Pre-epiglottic Space and Epiglottis to Vocal Cord Ratio in Order to Predict Difficult Intubation in Adults: A Multivariate Analysis
Abstract
Objective: We aimed to enhance the prediction of difficult intubation by using ultrasonographic parameters (pre-epiglottic space (Pre-E), distance between epiglottis to middle part of vocal cord (E-VC) and Pre-E/E-VC) adjusting for traditional airway assessments.
Material and Methods: This prospective cohort study was conducted at a super-tertiary care hospital in Thailand. Participants aged 18-65 years with ASA classification I-III and who required general anesthesia with endotracheal intubation were included. Preoperative traditional and ultrasonographic airway assessments were performed by two investigators. The outcome was difficult intubations as diagnosed by laryngoscopic view grade 3 or 4. Multivariate logistic regression was used to identify predictors for difficult intubation presented by adjusted odds ratio (OR) and 95% confidence interval (CI).
Results: A total of 94 patients were recruited. The incidence of difficult intubation was 15%. The median Pre-E/E-VC ratio among this group was 0.8 compared with 1.0 in the control group (p-value 0.124). The cut-off point of <1.0 of Pre- E/E-VC was not associated with difficult intubation after adjusting for sex and other traditional parameters (p-value 0.11). Predictors of difficult intubation were female sex (OR [95% CI]: 13.8 [2.8, 68.3]), sternomental distance ≤175 mm (OR [95% CI]: 11.6 [1.9, 71.4]) and interincisor gap <4 cm (OR [95% CI]: 19.8 [1.1, 373.8]) with the area under the receiver operating characteristic curve at 0.88 and a specificity of 90.0%.
Conclusion: There was no association between the Pre-E/E-VC in predicting difficult intubation in low-risk patients. The ultrasonographic measurements of Pre-E/E-VC were not helpful in predicting difficult intubations in our setting. Trial registration: thaiclinicaltrials.org: TCTR20180115002, Registered 9 January 2018 - Prospectively registered, https:// www.thaiclinicaltrials.org/#
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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.
Langenstein H, Cunitz G. Die schwierige Intubation beim Erwachsenen [Difficult intubation in adults]. Anaesthesist 1996;45:372-83.
Bajracharya GR, Truong AT, Truong DT, Cata JP. Ultrasoundassisted evaluation of the airway in clinical anesthesia practice: past, present and future. Int J Anesthesiol Pain Med 2015;1:1-2.
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.
Gupta D, Srirajakalidindi A, Ittiara B, Apple L, Toshniwal G, Haber H. Ultrasonographic modification of Cormack Lehane classification for pre-anesthetic airway assessment. Middle East J Anaesthesiol 2012;21:835-42.
Reddy PB, Punetha P, Chalam KS. Ultrasonography - A viable tool for airway assessment. Indian J Anaesth 2016;60:807-13.
Soltani Mohammadi S, Saliminia A, Nejatifard N, Azma R. Usefulness of ultrasound view of larynx in pre-anesthetic airway assessment: a comparison with Cormack-Lehane classification during direct laryngoscopy. Anesth Pain Med 2016;6:e39566. doi: 10.5812/aapm.39566.
Rana S, Verma V, Bhandari S, Sharma S, Koundal V, Chaudhary SK. Point-of-care ultrasound in the airway assessment: a correlation of ultrasonography-guided parameters to the Cormack-Lehane classification. Saudi J Anaesth 2018;12:292-6.
Patel B, Khandekar R, Diwan R, Shah A. Validation of modified Mallampati test with addition of thyromental distance and sternomental distance to predict difficult endotracheal intubation in adults. Indian J Anaesth 2014;58:171-5.
Srinivasan C, Kuppuswamy B. Comparison of validity of airway assessment tests for predicting difficult intubation. Indian Anaesth Forum 2017;18:63-8.
Eiamcharoenwit J, Itthisompaiboon N, Limpawattana P, Suwanpratheep A, Siriussawakul A. The performance of neck circumference and other airway assessment tests for the prediction of difficult intubation in obese parturients undergoing cesarean delivery. Int J Obstet Anesth 2017;31:45-50.
Apfelbaum JL, Hagberg CA, Connis RT, Blitt CD, Connis RT, Nickinovich DG, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31-81.
Oofuvong M, Geater AF, Chongsuvivatwong V, Pattaravit N, Nuanjun K. Association between intraoperative and postanesthetic care unit respiratory events among 12,641 children in southern Thailand. BJMMR 2015;6:1101-12.
Karnjanawanichkul O, Pattaravit N, Uakritdathikarn T, Juthasantikul W, Boonchuduang S. A comparison of upper lip bite test with modified mallampati classification in predicting difficult laryngoscopic intubation. Thai J Anesthesiology 2010; 36:1-8.
Oofuvong M, Nuanjun K, Sangkaew T, McNeil E. Grading of bag-mask ventilation difficulty and association with unanticipated difficult laryngoscopy/intubation in children at a training center university hospital: a prospective cohort Study. J Anesth Clin Res 2020;11:937. doi: 10.35248/2155-6148.20.11.937.
Falcetta S, Cavallo S, Gabbanelli V, Pelaia P, Sorbello M, Zdravkovic I, et al. Evaluation of two neck ultrasound measurements as predictors of difficult direct laryngoscopy: A prospective observational study. Eur J Anaesthesiol 2018;35:605-12.
Koundal V, Rana S, Thakur R, Chauhan V, Ekke S, Kumar M. The usefulness of point of care ultrasound (POCUS) in preanaesthetic airway assessment. Indian J Anaesth 2019;63: 1022-8.
Chan SMM, Wong WY, Lam SKT, Wong OF, Law WSS, Shiu WYY, et al. Use of ultrasound to predict difficult intubation in Chinese population by assessing the ratio of the pre-epiglottis space distance and the distance between epiglottis and vocal folds. Hong Kong J Emerg Med 2018;25:152-9.
Yadav U, Singh RB, Chaudhari S, Srivastava S. Comparative Study of preoperative airway assessment by conventional clinical predictors and ultrasound-assisted predictors. Anesth Essays Res 2020;14:213-8.
Abraham S, Himarani J, Mary Nancy S, Shanmugasundaram S, Krishnakumar Raja VB. Ultrasound as an assessment method in predicting difficult intubation: a prospective clinical study. J Maxillofac Oral Surg 2018;17:563-9.
Sotoodehnia M, Rafiemanesh H, Mirfazaelian H, Safaie A, Baratloo A. Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis. BMC Emerg Med 2021;21:76. doi:10.1186/s12873-021-00472-w
Gomes SH, Simões AM, Nunes AM, Pereira MV, Teoh WH, Costa PS, et al. Useful ultrasonographic parameters to predict difficult laryngoscopy and difficult tracheal intubation-a systematic review and meta-analysis. Front Med (Lausanne) 2021;8:671658. doi:10.3389/fmed.2021.671658.
Carsetti A, Sorbello M, Adrario E, Donati A, Falcetta S. Airway ultrasound as predictor of difficult direct laryngoscopy: a systematic review and meta-analysis. Anesth Analg 2022;134: 740-50.
Savva D. Prediction of difficult tracheal intubation. Br J Anaesth 1994;73:149-53.
Ramadhani SA, Mohamed LA, Rocke DA, Gouws E. Sternomental distance as the sole predictor of difficult laryngoscopy in obstetric anaesthesia. Br J Anaesth 1996;77:312-6.
Langenstein H, Cunitz G. Difficult intubation in adults. Anaesthesist 1996;45:372-83.
Gupta S, Sharma KRR, Jain D. Airway asessement: predictors of difficult airway. Indian J Anaesth 2005;49:257-62.
Alemayehu T, Sitot M, Zemedkun A, Tesfaye S, Angasa D, Abebe F. Assessment of predictors for difficult intubation and laryngoscopy in adult elective surgical patients at Tikur Anbessa Specialized Hospital, Ethiopia: A cross-sectional study. Ann Med Surg (Lond) 2022;77:103682. doi:10.1016/j.amsu.2022.103682.
Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg 2003;96:595-9.
Prathep S, Jitpakdee W, Woraathasin W, Oofuvong M. Predicting difficult laryngoscopy in morbidly obese Thai patients by ultrasound measurement of distance from skin to epiglottis: a prospective observational study. BMC Anesthesiol 2022;22:145. doi: 10.1186/s12871-022-01685-7.
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