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Current Anaesthesia & Critical Care xxx (2009) 17

Contents lists available at ScienceDirect

Current Anaesthesia & Critical Care


journal homepage: www.elsevier.com/locate/cacc

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FOCUS ON: BARIATRICS

Airway management in obese patients

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John Myatt*, Kevin Haire

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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:

TE

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Anaesthesia in morbidly obese patients can present many


challenges. The overriding concern of most anaesthetists however,
is airway management, as traditionally, obese patients have been
thought to be at greater risk of difcult airway and/or difcult
intubation, when compared with the general population. There is
plenty in the literature regarding this subject area, but the
mundane is rarely reported, and so this article aims to clarify the
incidence and objectively review, the evidence for difcult airway
in the obese population.
The term difcult airway has been dened by the American
Society of Anesthesiologists (ASA) taskforce as the clinical situation
in which a conventionally trained anaesthetist experiences problems with mask ventilation or tracheal intubation or both.1 Difcult
endotracheal intubation has also been dened by the ASA as more
than 2 attempts at intubation or attempts lasting more than 10 min.
The literature concerning difcult intubation uses numerous
different denitions of difcult intubation and this lack of
consensus translates to difculty in comparing airway studies.
Some authors use the Cormack and Lehane grading of 3 or 4 (C & L,
grades 34) as an end-point to dene difcult laryngoscopy and
hence difcult intubation, in an attempt to simplify the issue.
However difcult laryngoscopy does not always equate with
difcult tracheal intubation and easy laryngoscopy does not
always equate with easy intubation.
Other denitions of the difcult airway include complete failure
to intubate and more than three attempts to pass the endotracheal

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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).

N1 number of additional attempts;


N2 number of additional operators;
N3 number of alternative intubation techniques used;
N4 glottic exposure as dened by Cormack and Lehane;
N5 lifting force applied during laryngoscopy;
N6 need to apply external laryngeal pressure to improve view;
N7 position of vocal cords at intubation.
A summary of how the IDS score is calculated and the interpretation of this score is given in Table 1.
2. The obese airway
For the purpose of comparison with obese subjects (BMI > 30
kg/m2), the incidence of difcult intubation in unselected, nonobstetric patients has been quoted as 1.87.5%.2,4,5
Comparisons are difcult because the literature is confusing
with some airway studies suggest obesity to be a risk factor for

0953-7112/$ see front matter 2009 Published by Elsevier Ltd.


doi:10.1016/j.cacc.2009.09.004

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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Number of intubation attempts >1


Number of operators >1
Number of alternative techniques

N1
N2
N3

Cormack & Lehane Grade-1


Lifting force required: Normal
Increased
Laryngeal pressure: Not applied
Applied
Vocal Cord Mobility: Abduction:
Adduction:
Total: IDS Sum of scores

N4
N5 0
N5 1
N6 0
N6 1
N7 0
N7 1
N1N7

Every additional attempt adds 1 pt


Every additional operator adds 1 pt
Each alternative technique adds 1 pt. Repositioning of the patient, change of
materials (blade, ET tube, addition of a stylette), change in approach (nasotracheal/orotracheal)
or use of another technique (breoptic, intubation through an LMA, etc)
Apply Cormack grade for 1st oral attempt. For successful blind intubation, N4 0.

0
0 < IDS  5
5 < IDS
IDS N

difcult intubation, yet others conclude difcult intubation is no


more common than in non-obese subjects. The studies vary
depending upon whether they examine the association of obesity
with difcult laryngoscopy alone or include other measures of
difcult intubation. The ndings of recent, relatively large and welldesigned comparative studies looking at these associations will be
briey reported.
In a prospective study of 764 mixed surgical patients presenting
for surgery, it was found that increased BMI correlated with
increased Mallampati (MP) class, but not with increased grade of
laryngoscopy.6 In a controlled study of 200 morbidly obese patients
undergoing elective surgery, the magnitude of BMI had no inuence
on difculty of laryngoscopy (C & L, grade 34)7 when examining
the various risk factors for difcult laryngoscopy. Again, using C & L,
grade 34 as the descriptor of difcult laryngoscopy, a recent study
(Difcult Airway Society annual conference, 2008) of 397 patients
with a BMI >50 kg/m2, found an incidence of 6% to be similar to the
quoted incidence for the general population.8 Similarly, Juvin et al.9
have previously found the incidence of difcult laryngoscopy (C & L,
grade 34) to be the same in 134 lean (BMI < 30 kg/m2) patients
when compared with 129 obese (BMI  35 kg/m2) patients (10.4 vs
10.1% respectively). However, the IDS score was 5, indicating
moderate to major difculty in intubation, in 3 lean (2.2%) and 20
(15.5%) obese patients (P 0.0001). In another recent study using
the IDS scoring system to prospectively compare 70 obese (BMI 
30 kg/m2) and 61 lean patients (BMI < 30 kg/m2), the IDS score was
>5 more frequently in obese compared to lean patients (14% vs 3%
respectively, P 0.03). This study also analysed which pre-operative measurements were associated with difcult intubation
(see Section on Predictors of difcult airway below).10
In a large prospective, Canadian study of 18,205 non-obstetric,
general surgical patients, undergoing direct laryngoscopy, there
was a signicantly increased proportion of overweight patients
(dened as male >120 kg, female >100 kg, n 451) in whom
tracheal intubation was recorded as difcult and who required >2
laryngoscopies before successful intubation (5.5% described as
difcult vs 2.4% described as easy, P < 0.01).2
However, Gaszynski et al. analysed the incidence of difcult
intubation in 87 morbidly obese patients using the ASA denition
of difcult intubation (attempts lasting more than 10 min or greater
than two attempts) and found that the incidence was similar to that
in lean patients (4.6%).11
In summary, most studies suggest that difcult intubation, if
dened by difcult laryngoscopy alone, does not appear to be more

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NB Impossible intubation: IDS takes value attained before abandonment


of intubation attempts.

Interpretation of IDS Score

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Selicks manoeuvre adds no points

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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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common in the obese. However some well-designed studies


suggest that there may be an increased incidence when including
other measures to dene difcult intubation, but this is dependent
on which measure or denition of difcult intubation is used. It
appears that the IDS score is a more objective and reliable measure
of difcult intubation and has been increasingly used in studies of
obese patients. Despite the difculty in reaching a consensus from
the literature, it is apparent that there are a high proportion of
obese patients that do not present an airway problem. However,
identifying the individual factors that appear to be more closely
associated with difcult intubation is paramount and these are
further discussed below.

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3. Predictors of difcult airway

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As anaesthetists, rather than making assumptions based on BMI


alone, we must aim to identify particular features in obese patients
likely to predict problems with airway management. The associated
features are outlined below.

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Table 1
The intubation difculty scale.

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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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3.2. Mallampati classication

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The Mallampati (MP) classication, rst described by a group


from Boston in 1985, uses the structures visible at the back of the
mouth to predict difcult tracheal intubation.
As has been previously described, the Mallampati score has
a poor sensitivity and specicity and this calls into question its
usefulness in clinical practice. However, it has nonetheless become
an integral part of the routine pre-operative airway assessment and
the evidence for its use in obesity is considered here.
In the study by Juvin et al. a Mallampati score of 3 or 4 was the
only independent risk factor for difcult intubation in obese
patients with a specicity and positive predictive value of 62% and
29% respectively.9 This reected the ndings of another study of
100 morbidly obese patients (BMI > 40 kg/m2), where the product

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doi:10.1016/j.cacc.2009.09.004

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of the graded laryngoscopy view and number of intubation


attempts was used to dene difcult intubation.12 Mallampati score
of 3 or 4 was also signicantly associated with difcult tracheal
intubation in the study by Gonzalez et al.10

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3.3. Neck circumference

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Neck circumference is generally measured at the level of the


superior border of the cricoid cartilage. Large-neck circumference
has been shown in several studies to be a predictor of difcult
intubation in morbidly obese patients.1012 In the study by Brodsky
et al., a neck circumference of 40 cm was associated with a 5%
probability of problematic intubation (described as grade of
laryngoscopy view multiplied by intubation attempts 3), whereas
at 60 cm, the probability was 35% (P 0.02). Furthermore, a largeneck circumference was signicantly associated with male gender
(P < 0.001), a higher MP score (P 0.0029), grade 3 laryngoscopy
(P 0.0375) and Obstructive Sleep Apnoea (OSA) (P 0.0372).12
Ezri et al. carried out an ultrasound examination of the anterior
neck in 50 morbidly obese patients. Laryngoscopy was found to be
more difcult in patients with greater amount of pre-tracheal soft
tissue and greater overall neck circumference.13

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3.4. Thyromental distance

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3.5. Other airway descriptors

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CT

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Reduced mouth opening (inter-incisor gap) has not been found


to be a signicant independent predictor of difcult intubation in
the obese.9,12 Mandibular recession and buck teeth were also not
found to be signicant risk factors in the study by Juvin et al.9 There
was no evidence that the authors could nd for the use of sternomental distance in obese subjects.

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3.6. Obstructive sleep apnoea

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Obstructive Sleep Apnoea (OSA) is dened as intermittent and


repeated upper airway collapse, leading to partial or total airway
occlusion for short periods of time during sleep. This results in an
irregular breathing pattern, episodic sleep-associated oxygen
desaturation and hypercarbia, along with cardiovascular dysfunction and excessive daytime sleepiness. It is widely under-diagnosed
in the obese and has a prevalence of up to 70%. OSA has not been
shown to be an independent risk factor for difcult intubation in the
aforementioned studies.9,12 However, some studies have shown
that difcult intubation is more common in obese patients with OSA
and large-neck circumference compared to non-obese subjects.14 It
has been demonstrated that patients with OSA have larger necks
than equally obese patients without OSA.15,16 The evidence suggests
increased neck soft tissue volume, along with a more collapsible
airway, results in both intubation and ventilation difculties in
obese patients with OSA. Literature reviews concerning obesity,
OSA and the airway have identied many disastrous respiratory

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outcomes. These mainly relate to failure of intubation, airway


obstruction following extubation and respiratory arrest after opioid
and sedative medication in the post-operative period.
Pre-operative CPAP treatment in obese patients with OSA has
been shown to improve early anatomical and later functional
aspects of the upper airway. In addition, many authors report
generally improved cardio-respiratory function with this therapy
and would advocate a period of pre-operative optimisation. More
detailed information on OSA and the other sleep disorders can be
found in the article by Dakin and Margarson17 elsewhere in this Q1
supplement.
In summary, the literature suggests that standard clinical tests
for predicting difcult intubation are less useful in the morbidly
obese.11 It appears there exists good evidence for measuring neck
circumference as part of the pre-operative airway evaluation in
obese patients, in addition to MP scoring and TM distance.
However, the actual neck size that is predictive of problems with
airway management or that justies interventions such as awake
breoptic intubation (AFOI) is not known and further work is
required to elucidate this.

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4. Pre-operative airway assessment

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Particular features that should be noted in the patient history


are; the presence of suspected or diagnosed OSA, problems with
previous anaesthetics/airway management and the presence of
treated or untreated gastro-oesophageal reux disease (GORD).
Additionally, a thorough review of previous anaesthetic records is
essential wherever possible.
Obese patients at risk of airway obstruction under general
anaesthesia have previously been characterized as having; a short
mental-hyoid distance, attened, compressed anteriorposterior
craniofacial architecture, retrognathism, relative macroglossia, and
a narrower, bulky oropharynx. For optimal airway examination in
obese patients, the following should be noted: neck circumference,
MP score, thyromental distance, assessment of mouth opening and
jaw protrusion, range of neck movement and general assessment of
craniofacial architecture. The presence of a cervical fat pad or
hump should also be noted as this can lead to difculty in positioning the patient optimally for intubation (see Section on Airway
management below).

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5. Airway management

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An individualised strategy for airway management that is based


on published standards should be formulated for each obese
patient presenting for surgery. In the UK, the Association of
Anaesthetists of Great Britain and Ireland have recently published
guidelines on the Perioperative Management of the Morbidly
Obese Patient which include advice on airway management,
stafng and equipment requirements.18 A range of difcult airway
equipment should be prepared and checked in advance, and
a trained assistant, in addition to more experienced anaesthetic
input should be available if required.
If a history of GORD has been found at the pre-operative visit,
appropriate antacid prophylaxis with either a Histamine-2 receptor
antagonist or proton pump inhibitor, should be considered prior to
arrival in the anaesthetic room. In general, any sedating premedication should be avoided because of the risk of increased
sensitivity to the central respiratory-depressant effects.

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5.1. Positioning

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A ramped or semi-sitting position has been shown to produce


a better view at laryngoscopy compared with the standard snifng

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Thyromental (TM) distance (also known as Patils test) is the


distance from the tip of the thyroid cartilage to the tip of the
mandible with the neck fully extended. A problematic intubation is
associated with a TM distance less than 6.5 cm and this estimates
the potential space into which the tongue can be displaced on
laryngoscopy. A distance of less than 6 cm is associated with
difcult laryngoscopy and predicts 75% of difcult laryngoscopies
in the general surgical population.
Difcult tracheal intubation was associated with reduced thyromental distance in the study by Gonzalez et al.,10 but this association has not been reported by other investigators.12

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5.2. Induction

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Morbid obesity is associated with a reduction in the time to


desaturation after apnoea following standard pre-oxygenation and
induction of general anaesthesia. There are several strategies
available that can be employed to minimise this occurrence.
Pre-oxygenation should be carried out in the head-up or sitting,
rather than the supine, position as this increases functional residual
capacity (FRC) and allows a higher oxygen tension to develop. This
results in a clinically signicant increase in the desaturation safety
period and allows greater time for airway control and intubation. In
a randomised controlled trial (RCT) of morbidly obese patients
undergoing laparoscopic gastric banding (BMI > 40 kg/m2), oxygen
saturation and the desaturation safety period following 3 min of
pre-oxygenation was measured in either the supine or 25 head-up
position. The group in the 25 head-up position achieved a 23%
higher pre-induction oxygen tension compared with the supine
group (442  104 vs 360  99 mmHg respectively, P 0.012) and
took longer to reach an oxygen saturation level of 92% (201  55 vs
155  69 s, P 0.023).22 In another study comparing the preoxygenation of obese patients in the sitting and supine position, the
tolerance to apnoea post-intubation was signicantly increased in
the sitting group. The mean time to desaturate to 90% was 214 (28)
in the sitting group vs 162 (38) seconds (P < 0.05) in the supine
group.23
The RTP may be even better for prolonging the time to desaturation following induction of anaesthesia. Thirty degrees of RTP
has been shown to prolong the safe apnoea period in obese
neurosurgical patients following induction when compared to the
supine position.24 Thirty degrees of RTP was also found to provide
the longest time before desaturation to 92% following induction of
anaesthesia and 5 min of ventilation, compared to both the supine
and 30 sitting positions.25
CPAP may enhance pre-oxygenation further, although the
optimal level and duration of applied positive pressure has not
been fully elucidated. In one study, 7.5 cmH2O CPAP during 3 min of
pre-oxygenation did not have any effect on the time to desaturate
to 90% during apnoea following induction and intubation in a group
of 20 morbidly obese women. However, another did nd signicant
benet from CPAP and PEEP prior to intubation.26 Patients were
pre-oxygenated with 10 cmH2O CPAP for 5 min prior to induction
and then ventilated with 10 cmH2O PEEP for 5 min post-induction
until tracheal intubation. The time taken to desaturate to 90%
during apnoea was then measured and arterial gas tensions
recorded just before apnoea commenced and at 92% oxygen

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5.3. Facemask ventilation and supraglottic devices

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In the authors experience, if correctly positioned, most obese


patients are relatively easy to ventilate with a facemask, with or
without a Guedel airway. An audit of a sequential group (n 48) of
obese patients (BMI of 45.9  6.6 kg/m2) undergoing bariatric
surgery and presented at the Difcult Airway Society (DAS) 2008
annual conference, found all patients to be either easy or
manageable when ventilated with a facemask  Guedel airway.29
Other studies have shown that the incidence of difcult mask
ventilation (DMV) is increased in overweight and obese patients.
For example, in a prospective study of 1502 general surgical
patients, Langeron et al. showed that DMV was associated with BMI
>26 kg/m2.30 The possibility of this must be borne in mind when
developing a strategy for intubation.
Supraglottic airways may provide a satisfactory airway for minor
procedures in obese patients who are not at an enhanced risk of
gastroesophageal reux, but this may not be an ideal technique.
Supraglottic devices are perhaps most useful when ventilating
obese patients prior to planned endotracheal intubation or for
facilitating intubation by a secondary technique (see section on
Secondary intubation techniques). Both the standard Laryngeal
Mask Airway (LMA) and ProSeal Laryngeal Mask Airway (PLMA) can
be used to ventilate obese patients. A study comparing 60 obese
patients (BMI > 30 kg/m2) randomised for ventilation with either
the LMA or PLMA, found that both are effective in ventilating obese
patients.31 The LMA however, did require a greater cuff pressure
than the PLMA, but this was not associated with an increased
incidence of sore throat. It was also found that in 10% of cases where
the PLMA was used, the drainage tube was not patent, and the
authors recommend this be checked with a gastric tube prior to use.

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saturation. In the control group, pre-oxygenation and ventilation


were similarly carried out but without the application of CPAP or
PEEP. The duration of non-hypoxic apnoea was 50% longer in the
CPAP/PEEP group compared with the control group (188  46 vs
127  43 s respectively, P 0.002). In addition, PaO2 was signicantly higher before apnoea in the CPAP group.
Nasopharyngeal oxygen insufation in morbidly obese patients
following induction of anaesthesia has also been shown to decrease
the severity of desaturation after 4 min of apnoea. Nasopharyngeal
insufation may therefore be useful during intubation attempts to
buy more time.
Some authors and many centres still advocate rapid sequence
induction (RSI) with cricoid pressure in all morbidly obese patients,
although this practice is now controversial. The risks and benets of
any induction method must be carefully considered in each individual patient. In the elective, fasted obese patient not anticipated
to be at increased risk of airway problems and without risk factors
for pulmonary aspiration, there now appears to be anecdotal
consensus that RSI is not necessary in every obese patient.
Although residual gastric volume and acidity are increased in
fasting morbidly obese compared with lean surgical patients,
recent studies have failed to demonstrate a relationship between
obesity and the incidence of pulmonary aspiration. However, when
indicated by symptomatic GORD or hiatus hernia, suxamethonium
remains the neuromuscular blocking agent of choice.
In the group of patients who have previously undergone bariatric
surgery, anatomical and physiological changes in the stomach
appear to increase the risk of aspiration when compared with nonbariatric patients.27 It is therefore also recommended that RSI is used
in such patients, even where there has been substantial weight loss
following bariatric intervention. Further detail on induction techniques and choice of anaesthetic agents in the obese population can
be found in the article by ONeill & Allam elsewhere in this issue.28

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the morning air position (a conventional sniff position was


obtained by placing a rm 7-cm cushion underneath the patients
head).19 More specically, several authors recommend that the
patients head, upper body and shoulders be signicantly elevated
above the chest with the head extended to optimise the view at
laryngoscopy. A towel or folded blankets under the shoulders and
head can compensate for an exaggerated exed position from
a posterior cervical fat pad. Head elevation beyond the snifng
position by raising the back and shoulders has been described as
the Head-Elevated Laryngoscopy Position (HELP) and facilitates
alignment of the pharyngeal, laryngeal and oral axes of the airway
during intubation, especially in the obese patient.20 It has been
suggested that the optimal intubating position can be achieved by
ensuring an imaginary horizontal line connecting the patients
sternal notch and external auditory meatus.21 The exact method
used to achieve this position does not appear important. Blankets,
pillows (including a pre-manufactured elevation pillow) and towels
have all been used, in addition to the reverse Trendelenburg (RTP),
or ramped table position with adjustment of head position.

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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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6.2. Indirect laryngoscopy

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Several studies and audits have reported on the use of indirect


laryngoscopy to facilitate tracheal intubation in obese patients.
The Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) is
designed to enable visualisation of the glottis and passage of the
endotracheal tube (ETT) through the vocal cords without necessary
alignment of the oral, pharyngeal and laryngeal axes. A study of 106
morbidly obese patients (BMI > 35 kg/m2) undergoing surgery
were randomised for intubation with either the standard Macintosh or Airtraq laryngoscope.32 If tracheal intubation was not
achieved within 120 s with the selected device, laryngoscopes were
switched. In the Airtraq group, all patients were successfully
intubated within 120 s, whereas in the Macintosh group, six
patients required intubation with the Airtraq laryngoscope. The
mean time (SD) taken for tracheal intubation was 24 (16) and 56
(23) seconds for the Airtraq and Macintosh laryngoscopes
respectively (p < 0.001). In addition, oxygen saturation was better
maintained in the Airtraq group. Using the intubation difculty
score (IDS), a score >5 (indicating difcult intubation) was recorded in 11 patients in the Macintosh group, but in none of the Airtraq group. In the latter group, all patients were documented to
have C & L grade 1 laryngoscopic view. It is relevant to note that
patients were not optimally positioned in a standardised fashion
for direct laryngoscopy and this may have favoured better
outcomes with the Airtraq device. The same study also recorded
10 intubations when using the Airtraq as traumatic, due to difculty in passing the device into the pharynx. It is important to note
that the Airtraq may be difcult to use in patients with restricted
mouth opening as the laryngoscope has a thickness of 1.8 cm and
width of 2.8 cm. Interestingly, there is a case report of the use of the
Airtraq for awake intubation in a morbidly obese patient (BMI 38
kg/m2) with a history of GORD, where both ventilation and intubation were anticipated to be difcult. Laryngoscopy and tracheal
intubation in this case were successfully achieved using sedation
and topical airway anaesthesia.
Several different types of videolaryngoscope are now available.
Videolaryngoscopy has been shown to signicantly improve the C &
L grade of view compared to direct laryngoscopy in almost a third of
morbidly obese patients.33
There is good emerging evidence for the use of the Glidescope
videolaryngoscope (GVL, Verathon Medical, Aylesbury, Bucks, UK)
in morbidly obese patients. In one series of 32 patients (BMI 54.1 
8.1 kg/m2), all were successfully intubated with the GVL, 93.1% on
the rst attempt.34 In another series of 48 patients at our institution, (BMI 45.9  6.6 kg/m2), 95.8% were successfully intubated
using the GVL with 72.9% of these achieved on the rst attempt. At
the time of the audit, the GVL was new to our department and all
grades of junior anaesthetist were permitted to intubate under
supervision.29 In both of these reports, the Glidescope was used
with a styletted endotracheal tube as recommended by the
manufacturer.
Other indirect laryngoscopes reported on for use in morbidly
obese patients include the Bullard laryngoscope, and a case report

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6.3. Awake breoptic intubation

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Routine awake intubation of the morbidly obese patient has not


been validated, does not appear necessary in most cases35 and it
can prove difcult and unpleasant for the patient. However, it is still
the preferred method of some clinicians and may be essential if
there is signicant restriction of mouth opening. Awake breoptic
intubation (AFOI) certainly does have a place in the morbidly obese
where there is history of DMV and/or difcult intubation, or where
these are suspected from the airway examination. However, the
emergence of indirect laryngoscopes and secondary intubation
techniques utilising ventilation through an LMA or supraglottic
device, have made awake breoptic intubation less common in the
obese.
A technique using nasal CPAP applied to the contralateral nostril
during nasotracheal breoptic intubation has been described.
Simultaneous application of 20 cmH2O CPAP using a nasal pillow
helped maintain oxygenation during intubation, with a splinting
effect on the pharynx reported to facilitate visualisation of
anatomical landmarks and translaryngeal passage of the brescope.

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These techniques involve use of an LMA or supraglottic device to


allow ventilation prior to tracheal intubation by a secondary technique. The secondary intubation techniques include blind tracheal
intubation, e.g. through an intubating LMA, (ILMA, Intavent
Orthox, Maidenhead, Berks, UK), breoptic intubation through an
LMA or other supraglottic device, and video-guided tracheal intubation, e.g. using an LMA CTrach (Intavent Orthox, Maidenhead,
Berks, UK).
Some clinicians consider the additional time required between
loss of consciousness and securing the airway in these secondary
intubation strategies as more risky in terms of aspiration in the
morbidly obese patient. However, there are several studies that
have used LMA devices to facilitate tracheal intubation in obese
patients who have low regurgitation risk and normal gastric
emptying and more detail on these are given below. They may have
the advantage of providing better oxygenation during the intubation process and produce less airway stimulation compared to
direct laryngoscopy.36
Fibreoptic intubation through a standard LMA is nearly 100%
successful in most series and is a technique that may be considered
in the obese patient. There is presently however, little evidence for
its use in obese subjects. The PLMA has been described as an efcacious temporary ventilatory device in obese patients prior to
direct laryngoscope-guided tracheal intubation. In a study of 60
obese patients (BMI 3560 kg/m2), an effective airway was
obtained using a PLMA on the rst or second insertion attempt and
positive pressure ventilation (8 ml/kg) was possible in 95% of
patients after muscle relaxation. A breoptic view of the vocal cords
from the airway tube was achieved in 75% of patients.37
The ILMA or Fastrach (Intavent Orthox, Maidenhead, Berks,
UK) is a specic device that allows effective ventilation and blind
tracheal intubation in patients with normal and abnormal airways.
It has several original features that provide better conditions than
the standard LMA for achieving effective ventilation and tracheal
intubation. These include an anatomical curve, rigid airway tube
with guiding handle, epiglottic elevating bar and guiding ramp to
guide insertion of the tracheal tube. One prospective study using
the ILMA as an elective ventilatory device and intubation guide in
118 obese (BMI 45  5 kg/m2) patients, revealed successful tracheal

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6.1. Direct laryngoscopy

exists on its successful emergency use in a morbidly obese parturient with documented previous difcult intubation.

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Algorithms to manage the unanticipated difcult airway in


general surgical patients have been published by the Difcult
Airway Society in the UK. However, in the obese patient, the exact
strategy used will depend on local guidelines, experience of the
anaesthetist and equipment available. The range of techniques that
may be employed are as listed in section on Secondary intubation
techniques.
Case reports regarding emergency intubation and/or unanticipated difcult airway in morbidly obese patients do exist. The ILMA
has been used for rescue oxygenation and tracheal intubation in
a morbidly obese patient in an out-of-hospital location.39 The
Combitube (Armstrong Medical, Lincolnshire, Illinois, USA) has
been used for successful emergency airway management following
failed intubation prior to formal tracheostomy.40

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8.1. Surgical airway

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Surgical access to the airway is technically more difcult in


obese patients and is associated with an increased risk of perioperative complications. Ultrasound guidance for percutaneous
dilatational tracheostomy has been described in a morbidly obese
patient in the critical care unit setting and may help delineate the
anatomy in obese patients with large-neck circumference.

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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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Post-operative airway and respiratory complications in obese


subjects are discussed in greater detail by ONeill & Allam.28
The incidence of atelectasis has been reported as 45% in obese
patients after upper abdominal surgery. Laparoscopic, compared
with open techniques, have less detrimental effects on respiratory
dynamics. Treatment with prophylactic post-operative CPAP or
BiPAP has been advocated in obese subjects to reduce post-operative airway obstruction and pulmonary dysfunction, and there is
also evidence to suggest it may decrease rates of respiratory
infection.
Adult obese patients with suspected or conrmed OSA, present
a formidable challenge throughout the peri-operative period.
Tracheal intubation and extubation strategies must be made with
particular care in these patients. They have increased sensitivity to
opioid-induced respiratory depression and depression of the
arousal to obstructed breathing, and in the post-operative period,
continuous visual and electronic monitoring is recommended,
ideally in a high dependency or intensive care unit setting.41,42
Other measures aimed at improving post-operative pulmonary
function include incentive spirometry, deep breathing exercises
and intermittent positive pressure breathing, although good
evidence for benet from these is lacking.
Adequate analgesia is necessary to aid and improve pulmonary
function, although care should be taken with opioid analgesics in
those with OSA. Epidural analgesia may be benecial in some
patients undergoing open surgery, but respiratory arrest has been
reported in patients with OSA on the third or fourth post-operative
day, after accumulation of neuraxial opioids.
Many abdominal procedures require free naso-gastric drainage
post-operatively. This may help to reduce the risk of reux and
aspiration following surgery.

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9. Post-operative airway complications

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intubation in 96.7%, with the majority of these on rst attempt and


within 120 s.38 Failures were due to unsuccessful attempts to pass
the tracheal tube into the trachea, and these patients were
successfully intubated with a Macintosh laryngoscope, although
a brescope through the ILMA could also have been used. There
were no cases of DMV, and ventilation through the ILMA was easily
achieved without arterial hypoxaemia. The ILMA may be a valuable
device in airway management of obese patients and its use
complements conventional laryngoscopy.
The LMA CTrach (CT) is a modied version of the ILMA with
two integrated breoptic bundles emerging at the distal end of the
airway tube. It is attached to a full colour viewer that provides both
the light source and image treatment to allow continuous videoendoscopy of illuminated anatomical structures. The CT facilitates
positioning of the mask in the pharynx to optimise laryngeal view
and observe tracheal intubation. A study comparing 104 morbidly
obese patients (BMI 43.5  9 kg/m2) randomised for intubation
with either direct laryngoscopy or the CT, found all patients could
be successfully intubated with either method.36 It is important to
note that the clinicians using the CT had extensive training in its use
and methods of view optimisation. Of the patients from the CT
group, 49% required laryngeal mask manipulation (for ventilation
and view optimisation) resulting in prolonged time to intubation by
approximately 1 min when compared to the direct laryngoscopy
group. Blind tracheal intubation was required in 17% of patients in
the direct laryngoscopy group, while tracheal intubation was witnessed in all patients in the CT group. The CT group were also found
to have improved oxygenation during the intubation period with
signicantly fewer patients reaching saturation levels below 92%
A recent case report however, describes pulmonary aspiration in
a male, morbidly obese patient during tracheal intubation when
using the CT. The patient did have a history of symptomatic GORD
and the CT was only employed following failed intubation with
direct laryngoscopy and difcult facemask ventilation. Reassuringly, the CT did enable good quality ventilation, early recognition
of regurgitation and tracheal intubation was eventually achieved.

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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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doi:10.1016/j.cacc.2009.09.004

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