass index (BMI) was not. The MMT cut-off with the highest odds ratio was the class II, which also presented significantly higher sensitivity (94.44%). The balanced accuracy was 67.11% (95% CI: 62.78-71.44%) for the cut-off of class II and 71.68% (95% CI: 63.83-79.54) for the class III. CONCLUSION MMT seems to be more clinically useful when the class II is employed as the threshold for possible difficult laryngoscopies. At this cut-off, MMT shows the considerable highest sensitivity plus the highest odds ratio, prioritizing thus the anticipation of difficult laryngoscopies.
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Affiliation(s)
- Clístenes C de Carvalho
- Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil; Universidade Federal de Campina Grande, Campina Grande, PB, Brazil.
| | | | | | - Flávia A de Orange
- Instituto de Medicina Integral Professor Fernando Figueira, Recife, PE, Brazil; Hospital das Clínicas de Pernambuco, Recife, PE, Brazil
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Sepúlveda Haro E, Raigón Ponferrada A, Ramírez Aliaga M, Galache Laza M, Guerrero Orriach JL, Cruz Mañas J. Mallampati class zero airway. A narrative review. Minerva Anestesiol 2021; 88:390-395. [PMID: 34636224 DOI: 10.23736/s0375-9393.21.15945-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We aim to summarize the current knowledge about Mallampati class zero airway and its implication on airway management. Mallampati class zero airway describes a visible epiglottis on pharyngoscopic view. We reviewed the reported studies about visible epiglottis on pharyngoscopy and 35 publications were selected. Mallampati class zero airway has a low prevalence in the general population and it is more frequent in children and female. The cause for this phenomenon is not well understood but in clinical practice it is associated with an easy airway. Its inclusion as a new class in modified Mallampati classification would facilitate its diffusion and promote further investigation.
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Affiliation(s)
- Enrique Sepúlveda Haro
- Department of Anesthesiology and Critical Care Medicine, Virgen de la Victoria University Hospital, Málaga, Spain -
| | - Aida Raigón Ponferrada
- Department of Anesthesiology and Critical Care Medicine, Virgen de la Victoria University Hospital, Málaga, Spain
| | - Marta Ramírez Aliaga
- Department of Anesthesiology and Critical Care Medicine, Virgen de la Victoria University Hospital, Málaga, Spain
| | | | - José L Guerrero Orriach
- Department of Anesthesiology and Critical Care Medicine, Virgen de la Victoria University Hospital, Málaga, Spain
| | - José Cruz Mañas
- Department of Anesthesiology and Critical Care Medicine, Virgen de la Victoria University Hospital, Málaga, Spain
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Seet E, Chung F, Wang CY, Tam S, Kumar CM, Ubeynarayana CU, Yim CC, Chew EFF, Lam CKM, Cheng BCP, Chan MTV. Association of Obstructive Sleep Apnea With Difficult Intubation: Prospective Multicenter Observational Cohort Study. Anesth Analg 2021; 133:196-204. [PMID: 33720906 DOI: 10.1213/ane.0000000000005479] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) has been found to be associated with difficult airway, although there is a paucity of prospective studies investigating thresholds of OSA severity with difficult airway outcomes. The aim of this study was to examine the association between OSA and difficult intubation or difficult mask ventilation. We also explored the utility of the Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, and Gender (STOP-Bang) score for difficult airway prediction. METHODS The Postoperative Vascular Complications in Unrecognized Obstructive Sleep Apnea (POSA) trial was an international prospective cohort study of surgical patients 45 years or older with one or more cardiac risk factor presenting for noncardiac surgery, with planned secondary analyses of difficult airway outcomes. Multivariable logistic regression analyses tested associations between OSA severity and predictors of difficult airway with difficult intubation or difficult mask ventilation. Overall, 869 patients without prior diagnosis of OSA were screened for OSA risk with the STOP-Bang tool, underwent preoperative sleep study, and had routine perioperative care, including general anesthesia with tracheal intubation. The primary outcome analyzed was difficult intubation, and the secondary outcome was difficult mask ventilation. RESULTS Based on the sleep studies, 287 (33%), 324 (37%), 169 (20%), and 89 (10%) of the 869 patients had no, mild, moderate, and severe OSA, respectively. One hundred and seventy-two (20%) had a STOP-Bang score of 0-2 (low risk), 483 (55%) had a STOP-Bang score of 3-4 (intermediate risk), and 214 (25%) had a STOP-Bang score 5-8 (high risk). The incidence of difficult intubation was 6.7% (58 of 869), and difficult mask ventilation was 3.7% (32 of 869). Multivariable logistic regression demonstrated that moderate OSA (odds ratio [OR] = 3.26 [95% confidence interval {CI}, 1.37-8.38], adjusted P = .010) and severe OSA (OR = 4.05 [95% CI, 1.51-11.36], adjusted P = .006) but not mild OSA were independently associated with difficult intubation compared to patients without OSA. Relative to scores of 0-2, STOP-Bang scores of 3-4 and 5-8 were associated with increased odds of difficult intubation (OR = 3.01 [95% CI, 1.13-10.40, adjusted P = .046] and 4.38 [95% CI, 1.46-16.36, adjusted P = .014]), respectively. OSA was not associated with difficult mask ventilation, and only increasing neck circumference was found to be associated (adjusted P = .002). CONCLUSIONS Moderate and severe OSA were associated with difficult intubation, and increasing neck circumference was associated with difficult mask ventilation. A higher STOP-Bang score of 3 or more may be associated with difficult intubation versus STOP-Bang score of 0-2. Anesthesiologists should be vigilant for difficult intubation when managing patients suspected or diagnosed with OSA.
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Affiliation(s)
- Edwin Seet
- From the Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Anaesthesia, Khoo Teck Puat Hospital, National Healthcare Group, Singapore
| | - Frances Chung
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Chew Yin Wang
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Stanley Tam
- Department of Anesthesia, Scarborough Health Network, Scarborough, Ontario, Canada
| | - Chandra M Kumar
- Department of Anaesthesia, Khoo Teck Puat Hospital, National Healthcare Group, Singapore
| | | | - Carolyn C Yim
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Eleanor F F Chew
- Department of Anesthesiology and Intensive Care, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Carmen K M Lam
- Department of Anaesthesia, Tuen Mun Hospital, Hong Kong Special Administrative Region, China
| | - Benny C P Cheng
- Department of Anaesthesia, Tuen Mun Hospital, Hong Kong Special Administrative Region, China
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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Airway Abnormalities in Adult Mucopolysaccharidosis and Development of Salford Mucopolysaccharidosis Airway Score. J Clin Med 2021; 10:jcm10153275. [PMID: 34362059 PMCID: PMC8347638 DOI: 10.3390/jcm10153275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
(1) Background: Mucopolysaccharidoses (MPS) are a heterogeneous group of lysosomal storage disorders caused by the absence of enzymes required for degradation of glycosaminoglycans (GAGs). GAGs deposition in tissues leads to progressive airway narrowing and/or tortuosity. Increased longevity of patients has posed newer problems, especially the airway. This study aims to characterise various airway abnormalities in adult MPS from a regional centre and proposes a method to quantify the severity of the airway disease. (2) Methods: Retrospective analysis by case notes review, clinical examination, endoscopy, cross-sectional imaging, 3-dimensional reconstruction, and physiological investigations were used to assess the airway abnormalities. Quantitative assessment of the airway severity was performed a validated questionnaire of 15 parameters to derive Salford Mucopolysaccharidosis Airway Score (SMAS). (3) Results: Thirty-one adult MPS patients (21M/ 9F; median 26.7 years; range 19–42 years) were reviewed. There were 9 MPS I, 12 MPS II, 2 MPS III, 5 MPS IV, 2 MPS VI, and 1 MPS VII. Airway abnormalities in each MPS type are described. Patients scoring more than 35 on SMAS had some form of airway intervention. The area under curve of 0.9 was noted at a score of 25, so SMAS more than 25 may predict a difficult airway and potential to have complications. Pearson’s correlation between SMAS and height, weight, BMI were poor (p < 0.05). (4) Conclusions: Airway abnormalities in adult MPS are varied and complex. Assessment of the airway should be holistic and include multiple parameters. An objective multidimensional score such as SMAS may help to predict and manage difficult airways warranting further investigation and validation.
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Matsuo M, Takemura Y, Yamazaki M. Limited Utility of Routine Tests Prior to Ophthalmologic Surgery: An Observational Study in a Japanese Hospital. JMA J 2021; 4:270-276. [PMID: 34414322 PMCID: PMC8355728 DOI: 10.31662/jmaj.2020-0112] [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: 12/14/2020] [Accepted: 03/17/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Routine preoperative testing for low-risk surgeries without a clinical indication should be avoided; however, such tests are still frequently performed in Japan. This study was performed to assess the impact of routine preoperative tests in low-risk surgery in a Japanese medical setting. Methods: We performed a retrospective chart review to examine the utility of routine tests with respect to anesthetic management and postoperative complications in all patients aged ≥ 18 years whom ophthalmologists consulted with anesthesiologists before ophthalmologic surgery under general anesthesia. Results: During the 10-year study period, 1,234 anesthetic consultations and 1,211 routine preoperative tests (laboratory tests, chest X-rays, and electrocardiograms) were performed in Toyama University Hospital. In total, 59 patients (4.8% of the study population) canceled surgery after a battery of preoperative evaluation. Among them, 10 patients had incidental abnormalities that necessitated additional tests, and only three patients (0.2%) canceled surgery. In-hospital postoperative complications developed in nine patients (0.7%) whose routine test results made it difficult to predict development of these adverse events. No severe life-threatening events were noted in this survey. Conclusions: Routine tests prior to eye surgery for adults were of low value for perioperative management and prediction of development of in-hospital complications in this Japanese medical setting. Anesthesiologists and ophthalmologists should selectively order preoperative tests based on the medical interview and physical examination.
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Affiliation(s)
- Mitsuhiro Matsuo
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yoshinori Takemura
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Mitsuaki Yamazaki
- Department of Anesthesiology, Faculty of Medicine, University of Toyama, Toyama, Japan
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42
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Carvalho CCD, Santos Neto JM, Orange FAD. Predictive performance of thyromental height for difficult laryngoscopies in adults: a systematic review and meta-analysis. Braz J Anesthesiol 2021:S0104-0014(21)00271-2. [PMID: 34252454 PMCID: PMC10362459 DOI: 10.1016/j.bjane.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 06/07/2021] [Accepted: 06/20/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Thyromental height (TMH) was first reported as a great single test for prediction of difficult laryngoscopies, although further studies have shown variable estimates of its accuracy. We thus performed this meta-analysis to summarize the predictive values of TMH mainly for prediction of difficult laryngoscopies. METHODS A search in PubMed, EMBASE, LILACS, and Scielo was conducted in June 2020. We included prospective cohorts fully reported with patients ≥ 16 years old, providing data on predictive values of TMH for prediction of either difficult laryngoscopies or difficult intubations. Diagnostic properties and association between TMH and Cormack and Lehanes's classification by direct laryngoscopy were evaluated. A random-effects meta-analysis using hierarchical models was performed. RESULTS Eight studies evaluating 2844 patients were included. All included studies had high risk of bias and low concern regarding applicability. There was significant heterogeneity among the studies. The pooled diagnostic odds ratio (DOR) and positive (LR+) and negative (LR-) likelihood ratios were as follows: DOR, 57.94 (95% CI: 18.19-184.55); LR+, 11.32 (95% CI: 4.28-29.92); and LR-, 0.23 (95% CI: 0.15-0.35). Summary sensitivity and specificity for studies with common threshold were 82.6 (95% CI: 74-88.8%) and 93.5 (95% CI: 79-98.2%), respectively. The estimated AUC was 81.1%. CONCLUSION TMH arises as a good predictor of difficult laryngoscopies in adult patients from diverse populations presenting better predictive values than most previously reported bedside tests. However, the high risk of bias throughout the studies may have skewed the results of the individual research as well as the summary points of the present meta-analysis.
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Affiliation(s)
| | - Jayme Marques Santos Neto
- Universidade Federal de Pernambuco (UFPE), Hospital das Clínicas, Department of Anesthesia, Recife, PE, Brazil
| | - Flávia Augusta de Orange
- Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Department of Post-graduation, Recife, PE, Brazil
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Moura ECR, Filho ASM, de Oliveira EJSG, Freire TT, da Cunha Leal P, de Sousa Gomes LMR, Servin ETN, de Oliveira CMB. Comparative Study of Clinical and Ultrasound Parameters for Defining a Difficult Airway in Patients with Obesity. Obes Surg 2021; 31:4118-4124. [PMID: 34227021 DOI: 10.1007/s11695-021-05528-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/28/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Patients with obesity have anatomical changes due to increased adipose tissue that negatively affect airway accessibility, making it difficult to establish an advanced airway through orotracheal intubation. This article aims to evaluate the correlation of clinical and sonographic parameters as predictors of difficult airway management (DAM) in patients with obesity and to establish the predictive value of the skin-epiglottis distance as an indicator of a probable DAM. METHODS This is an observational, prospective study of 100 patients with obesity who underwent bariatric surgery over a 12-month period. The patients were categorized into the easy airway and the difficult airway groups, according to the Cormack-Lehane classification in the laryngoscopy evaluation, and the clinical and sonographic variables collected were statistically evaluated to obtain the relation with the presence of DAM, according to the Cormack-Lehane classification. RESULTS The mouth opening (p = 0.010) and the skin-epiglottis distance (p = 0.019) were statistically significant when comparing the easy airway and the difficult airway groups of the Cormack-Lehane classification. The predictive value of the skin-epiglottis distance for difficult airway assessment was 29.3 mm. The neck circumference (p = 0.225), the Mallampati index (p = 0.260), and the other clinical variables showed no statistical relevance when compared in isolation with the Cormack-Lehane groups. CONCLUSION The ultrasound method as a predictor of difficult intubation is promising in anesthetic practice when used according to standardized measurements evaluation and cutoff values.
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Affiliation(s)
- Ed Carlos Rey Moura
- São Domingos Hospital, São Luís, Brazil.,Federal University of Maranhão, São Luís, Brazil
| | | | | | | | - Plínio da Cunha Leal
- São Domingos Hospital, São Luís, Brazil.,Federal University of Maranhão, São Luís, Brazil
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Sorbello M, Falcetta S. Time to include ultrasounds in pre-procedural airway evaluation? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2021.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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45
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Clinical considerations in providing intravenous sedation with midazolam for obese patients in dentistry. Br Dent J 2021; 230:587-593. [PMID: 33990742 DOI: 10.1038/s41415-021-2944-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/07/2020] [Indexed: 11/08/2022]
Abstract
The widespread prevalence of obesity continues to rise. Obesity and dental disease share common risk factors and so the demand for dental care for obese patients is escalating. For some of these patients, there is a corresponding need to be able to provide intravenous sedation safely when it is necessary and appropriate to do so. However, obesity often presents with multiple comorbidities and airway complexities, leading to more challenging management and potentially increased risk. The risk assessment process as well as patient monitoring and management strategies will be explored in this article. By reviewing the literature from dentistry and other medical specialties, we also aim to establish the potential benefit in administering supplemental oxygen and the use of capnography in monitoring this cohort of patients.
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Deriy L, Gerstein NS. Moving past Mallampati: airway ultrasound in predicting difficult face mask ventilation. Minerva Anestesiol 2021; 87:4-6. [PMID: 33538414 DOI: 10.23736/s0375-9393.20.15283-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Lev Deriy
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM, USA -
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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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Zheng Z, Ma W, Du R. Effectiveness and validity of midsagittal tongue cross-sectional area and width measured by ultrasound to predict difficult airways. Minerva Anestesiol 2021; 87:403-413. [PMID: 33591134 DOI: 10.23736/s0375-9393.20.14769-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Increased tongue volume measured by ultrasound has been proven to be related to difficult airways. Tongue volume is an indirect parameter and is derived from multiplying the midsagittal tongue cross-sectional area (CSA) by the tongue width. However, few studies have focused on the ability of tongue CSA and tongue width to predict difficult airways. This study aimed to investigate the predictive value of tongue CSA and tongue width for predicting difficult laryngoscopy and difficult intubation. METHODS This study included 244 adult patients who underwent general anesthesia and endotracheal intubation. Demographic variables were collected, and clinical airway assessments were performed. A curvilinear low-frequency probe was used for ultrasonography, and midsagittal tongue CSA and tongue width were measured before anesthesia. The laryngoscopic view and the difficulty of intubation was graded or scored after induction of anesthesia. RESULTS A total of 230 patients were analyzed. Twenty-eight (12.2%) patients experienced difficult laryngoscopy and twelve (5.2%) patients experienced difficult intubation. Midsagittal tongue CSA evaluated by ultrasonography could help identify patients with difficult laryngoscopy (sensitivity 0.71, specificity 0.60) and patients with difficult intubation (sensitivity 0.50, specificity 0.97). And tongue width could help identify patients with difficult laryngoscopy (sensitivity 0.39, specificity 0.89). CONCLUSIONS Ultrasonic measurement of midsagittal tongue CSA may be a valuable predictor of difficult laryngoscopy and difficult intubation. By contrast, tongue width measured by ultrasound may be a weak predictor of difficult laryngoscopy, but its predictive ability was questionable.
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Affiliation(s)
- Zhenwei Zheng
- Department of Anesthesiology, First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Anesthesiology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Wuhua Ma
- Department of Anesthesiology, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China -
| | - Ruiming Du
- Department of Anesthesiology, Second Affiliated Hospital of Shantou University Medical College, Shantou, China
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Wu H, Hu D, Chen X, Zhang X, Xia M, Chai X, Wang S, Zhang W. The evaluation of maximum condyle-tragus distance can predict difficult airway management without exposing upper respiratory tract; a prospective observational study. BMC Anesthesiol 2021; 21:28. [PMID: 33494705 PMCID: PMC7829489 DOI: 10.1186/s12871-021-01253-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/20/2021] [Indexed: 11/26/2022] Open
Abstract
Background Routine preoperative methods to assess airway such as the interincisor distance (IID), Mallampati classification, and upper lip bite test (ULBT) have a certain risk of upper respiratory tract exposure and virus spread. Condyle-tragus maximal distance(C-TMD) can be used to assess the airway, and does not require the patient to expose the upper respiratory tract, but its value in predicting difficult laryngoscopy compared to other indicators (Mallampati classification, IID, and ULBT) remains unknown. The purpose of this study was to observe the value of C-TMD to predict difficult laryngoscopy and the influence on intubation time and intubation attempts, and provide a new idea for preoperative airway assessment during epidemic. Methods Adult patients undergoing general anesthesia and tracheal intubation were enrolled. IID, Mallampati classification, ULBT, and C-TMD of each patient were evaluated before the initiation of anesthesia. The primary outcome was intubation time. The secondary outcomes were difficult laryngoscopy defined as the Cormack-Lehane Level > grade 2 and the number of intubation attempts. Results Three hundred four patients were successfully enrolled and completed the study, 39 patients were identified as difficult laryngoscopy. The intubation time was shorter with the C-TMD>1 finger group 46.8 ± 7.3 s, compared with the C-TMD<1 finger group 50.8 ± 8.6 s (p<0.01). First attempt success rate was higher in the C-TMD>1 finger group 98.9% than in the C-TMD<1 finger group 87.1% (P<0.01). The correlation between the C-TMD and Cormack-Lehane Level was 0.317 (Spearman correlation coefficient, P<0.001), and the area under the ROC curve was 0.699 (P<0.01). The C-TMD < 1 finger width was the most consistent with difficult laryngoscopy (κ = 0.485;95%CI:0.286–0.612) and its OR value was 10.09 (95%CI: 4.19–24.28), sensitivity was 0.469 (95%CI: 0.325–0.617), specificity was 0.929 (95%CI: 0.877–0.964), positive predictive value was 0.676 (95%CI: 0.484–0.745), negative predictive value was 0.847 (95%CI: 0.825–0.865). Conclusion Compared with the IID, Mallampati classification and ULBT, C-TMD has higher value in predicting difficult laryngoscopy and does not require the exposure of upper respiratory tract. Trial registration The study was registered on October 21, 2019 in the Chinese Clinical Trial Registry (ChiCTR1900026775).
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Affiliation(s)
- Hao Wu
- Department of Anesthesiology, First Affiliated Hospital of the University of Science and Technology of China, Anhui Provincial Hospital, 17 Lujiang Road, Hefei, 230000, Anhui, China
| | - Dandan Hu
- Department of Oncology, First Affiliated Hospital of the University of Science and Technology of China, Provincial Cancer Hospital, Hefei, Anhui, China
| | - Xu Chen
- Department of Anesthesiology, First Affiliated Hospital of the University of Science and Technology of China, Anhui Provincial Hospital, 17 Lujiang Road, Hefei, 230000, Anhui, China
| | - Xuebing Zhang
- Department of Anesthesiology, First Affiliated Hospital of the University of Science and Technology of China, Anhui Provincial Hospital, 17 Lujiang Road, Hefei, 230000, Anhui, China
| | - Min Xia
- Department of Anesthesiology, First Affiliated Hospital of the University of Science and Technology of China, Anhui Provincial Hospital, 17 Lujiang Road, Hefei, 230000, Anhui, China
| | - Xiaoqing Chai
- Department of Anesthesiology, First Affiliated Hospital of the University of Science and Technology of China, Anhui Provincial Hospital, 17 Lujiang Road, Hefei, 230000, Anhui, China
| | - Sheng Wang
- Department of Anesthesiology, First Affiliated Hospital of the University of Science and Technology of China, Anhui Provincial Hospital, 17 Lujiang Road, Hefei, 230000, Anhui, China
| | - Wei Zhang
- Department of Anesthesiology, First Affiliated Hospital of the University of Science and Technology of China, Anhui Provincial Hospital, 17 Lujiang Road, Hefei, 230000, Anhui, China.
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