Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ASCO Annual Meeting 2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

2024 ASCO Annual Meeting

Keep up to date with all the top stories and latest evidence with our hub page, including official congress videos and expert takeaways.
ADVANCED SEARCH
Log in
Top
BMC Anesthesiology
Published in: BMC Anesthesiology 1/2018

Open Access 01-12-2018 | Research article

The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis

Authors: Tingting Wang, Shen Sun, Shaoqiang Huang

Published in: BMC Anesthesiology | Issue 1/2018

Login to get access

Abstract

Background

Obesity is a serious disorder and may bring about many difficulties of perioperative management. A systematic review was conducted to assess the association between obesity and difficult intubation.

Methods

We searched electronic databases for related reviews and references of meta-analyses on August 14, 2017. The databases of PubMed, Embase, and the Cochrane controlled trials register were searched compared obese with non-obese patients in which difficult intubation rate of the adult population were retrieved. Patients with a BMI ≥ 30 kg·m− 2 were considered obese. The primary outcome was difficult tracheal intubation; secondary outcomes were the rates of difficult laryngoscopy and Mallampati score ≥ 3. This review included papers published from 1998 to 2015.

Results

This review included 204,303 participants in 16 studies. There was a statistically significant association between obesity and risk of difficult tracheal intubation (pooled RR = 2.04, 95% CI: 1.16–3.59, p = 0.01; I2 = 71%, p = 0.008, Power = 1.0). It also showed significantly association between obesity and risk of difficult laryngoscopy (pooled RR = 1.54, 95% CI: 1.25–1.89, p < 0.0001; I2 = 45%, p = 0.07, Power = 1.0), obesity and risk of Mallampati score ≥ 3 (pooled RR = 1.83, 95% CI: 1.24–2.69, p = 0.002; I2 = 81%, p < 0.00001, Power = 0.93). However, there were no association of obesity and risks of difficult intubation compared with non-obesity in the cohort studies (pooled RR = 3.41, 95% CI: 0.88–13.23, p = 0.08; I2 = 50%, p = 0.14) and the elective tracheal intubation (pooled RR = 2.31, 95% CI: 0.76–6.99, p = 0.14; I2 = 73%, p = 0.01), no associated with an increased risk of difficult laryngoscopy in the sniffing position (pooled RR = 2.00, 95% CI: 0.97–4.15, p = 0.06; I2 = 67%, p = 0.03).

Conclusion

Obesity was associated with an increased risk of difficult intubation, difficult laryngoscopy and Mallampati score ≥ 3 in adults patients undergoing general surgical procedures. However, there were no association of obesity and risks of difficult intubation compared with non-obesity in the cohort studies and the elective tracheal intubation, no associated with an increased risk of difficult laryngoscopy in the sniffing position. Future analyses should explore the association of BMI and difficult airway.
Literature
1.
Wollner M, Paulo Roberto BB, Alysson Roncally SC, Jurandir N, Edil LS. Accuracy of the WHO's body mass index cut-off points to measure gender- and age-specific obesity in middle-aged adults living in the city of Rio de Janeiro, Brazil. J Public Health Res. 2017;21:904.
2.
Wahlqvist ML, Krawetz SA, Rizzo NS, Dominguez-Bello MG, Szymanski LM, Barkin S, et al. Early-life influences on obesity: from preconception to adolescence. Ann N Y Acad Sci. 2015;1347:1–28.CrossRefPubMedPubMedCentral
3.
4.
Johnston KD, Rai MR. Conscious sedation for awake fibreoptic intubation: a review of the literature. Can J Anaesth. 2013;60:584–99.CrossRefPubMed
5.
Ahmadi K, Ebrahimi M, Hashemian AM, Sarshar S, Rahimi-Movaghar V. GlideScope video laryngoscope for difficult intubation in emergency patients: a quasi-randomized controlled trial. Acta Med Iran. 2015;53:738–42.PubMed
6.
Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429–37.CrossRefPubMed
7.
Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, Fourcade O. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008;106:1132–6.CrossRefPubMed
8.
Mashour GA, Kheterpal S, Vanaharam V, Shanks A, Wang LY, Sandberg WS, et al. The extended Mallampati score and a diagnosis of diabetes mellitus are predictors of difficult laryngoscopy in the morbidly obese. Anesth Analg. 2008;107:1919–23.CrossRefPubMed
9.
Henderson J. Airway management in the adult. In: Miller RD, editor. Miller’s anesthesia. 2nd ed. Philadelphia: Churchill Livingstone Elsevier; 2010. p. 1573–610.CrossRef
10.
Chou HC, Wu TL. A reconsideration of three axes alignment theory and sniffing position. Anesthesiology. 2002;97:753–4.CrossRefPubMed
11.
Practice guidelines for management of the difficult airway. A report by the American society of anesthesiologists task force on management of the difficult airway. Anesthesiology. 1993;78:597–602.CrossRef
12.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A, American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251–70.CrossRefPubMed
13.
Adnet F, Borron SW, Racine SX, et al. The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology. 1997;87:1290–7.CrossRefPubMed
14.
Lavi R, Segal D, Ziser A. Predicting difficult airways using the intubation difficulty scale: a study comparing obese and non-obese patients. J Clin Anesth. 2009;21:264–7.CrossRefPubMed
15.
Cormack RS, Lehane J. Difficult tracheal intubation in obstretrics. Anaesthesia. 1984;39:1105–11.CrossRefPubMed
16.
Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429–34.CrossRefPubMed
17.
Sterne JA, Higgins JP, Reeves BC, on behalf of the development group for ROBINS-I. ROBINS-I: a tool for assessing Risk Of Bias In Non-randomized Studies of Interventions, Version 7, March, 2016.
18.
Greenland S. Quantitative methods in the review of epidemiologic literature. Epidemiol Rev. 1987;9:1–30.CrossRefPubMed
19.
Adnet F, Baillard C, Borron SW, Denantes C, Lefebvre L, Galinski M, et al. Randomized study comparing the “sniffing position” with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology. 2001;95:836–41.CrossRefPubMed
20.
Polanin JR, Pigott TD. The use of meta-analytic statistical significance testing. Res Synth Methods. 2015;6:63–73.CrossRefPubMed
21.
Faul F, Erdfelder E, Lang AG, Buchner A. G*power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–91.CrossRefPubMed
22.
Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009;41:1149–60.CrossRefPubMed
23.
Dargin JM, Emlet LL, Guyette FX. The effect of body mass index on intubation success rates and complications during emergency airway management. Intern Emerg Med. 2013;8:75–82.CrossRefPubMed
24.
Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600.CrossRefPubMed
25.
Basaranoglu G, Columb M, Lyons G. Failure to predict difficult tracheal intubation for emergency caesarean section. Eur J Anaesthesiol. 2010;27:947–9.CrossRefPubMed
26.
Ezri T, Medalion B, Weisenberg M, Szmuk P, Warters RD, Charuzi I. Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anaesth. 2003;50:179–83.CrossRefPubMed
27.
Heinrich S, Birkholz T, Irouschek A, Ackermann A, Schmidt J. Incidences and predictors of difficult laryngoscopy in adult patients undergoing general anesthesia: a single-center analysis of 102,305 cases. J Anesth. 2013;27:815–21.CrossRefPubMed
28.
Lee SL, Hosford C, Lee QT, Parnes SM, Shapshay SM. Mallampati class, obesity, and a novel airway trajectory measurement to predict difficult laryngoscopy. Laryngoscope. 2015;125:161–6.CrossRefPubMed
29.
Voyagis GS, Kyriakis KP, Dimitriou V, Vrettou I. Value of oropharyngeal Mallampati classification in predicting difficult laryngoscopy among obese patients. Eur J Anaesthesiol. 1998;15:330–4.CrossRefPubMed
30.
Magalhães E, Oliveira Marques F, Sousa Govêia C, Araújo Ladeira LC, Lagares J. Use of simple clinical predictors on preoperative diagnosis of difficult endotracheal intubation in obese patients. Braz J Anesthesiol. 2013;63:262–6.CrossRefPubMed
31.
Turkay Aydogmus M, Erkalp K, Nadir Sinikoglu S, Usta TA, O ULger G, Alagol A. Is ultrasonic investigation of transverse tracheal air shadow diameter reasonable for evaluation of difficult airway in pregnant women: a prospective comparative study. Pak J Med Sci. 2014;30:91–5.PubMedPubMedCentral
32.
Aslani A, Husarova V, Ecimovic P, Loughrey J, McCaul C. Anaesthetic outcomes in obese parturients: the effect of assessment in the high-risk clinic. Ir J Med Sci. 2012;181:93–7.CrossRefPubMed
33.
Combes X, Sauvat S, Leroux B, Dumerat M, Sherrer E, Motamed C, Brain A, D'Honneur G. Intubating laryngeal mask airway in morbidly obese and lean patients: a comparative study. Anesthesiology. 2005;102:1106–9.CrossRefPubMed
34.
Yildiz TS, Ozdamar D, Arslan I, Solak M, Toker K. The LMA CTrach™ in morbidly obese and lean patients undergoing gynecological procedures: a comparative study. J Anesth. 2010;24:849–53.CrossRefPubMed
35.
Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Wetterslev J. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology. 2009;110:266–74.
36.
Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987;42:487–90.
37.
Koenig S. Pulmonary complications of obesity. Am J Med Sci. 2001;321:249–79.
38.
Dixon B, Dixon J, Carden J, Burn A, Schachter L, Playfair J, Laurie C, O’Brien P. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102:1110–5.
39.
Kabon B, Nagele A, Reddy D, Eagon C, Fleshman J, Sessler D, Kurz A. Obesity decreases perioperative tissue oxygenation. Anesthesiology. 2004;100:274–80.
40.
Farmery A, Roe P. A model to describe the rate of oxyhaemoglobin desaturation during apnoea. Brit J Anaesth. 1996;76:284–91.
41.
Benumof J, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology. 1997;87:979–82.
42.
Miller RD: Endotracheal intubation, Anesthesia, 5th edition. Edited by Miller RD. Philadelphia: Churchill Livingstone, 2000, pp 1426–36.
43.
Benumof JL: Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single-lumen tube), Airway Management, Principles and Practices. Edited by Benumof JL. St Louis, Mosby, 1996, pp 261–76.
44.
Adnet F, Borron SW, Lapostolle F, Lapandry C: The three axis alignment theory and the “sniffing position”: Perpetuation of an anatomical myth? Anesthesiology. 1999;91:1964–5.
45.
Adnet F, Borron SW, Dumas JL, Lapostolle F, Cupa M, Lapandry C: Study of the “sniffing position” by magnetic resonance imaging. Anesthesiology. 2001;94:83–6.
46.
Bannister FB, Macbeth RG: Direct laryngoscopy and tracheal intubation. Lancet. 1944;2:651–4.
47.
 Jain D. Can positioning alter the success of endotracheal intubation in obese? Braz J Anesthesiol. 2014;64:216.
Metadata
Title
The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis
Authors
Tingting Wang
Shen Sun
Shaoqiang Huang
Publication date
01-12-2018
Publisher
BioMed Central
Published in
BMC Anesthesiology / Issue 1/2018
Electronic ISSN: 1471-2253
DOI
https://doi.org/10.1186/s12871-018-0534-4

Other articles of this Issue 1/2018

BMC Anesthesiology 1/2018 Go to the issue

Research article

Bispectral index to guide induction of anesthesia: a randomized controlled study

Research article

RETRACTED ARTICLE: Effect of perioperative infusion of Dexmedetomidine combined with Sufentanil on quality of postoperative analgesia in patients undergoing laparoscopic nephrectomy: a CONSORT-prospective, randomized, controlled trial

Research article

Analgesic effect of Ropivacaine combined with Dexmedetomidine on brachial plexus block

Review

High flow nasal therapy in perioperative medicine: from operating room to general ward

Research article

Does fentanyl or remifentanil provide better postoperative recovery after laparoscopic surgery? a randomized controlled trial

Research article

Dexmedetomidine infusion as an analgesic adjuvant during laparoscopic сholecystectomy: a randomized controlled study