Skip to main content
Log in

Difficult Tracheal Intubation in Obese Gastric Bypass patients

Obesity Surgery Aims and scope Submit manuscript



Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation.


This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients undergoing gastric bypass. Tracheal intubation was done preoperatively together with scoring of Intubation Score (IS), Mallampati (MLP), and Cormack-Lehane classification (CLC) and registration of the quantities of anesthetics and total attempts on cannulation.


The overall proportion of patients with DTI was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass index (BMI) <40, CLC >2, ASA scores >2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra-venous and intra-arterial cannulation was succeeded in first attempt in 85 and 86 % of the patients, respectively, and there were no association between BMI and difficult vascular access.


We found no association between increasing BMI and DTI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2


  1. American Society of Anesthesiologists. Practice guidelines for management of the difficult airway. Anesthesiology. 2013;118:251–70.

    Article  Google Scholar 

  2. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429–34.

    Article  CAS  PubMed  Google Scholar 

  3. Shiga T, Wajima Z, Inoue T, et al. Predicting difficult intubation in apparently normal patients. Anesthesiology. 2005;103:429–37.

    Article  PubMed  Google Scholar 

  4. El-ganzouri AR, Mccarthy RJ, Tanck EN, et al. Preoperative multivariate airway assessment: risk index predictive value of a multivariate risk index. Anesth Analg. 1996;82:1197–204.

    CAS  PubMed  Google Scholar 

  5. Schwab RJ, Gupta KB, Gefter WB, et al. Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls. Am J Respir Crit Care Med. 1995;152:1673–89.

    Article  CAS  PubMed  Google Scholar 

  6. Lohser J, Kulkarni V, Brodsky JB. Anesthesia for thoracic surgery in morbidly obese patients. Curr Opin Anaesthesiol. 2007;20:10–4.

    Article  PubMed  Google Scholar 

  7. Lundstrøm LH, Møller AM, Rosenstock C, et al. High body mass index is a weak predictor for difficult and failed tracheal intubation. Anesthesiology. 2009;110:266–74.

    PubMed  Google Scholar 

  8. Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600.

    Article  PubMed  Google Scholar 

  9. Aceto P, Perilli V, Modesti C, et al. Airway management in obese patients. Surg Obes Relat Dis. 2013;9:809–15.

    Article  PubMed  Google Scholar 

  10. Brodsky JB, Lemmens HJM, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732–6.

    Article  PubMed  Google Scholar 

  11. Karkouti K, Rose DK, Wigglesworth D, et al. Reports of investigation predicting difficult intubation: a multivariable analysis. Can J Anesth. 2000;47:730–9.

    Article  CAS  PubMed  Google Scholar 

  12. Adnet F, Borron S, Racine S, et al. The intubation difficulty scale (IDS). Am Soc Anesthesiol. 1997;87:1290–7.

    Article  CAS  Google Scholar 

  13. Ezri T, Medalion B, Weisenberg B, et al. Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anesth. 2003;50:179–83.

    Article  PubMed  Google Scholar 

  14. Heinrich S, Birkholz T, Irouschek A, et al. Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia: a single-center analysis of 102,305 cases. J Anesth. 2013;27:815–21.

    Article  CAS  PubMed  Google Scholar 

  15. Neligan PJ, Porter S, Max B, et al. Obstructive sleep apnea is not a risk factor for difficult intubation in morbidly obese patients. Anesth Analg. 2009;109:1182–6.

    Article  PubMed  Google Scholar 

  16. Kim WH, Ahn HJ, Lee CJ, et al. Neck circumference to thyromental distance ratio: a new predictor of difficult intubation in obese patients. Br J Anaesth. 2011;106:743–8.

    Article  CAS  PubMed  Google Scholar 

  17. Lavi R, Segal D, Ziser A. Predicting difficult airways using the intubation difficulty scale: a study comparing obese and non-obese patients. J Clin Anesth. 2009;21:264–7.

    Article  PubMed  Google Scholar 

  18. Sommer T, Larsen JF, Raundahl U. Eliminating learning curve-related morbidity in fast track laparoscopic Roux-en-Y gastric bypass. J Laparoendosc Adv Surg Tech A. 2011;21:307–12.

    Article  PubMed  Google Scholar 

  19. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39:1105–11.

    Article  CAS  PubMed  Google Scholar 

  20. Wilson ME, Spiegelhalter D, Robertson JA, et al. Predicting difficult intubation. Br J Anaesth. 1988;61:211–6.

    Article  CAS  PubMed  Google Scholar 

  21. Myatt J, Haire K. Airway management in obese patients. Curr Anaesth Crit Care. 2010;21:9–15.

    Article  Google Scholar 

  22. Juvin P, Blarel A, Bruno F, et al. Is peripheral line placement more difficult in obese than in lean patients? Anesth Analg. 2003;96:1218.

    Article  PubMed  Google Scholar 

  23. Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med. 2006;13:1275–9.

    Article  PubMed  Google Scholar 

  24. Dargin JM, Emlet LL, Guyette FX. The effect of body mass index on intubation success rates and complications during emergency airway management. Intern Emerg Med. 2013;8:75–82.

    Article  PubMed  Google Scholar 

  25. Gonzalez H, Minville V, Delanoue K, et al. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008;106:1132–6.

    Article  PubMed  Google Scholar 

  26. Kristensen MS. Airway management and morbid obesity. Eur J Anaesthesiol. 2010;27:923–7.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Niclas Dohrn.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

For this type of study, formal consent is not required. Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dohrn, N., Sommer, T., Bisgaard, J. et al. Difficult Tracheal Intubation in Obese Gastric Bypass patients. OBES SURG 26, 2640–2647 (2016).

Download citation

  • Published:

  • Issue Date:

  • DOI: