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Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia

A single-center analysis of 102,305 cases

Abstract

Background

Hypoxemia caused by difficulties in airway management presents a major cause for perioperative morbidity and mortality. The ability to predict difficult laryngoscopy more accurately would enable anesthesiologists to take specific precautions to reduce airway risks and prevent patient-threatening events.

Methods

Over a 6-year period of time, all anesthesia records with a documented direct laryngoscopic view were retrieved from the electronic data management system and statistically processed. The Cormack–Lehane four-point scale of grading laryngoscopy was used to assess visibility of the vocal cords.

Results

Of 102,306 cases, the overall rate of difficult laryngoscopy was 4.9 %. Male gender (6.5 %), Mallampati score III and IV (17.3 %), obesity with a BMI ≥35 kg/m2 (6.1 %), as well as physical status ASA III or IV (6.2 %), were identified as risk factors for difficult laryngoscopy. Patients undergoing surgery in the departments of oromaxillofacial (8.9 %), ear nose throat surgery (ENT) (7.4 %), and cardiac surgery (7.0 %) showed the highest rates of difficult laryngoscopy.

Conclusions

The results indicate that the risk for difficult airway situations might substantially differ between surgical patient groups. In hospitals with departmental structures and spatially separated operating rooms, the deduction might be increased awareness and particular structural preparation for difficult airway situations in the respective subspecialties.

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References

  1. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33–9.

    PubMed  Article  Google Scholar 

  2. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98(5):1269–77.

  3. Airway management. Guidelines of the German Society of Anesthesiology and Intensive Care Medicine. Anesth Intensivmed 2004;45:302–6.

    Google Scholar 

  4. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anesthesia. 2004;59(7):675–94.

    CAS  Article  Google Scholar 

  5. Barron FA, Ball DR, Jefferson P, Norrie J. ‘Airway Alerts.’ How UK anesthetists organise, document and communicate difficult airway management. Anaesthesia. 2003;58(1):73–7.

    CAS  PubMed  Article  Google Scholar 

  6. Stringer KR, Bajenov S, Yentis SM. Training in airway management. Anaesthesia. 2002;57(10):967–83.

    CAS  PubMed  Article  Google Scholar 

  7. Deller A. Incidence and predictability of difficult intubation. Anaesthesiol Intensivmed Notfallmed Schmerzther. 1995;30(3):169–71.

    CAS  Article  Google Scholar 

  8. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anesth Soc J. 1985;32(4):429–34.

    CAS  Article  Google Scholar 

  9. Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anesth. 1994;41(5 pt 1):372–83.

    CAS  PubMed  Article  Google Scholar 

  10. Safavi M, Honarmand A, Zare N. A comparison of the ratio of patient’s height to thyromental distance with the modified Mallampati and the upper lip bite test in predicting difficult laryngoscopy. Saudi J Anesth. 2011;5(3):258–63.

    Article  Google Scholar 

  11. Lundstrom LH, Vester-Andersen M, Moller AM, Charuluxananan S, L’Hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. Br J Anaesth. 2011;107(5):659–67.

    CAS  PubMed  Article  Google Scholar 

  12. Lundstrom LH, Moller AM, Rosenstock C, Astrup G, Wetterslev J. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology. 2009;110(2):266–74.

    PubMed  Google Scholar 

  13. Heinrich S, Horbach T, Salleck D, Birkholz T, Irouschek A, Schmidt J. Perioperative anesthesiological management in 167 patients undergoing bariatric surgery. Zentralbl Chir. 2011;136(6):604–11.

    Google Scholar 

  14. Cormack RS. Cormack–Lehane classification revisited. Br J Anesth. 2010;105(6):867–8.

    CAS  Article  Google Scholar 

  15. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103(2):429–37.

    PubMed  Article  Google Scholar 

  16. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987;42(5):487–90.

    CAS  PubMed  Article  Google Scholar 

  17. Lee A, Fan LT, Gin T, Karmakar MK. A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesth Analg. 2006;102(6):1867–78.

    PubMed  Article  Google Scholar 

  18. Adamus M, Fritscherova S, Hrabalek L, Gabrhelik T, Zapletalova J, Janout V. Mallampati test as a predictor of laryngoscopic view. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2010;154(4):339–43.

    PubMed  Article  Google Scholar 

  19. Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope. Anesth Analg. 2008;106(5):1495–500.

    Google Scholar 

  20. Schmitt HJ, Kirmse M, Radespiel-Troger M. Ratio of patient’s height to thyromental distance improves prediction of difficult laryngoscopy. Anesth Intensive Care. 2002;30(6):763–5.

    CAS  Google Scholar 

  21. Butler PJ, Dhara SS. Prediction of difficult laryngoscopy: an assessment of the thyromental distance and Mallampati predictive tests. Anesth Intensive Care. 1992;20(2):139–42.

    CAS  Google Scholar 

  22. Jin Huh H-YS, Kim S-H, Yoon T-K, Kim D-K. Diagnostic predictor of difficult laryngoscopy: the hyomental distance ratio. Anesth Analg. 2009;108:544–8.

    PubMed  Article  Google Scholar 

  23. Naguib M, Scamman FL, O’Sullivan C, Aker J, Ross AF, Kosmach S, Ensor JE. Predictive performance of three multivariate difficult tracheal intubation models: a double-blind, case-controlled study. Anesth Analg. 2006;102(3):818–24.

    PubMed  Article  Google Scholar 

  24. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009;110(4):891–7.

    PubMed  Article  Google Scholar 

  25. Lundstrom LH, Moller AM, Rosenstock C, Astrup G, Gatke MR, Wetterslev J. Avoidance of neuromuscular blocking agents may increase the risk of difficult tracheal intubation: a cohort study of 103,812 consecutive adult patients recorded in the Danish Anesthesia Database. Br J Anesth. 2009;103(2):283–90.

    CAS  Article  Google Scholar 

  26. Goodwin MW, Pandit JJ, Hames K, Popat M, Yentis SM. The effect of neuromuscular blockade on the efficiency of mask ventilation of the lungs. Anesthesia. 2003;58(1):60–3.

    CAS  Article  Google Scholar 

  27. Heinrich S, Birkholz T, Ihmsen H, Irouschek A, Ackermann A, Schmidt J. Incidence and predictors of difficult laryngoscopy in 11,219 pediatric anesthesia procedures. Paediatr Anesth. 2012;22(8):729–36.

    Google Scholar 

  28. Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, Desmonts JM. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97(2):595–600.

    Google Scholar 

  29. Ezri T, Medalion B, Weisenberg M, Szmuk P, Warters RD, Charuzi I. Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anesth. 2003;50(2):179–83.

    PubMed  Article  Google Scholar 

  30. Ezri T, Weisenberg M, Khazin V, Zabeeda D, Sasson L, Shachner A, Medalion B. Difficult laryngoscopy: incidence and predictors in patients undergoing coronary artery bypass surgery versus general surgery patients. J Cardiothorac Vasc Anesth. 2003;17(3):321–4.

    PubMed  Article  Google Scholar 

  31. Arsenijevic S, Pantovic V, Gledovic Z, Stojanovic J, Belic B. Demographic characteristics of patients with laryngeal cancer and their socioeconomic status. J BUON. 2010;15(1):131–35.

    Google Scholar 

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No external funding and no competing interests are declared.

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Correspondence to S. Heinrich.

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Heinrich, S., Birkholz, T., Irouschek, A. et al. Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia. J Anesth 27, 815–821 (2013). https://doi.org/10.1007/s00540-013-1650-4

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  • DOI: https://doi.org/10.1007/s00540-013-1650-4

Keywords

  • Difficult airway
  • Poor laryngoscopic view
  • Airway management