Difficult Tracheal Intubation Is More Common in Obese Than in Lean Patients

Hôpital Bichat - Claude-Bernard (Hôpitaux Universitaires Paris Nord Val de Seine), Lutetia Parisorum, Île-de-France, France
Anesthesia & Analgesia (Impact Factor: 3.47). 08/2003; 97(2):595-600, table of contents. DOI: 10.1213/01.ANE.0000072547.75928.B0
Source: PubMed


Whether tracheal intubation is more difficult in obese patients is debatable. We compared the incidence of difficult tracheal intubation in obese and lean patients by using a recently validated objective scale, the intubation difficulty scale (IDS). We studied 134 lean (body mass index, <30 kg/m2) and 129 obese (body mass index, >or=35 kg/m2) consecutive patients. The IDS scores, categorized as difficult intubation (IDS >or=>5) or not (IDS <5), and the patient data, including oxygen saturation (SpO2) while breathing oxygen, were compared between lean and obese patients. In addition, risk factors for difficult intubation were determined in obese patients. The IDS score was >or=5 in 3 lean and 20 obese patients (P = 0.0001). A Mallampati score of III-IV was the only independent risk factor for difficult intubation in obese patients (odds ratio, 12.51; 95% confidence interval, 2.01-77.81), but its specificity and positive predictive value were 62% and 29%, respectively. SpO2 values noted during intubation were (mean +/- SD) 99% +/- 1% (range, 91%-100%) and 95% +/- 8% (range, 50%-100%) in lean and obese patients, respectively (P < 0.0001). We conclude that difficult intubation is more common among obese than nonobese patients. None of the classic risk factors for difficult intubation was satisfactory in obese patients. The high risk of desaturation warrants studies to identify new predictors of difficult intubation in the obese. IMPLICATIONS: We report a difficult intubation rate of 15.5% in obese patients and 2.2% in lean patients. None of the risk factors for difficult intubation described in the lean population was satisfactory in the obese patients. We also report a high risk of desaturation in obese patients with difficult intubation.

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    • "Obesity is defined as having a BMI higher than 30 kg m-2. Due to massive adipose tissue presence, oral opening and jaw movement limitations and tightening in pharyngeal distance are seen in obese patients.15 Endotracheal intubation is more difficult in obese patients and pregnant women in comparison to patients with normal body weight.8,16,17 "
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    ABSTRACT: Objective: The aim of this study was to compare clinical screening tests (modified Mallampati score, Cormack-Lehane score, thyromental distance, and sternomental distance) with ultrasonic measurements of the upper airway in predicting difficult intubation in pregnant women whose Body Mass Index (BMI) is higher and lower than 30 kg m-2. Methods: This study was designed as a prospective observational trial, and consisted of 40 pregnant women of American Society of Anesthesiologists (ASA) 1-2 groups. Patients with a BMI lower than 30 kg m-2 were included in Group 1 (n=20), and patients with a BMI higher than 30 kg m-2 were included in Group 2 (n=20). In the supine position with head in mild extension, the diameter of the transverse tracheal air shadow in the subglottic area of the front neck was measured using ultrasonography. Modified Mallampati score, Cormack-Lehane score, thyromental distance and sternomental distance measurements were recorded. Results: No statistically significant difference was detected between groups regarding mean age, mean number of pregnancy, ASA scores and comorbid disease. Mean body weight (p=0.0001) and mean pre-pregnancy weight (p=0.0001) were significantly higher in Group 2. There was no statistically significant difference between groups regarding mean modified Mallampati score, thyromental distance, sternomental distance measurements, Cormack-Lehane score, and mean ultrasonic measurements. Conclusion: It was found that BMI higher or lower than 30 kg m-2 has no effect on ultrasonic measurements and clinical airway tests. We thought that ultrasonic measurement could not give us valuable information in obese or non-obese pregnant women.
    Full-text · Article · Feb 2014 · Pakistan Journal of Medical Sciences Online
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    • "The elevated risk for emergency and elective caesarean section in overweight women is supported by many large studies [14,35,36]. This goes along with peri-operative problems such as the placement of an epidural catheter or tracheal tube in obese patients [37]. For example, a six-year review of failed intubation in 36 obstetric patients out of 8970 (incidence 1:249) general anaesthetics, showed an average BMI of 33 in the UK [38]. "
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    ABSTRACT: To investigate the association between overweight and severe acute maternal morbidity (SAMM) in a low-risk pregnant population. Nationwide case-control study. The Netherlands, august 2004 to august 2006. 1567 cases from initially primary care and 2994 women from primary care practices as controls, out of 371 012 women delivering in the Netherlands during the study period. Cases were women with SAMM obtained from a nationwide prospective study. All women in this cohort who initially had low-risk pregnancies were compared with low-risk women without SAMM to calculate odd ratios (ORs) to develop SAMM by body mass index (BMI) category. We divided body mass index in three overweight categories and calculated the ORs (95% CI) of total SAMM and per specific endpoint by logistic regression, with normal weight as reference. We adjusted for age, parity and socio-economic status. SAMM, defined as Intensive Care Unit (ICU)-admission, Uterine Rupture, Eclampsia or Major Obstetric Haemorrhage (MOH). SAMM was reported in 1567 cases which started as low-risk pregnancies. BMI was available in 1097 (70.0%) cases and 2994 control subjects were included. Analysis showed a dose response relation for overweight (aOR, 1.3; 95% CI, 1.0-1.5), obese (aOR, 1.4; 95% CI, 1.1-1.9) and morbidly obese (aOR, 2.1; 95% CI, 1.3-3.2) women to develop SAMM compared to normal weight. Sub analysis showed the same dose response relation for ICU-admission, Uterine Rupture and Eclampsia. We found no association for MOH. Overweight without pre-existent co-morbidity is an important risk-indicator for developing SAMM. This risk increases with an increasing body mass index.
    Full-text · Article · Sep 2013 · PLoS ONE
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    • "Often, facemask ventilation and maintenance of adequate oxygenation is far more likely to be an issue. Several studies have shown that BMI alone is not a risk factor for difficult tracheal intubation, that is, the most severely overweight were not more difficult to intubate than other patients [8,16,17]. The strongest predictors of difficult intubation are: 1) male gender; 2) large neck circumference [8,18]; 3) limited neck mobility; 4) crowded mouth, as indicated by a high Mallampati score [8,18]; and 5) obstructive sleep apnea. "
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    ABSTRACT: Background As a result of the increasing prevalence of obesity in the UK, anesthetists are increasingly encountering overweight and obese patients in routine practice. There is currently a paucity of evidence to guide best clinical practice for anesthetists managing overweight and obese patients. The current guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI), entitled Peri-Operative Management of the Morbidly Obese Patient, give an excellent overview of organizational issues, but leave much clinical detail to the discretion of the individual clinician. Methods In May 2010, a panel of experts convened to develop consensus on anesthesia of overweight, obese and morbidly obese patients, in consultation with the Society for Obesity and Bariatric Anaesthesia (SOBA). All Panel members are practicing clinicians from recognized bariatric surgical training centers and have extensive experience of anesthesia for obese patients. This statement aims to provide guiding principles on best practice for this challenging patient demographic, and to increase awareness of current issues so that these can be addressed more appropriately. Results In this document, we emphasize key principles for best practice, rather than giving prescriptive guidance and specific regimens for all clinical eventualities. We provide evidence-based justification for best-practice techniques, where this exists. In areas for which there is no evidence, but there is clear consensus, we offer this as guidance. We also aim to dispel misconceptions that have arisen in the anesthetic practice of overweight, obese, and morbidly obese patients. Conclusion Ultimately, the choice of specific technique depends on clinician experience, patient characteristics, and center facilities. As well as providing guiding principles for anesthesia, this consensus statement also highlights other areas where anesthetists can contribute towards the enhanced recovery and overall quality of patient care.
    Full-text · Article · Jun 2013
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