Article

Airway Management Using the Intubating Laryngeal Mask Airway for the Morbidly Obese Patient

Department of Anesthesiology and Intensive Care, European Hospital Georges Pompidou, Paris, France.
Anesthesia & Analgesia (Impact Factor: 3.47). 06/2003; 96(5):1510-5, table of contents. DOI: 10.1213/01.ANE.0000057003.91393.3C
Source: PubMed
ABSTRACT
Unlabelled:
We studied the effectiveness of the intubating laryngeal mask airway (ILMA) in morbidly obese patients scheduled for bariatric surgery. We included 118 consecutive morbidly obese patients (body mass index, 45 +/- 5 kg/m(2)). After the induction of general anesthesia, the laryngeal view was classified by the first observer according to the method of Cormack and Lehane. The ILMA was then inserted, and the trachea was intubated through the ILMA by a second observer. The rate of successful tracheal intubation with ILMA was 96.3%. The success rate, the number of attempts, and the total duration of the procedure were not different among patients with low-grade (Cormack 1-2) and patients with high-grade (Cormack 3-4) laryngeal views. The time required for insertion of the ILMA was slightly longer in patients with high-grade laryngeal views. Failures of the technique were not explained by the experience of the practitioner or airway characteristics. No adverse effect related to the technique was reported. Results of this study suggest that using the ILMA provides an additional technique for airway management of morbidly obese patients.

Implications:
The intubating laryngeal mask airway (ILMA) provides an additional technique for airway management of morbidly obese patients. The best choice of the primary technique (laryngoscopy or ILMA) for tracheal intubation of an adult obese patient remains to be determined.

Full-text

Available from: Philippe Cadi, Dec 15, 2014
Airway Management Using the Intubating Laryngeal Mask
Airway for the Morbidly Obese Patient
Je´roˆme Frappier, MD, Thierry Guenoun, MD, Didier Journois, MD, Herve´ Philippe, MD,
Emma Aka,
MD, Philippe Cadi, MD, Jacqueline Silleran-Chassany, MD, and Denis Safran, MD
Department of Anesthesiology and Intensive Care, European Hospital Georges Pompidou, Paris, France
We studied the effectiveness of the intubating laryngeal
mask airway (ILMA) in morbidly obese patients sched-
uled for bariatric surgery. We included 118 consecutive
morbidly obese patients (body mass index, 45 5 kg/m
2
).
After the induction of general anesthesia, the laryngeal
view was classified by the first observer according to the
method of Cormack and Lehane. The ILMA was then in-
serted, and the trachea was intubated through the ILMA
by a second observer. The rate of successful tracheal intu-
bation with ILMA was 96.3%. The success rate, the num-
ber of attempts, and the total duration of the procedure
were not different among patients with low-grade (Cor-
mack 1–2) and patients with high-grade (Cormack 3– 4)
laryngeal views. The time required for insertion of the
ILMA was slightly longer in patients with high-grade la-
ryngeal views. Failures of the technique were not ex-
plained by the experience of the practitioner or airway
characteristics. No adverse effect related to the technique
was reported. Results of this study suggest that using the
ILMA provides an additional technique for airway man-
agement of morbidly obese patients.
(Anesth Analg 2003;96:1510–5)
A
irway management is a major factor underlying
morbidity and mortality related to anesthesia in
the morbidly obese population. Thus, a body
mass index (BMI) 26 kg/m
2
results in a 3-fold in
-
crease in difficult ventilation via a mask (1) and in a
10-fold increased incidence of difficult endotracheal
intubation (2,3). Inability to maintain a patent airway
can be problematic in the obese, because lung and
chest mechanical properties are markedly impaired in
sedated, paralyzed obese patients (4). This may ac-
count for impaired arterial oxygenation and may even
result in an unfavorable outcome.
The intubating laryngeal mask airway (ILMA; Fas-
trach™; Laryngeal Mask Co., Henley on Thames, UK)
is a specific device that allows effective ventilation and
blind tracheal intubation in patients with normal and
abnormal airways. Because of its original features (an-
atomical curve, rigid airway tube with guiding han-
dle, epiglottic elevating bar, and guiding ramp to
guide the tracheal tube), the ILMA provides better
conditions than the standard laryngeal mask for
achieving effective ventilation and tracheal intubation
(5). In an adult population with an anticipated difficult
airway, Langeron et al. (6) obtained a frequent success
rate of tracheal intubation with both the ILMA and
fiberoptic techniques. In this study, the incidence of
successful intubation, the number of attempts, and the
median time to achieve tracheal intubation were sim-
ilar with the two techniques.
Thus, the ILMA could represent an additional tech-
nique in airway management of the adult obese pa-
tient. We therefore undertook a prospective study to
assess the effectiveness of the ILMA as a primary,
electively instituted ventilatory device and intubation
guide for airway management in adult obese patients.
This study was performed on the entire consecutive
obese population scheduled for bariatric surgery, in-
cluding those with and without potential difficult in-
tubation conditions, as assessed by the usual preoper-
ative criteria.
Preoperative prediction of potential difficulty with
airway management by using individual tests, such as
a Mallampati score, seems to have a lesser value in
obese patients as compared with lean patients (2).
Consequently, anesthesia of morbidly obese patients
remains at frequent, but not foreseeable, risk of diffi-
cult mask ventilation or tracheal intubation.
The validity of readily available clinical criteria to
predict difficult intubation has been tested to stratify
the risk of difficult intubation in the adult obese pop-
ulation. We assessed the usefulness of the Mallampati
score alone or combined with other variables (3) to
Accepted for publication January 3, 2003.
Address correspondence and reprint requests to Je´roˆme Frappier,
MD, De´partement d’Anesthe´sie-Re´animation, Hoˆpital Europe´en
Georges Pompidou, 15 Rue Leblanc,75988 Paris Cedex, France. Ad-
dress e-mail to jfrappier@invivo.edu.
DOI: 10.1213/01.ANE.0000057003.91393.3C
©2003 by the International Anesthesia Research Society
1510 Anesth Analg 2003;96:1510–5 0003-2999/03
Page 1
predict difficult intubation by using the ILMA in mor-
bidly obese patients.
Methods
This study was approved by the local Human Subjects
Committee, and written, informed consent was ob-
tained from all patients. Over a 12-mo period (January
2001 to December 2001), all morbidly obese patients
(defined as a BMI 40 kg/m
2
) scheduled for bariatric
surgery requiring general anesthesia with tracheal in-
tubation were eligible for inclusion in this prospective
study. Patients were excluded if they were younger
than 18 yr, had an ASA physical status of IV or V, or
had a medical history of impossible tracheal intuba-
tion or awake fiberoptic intubation or if preoperative
evaluation showed evidence that an awake fiberoptic
intubation or a rapid-sequence induction would be
required.
All data were collected by certified anesthesiologists
on a single standardized form during the preoperative
visit, during the induction of anesthesia, and in the
postoperative period. During the preoperative visit,
the following information was collected by certified
anesthesiologists not subsequently involved in the air-
way management of the patients:
1. Demographic and morphologic data: age, sex,
weight, height, BMI (calculated as weight ex-
pressed in kilograms divided by the square of the
height expressed in meters), ASA physical status,
and surgical procedure.
2. Predicting factors for difficult tracheal intuba-
tion, as defined in the French Society of Anesthe-
siologists guidelines on management of the dif-
ficult intubation (7).
The visibility of oropharyngeal structures was as-
sessed with the patient in the sitting position, with the
head in a neutral position, with the tongue fully pro-
truding, and without phonation, according to the Mal-
lampati classification (8) as modified by Samsoon and
Young (9). Mouth opening (MO) in patients with an-
terior teeth was recorded as the interincisor gap and
was measured (in millimeters) with the mouth fully
opened. In edentulous patients, the intergingival dis-
tance with the mouth fully opened was recorded. Thy-
romental distance (TMD) was measured (in millime-
ters) along a straight line from the thyroid notch to the
most anterior part of the chin with the head fully
extended. Cervical spine extension was categorized as
90° (normal), 80°–90° (correct), or 80° (limited or
fixed). A history of anticipated or unanticipated diffi-
culties with tracheal intubation was also recorded.
Additional factors possibly related to difficult tracheal
intubation in obese patients, such as a short neck or a
history of sleep apnea obstructive syndrome, were
also collected.
Before the induction of anesthesia, preoxygen-
ation through an adequately sized facial mask with
100% oxygen during 5 min was performed for all
patients. Anesthesia was induced with IV propofol
(2.53 mg/kg). After effective mask ventilation was
demonstrated, sufentanil (0.2
g/kg) and atra-
curium (0.4 0.6 mg/kg) were injected to obtain sat-
isfactory intubation conditions. The occurrence of
difficult mask ventilation was a reason for stopping
the procedure. The patient was then managed ac-
cording to the recommendations of the French So-
ciety of Anesthesiologists (7).
Two different observers were involved in the
study. Mask ventilation and direct laryngoscopy
with a Macintosh No. 4 blade were performed by
the attending anesthesiologist. We defined difficult
mask ventilation as an inability to obtain chest
excursion sufficient to maintain a clinically accept-
able capnogram wave form, despite optimal head
and neck positioning and use of an oral airway and
optimal application of a face mask.
The laryngeal view was graded according to the
method described by Cormack and Lehane (10) as
Grade 1 (full view of the glottis), Grade 2 (glottis
partly exposed, anterior commissure not seen), Grade
3 (only epiglottis seen), or Grade 4 (epiglottis not seen)
and was blinded to the second physician or nurse
anesthetist inserting the ILMA device. Grade III and
IV laryngeal views were considered as representing
progressively more difficult conditions for tracheal
intubation (1013). Tracheal intubation with the ILMA
was performed, as previously described (5), by staff
anesthesiologists, including experienced (defined as a
personal experience of five or more insertions of the
ILMA) and inexperienced (fewer than five insertions
of the ILMA) anesthesiologists. All the practitioners
were trained for the ILMA insertion before the study
by using an intubation mannequin. The initial size for
the ILMA was selected according to the patientsMO
and height. A Size 4 or 5 and a 7.5- or 8-mm straight-
cuffed silicone tube included in the ILMA set (SEBAC,
Pantin, France) were usually chosen. Failure of the
ILMA technique was defined as three unsuccessful
attempts during either laryngeal mask insertion or
tracheal intubation.
The following data were collected for each patient:
laryngeal view classified according to the method of
Cormack and Lehane (attending anesthesiologist), ex-
perience of the second anesthesiologist or certified
nurse anesthetist for the ILMA, duration time for in-
sertion of the laryngeal mask, total duration of the
ILMA insertion, the number of attempts for laryngeal
mask insertion, and tracheal intubation through the
laryngeal mask. Systolic, diastolic, and mean arterial
blood pressure and heart rate were recorded during
the procedure. Arterial oxygenation during the mask
ventilation, laryngoscopy, and ILMA insertion was
ANESTH ANALG FRAPPIER ET AL. 1511
2003;96:15105 INTUBATING LARYNGEAL MASK AIRWAY IN OBESE PATIENTS
Page 2
assessed by pulse oximetry. According to the hemo-
globin dissociation curve, a decrease in arterial oxygen
saturation can reflect arterial hypoxemia. Mild hypox-
emia was defined as an Spo
2
value 95% for more
than 1 min, whereas an Spo
2
value 90% for more
than 1 min reflected severe hypoxemia. Bleeding
and/or pharyngeal postoperative pain due to the la-
ryngeal mask was also documented.
Data are expressed as mean sd or median with
interquartile range for nongaussian variables. Com-
parison of two or more medians was performed with
the Mann-Whitney U-test or the Kruskal-Wallis test
when appropriate. A P value 0.05 was required to
reject the main null hypothesis.
Sensitivity, specificity, and positive and negative
predictive values were calculated, by using the stan-
dard formulas, to assess the accuracy of two tests to
predict difficult intubation, defined as a Cormack
grade of 3 or 4. Each airway assessment variable was
stratified into risk categories. A patient with a Mal-
lampati score of I or II was a priori considered as a low
risk for difficult intubation, whereas a patient with a
Mallampati score of III or IV was considered as high
risk.
The simplified airway risk index (SAR index) de-
scribed by El-Ganzouri et al. (3) assigned a value of 0,
1, or 2 to the following risk factors: MO (35 mm, 0;
35 mm, 1), TMD (65 mm, 0; 60 65 mm, 1; 60 mm,
2), Mallampati score (I, 0; II, 1; III or IV, 2), cervical
spine extension (90°,0;80°–90°,1;80°, 2), body
weight (90 kg, 0; 90110 kg, 1; 110 kg, 2), and
history of difficult intubation (none, 0; questionable, 1;
definite, 2). A SAR score 4 categorized the patient as
at risk for difficult intubation.
Results
A total of 118 patients were enrolled in the study.
Patient characteristics, including demographic and
medical data, are reported in Table 1. The large pro-
portion (84%) of female patients is usual in patients
undergoing bariatric surgery. The ILMA intubations
were performed by 22 staff anesthesiologists or nurse
anesthetists. Complete ILMA intubation was success-
ful in 114 cases (96.7%). The four patients in whom
ILMA intubation failed were successfully intubated
with the Macintosh blade. Failures were always re-
lated to unsuccessful attempts to pass the tracheal
tube through the trachea. Three of these patients ex-
hibited laryngoscopy Grade 1 or 2, whereas one pa-
tient had Grade 3 laryngoscopy. There was no difficult
mask ventilation, as previously defined. Mild hypox-
emia occurred in 37 patients before the laryngeal mask
insertion, but no episode of severe arterial hypoxemia
was observed.
Tracheal intubation with ILMA was not different in
obese patients with high (3 or 4) Cormack grades, as
compared with obese patients with normal laryn-
geal views (Cormack Grades 1 or 2), even if the me-
dian duration time for laryngeal mask insertion ap-
pears to be longer (41 versus 30 s) in patients with high
grades as compared with patients with low-grade la-
ryngeal views (Table 2). No difference was found be-
tween experienced and inexperienced practitioners for
the ILMA insertion with respect to the duration time
required in achieving laryngeal mask insertion or tra-
cheal intubation (Figs. 1 and 2).
Compared with Mallampati Class IIIIV, applying
the SAR index at a value of 4 for stratification of
difficulty with laryngeal visualization results in the
same predictive values with greater sensitivity ( 68%
versus 47%) but lower specificity (53% versus 71%;
Table 3). No hemodynamic instability during either
laryngoscopy or ILMA insertion was observed. Tran-
sient pharyngeal pain was noticed in two patients in
the postoperative period, and mild bleeding was
found in 20 patients, as usual after the laryngeal mask
removal.
Discussion
The ILMA device ensures a frequent incidence of tra-
cheal intubation (96.7%) in a population of morbidly
obese patients. However, 16% of patients exhibited
Cormack 3 4 laryngeal views, suggesting difficulties
with tracheal intubation with a Macintosh blade. In
this study, tracheal intubation through the ILMA was
generally achieved in two minutes, with most patients
intubated at the first attempt.
Table 1. General Characteristics, Criteria for Anticipated
Difficult Intubation, and Anesthetic Requirements of the
Subjects Included in the Study
Variable Data
Age (yr) 40 10
Sex (M/F) 19/99
Height (cm) 166 8
Weight (kg) 125 17
Body mass index (kg/m
2
)
45 5
Mallampati class
I 30 (25)
II 50 (42)
III 34 (29)
IV 4 (3)
Mouth opening (mm) 45 (4050)
Thyromental distance (mm) 80 (7090)
Head and neck movement
90° 51 (43)
80°–90° 54 (46)
80° 13 (11)
Propofol (mg) 350 (300400)
Sufentanil (
g) 20 (1520)
Atracurium (mg) 50 (5050)
Data are expressed as mean sd, n (%), or median (25%75% confidence
interval). Because of rounding, adding percentages may not provide a sum of
100%.
1512 FRAPPIER ET AL. ANESTH ANALG
INTUBATING LARYNGEAL MASK AIRWAY IN OBESE PATIENTS 2003;96:1510 5
Page 3
The main factors related to failed or difficult in-
tubation (preoperative clinical criteria used to pre-
dict difficult intubation, poor visualization of the
glottic aperture during laryngoscopy) did not affect
the success rate of blind tracheal intubation. Thus,
airway management with the ILMA device in obese
patients may be considered as valuable and comple-
mentary to conventional laryngoscopy. The efficacy
of the ILMA as a primary, electively instituted ven-
tilatory device and intubation guide for airway
management of a homogeneous group of morbidly
obese patients has not been studied. A previous
study suggested that tracheal intubation was easier
in the abnormal than in the normal airway, because
the anterior larynx, representing more difficult
conditions for tracheal intubation, facilitated a bet-
ter alignment of the ILMA and glottic aperture (5).
Because an anterior larynx is a common airway
characteristic in morbidly obese patients, the ILMA
may represent a primary means of establishing an
airway in this group of patients.
The level of clinician experience for this technique
does not seem to influence either the mean duration or
the number of attempts required to achieve adequate
ventilation or tracheal intubation. Thus, airway manage-
ment with the ILMA is easily achieved, even by inexpe-
rienced practitioners in obese patients in whom difficult
mask ventilation and tracheal intubation is common.
Our findings agree with those previously published,
suggesting a rapid learning curve for this technique (14).
Table 2. Comparison of Patients Intubated with the Intubating Laryngeal Mask Airway (ILMA) According to Their
Laryngeal View
Variable
Cormack
Grade 12
Cormack
Grade 34 P value
No. of patients 99 (84) 19 (16)
Spo
2
95%
29 (29) 8 (42) 0.51
Number of attempts for the ILMA 1 (11) 1 (11) 0.46
Time to insert the ILMA (s) 30 (2440) 41 (3060) 0.04
Number of attempts for blind intubation 1 (11) 1 (11) 0.55
Total duration (s) 120 (94171) 122 (120180) 0.61
Data are expressed as mean sd, n (%), or median (25%75% confidence interval).
Figure 1. Influence of the practitioners experience on the total time required to achieve tracheal intubation with the intubating laryngeal
mask airway (ILMA) device. Data are expressed as median, minimal, and maximal values and 25%75% confidence intervals.
ANESTH ANALG FRAPPIER ET AL. 1513
2003;96:15105 INTUBATING LARYNGEAL MASK AIRWAY IN OBESE PATIENTS
Page 4
The effectiveness of the Mallampati score and the
SAR index to predict difficult laryngoscopy in obese
patients is not the same. In our study, more than 50%
of the difficult laryngoscopies were not detected by
the Mallampati assessment. In contrast, the multivar-
iate SAR index, which combines several airway risk
factors, afforded a much greater ability to discriminate
the actual occurrence of Grade 3 4 laryngeal views.
Our estimates of positive predictive values, based on a
small number of patients, have to be interpreted with
caution. Preoperative assessment of the airway may
facilitate appropriate preparation when difficulty with
ventilation or tracheal intubation is anticipated before
initiation of anesthesia. Much information has been
published on preoperative risk factors, such as MO,
Mallampati classification, head and neck movement or
TMD, or a history of difficult intubation. The accuracy
of these preoperative tests used alone is poor, showing
low sensitivity and positive predictive value but good
specificity and negative predictive value (3,13,15). The
combination of theses variables, providing a multivar-
iate model for stratifying risk of difficult tracheal in-
tubation, seems to improve prediction of difficult in-
tubation in obese patients (3).
Our findings suggest the ease of establishing an
airway with the ILMA device in obese patients. Diffi-
cult mask ventilation is more common in the obese
patient (1). A reduced posterior airway space behind
the base of the tongue, together with an increased
BMI, and upper airway obstruction after the induction
of general anesthesia can cause major collapse of the
pharynx and may explain difficult mask ventilation in
these patients. In our group of morbidly obese pa-
tients, ventilation through the ILMA was easily
achieved without arterial hypoxemia. Further studies
are needed to assess the effectiveness of the ILMA as
an effective primary means of establishing an airway
when difficult mask ventilation occurs.
Despite the unquestionable effectiveness of this de-
vice in achieving ventilation and tracheal intubation in
morbidly obese patients, the ILMA device cannot be
Figure 2. Influence of the practitioners experience on the time for laryngeal mask insertion with the intubating laryngeal mask airway (ILMA)
device. Data are expressed as median, minimal, and maximal values and 25%75% confidence intervals.
Table 3. Sensitivity, Specificity, and Predictive Values for
Mallampati Score and Simplified Airway Index (SAR
Index)
Variable
Mallampati
score
SAR
index
Sensitivity (%) 47 68
Specificity (%) 71 53
Positive predictive value (%) 24 22
Negative predictive value (%) 88 90
A Mallampati score of III or IV and a SAR index of 4 are predictors of,
and laryngoscopy Grade 3 or 4 is a diagnosis of, difficult intubation.
1514 FRAPPIER ET AL. ANESTH ANALG
INTUBATING LARYNGEAL MASK AIRWAY IN OBESE PATIENTS 2003;96:1510 5
Page 5
recommended as a routine airway for use during gen-
eral anesthesia in this group of patients. The incidence
of difficult intubation in these patients is 10%15%
(2,3); the incidence of failure to intubate is unknown.
In the general population, the incidence of failure to
intubate varies from 0.05% to 0.35% (9,10). Conse-
quently, the incidence of failed intubation with the
ILMA in our study (3.3%) is probably not less than
that expected with rigid laryngoscopy in an obese
patient. In a retrospective study of morbidly obese
patients anesthetized between January and December
of 1999 in our institution, the incidence of failed intu-
bations with laryngoscopy was 1.7% (data not shown).
Furthermore, no clearly defined algorithm has been
described for when blind intubation fails, even if pas-
sage of a fiberoptic bronchoscope through the laryn-
geal mask airway is nearly 100% successful in most
series (16).
In summary, this study indicates that the ILMA is
an effective and safe ventilatory device and blind in-
tubation guide in morbidly obese patients. The choice
of the primary technique (laryngoscopy or ILMA) for
tracheal intubation of an adult obese patient remains
to be determined.
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Page 6
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