Prediction Of Difficult Intubation Research Articles

Quantitative Compliance Based Classification of Submental Sign or Javid Sign

Prediction of difficult intubation is still a dilemma. Despite various predictors of difficult airway reported and discussed in the literature, no definite test exists to prevent mortality and morbidity related to difficult airway. Using a combination of different predictors of difficult intubation is logical to help minimizing this difficulty and establishing a safe anesthesia. Detection and presentation of any novel predictor can be helpful in achieving this goal. “Submental Sign” or “Javid Sign” a new predictor of difficult intubation, was reported by MJ Javid in 2011, but qualitative characteristic of this predictor was the most considerable drawback for using Submental Sign as an accurate predictor. The goal of this study is quantitative classification of Submental Sign or Javid classification to overcome false positive and false negative results of Submental Sign. In this article a novel scale is introduced for evaluating submental compressibility quantitatively.

Predictors of paediatric difficult intubation according to the experience of a university hospital in a low- and middle-income country: A prospective observational study.

Difficult airway management is one of the main challenges in paediatric anaesthesia, particularly in low- and middle-income countries. The aim of this study was to investigate the main predictors of difficult paediatric intubation. In this observational study, we included all children aged less than five years undergoing intra-abdominal surgery with endotracheal intubation. Patients were divided into two groups according to the incidence of difficult intubation. Then, we investigated predictors for difficult paediatric intubation. We included 217 children, and difficult intubation was observed in 10% of them. Predictors were as follows: Mallampati III-IV class (adjusted odds ratio = 2.21; 95% confidence interval = 1.1-6.4), limited mouth opening (adjusted odds ratio = 2.4; 95% confidence interval = 1.8-3.5), facial dysmorphia (adjusted odds ratio = 2.6; 95% confidence interval = 1.32-7.4) and anaesthesia without muscle relaxant (adjusted odds ratio = 1.8; 95% confidence interval = 1.0-5.1) or without opioids during crash inductions (adjusted odds ratio = 1.7; 95% confidence interval = 1.01-4.8). Facial dysmorphia and limited mouth opening were predictors of difficult intubation in children. Furthermore, it seems that Mallampati class and anaesthesia technique may also predict challenging intubation, which may guide us to change our perioperative practice.

Difficult Airway Prediction in Infants with Apparently Normal Face and Neck Features.

Background/Objectives: Prediction of a difficult airway during pre-anesthetic evaluation is of great importance because it enables an adequate anesthetic approach and airway management. As there is a scarcity of prospective studies evaluating the role of anthropometric measures of the face and neck in predicting difficult airways in infants with an apparently normal airway, we aimed to identify the aforementioned predictors of difficult facemask ventilation and intubation in infants. Methods: A prospective, observational study that included 97 infants requiring general endotracheal anesthesia was conducted. Anthropometric and specific facial measurements were obtained before ventilation and intubation. Results: The incidence of difficult facemask ventilation was 15.5% and 38.1% for difficult intubation. SMD (sternomental distance), TMA (tragus-to-mouth angle distance), NL (neck length) and mouth opening were significantly lower in the difficult facemask ventilation group. HMDn (hyomental distance in neutral head position), HMDe (hyomental distance in neck extension), TMD (thyromental distance), SMD, mandibular development and mouth opening were significantly different in the intubation difficulty group compared to the non-difficult group. HMDn and HMDe showed significantly greater specificities for difficult intubation (83.8% and 76.7%, respectively), while higher sensitivities were observed in TMD, SMD and RHSMD (ratio of height to SMD) (89.2%, 75.7%, and 70.3%, respectively). Regarding difficult facemask ventilation, TMA showed greater sensitivity (86.7%) and SMD showed greater specificity (80%) compared to other anthropometric parameters. In a multivariate model, BMI (body mass index), COPUR (Colorado Pediatric Airway Score), BOV (best oropharyngeal view) and TMA were found to be independent predictors of difficult intubation, while BMI, ASA (The American Society Physical Status Classification System), CL (Cormack-Lehane Score), TMA and SMD predicted difficult facemask ventilation. Conclusions: Preoperative airway assessment is of great importance for ventilation and intubation. Patient's overall condition and facial measurements can be used as predictors of difficult intubation and ventilation.

Comparison of the Thyromental Distance, Thyrohyoid Distance, and Mallampati Scores in Prediction of Difficult Intubation in Patients Undergoing General Anaesthesia: An Observational Study

Abstract Background: Several studies have been conducted to assess the accuracy of predictors of difficult intubation, but the results are still very variable. This study aims to discover the incidence of difficult intubation in our cohort. We also compared the accuracy of the Mallampati score, thyromental distance, and thyrohyoid distance in predicting intubation difficulties in patients who will undergo surgery under general anesthesia. Materials and Methods: This prospective, observational study was conducted on 100 subjects who met the inclusion and exclusion criteria and had their Mallampati score, thyromental distance, and thyrohyoid distance measured preoperatively. After inducing anesthesia, the degree of difficulty in intubation was assessed using the Cormack-Lehane grading. The Mallampati score, thyromental distance, and thyrohyoid distance were then tested for accuracy as predictors of the occurrence of difficult intubation using the binomial logistic regression. Results: The incidence of difficult intubation was 21%. We found a significant difference (P < 0.001) between the Mallampati score and the degree of intubation difficulty, where subjects with a Mallampati score of 1–2 experienced fewer intubation difficulties. The mean thyromental distance differed significantly between subjects with and without difficulty intubating (6.3 ± 0.6 vs. 4.6 ± 0.6 cm, P < 0.001). There was also a significant difference in the mean thyrohyoid distance between subjects with and without difficulty intubating (3.6 ± 0.4 vs. 2.0 ± 0.2, P < 0.001). Conclusion: Mallampati score, thyromental distance, and thyrohyoid distance were not significant as single predictors of difficult intubation, but they were significant when combined.

Hip to Neck Circumference Ratio as an Independent Predictor of Difficult Intubation in Obese Patients

Background: Anaesthesiologists face difficult intubation (DI) more frequently in obese patients. Thus, we aimed to test if central obesity indices including hip circumference (HC), neck circumference (NC) or waist circumference (WC) can effectively predict DI and difficult mask ventilation (DMV) in them. Methods: HC, NC, WC, mask ventilation grade, intubation difficulty scale (IDS), history of snoring and obstructive sleep apnoea (OSA) were measured in 300 patients with BMI ≥ 30 kg/m2. Receiver operating characteristic curve (ROC) and multivariate, logistic regression were employed to identify predictors of DI (IDS ≥5) and DMV define as mask ventilation grade of 3 or 4. Results: DI and DMV were, respectively, detected in 14.7% and 12.7% of subjects. According to Multiple logistic regression analysis BMI (Odds ratio (OR):1.17, 95% confidence interval (CI): 1.08-1.28, p<0.001), NC (OR: 1.26, 95% CI: 1.04-1.52, p=0.01), HC (OR:1.06, 95% CI: 1.03-1.10) and HC/NC ratio (OR: 4.9, 95% CI: 1.64-14.92, p= 0.004) considered as independent predictors of DI. The same analysis recognized BMI (OR:1.13, 95% CI: 1.03-1.24, p=0.006), WC (OR: 1.06, 95% CI:1.01-1.11, p=0.01), and HC/BMI ratio (OR=0.18, 95% CI:0.06-0.53, p=0.002) as DMV predictors. Sensitivity of BMI >35.8 kg/m2, NC >39.9 centimetres (cm), HC>118cm and HC/NC ratio >2.9 were determined as 70.5%, 68.2%, and 69.3% respectively for prediction of DI. Sensitivity of BMI >36.6 kg/m2 and WC >118 cm for predicting DMV were identified as 71.0% and 73.6%. Conclusion: This study proposes to simultaneously consider the HC/NC ratio and WC as a predictor of difficult airway in the obese.

Comparison Of Outcome Between Conventional And Video Laryngoscope In Predicted Difficult Intubation

Background: Endotracheal intubation is the mainstay of airway management in general anaesthesia. Failure to intubate the trachea, often known as difficult intubation, is always a possibility. To overcome difficult intubation, different methods of instrumental support were developed. Some authors. Methods: From March 2018 to September 2019, a comparative cross-sectional study was conducted at BSMMU, Dhaka in the department of anesthesia, analgesia, and intensive care medicine. A total of 60 patients with predicted difficult intubation who were scheduled for elective surgery under general anaesthesia with endotracheal intubation were selected for the study. Prediction of difficult intubation was assessed by modified Mallampati class III and IV or thyromental height. Results: Time taken from visualization of glottis for insertion of ETT was 12.8±2.3 sec in conventional laryngoscope which was significantly lower in video laryngoscope (15.0±3.6) (p =0.006). Time taken to visualize the glottis was 13.2±1.7 sec in conventional laryngoscope and 13.2±4.0 sec in video laryngoscope (p>0.05). Total time for tracheal intubation was 49.0±6.4 sec in conventional laryngoscope and 53.2±9.9 sec in video laryngoscope (p>0.05). Intubation with first attempt by video laryngoscope was (30/30; 100%) as compared with conventional laryngoscope (27/30; 90%) (p>0.05). Conclusion: It is evident from the study that intubation with video laryngoscope in comparison to conventional laryngoscope might provide better outcome in terms of ease of intubation and number of attempts during intubation for patients undergoing elective surgery under general anaesthesia. Bangladesh Armed Forces Med J Vol 56 No (1) June 2023, pp 7-13

Modified Mallampati Test in Supine versus Sitting Position as a Predictor for Difficult Intubation – An Observational Study

Abstract Background: The modified Mallampati test (MMT) is routinely employed to predict difficult laryngoscopy and tracheal intubation. This test, as a standard, when conducted with a patient in a sitting position, exhibits limited practicality due to its relatively low sensitivity and specificity in predicting difficult tracheal intubation (DTI). It is hypothesised that MMT, when performed with a patient lying supine, may improve its efficacy as a predictor of DTI. Methods: This single-centre prospective observational study was conducted involving 455 adult patients requiring general endotracheal anaesthesia. During preanaesthetic evaluation, MMT was performed in the sitting position as a standard (sitting MMT). Subsequently, independent observers recorded the MMT in the supine position (supine MMT) before administering general anaesthesia. The sitting and supine MMT were correlated with Cormack and Lehane grades using the Chi-square test. Diagnostic performance metrics, including the area under the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive predictive values (PPV) and negative predictive values, were employed to assess the predictive capabilities of MMT in both positions. Results: Out of 455 patients, 72 (15.8%) experienced difficult intubation (defined as Cormack–Lehane Grade III and above). Both MMT in the sitting and supine positions demonstrated strong predictive capabilities for DTI, with areas under the ROC of 0.799 and 0.779, respectively. While sitting in the MMT position exhibited higher sensitivity (55.6% vs. 28.8%), supine MMT demonstrated a superior PPV (86.1% vs. 55.6%). Conclusion: MMT, when conducted with a patient in a supine position emerges as an alternative and a reliable predictor for predicting DTI.

Comparison of Modified Mallampati Classification in Supine and Sitting Positions to Predict Difficult Tracheal Intubation in Diabetic Patients.

Airway management of patients with long-standing diabetes poses a major challenge for anaesthesiologists due to stiff joint syndrome affecting the atlanto-occipital joint. In certain cases requiring immobilization, the Mallampati test must often be performed in the supine position for obvious reasons. Hence, we determined the diagnostic precision (sensitivity and specificity) of the modified Mallampati test in sitting and supine positions among the diabetic population in predicting difficult tracheal intubation. A single-center prospective observational study on adult diabetic patients undergoing general anesthesia and orotracheal intubation was carried out. An observer recorded the modified Mallampati in the sitting posture during the pre-anesthetic examination. The Mallampati in the supine position was determined while in the operating room, and the difficulty of intubation was noted, and diagnostic precision was calculated. The main objective was to predict a difficult airway by calculating the sensitivity, specificity, positive predictive value, and negative predictive value. Out of the 150 participants, Mallampati grading in a sitting position was correctly able to identify 42.5% of difficult intubation cases, whereas it was 97.5% with Mallampati in the supine position. Mallampati grading in the sitting position was able to correctly identify 89.1% of easy intubation cases, which was 63.6% with Mallampati in the supine position. The correlation of Mallampati in the supine position with CL grading was statistically significant (P < 0.001). Among diabetic patients, the modified Mallampati test in the supine position can be considered a more accurate and sensitive predictor of difficult intubation than the sitting posture.

The Importance of Evaluation of Neck Circumference to Thyromental Distance Ratio as a Predictor of Difficult Intubation

Background: Pre-operative airway assessment for predicting difficult intubation is of utmost importance for anaesthesiologists to ensure adequate oxygenation and ventilation which is a priority.&#x0D; Aims &amp; Objectives: To evaluate the effectiveness of neck circumference (NC) to thyromental distance (TMD) ratio (NC/TMD) as a predictor of difficult intubation and its correlation with established predictors namely Mallampatti grading (MPC grading), Modified Cormack Lehane’s Score (MCLS grading).&#x0D; Methods: 140 patients of age between 18 to 60 years with ASA I, II were selected. Pre-operative, MPC grading and NC to TMD ratio was measured. Intra-operatively, MCLS grading, time taken for intubation, number of attempts taken for intubation, any additional use of equipment required and grading ease of intubation were noted. Correlation was done between them.&#x0D; Results: Out of 140 patients, NC/TMD ratio of &gt;5 was found in 20 patients in which 19 patients required an adjuvant during intubation. NC/TMD ratio had significantly higher sensitivity (75.20) and specificity (99.02) as compared to sensitivity (56.31) and specificity (92.38) of MPC grading. ROC curve for NC/TMD ratio had higher area under curve (AUC = 0.74) than Mallampatti grading (AUC = 0.66).&#x0D; Conclusion: As compared to MPC grading, NC/TMD has emerged out as a better predictor of difficult intubation.

Difficult Airway in a Patient with Well-Differentiated Epidermoid Carcinoma: A Case Report

Introduction: Cutaneous epidermoid carcinoma (SCC) is a common skin tumor that can arise from precursor lesions or de novo. It is the second leading cause of death from skin cancer and its incidence is expected to double by 2030. Risk factors include gender, ionizing radiation, alcohol and tobacco use, and HPV infection. SCC can be classified into five types according to the Peniche classification, with the ulcerative form being the most frequent. Anesthesia management for head and neck cancers is challenging due to airway complications. Case presentation: An 82-year-old female with a history of biomass combustion smoke exposure and hypertension presented with a painful papular lesion on the left nasal wing. Biopsy revealed well-differentiated epidermoid cancer. Despite treatment, the lesion progressed rapidly, leading to a request for surgical resection. The patient had predictors of difficult intubation and ventilation, and initial intubation attempts were unsuccessful. After aspiration of secretions and intracavitary bleeding, successful intubation was achieved on the second attempt. Controlled ventilation was initiated with specific settings. Clinical discussion: A difficult airway can pose challenges for anesthesiologists, especially in patients with head and neck cancer. Pre-anesthetic evaluation and preparation for rescue devices or maneuvers are crucial. In this case, the patient had a difficult Intubation Prediction Index. General anesthesia allowed for invasive monitoring, venous access, and reliable mechanical ventilation. Direct laryngoscopy was performed due to retro nasal bleeding, with equipment available for difficult airway management and aspiration. Conclusion: Anesthetic management for patients with head cancer presents challenges in airway management and carries the risk of complications. Pre-anesthetic and airway assessment are crucial to prevent complications and ensure successful intubation.

Incidence and Predictors of Difficult Intubation in Patients Undergoing Thyroid Surgery

Introduction: Thyroid enlargement is considered a risk factor for challenging direct laryngoscopy and intubation. Airway management in patients with thyroid swelling presents unique challenges, requiring thorough preparation for potential difficult airways. Although airway management in the overall population has been thoroughly researched, there is a scarcity of literature specifically addressing airway management in individuals who have thyroid enlargement. Aim: To evaluate the incidence of difficult intubation in patients undergoing thyroid surgery, utilising the Intubation Difficulty Score (IDS). Materials and Methods: This cross-sectional observational study was conducted among 258 patients in the Department of Anaesthesiology, Government TD Medical College, Alappuzha, Kerala, India. Various parameters including Modified Mallampati score, neck circumference, Body Mass Index (BMI), inter-incisor distance, retrognathia, neck extension, thyromental distance, tracheal deviation, and tracheal compression were assessed for all patients with thyroid swelling. The incidence of difficult endotracheal intubation was analysed using the IDS and the time taken for successful intubation was recorded. Data were presented as mean±standard deviation (SD), frequencies, and percentages. The association between variables was analysed using the Chi-square test. Results: Thyroid disorders were more common in females 220 (85.3%) than in males 38 (14.7%). The variables such as BMI, Mallampati score, thyromental distance, inter-incisor distance, and neck mobility were not found to be associated with difficult intubation. However, increased neck circumference (&gt;43 cm) was statistically significant (p-value=0.007) in relation to difficult intubation. According to IDS, 94.2% of patients had easy intubation, while 5.8% experienced difficult intubation. In terms of intubation times, 72.5% of patients were intubated within 10-15 seconds, 24.4% within 16-20 seconds, and 3.1% took longer than 20 seconds. Conclusion: Thyroid surgery itself is not an independent predictive factor for difficult intubation. Among the predictive factors in the study population, a neck circumference greater than 43 cm was found to be associated with difficult endotracheal intubation during thyroid surgery

Comparison of Neck Extension versus Ultrasound Guided Distance Measured From Skin to Epiglottis (DSE) As Sole Predictors of Difficult Intubation

Objective: The objective of this study is to compare the conventional measurement of neck extension versus ultrasound guided distance measured from skin to epiglottis (DSE) as sole predictors in determining difficult airway and laryngoscopy. Study Design &amp; Setting: Prospective observational study. Anesthesia department of Combined Military Hospital, Rwp from Jan-Jun 2023. Methodology: All the patients included in the study were divided into two groups, Group N (n=75) undergoing neck extension as sole predictor and Group E (n=75) using DSE by USG as a sole predictor for difficulty airway. Primary variables measured were the sensitivity, specificity, positive and negative predicted values for neck extension and ultrasound guided DSE when compared with the outcome of the gold standard Cormack Lehane classification at intubation. Results: Comparison of sensitivity and specificity of both parameters in diagnosing difficult airway showed a sensitivity of 76.9% in Group N (neck extension) versus 88.4% in Group E (DSE). Specificity showed 69.4% in Group N versus 87.5% in Group E. Neck extension had a positive predictive value of 73.2% whereas DSE was superior with a positive predictive value of 90.5%. The negative predictive value was also considerably less with neck extension as the sole perimeter with 73.5% versus 84.8% when DSE was used. Conclusion: We conclude that the ultrasound guided distance measured from skin to epiglottis is superior to conventional neck extension when used as sole agents to diagnose difficult airway in suspected patients.

Evaluation of Thyromental Height Test for Predicting Difficult Laryngoscopy in Morbid Obese Patients Candidate for Bariatric Surgery: An Observational Study

Upper airway management in morbid obese patients undergoing bariatric surgery is a major challenge during induction of anesthesia. Bed side Thyromental Height Test (TMHT) is an easy and valid predictor for prediction of difficult airway in non‑obese patients, but its precision in morbid obese patients haven’t been evaluated yet. The purpose of present study is to find the accuracy of TMHT for the prediction of difficult laryngoscopy in morbid obese patients undergoing bariatric surgery. The present prospective observational study was performed on 95 morbid obese patients at Sina hospital during 2020. Preoperative exams of patients include the assessment of Mallampati classification, thyromental height, thyromental, sternomental and interincisor distances. After induction of anesthesia, the laryngoscopy view was evaluated using the Cormack Lehane classification, and the relationship between these tests to prediction of difficult laryngoscopy view based on the Cormack Lehane degrees (grades 3,4) were evaluated. A total of 95 morbid obese patients with a mean BMI of 44.7±5.6 kg/m2.were included in the study. 67.3% of them were women. The incidence of difficult laryngoscopy (C &amp; L III, IV) was 16.8%. TMHT less than 56.5 mm, with 98% positive predictive value and 93% accuracy was the best predictor of difficult intubation in these patients. The accuracy of thyromental, sternomental and interincisor distance, with cut off value less than 51.5 mm, 89.5 mm, 41.5 mm respectively was less than TMHT in prediction of difficult laryngoscopy in morbid obese patients. In morbid obese patients with a BMI greater than 40, thyromental height less than 56.5 mm with 98% positive predictive value and 93% accuracy is the best predictor for difficult laryngoscopy view.

Anesthesia Management in Morbidly Obese Patient Undergoing Neurosurgical Procedure: A Case Report

Background: Anesthesia management in morbidly obese patients undergoing any neurosurgical procedure is particularly challenging. This case report aims to further discuss the importances and concerns regarding the anesthesia management of decompression craniectomy in morbidly obese patients.&#x0D; Case presentation: A 46-years-old male patient was diagnosed with intracerebral hemorrhage on regio left external capsule due to hypertensive emergency suspected from Middle Cerebral Artery (MCA) aneurysma rupture. Decompression craniectomy with clot evacuation was planned. This patient has morbid obesity. Prediction of difficult intubation and mask ventilation can be assessed using LEMONS, MOANS, Mallampati score and STOP-Bang Questionnaire. The dosage of anesthetic agents used in these patients had been adjusted according to current recommendations. Intraoperatively, patient’s hemodynamic was successfully maintained stable. Postoperatively, patient was closely monitored in the intensive care unit. &#x0D; Conclusion: It is imperative to acquire adequate knowledge on choosing the effective anesthetic management during the preoperative, intraoperative, and postoperative periods to achieve good outcome in morbidly obese patient undergoing neurosurgical procedures.

Difficult intubation predictors in obstructive sleep apnea patient

Difficult intubation predictors in obstructive sleep apnea patient

The Value of Ultrasound in the Assessment – Prediction of Difficult Intubation

Recently, the value of ultrasound has been recognized as a promising non-invasive method of predicting the difficult airway.

Comparison of Upper Lip Bite Test and Modified Mallampati Classification as Predictor of Difficult Intubation in Patients for Surgery under General Anaesthesia

Comparison of Upper Lip Bite Test and Modified Mallampati Classification as Predictor of Difficult Intubation in Patients for Surgery under General Anaesthesia

Prediction of difficult laryngoscopy / difficult intubation cases using upper airway ultrasound measurements in emergency department: a prospective observational study

IntroductionDifficult laryngoscopy and intubation are serious problems among critically ill patients in emergency department (ED) so utility of a rapid, accurate and noninvasive method for predicting of these patients are necessary. Ultrasonography has been recently used in this regard and this study was conducted to investigate the correlation of some introduced upper airway ultrasound parameters with difficult laryngoscopy / difficult intubation in patients referred to the ED.MethodIn this prospective observational study all patients ≥ 18-year-old who had an indication for rapid sequence intubation (RSI) were included. Ultrasound parameters including Hyoid Bone Visibility (HBV), Distance from Skin to Hyoid Bone (DSHB), Distance from Skin to Vocal Cords (DSVC), Distance from Skin to Thyroid Isthmus (DSTI), and Distance between Arytenoids Cartilages (DBAC) were measured in all cases. The patients underwent RSI and thereafter the patients’ baseline characteristics, Cormack-Lehane grade, number of attempted laryngoscopy were recorded in a pre-prepared check list and compared with measured ultrasound parameters. The “difficult laryngoscopy” was defined as Cormack-Lehane classification grades III/IV; and need for more than 3 intubation attempts was considered as “difficult intubation”.ResultsOne hundred and twenty-three patients (52% male) were included of whom 10 patients (8.1%) were categorized as difficult laryngoscopy cases; and just 4 (3.3%) cases underwent more than 3 laryngoscopy attempts who considered as difficult intubation cases. The mean age of the patients in non-difficult and difficult intubation groups were 69.2 ± 15.16 and 68.77 ± 17.37 years, respectively (p > 0.05). There was no significant relationship between difficult laryngoscopy and HBV (p = 0.381) but has significant correlation with difficult intubation (p = 0.004). The DSHB had a significant correlation with difficult laryngoscopy (p = 0.002) but its correlation with difficult intubation was not significant (p = 0.629). The DSVC and DSTI had a significant relationship with both difficult laryngoscopy (p = 0.003 and p = 0.001), and difficult intubation (p = 0.025 and p = 0.001). The DBAC had not significant correlation neither with the difficult laryngoscopy (p = 0.142), nor with difficult intubation (p = 0.526).ConclusionThe findings showed that ultrasound parameters including soft tissue DSHB, DSVC and DSTI could be proper predictors of difficult laryngoscopy. Also, HBV, DSVC and DSTI may be proper predictors for difficult intubation. But DBAC was not useful in this regard.

Airway Management of Orofacial Infections Originating in the Mandible.

The primary aim of this study was to assess the incidence of a difficult airway and emergency tracheostomy in patients with orofacial infections originating in the mandible, and a secondary aim was to determine the potential predictors of difficult intubation. This retrospective single-center study included all patients who were referred between 2015 and 2022 with an orofacial infection originating in the mandible and who were surgically drained under intubation anesthesia. The incidence of a difficult airway regarding ventilation, laryngoscopy, and intubation was analyzed descriptively. Associations between potential influencing factors and difficult intubation were examined via multivariable analysis. A total of 361 patients (mean age: 47.7 years) were included in the analysis. A difficult airway was present in 121/361 (33.5%) patients. Difficult intubation was most common in patients with infections of the massetericomandibular space (42.6%), followed by infections of the mouth floor (40%) and pterygomandibular space (23.5%). Dyspnea and stridor were not associated with the localization of infection (p = 0.6486/p = 0.4418). Multivariable analysis revealed increased age, restricted mouth opening, higher Mallampati scores, and higher Cormack-Lehane classification grades as significant predictors of difficult intubation. Higher BMI, dysphagia, dyspnea, stridor and a non-palpable mandibular rim did not influence the airway management. Patients with a difficult airway were more likely to be admitted to the ICU after surgery than patients with regular airway were (p = 0.0001). To conclude, the incidence of a difficult airway was high in patients with orofacial infections originating in the mandible. Older age, limited mouth opening, a higher Mallampati score, and a higher Cormack-Lehane grade were reliable predictors of difficult intubation.

Intubation of Critically Ill COVID-19 Patients Using Conventional Laryngoscope in the ICU

Background: Video laryngoscopy is recommended for critically ill COVID-19 patients due to safety concerns and avoid complications. It is not available in some places and thereby forcing the operator to rely on conventional laryngoscope. Intubations in critically ill COVID-19 patients are challenging and may lead to adverse complications which may be affected by the laryngoscope used. The aim of the study was to analyse predictors of difficult intubation, complexity of intubation and complications of using conventional laryngoscopy in intubations of COVID-19 patients in ICU. Methods: A prospective observational study was done in COVID Intensive Care Unit of the Base Hospital- Teldeniya, Sri Lanka from 1st of January 2021 to August 2021. The data was collected using a Performa filled by operator at the end of the intubation. Apart from demographic data and clinical parameters, data related to intubation including MACOCHA score which is a validated score predicting difficult intubation in ICU(3) and Intubation difficulty scale (IDS) which measures the actual complexity of intubation(4) were collected. The complications related to intubation were also analysed. Results: Approximately 84 out of 91 emergency intubations were done using conventional laryngoscope. Out of them 50.72 % were male and 49.27% Were female. Mean age was 50.75 years. First pass success rate was 83.3%. 25% had MACOCHA score more than 3. Most patients scored on the desaturation component of the score. Despite this only 50% of the predicted difficult intubations actually had major difficulty in intubation. The commonest complication was hypotension. 12 had suffered cardiac arrest, and 4 of them were fatal. Conclusions: Intubation of Critically ill COVID-19 patients are challenging but can be done successfully with conventional laryngoscope. However, one must prepare for complications including cardiac arrest.