Ewha Med J.  2017 Jul;40(3):115-121. 10.12771/emj.2017.40.3.115.

Retrospective Analysis of Difficult Intubation

• Lim CH
• Kim YJ
• Kim JH
• Jeong JS

• KMID: 2386388
• DOI: http://doi.org/10.12771/emj.2017.40.3.115

Abstract

OBJECTIVES
We analyzed retrospectively incidence, management, and predictors of difficult intubation, which have been known through practical cases.
METHODS
A total of 217 cases of difficult intubation (DI) between 2010 and 2014 were investigated. Risk factors such as age, body mass index, Mallampati score, thyromental distance, degree of mouth opening and range of neck motion, Cormack-Lehane grade, intubation and airway management techniques were investigated. The cases of each department were analyzed and the airway management techniques according to simplified risk scores (SRS) were also investigated.
RESULTS
The average incidence of DI was 0.49%. Patients undergoing surgery in the departments of oro-maxillo-facial surgery (1.35%), ophthalmologic surgery (0.96%), urologic surgery (0.80%), and head and neck surgery of ear-nose-throat (0.62%) showed the higher incidence of DI. Difficult mask ventilation (10 of 217, 4.6%) was occurred with DI. Higher SRS were related to high rates of video laryngoscope use and fiberoptic guided intubation. There was a decrease in the use of McCoy blades after 2013, an increase in the use of video laryngoscope, and a consistent rate of fiberoptic intubation.
CONCLUSION
It is not easy to check all the predictors of DI in a preanesthetic evaluation and the predictors are not accurate. The role of clinical preparation and practical management is important, and the most important thing is to establish a planned induction strategy. Multiple factors system, such as simplified risk factors should be used to evaluate patients to prepare for appropriate airway management techniques in case of DI.

Keyword

Airway management; Intubation; Laryngoscopy; Tracheal, Endotracheal intubation

MeSH Terms

Airway Management
Body Mass Index
Head
Humans
Incidence
Intubation*
Laryngoscopes
Laryngoscopy
Masks
Mouth
Neck
Retrospective Studies*
Risk Factors
Ventilation

Reference

1. Lundstrom LH, Moller AM, Rosenstock C, Astrup G, Gatke MR, Wetterslev J, et al. A documented previous difficult tracheal intubation as a prognostic test for a subsequent difficult tracheal intubation in adults. Anaesthesia. 2009; 64:1081–1088.

2. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. 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; 118:251–270.

3. Lundstrom LH, Vester-Andersen M, Moller AM, Charuluxananan S, L'hermite J, Wetterslev J, et al. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177,088 patients. Br J Anaesth. 2011; 107:659–667.

4. 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; 103:429–437.

5. Wilson ME. Predicting difficult intubation. Br J Anaesth. 1993; 71:333–334.

6. Yentis SM. Predicting difficult intubation: worthwhile exercise or pointless ritual? Anaesthesia. 2002; 57:105–109.

7. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984; 39:1105–1111.

8. Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R. Clinical anesthesia. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2013.

9. Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O'Reilly M, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006; 105:885–891.

10. Eberhart LH, Arndt C, Aust HJ, Kranke P, Zoremba M, Morin A. A simplified risk score to predict difficult intubation: development and prospective evaluation in 3763 patients. Eur J Anaesthesiol. 2010; 27:935–940.

11. 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; 27:815–821.

12. Ezri T, Warters RD, Szmuk P, Saad-Eddin H, Geva D, Katz J, et al. The incidence of class “zero” airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade. Anesth Analg. 2001; 93:1073–1075.

13. Lundstrom LH, Moller 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; 110:266–274.

14. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987; 42:487–490.

15. Krage R, van Rijn C, van Groeningen D, Loer SA, Schwarte LA, Schober P. Cormack-Lehane classification revisited. Br J Anaesth. 2010; 105:220–227.

16. Saito T, Liu W, Chew ST, Ti LK. Incidence of and risk factors for difficult ventilation via a supraglottic airway device in a population of 14,480 patients from South-East Asia. Anaesthesia. 2015; 70:1079–1083.

17. Moon HY, Baek CW, Kim JS, Koo GH, Kim JY, Woo YC, et al. The causes of difficult tracheal intubation and preoperative assessments in different age groups. Korean J Anesthesiol. 2013; 64:308–314.

18. Hyuga S, Sekiguchi T, Ishida T, Yamamoto K, Sugiyama Y, Kawamata M. Successful tracheal intubation with the McGrath(®) MAC video laryngoscope after failure with the Pentax-AWS™ in a patient with cervical spine immobilization. Can J Anaesth. 2012; 59:1154–1155.