Prediction Of Difficult Intubation Research Articles

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

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.

Evaluation of neck-circumference- thyromental- distance ratio as a predictor of difficult intubation: A prospective, observational study.

Preoperative identification of difficult airway and subsequent planning is of utmost importance for a patient's safety. Previous studies have identified the ratio of the neck circumference (NC) to the thyromental distance (TMD); NC/TMD as a reliable predictor of difficult intubation in obese patients. But there is a lack of studies evaluating the NC/TMD in non-obese patients. Therefore, the aim of this study was to compare the NC/TMD as a predictor of difficult intubation in both obese and non-obese patients. A prospective, observational study was conducted after obtaining institutional ethics committee clearance and written and informed consent from each patient. One hundred adult patients undergoing elective surgeries under general anaesthesia with orotracheal intubation were included in this study. Difficulty in intubation was assessed using the Intubation Difficulty Scale. The NC/TMD was calculated and the predictive accuracy of NC/TMD and other established parameters in obese and non-obese patients were compared. Univariate logistic regression analysis showed that gender, weight, body mass index, inter-incisor gap, Mallampati classification, NC, TMD, sternomental distance, and NC/TMD had a significant association with difficult intubation. NC/TMD has a higher sensitivity, specificity, and positive and negative predictive value with better predictability in comparison to other parameters. The NC/TMD is a reliable and better predictor of difficult intubation in both obese and non-obese patients in comparison to NC, TMD, and sternomental distance alone.

Pre-epiglottic Space and Epiglottis to Vocal Cord Ratio in Order to Predict Difficult Intubation in Adults: A Multivariate Analysis

Objective: We aimed to enhance the prediction of difficult intubation by using ultrasonographic parameters (pre-epiglottic space (Pre-E), distance between epiglottis to middle part of vocal cord (E-VC) and Pre-E/E-VC) adjusting for traditional airway assessments. Material and Methods: This prospective cohort study was conducted at a super-tertiary care hospital in Thailand. Participants aged 18-65 years with ASA classification I-III and who required general anesthesia with endotracheal intubation were included. Preoperative traditional and ultrasonographic airway assessments were performed by two investigators. The outcome was difficult intubations as diagnosed by laryngoscopic view grade 3 or 4. Multivariate logistic regression was used to identify predictors for difficult intubation presented by adjusted odds ratio (OR) and 95% confidence interval (CI). Results: A total of 94 patients were recruited. The incidence of difficult intubation was 15%. The median Pre-E/E-VC ratio among this group was 0.8 compared with 1.0 in the control group (p-value 0.124). The cut-off point of &lt;1.0 of Pre- E/E-VC was not associated with difficult intubation after adjusting for sex and other traditional parameters (p-value 0.11). Predictors of difficult intubation were female sex (OR [95% CI]: 13.8 [2.8, 68.3]), sternomental distance ≤175 mm (OR [95% CI]: 11.6 [1.9, 71.4]) and interincisor gap &lt;4 cm (OR [95% CI]: 19.8 [1.1, 373.8]) with the area under the receiver operating characteristic curve at 0.88 and a specificity of 90.0%. Conclusion: There was no association between the Pre-E/E-VC in predicting difficult intubation in low-risk patients. The ultrasonographic measurements of Pre-E/E-VC were not helpful in predicting difficult intubations in our setting. Trial registration: thaiclinicaltrials.org: TCTR20180115002, Registered 9 January 2018 - Prospectively registered, https:// www.thaiclinicaltrials.org/#

Airway assessment: Predictors for difficult intubation – A prospective observational study

Airway management remains an important challenge in the contemporary practice of anaesthesia and preoperative airway assessment facilitates appropriate preparation when difficulty with intubation or ventilation is anticipated prior to induction of anaesthesia.: Aim: To study the important predictors for difficult laryngeal intubation. To determine the predictors of difficult laryngeal intubation. Secondary: To determine the most significant predictor for difficult intubation and to determine the incidence of unanticipated difficult intubation.This single centre prospective observational study done in Bangalore Baptist hospital (after obtaining clearance from ethical committee) included adult patients posted for elective surgeries who received general anaesthesia. Patients of either gender in the 18 – 65 year age group, with an American Society of Anaesthesiologists physical status classification of I or II, who required endotracheal intubation for general anaesthesia. The sample size was 413 with confidence level 95%. In our study the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of Mallampati class were found to be 75.8%, 78.06%, 37.90%, 94.80% respectively. The sensitivity, specificity, PPV and NPV of mouth opening were found to be 33.87%, 81.19%, 24.13%, 87.42% respectively. The sensitivity, specificity, PPV and NPV of upper lip bite test found to be 27.41%, 96.29%, 56.66%, 88.25% respectively. The sensitivity, specificity, PPV and NPV of neck extension found to be 54.83%, 92.59%, 56.66%, 92.06% respectively. The sensitivity, specificity, PPV and NPV of BMI found to be 53.22%, 75.49%, 27.73%, 90.13% respectively. The incidence of difficult intubation was 15%.:In conclusion, no single predictor is sufficient for prediction of difficult intubation on its own. All the studied bedside tests are poor to moderate predictors of difficult intubation. All the tests showed poor positive predictive values and high negative predictive values which suggests that they can be more useful predictors of easy intubation than difficult intubation.

Are the HEAVEN criteria reliable as a predictive tool for emergency airway management? A systematic review

Background: Airway management is one of the most vital skills used by advanced airway providers. Anticipating a difficult airway is crucial for the risk-benefit analysis and may help providers to determine the optimal airway management approach. Existing difficult airway assessment tools may have limited application in emergency airway management. In addition, these do not incorporate physiological factors. More recently, Davis and Olvera proposed the HEAVEN criteria as a novel difficult airway predictive tool for emergency airway management. The objective of this study is to review HEAVEN as a novel airway prediction tool. Material and Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results of a comprehensive search in three major databases, as well as hand searching, were screened in title/abstract and full-text stages. We included the journal articles which review HEAVEN as a novel airway prediction tool with both retrospective and prospective study designs. The population included patients requiring rapid sequence intubation (RSI) or delayed sequence intubation (DSI). Two investigators independently extracted the data with an electronic table in Microsoft Word. Due to the heterogeneity in included study designs, settings, methods, study outcomes, and measurement of the studies, we did not carry out a meta-analysis. The risk of bias (RoB) was assessed using Joanna Briggs Institute checklist. Results: Out of 103 records, only four studies were included. The most cited criterion was the anatomical challenge, which was significantly associated with first-attempt success in three studies. Most studies on HEAVEN did not support physiological factors as predictors of difficult intubation. Two studies reported significant associations between individual HEAVEN criteria and first-attempt success without desaturation. Some included studies reported significant associations between anatomical HEAVEN criteria (extremes of size, anatomical challenge, vomit/blood/fluid, and neck mobility) and difficult airway view. Furthermore, a prospective study reported that hypoxemia and vomit/blood/fluid were significantly associated with intubation complications. Based on the results of the RoB analysis, there wasn’t considerable bias in a great number of included studies. Conclusion: The HEAVEN criteria may represent a development over the traditional approaches. HEAVEN assessment tool considers both physiological and anatomical factors. In addition, all HEAVEN elements can be performed in emergent situations. The HEAVEN criteria seem to be a useful tool to predict difficult airways. There was a variation among studies in the definition of the difficult airway. There is currently no consensus on the definition of a difficult airway, which may explain some of the heterogeneity of the results of this systematic review. Due to the heterogeneity in included studies, we did not carry out a meta-analysis. Therefore, we suggested that future studies should consider homogeneous patient populations, a uniform study design, a matching study setting, and a widely accepted definition of the difficult airway to provide the opportunity to perform meta-analyses. The controversial results of studies highlighted a requirement for more prospective studies with an appropriate study design and considering the possible confounding factors to reach more reliable evidence.

Correlation between upper airway ultrasound and Cormack–Lehane grading during laryngoscopy – A prospective study

Background: Securing airway and adequate ventilation after induction of anesthesia is the utmost priority of anesthesiologists, failure of that can lead to hypoxic brain injury and death in a few minutes. Aims and Objectives: The aims of this study were to ascertain the role of ultrasonography in predicting difficult intubation by comparing different ultrasonographic parameters. Materials and Methods: One hundred patients posted for elective surgery under general anesthesia were studied. The study was carried out in two phases. The first phase – during the pre-anesthetic checkup, ultrasonographic measurements of Anterior neck soft-tissue thickness at the level of hyoid (ANS-Hyoid), anterior neck soft tissue thickness at the level of vocal cords (ANS-VC), pre-epiglottic space (Pre-E), distance from the epiglottis to the mid-point of the distance between the vocal cords (EVL), and the ratio of both (PES/EVL) was also done. In the second phase, Cormack–Lehane (CL) grade was noted during intubation. A Chi-square test was applied to correlate ultrasonographic parameters and CL grade. Sensitivity, specificity, an area under the receiver operating characteristic (ROC) curve, negative predictive value, and positive predictive value were calculated for various parameters. Results: In this study among the studied parameter, only ANS–VC was statistically significant in predicting difficult intubation (P&lt;0.0001). ANS-VC &gt;0.32 cm was 93.3% sensitive and 84.7% specific and had Area under the ROC curve of 85% in predicting CL grade 3 and 4 (difficult intubation). Conclusion: USG is a useful tool in predicting difficult intubation. ANS-VC &gt;0.32 cm is a highly sensitive and specific predictor of difficult intubation, while other USG parameters are not indicative of difficult intubation.

Measurement of Neck Circumference, Tongue thickness and Skin to Epiglottis Distance as Predictors of Difficult Intubation: A Prospective Study

Airway Assessment is essential in pre anesthetic assessment. Anticipating and preparing for difficulty in airway management is crucial to avoid airway catastrophes. Routine pre operative airway examination usually includes mouth opening and dentition, Mallampati classification, thyromental distance and neck movements. Neck circumference is a quick bedside test to determine difficult laryngoscopy. Increased tongue thickness and skin to epiglottis distance affects performance of laryngoscopy and tracheal intubation increasing the risk of difficult airway. Presently there is a search for non-invasive and accurate tools to overcome limitations of clinical airway assessment tests. Ultrasonography has been evolving as a useful device for airway assessment especially soft tissue structures in anterior surface of neck. Here we studied the measurement of neck circumference and ultrasound measurement of tonguethickness and skin to epiglottis distance as predictors for difficult intubation. The Aim of the study is to predict difficulty in intubation by measuring neck circumference, thickness of tongue and thickness of skin to epiglottis. Prospective observational study, 120 patients posted for surgery under general anesthesia, Department of anesthesia, Meenakshi medical college, Kanchipuram. After institutional Human ethical committee clearance, 120 Patients were screened during preoperative assessment for undergoing procedures under general anaesthesia. Neck circumference and other airway parameters were measured with measuring tape and distance between Skin to epiglottis and tongue thickness were measured with ultrasound linear probe. Patients were grouped into Group E( Easy Intubation) whose Cormack-lehane grade was 1 and 2 and Group D ( Difficult intubation) whose Cormack-lehane grade was 3 and 4. SPSS version 16 was used for statistical analysis. There was no statistical significance seen between age, sex, height among easy and difficult intubation but significance was seen with weight (p &lt;0.05), Thyromental distance(p&lt;0.05) and Sterno-mental distance(p&lt;0.05). High significance was seen in Distance between skin to epiglottis distance(p&lt;0.001), Tongue thickness(p&lt;0.001) and Neck Circumference(p&lt;0.001) in difficult intubation cases. Neck circumference and ultrasonographic measurement of tongue thickness and skin to epiglottis can avoid unanticipated difficult intubation.