Professional Documents
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Keywords:
Obesity
Morbid obesity
Airway management
Difcult intubation
Difcult airway
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tube. Although the view at laryngoscopy is a frequently used denition, the relationship between the number of laryngoscopy, the
number of tracheal intubation attempts and the degree of postoperative morbidity has not been clearly dened.2
The Intubation Difculty Scale (IDS)3 has been used in several
studies to assess difcult intubation and takes into account difcult
laryngoscopic view, number of attempts required to intubate the
trachea and other factors associated with difculty. It is a validated
objective scale producing a score that can be used to evaluate
intubating conditions and techniques. It correlates with time to
intubation and a Visual Analogue Scale (VAS) assessment of difculty. A point is scored for each variable encountered. The variables
used in the score are as follows:
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1. Introduction
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Airway management is often the principal concern of the majority of anaesthetists when presented with
an obese patient for general anaesthesia. Many anaesthetists will be increasingly encountering obese
patients requiring all types of surgery. With the expansion of bariatric surgery both worldwide and in the
UK, there is now a greater evidence base to inform and guide airway management in the obese patient.
This article aims to improve understanding of the term difcult airway in the obese population and
focuses primarily on evidence related to pre-operative airway assessment and intra-operative airway
management in the obese patient.
2009 Published by Elsevier Ltd.
s u m m a r y
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Magill Department of Anaesthesia, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
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* Corresponding author. Tel.: 44 (0)7811 354 907; fax: 44 (0)7092 052 604.
E-mail address: johnmyatt@doctors.org.uk (J. Myatt).
Please cite this article in press as: Myatt J, Haire K, Airway management in obese patients, Current Anaesthesia & Critical Care (2009),
doi:10.1016/j.cacc.2009.09.004
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N1
N2
N3
N4
N5 0
N5 1
N6 0
N6 1
N7 0
N7 1
N1N7
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0 < IDS 5
5 < IDS
IDS N
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Rules
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Score
Degree of difculty
Easy
Slight difculty
Moderate to major difculty
Impossible intubation
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Parameter
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ED
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Table 1
The intubation difculty scale.
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ARTICLE IN PRESS
3.1. BMI
It would seem intuitive that the higher the BMI, the greater the
expected difculty of intubation. However, several studies have
now refuted this and BMI itself has not been shown to be an
independent risk factor for difcult tracheal intubation in obese
patients.9,11,12 This suggests that the super obese (BMI >50 kg/m2)
are no more difcult to intubate than the obese or morbidly obese.
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Please cite this article in press as: Myatt J, Haire K, Airway management in obese patients, Current Anaesthesia & Critical Care (2009),
doi:10.1016/j.cacc.2009.09.004
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CT
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5. Airway management
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5.1. Positioning
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ED
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ARTICLE IN PRESS
Please cite this article in press as: Myatt J, Haire K, Airway management in obese patients, Current Anaesthesia & Critical Care (2009),
doi:10.1016/j.cacc.2009.09.004
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ARTICLE IN PRESS
5.2. Induction
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ED
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Please cite this article in press as: Myatt J, Haire K, Airway management in obese patients, Current Anaesthesia & Critical Care (2009),
doi:10.1016/j.cacc.2009.09.004
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The problems associated with direct laryngoscopy and techniques for optimising success are discussed above. However, there
are several alternative methods to direct laryngoscopy as a primary
intubation strategy. These include indirect laryngoscopy, the use of
semi-rigid scopes and breoptic intubation.
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Q2
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exists on its successful emergency use in a morbidly obese parturient with documented previous difcult intubation.
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Please cite this article in press as: Myatt J, Haire K, Airway management in obese patients, Current Anaesthesia & Critical Care (2009),
doi:10.1016/j.cacc.2009.09.004
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10. Conclusion
With an increasing incidence of obesity in the general surgical
population, appropriate management of the airway in this group of
patients is an important topic for all anaesthetists. The intraoperative management of ventilation, extubation strategy and
general post-operative monitoring of these patients is an equally
important topic discussed elsewhere in this issue by ONeill and
Allam.28
This article has focussed on the evidence for pre-operative
airway assessment and airway management of obese patients
requiring general anaesthesia. There is a rapidly expanding body of
evidence in this area, with an array of new intubation devices
available on how this may be best achieved. As always, the patient
must have an individualised management plan and the chosen
techniques must be familiar to all involved, with a clear back-up
plan for when unexpected difculties in airway management arise.
Conict of interest
None.
References
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ARTICLE IN PRESS
Please cite this article in press as: Myatt J, Haire K, Airway management in obese patients, Current Anaesthesia & Critical Care (2009),
doi:10.1016/j.cacc.2009.09.004
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ARTICLE IN PRESS
Please cite this article in press as: Myatt J, Haire K, Airway management in obese patients, Current Anaesthesia & Critical Care (2009),
doi:10.1016/j.cacc.2009.09.004
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