Risk Factors For Difficult Intubation Research Articles

General anesthesia for maternal surgery during pregnancy: dogmas, myths and evidence, a narrative review

Up to 1% of pregnant women require general anesthesia and maternal non-obstetric surgery during pregnancy, of which urgent abdominal procedures are most commonly indicated. This narrative review summarizes several dogmas and myths on the management of general anesthesia during pregnancy and the corresponding evidence. While historical studies found delayed gastric emptying during pregnancy, recent evidence concluded that gastric emptying remains nearly normal during the entire pregnancy until the onset of labor. To correctly estimate the aspiration risk, gastric ultrasound should be increasingly performed. Based on the available evidence, the application of cricoid pressure should be discouraged during rapid sequence induction of pregnant women. A cuffed endotracheal tube is traditionally recommended, but laryngeal masks have been used in > 9000 patients undergoing cesarean section without observation of aspiration. All material to manage a difficult airway should be available as difficult intubation remains an ongoing concern in obstetrics. Risk factors for difficult intubation are nonobstetric in nature. Due to the lack of evidence for hemodynamic management, it is not possible to make an evidence-based recommendation. We recommend to adhere to the expert opinion of maintaining maternal blood pressure close to the normal physiologic value by using (15°-)30° left lateral tilt position, intravenous fluids and noradrenaline or phenylephrine. Most recent clinical observational studies suggested to consider laparoscopic over open surgery as a standard treatment for abdominal surgery. While animal studies observed impaired fetal brain development after prenatal anesthesia exposure, this could not be confirmed by an observational clinical study.

Anesthetic Management with Intubation in Awake Patient with Ludwig's Angina Using Dexmedetomidine and Ketamine: A Case Report

Introduction: Ludwig's Angina (LA) is a bacterial infection of the submandibular space that can cause airway obstruction. Prompt surgical treatment and antimicrobial therapy are crucial. Airway evaluation is important to identify risk factors for difficult intubation and anatomical distortion that may require awake endotracheal intubation. Case presentation: A 22-year-old female presented to the emergency department with left submandibular pain, edema, increased skin temperature, and erythema with a history of grade III caries of 6 months evolution without treatment. Physical examination revealed extension to the left lateral neck region and mild respiratory distress. Classified as ASA grade III, the patient underwent awake intubation using dexmedetomidine (DXM) and ketamine (KET), followed by balanced general anesthesia for the surgical procedure. Clinical discussion: The patient's condition predicted high difficult airway, therefore awake intubation was performed to maintain spontaneous ventilation and reduce cardiac arrest risk. In this case, DXM was used to avoid anxiety and respiratory depression, while KET was employed for its analgesic, bronchodilator, and tachycardic effects. Conclusion: Ketamine and dexmedetomidine allow adequate spontaneous ventilatory mechanics, without respiratory depressant effect. Further research is needed to find more anesthetic drugs that can be used for intubation without suppressing autonomic ventilation, and to develop guidelines to prevent respiratory depressant effects in patients with LA.

Awake Nasal Fiberoptic Intubation in Lateral Position for Severely Obese Patients with Anticipated Difficult Airway: A Randomized Controlled Trial.

Obesity is a well-recognized risk factor for difficult intubation. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended. We aimed to investigate the utility of awake nasal fiberoptic intubation in severely obese patients with suspected difficult airway while positioning them in the lateral decubitus position. This randomized controlled trial compared lateral and supine positions for awake nasal fiberoptic intubation in severely obese patients with an anticipated difficult airway by assessing the success rate, time needed to secure the airway, peri-procedural adverse events, and postoperative satisfaction of patients. Sixty patients with a median age of 37 [inter-quartile range (IQR): 29-44] years were included, of which 47 (78.3%) were females. The median body mass index (BMI) was 45.5 [IQR: 42.5-50.8] kg/m2. The success rate of fiberoptic intubation was 100% in both groups. The time needed to successfully secure the airway was 188 [148.8-228.8] seconds (s) in the lateral position, compared to 214.5 [181.8-280.5] s in supine position (p = 0.019). Intraprocedural cough was more common in the supine position group (n = 8; 26.7%), compared to the lateral position group (n = 3; 10%; p = 0.095). Postoperative sore throat was more common in the lateral position group (n = 12; 40%) compared to the supine position (n = 5; 16.7%; p = 0.045). In conclusion, Intubation in the lateral position is a promising technique that is equivalent to the routine supine position during fiberoptic intubation. In fact, intubation in the lateral position took less time to successfully secure the airway.

Problems of endotracheal intubation in obese patient

Background: Performing intubation in obese patients is a challenging problem both in the intensive care unit (ICU) and patients with a high BMI face various complication.
 Methods: A prospective multiplex cohort study in Kirkuk governorate was conducted in obese patients (body mass index greater than 30 kg m2).  The primary endpoint was the occurrence of difficulty intubation.  Secondary endpoints were risk factors for difficult intubation, use of difficult airway management techniques, and serious, life-threatening complications related to intubation (cardiac problems, hypoxaemia, and severe cardiovascular collapse). 
 Results: Out of 100 patients, 48 patients had problems and complications as a result of intubation. These complications varied from simple to serious. 7 patients experienced hypoxia, 22 patients experienced difficulty in intubation, 5 patients experienced cardiac arrhythmias, and 2 patients had a dental injury that was. This complication is related to the body mass index.  
 Conclusions: In severely obese patients, the incidence of difficult intubation in the intensive care unit was related to BMI. Researchers did not encounter deaths resulting from intubation, perhaps due to the development of medicine and new tools.

Obesity is Unlikely to be an Impediment to First-Pass Success During the Intubation of Critically Ill Patients.

Background: Obesity has been described as a potential risk factor for difficult intubation among critically ill patients. Our primary aim was to further elucidate the association between obesity and first-pass success. Our secondary aim was to determine whether the use of hyper-angulated video laryngoscopy improves first-pass success compared to direct laryngoscopy when utilized for the intubation of critically ill obese patients. Study Design and Methods: A retrospective cohort study of adult patients undergoing endotracheal intubation outside of the operating room or emergency department between January 30, 2016 and May 1, 2020 at 3 campuses of an academic hospital system in the Bronx, NY. Our primary outcome was first-pass success of intubation. A multivariate logistic analysis was utilized to compare obesity status with first-pass success. Results: We identified 3791 critically ill patients who underwent endotracheal intubation of which 1417 were obese (body mass index [BMI] ≥ 30). The incidence of hyper-angulated video laryngoscopy increased over the study period. A total of 46.6% of obese patients underwent intubation with hyper-angulated video laryngoscopy as compared to 35.1% of the nonobese group. First-pass success was 79.2% among the entire cohort. Obesity status did not appear to be associated with first-pass success (adjusted odds ratio [OR] 1.07, 95% confidence interval [CI]: 090-1.27; P = .47). Hyper-angulated video laryngoscopy did not seem to improve first-pass success among obese patients as compared to nonobese patients (adjusted OR 1.21, 95% CI: 0.85-1.71; P = .29). These findings persisted even after redefining the obesity cutoff as BMI ≥ 40 and excluding patients intubated during cardiac arrests. Conclusion: We did not detect an association between obesity and first-pass success. Hyper-angulated video laryngoscopy did not appear offer additional benefit over direct laryngoscopy during the intubation of critically ill obese patients.

Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis

(Anesthesiology. 2022;136:697–708) Elucidating the contemporary rate of difficult or failed intubation in women undergoing general anesthesia for cesarean delivery is confounded in the literature by small sample size, and the unaccounted-for increased use of neuraxial anesthesia and video laryngoscope, all amounting to generally outdated information available for this question. As the mother and neonate are at high risk for adverse outcome with difficult intubation, it is important to understand characteristics that may increase the likelihood of this complication, as to initiate pertinent preparation and early neuraxial anesthesia. The aim of this study was to determine an updated frequency of difficult and failed intubation in the obstetric setting and identify risk factors of such that may be particular to women receiving general anesthesia for cesarean delivery.

Frequency and Risk Factors for Difficult Intubation in Women Undergoing General Anesthesia for Cesarean Delivery: A Multicenter Retrospective Cohort Analysis.

Estimates for the incidence of difficult intubation in the obstetric population vary widely, although previous studies reporting rates of difficult intubation in obstetrics are older and limited by smaller samples. The goals of this study were to provide a contemporary estimate of the frequency of difficult and failed intubation in women undergoing general anesthesia for cesarean delivery and to elucidate risk factors for difficult intubation in women undergoing general anesthesia for cesarean delivery. This is a multicenter, retrospective cohort study utilizing the Multicenter Perioperative Outcomes Group database. The study population included women aged 15 to 44 yr undergoing general anesthesia for cesarean delivery between 2004 and 2019 at 1 of 45 medical centers. Coprimary outcomes included the frequencies of difficult and failed intubation. Difficult intubation was defined as Cormack-Lehane view of 3 or greater, three or more intubation attempts, rescue fiberoptic intubation, rescue supraglottic airway, or surgical airway. Failed intubation was defined as any attempt at intubation without successful endotracheal tube placement. The rates of difficult and failed intubation were assessed. Several patient demographic, anatomical, and obstetric factors were evaluated for potential associations with difficult intubation. This study identified 14,748 cases of cesarean delivery performed under general anesthesia. There were 295 cases of difficult intubation, with a frequency of 1:49 (95% CI, 1:55 to 1:44; n = 14,531). There were 18 cases of failed intubation, with a frequency of 1:808 (95% CI, 1:1,276 to 1:511; n = 14,537). Factors with the highest point estimates for the odds of difficult intubation included increased body mass index, Mallampati score III or IV, small hyoid-to-mentum distance, limited jaw protrusion, limited mouth opening, and cervical spine limitations. In this large, multicenter, contemporary study of more than 14,000 general anesthetics for cesarean delivery, an overall risk of difficult intubation of 1:49 and a risk of failed intubation of 1:808 were observed. Most risk factors for difficult intubation were nonobstetric in nature. These data demonstrate that difficult intubation in obstetrics remains an ongoing concern.

Fifteen-minute consultation: Airway management in the acutely unwell child requiring intubation for the general paediatrician

Emergency endotracheal intubation is a high risk procedure in acutely unwell children and is commonly jointly managed by paediatricians and anaesthetists. This article aims to develop a shared understanding of...

Evaluation of super-obesity and super-super-obesity as risk factors for difficult intubation in patients undergoing bariatric surgery.

Super-obesity is a serious disorder which requires bariatric surgery. The association of super-obesity and difficult intubation was not adequately established. To determine if super-obesity and super-super-obesity are associated with difficult intubation or not. University Hospital. A cohort of obese patients scheduled for bariatric surgery was prospectively recruited. Super-obesity and super-super-obesity were defined as body mass index ≥50 kg/m2 and 60 kg/m2, respectively. Intubation difficulty was assessed by 2 methods: (1) intubation difficulty scale; (2) number of intubation attempts. Risk factors for difficult intubation were recorded. Univariate and multivariate analysis for risk factors for difficult intubation and difficult mask ventilation were performed. A total of 658 patients were enrolled in the study including 205 (31%) super-obese and 52 (8%) super-super-obese patients. Ninety-nine (15%) patients required more than 1 intubation attempt, while 215 (33%) patients had intubation difficulty scale ≥5. Ninety-four (14.4%) patients had mask ventilation of moderate difficulty, while only 2 (.3%) patients needed 2-person ventilation. The independent risk factors for difficult intubation using the two stated definitions were STOP-Bang and Mallampati score values. The independent risk factors for mask ventilation of moderate difficulty were STOP-Bang score, Mallampati score, and limited neck extension. Within obese patients, neither super-obesity nor super-super-obesity was associated with difficult intubation or difficult mask ventilation. High STOP-Bang and Mallampati score are the independent factors for difficult intubation.

OBESITY IS NOT A RISK FACTOR FOR COMPLICATIONS IN CRITICALLY ILL PATIENTS INTUBATED WITH VIDEO LARYNGOSCOPY

SESSION TITLE: Critical Care Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Obesity is a known risk factor for difficult intubation with direct laryngoscopy. Although video laryngoscopy (VL) may improve visualization, it is not known if VL can improve first pass success when intubation is performed on obese, critically ill patients. We hypothesized that when using VL, obesity would not be a risk factor for complications of endotracheal intubation. METHODS: We performed a retrospective cohort study of all patients intubated with VL by critical care practitioners on medical/surgical wards or ICUs at an academic medical center in Bronx, NY between January 30, 2016 to July 19, 2019. Pediatric patients and those intubated in the operating room or emergency department were excluded. Obesity was defined as BMI > 35. The primary outcome was first pass success. Secondary outcomes were difficult intubation (defined as requiring more than 2 attempts) and mortality within 24 hours. We performed a chi-square analysis to explore the effect of obesity on first pass success, difficult intubation and mortality. A multivariable logistic regression was utilized with correction for factors associated with difficulty during intubation. Sensitivity analysis was performed defining obesity as BMI > 40. RESULTS: There were 2638 patients during the study period and 668 were intubated with VL. Patients with obesity (BMI > 35) did not have a decreased first pass success (OR 1.04 CI 0.70-1.56; P=0.849) or increased risk of difficult intubation (OR 0.87 CI 0.39-1.95; P=0.73) or mortality within 24 hours (OR 0.8 CI 0.46-1.31; P=0.33). After adjusting for covariates, we did not note a significant association between obesity and first pass success (ORa 1.15 CI 0.72-1.83; P=0.55), difficult intubation (ORa 0.94 CI 0.37-2.37; P=0.90) or mortality (ORa 0.83 CI 0.47-1.44; P=0.50). We conducted a sensitivity analysis to examine the effect of more severe obesity and did not note an association between BMI > 40 (ORa 1.20 CI 0.66-2.17; P=0.58) on first pass success. CONCLUSIONS: When VL is used for the intubation of critically ill patients, we did not find obesity to be a risk factor for failed first pass intubation, difficult intubation or mortality 24 hours after the procedure. These findings did not change when different definitions of obesity were used. Based on our results, when VL is being utilized for the intubation of critically ill patients, obesity may not be a risk factor for complications. CLINICAL IMPLICATIONS: Obesity may not be a risk factor for first pass success or difficult intubation when video laparoscopy is utilized for emergent endotracheal intubation. DISCLOSURES: No relevant relationships by Lewis Eisen, source=Web Response No relevant relationships by Daniel Fein, source=Web Response No relevant relationships by Peter Nauka, source=Web Response No relevant relationships by Ariel Shiloh, source=Web Response

A case of laryngeal edema that developed during gastric endoscopic submucosal dissection and difficult tracheal intubation due to an epiglottic cyst

A 76-year-old male was scheduled for gastric endoscopic submucosal dissection (ESD) of early-stage gastric cancer. During the ESD procedure, hypoxemia caused by laryngeal edema occurred and ESD was discontinued. Emergency tracheal intubation was attempted but it was difficult due to the presence of a large epiglottic cyst. Using a McGRATH laryngoscope, tracheal intubation was managed successfully. He was treated with steroids for laryngeal edema, and was discharged to home without any sequelae. An epiglottic cyst is a risk factor for difficult intubation. In patients who are scheduled for upper endoscopic treatment that requires sedation, a large epiglottic cyst should be removed before treatment.

The predictive value of skin-to-epiglottis distance to assess difficult intubation in patients who undergo surgery under general anesthesia

Background: Intubation is crucial in the management of anesthesia because it is related to the maintenance of oxygenation and ventilation during general anesthesia. Clinical markers for predicting difficult airway have limitations, including requiring coordination with patients. The use of ultrasonography (USG) to measure the distance of the skin to epiglottis is expected to estimate the difficulty level of intubation. Patients and Methods: This was a cross-sectional study of 128 patients who underwent surgery under general anesthesia. We examined the skin-to-epiglottis distance using US prior to surgery. We then assessed the Cormack–Lehane scores during direct laryngoscopy for intubation. The unpaired t-test was used to assess differences in the skin-to-epiglottis distance between patients with easy intubation (Cormack–Lehane I and IIa) and difficult intubation (Cormack–Lehane IIb, III, and IV). Results: The cutoff value of skin-to-epiglottis distance between easy and difficult intubation was 26.05 mm. The sensitivity and specificity of this method to predict difficult airway were 69.4% and 93.5%, respectively. The positive and negative predictive values were 80.6% and 88.7%, respectively. Conclusion: The skin-to-epiglottis distance of >26.05 is a risk factor for difficult intubation.

Predictive parameters of difficult intubation in thyroid surgery: a meta-analysis.

Airway management is a fundamental goal for the anesthesiologist. The rate of difficult laryngoscopy in patients undergoing thyroid surgery ranges from 6.8% to 9.6%. An accurate and detailed preoperative evaluation of the airway seems to be a promising tool to predict a potentially difficult airway management. We aimed to identify possible risk factors and physical findings that predict difficult intubation in thyroid surgery. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were analyzed, and the reference lists from the retrieved articles and previous reviews were searched for additional studies. Difficult intubation was defined as Cormack and Lehane grade ≥3 or Intubation Difficulty Scale score >5 by direct laryngoscopy. Studies that used advanced airway devices or ultrasound-based airway management were excluded. Gender, Mallampati Score, interincisor gap, thyromental distance, body mass index, tracheal deviation, histology, mediastinal goiter, mandibular protrusion, neck circumference and neck movement were evaluated. Qualitative analysis has been conducted in case of insufficient data for an appropriate meta-analysis. Eight studies that evaluated the accuracy of clinical findings for identifying difficult intubation in thyroid patients were reviewed (5853 patients). Two authors independently screened articles, extracted data and assessed risk of bias. 7.21% [95% CI: 6.57-7.91%] of patients undergoing thyroid surgery were difficult to intubate. The physical examination findings that best predicted a difficult intubation included Mallampati Score ≥3 (positive odds ratio 4.75 [95% CI: 2.22-10.12]); shorter thyromental distance thresholds ranging from <6.5-<6 cm; OR 3.64 [95% CI: 1.9-7.01]); 'low' interincisor gap, defined as a critical distance between incisors (ranging from <3.5 - <4.4 cm; odds ratio 2.57 [95% CI: 1.83-3.62]); presence of tracheal deviation (positive odds ratio, 2.06 [95% CI: 1.58-2.69]); Body Mass Index >30 kg/m2 (odds ratio 1.95 [95% CI: 1.20-3.15]) and males (odds ratio 1.54 [95% CI: 1.21-1.95]). Histological examination positive for cancer didn't increase the risk for difficult intubation. For mediastinal goiter, mandibular protrusion, neck circumference and neck mobility only a qualitative analysis was performed. In thyroid patients, the presence of high Mallampati Score, shorter thyromental distance, interincisor gap, tracheal deviation (the unique thyroid pathology linked parameter), obesity and male gender were risk factors for difficult intubation. However, all these significant parameters should be used in preoperative assessment to anticipate difficult intubation in thyroid surgery.

A new simple score for prediction of difficult laryngoscopy: the EL.GA+ score.

Preoperative airway assessment plays a key role in the context of difficult airway management. Several scores have been proposed to predict difficult intubation including the el-Ganzouri index (EL.GA). Anatomical parameters such as the opening of the mouth or the circumference of the neck (which currently is not usually evaluated) are used to predict difficult intubation. The nutritional status of super-morbid obesity (body mass index [BMI] > 50 kg m-2) is a recognised risk factor for difficult intubation. This is a single-centre, retrospective, observational study whose aim is to validate an additional parameter (anatomical plus nutritional) to the El.GA index, hence the choice of the acronym for the definition of the study: EL.GA+, in predictivity of airway management; multiple logistic regression analysis was performed to determine the predictive role of BMI, neck circumference and opening of the mouth of intubation difficulty measured with the gold standard. In total, 240 patients who had an elective surgical procedure under general anaesthesia, requiring endotracheal intubation, were examined. The predictive value of the EL.GA score was confirmed by the values of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) according to the data reported in the literature. Furthermore, based on the values of the PPV and NPV (0.69 and 0.60 respectively), neck circumference of 42.5 cm can be taken as a cut-off value for which EL.GA+ becomes predictive of difficult intubation in patients with mild obesity (BMI of 30 to 35). The EL.GA+ score greatly increases the prediction of difficult laryngoscopy in mildly obese patients.

Accuracy of thyromental height test for predicting difficult intubation in elderly.

Studies of the accuracy of different airway tests are lacking in elderly. We evaluated and compared the accuracy of thyromental height in predicting difficult intubation in relation to the other traditional airway tests in elderly. We included 120 patients aged ≥ 65years scheduled for general anesthesia with tracheal intubation. Thyromental height, modified Mallampati test, thyromental distance and sternomental distance were evaluated. Cormack-Lehane grade > 2 was considered difficult laryngoscopy. Difficult tracheal intubation was considered if successful intubation required more than 2 attempts. The accuracy of different tests in predicting difficult intubation and difficult laryngoscopy were evaluated through area under receiver operating characteristic (AUROC) curves. Univariate and multivariate analyses were conducted to identify risk factors for difficult intubation and difficult laryngoscopy. Our cohort had a mean age of 71(7) years. We encountered difficult laryngoscopy in 15/120 (12%) patients, difficult intubation in 20/120 (17%) patients, and failed laryngoscopy requiring alternative methods for securing the airway in 3/120 (3%) patients. For predicting difficult intubation, thyromental height and modified Mallampati test showed the highest accuracy AUROC (95% confidence interval): 0.9 (0.83-0.95), cut-off value ≤ 5.9cm, and AUROC (95% confidence interval): 0.89 (0.82-0.94), cut-off value > 2, respectively. Low thyromental height and high modified Mallampati test were the only independent risk factors for difficult laryngoscopy and difficult intubation. In elderly scheduled for elective procedure, both thyromental height and modified Mallampati tests showed good accuracy in predicting difficult intubation and difficult laryngoscopy, whilst thyromental distance and sternomental distance were poor predictors.

Struma kao prediktor otežane intubacije - prikaz slučaja

Introduction: Preoperative examination and recognizing the risk factors for a difficult airway gives us the time for optimal preparation for difficult airway management. For goiter patients, in addition to the standard risk factors, there are goiter-related factors that may address to suspect of difficult intubation. Case report: Through this case report we summarize the presentation, airway examination and management of a patient with huge goiter. About 25-years earlier he noticed a swelling on the neck which increased in size progressively. Over the years he developed compressive symptoms, such as dysphagia, hoarseness and change in voice quality. All classical risk factors for difficult intubation, as well as goiter-related factors, were preoperatively evaluated. The neck circumference, the left displacement of the larynx and the radiological findings all pointed to a possible difficulty in airway management. The plan was to perform a direct laryngoscopy using a video-laryngoscope, without using a muscle relaxant, whereas the alternate plan was to use a flexible fibreoptic bronchoscope. The patient's airway was anesthetized with lignocaine spray into the laryngo-pharynx 30 minutes and 10 minutes before intubation. Oxygen was administered via facemask. The nasal catheter was placed to provide apnoic oxygenation during laryngoscopy and intubation. After induction of anesthesia a smooth video laryngoscopy was performed without using a muscle relaxant. A reinforced endotracheal tube with an intubating stylet was inserted without any difficulties in passing and placing the tube. Conclusion: Careful planning and detailed preoperative preparation are of crucial importance for a safe intraoperative and postoperative outcome in thyroid patients.

Standardised data reporting from pre-hospital advanced airway management \u2013 a nominal group technique update of the Utstein-style airway template

BackgroundPre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset.MethodsWe recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process.ResultsThe experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described.ConclusionsUsing a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.Trial registrationThe Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260).

Degree of obesity is not associated with more than one intubation attempt: a large centre experience

BackgroundThe role of obesity as a risk factor for difficult intubation remains controversial. We primarily assessed the association between body mass index (BMI) and difficult tracheal intubation. MethodsWe analysed electronic records of more than 67 000 adults having elective non-cardiac surgery requiring tracheal intubation at the Cleveland Clinic between 2011 and 2015. The association between BMI and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression adjusting for pre-specified confounders. ResultsAmongst 40 183 patients with BMI <30 kg m−2 and 27 519 with BMI ≥30 kg m−2, 9% required more than one intubation attempt. Increasing BMI up to 30 kg m−2 was significantly associated with increased odds of more than one intubation attempt [odds ratio (OR): 1.03; 97.5% confidence interval (CI): 1.02, 1.04] per unit increase in BMI, P < 0.001. However, the odds of difficult intubation remained unchanged once BMI exceeded 30 kg m−2 (P = 0.08). The results were similar when analysis was restricted to patients without history of airway abnormalities in whom intubation was attempted using a standard direct laryngoscope (OR: 1.03; 99.4% CI: 1.01, 1.04) per kg m−2 increase in BMI <30 kg m−2). ConclusionsIncreasing BMI was associated with increasing odds of difficult intubation in the lean range. At higher BMI, the odds of difficult intubation remain elevated, but there is no additional increase in odds with further increase in BMI. Obese patients were thus harder to intubate than lean ones, but difficult intubation was no more likely in morbidly obese patients than in those who were only slightly obese.

The Assessment of Risk Factors for Difficult Intubation in Thyroid Patients.

We aimed to assess possible risk factors related to difficult intubation in patients undergoing thyroid surgery. We prospectively collected data of 200 patients scheduled for thyroid surgery. Clinical risk factors were defined as: Mallampati score, interincisor gap, thyromental distance, sternomental distance, range of neck motion, body mass index, neck circumference, goiter, the presence of radiological findings suggesting compression and thyroid weight. All evaluations were performed with Macintosh assessed for Cormack and Lehane (CL) classification and modified intubation difficulty scale (MIDS). It was observed that the proportion of patients with a thyroid weight ≥40g, goiter, a Macintosh CL score=3-4 and the mean neck circumference were significantly higher in the group with a MIDS score >5 (p=0.018, p=0.011, p<0.001, respectively). The presence of a palpable goiter, thyroid weight ≥40g and thyromental distance <6.5cm were risk factors associated with difficult intubation in the multivariate regression model.

Critical Airway Team: A Retrospective Study of an Airway Response System in a Pediatric Hospital.

Objective Study the performance of a pediatric critical airway response team. Study Design Case series with chart review. Setting Freestanding academic children's hospital. Subjects and Methods A structured review of the electronic medical record was conducted for all activations of the critical airway team. Characteristics of the activations and patients are reported using descriptive statistics. Activation of the critical airway team occurred 196 times in 46 months (March 2012 to December 2015); complete data were available for 162 activations (83%). For 49 activations (30%), patients had diagnoses associated with difficult intubation; 45 (28%) had a history of difficult laryngoscopy. Results Activation occurred at least 4 times per month on average (vs 3 per month for hospital-wide codes). The most common reasons for team activation were anticipated difficult intubation (45%) or failed intubation attempt (20%). For 79% of activations, the team performed an airway procedure, most commonly direct laryngoscopy and tracheal intubation. Bronchoscopy was performed in 47% of activations. Surgical airway rescue was attempted 4 times. Cardiopulmonary resuscitation occurred in 41 activations (25%). Twenty-nine patients died during or following team activation (18%), including 10 deaths associated with the critical airway event. Conclusion Critical airway team activation occurred at least once per week on average. Direct laryngoscopy, tracheal intubation, and bronchoscopic procedures were performed frequently; surgical airway rescue was rare. Most patients had existing risk factors for difficult intubation. Given our rate of serious morbidity and mortality, primary prevention of critical airway events will be a focus of future efforts.