Expert Systems with Applications 36 (2009) 6588–6592

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Expert Systems with Applications

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

SVM-based decision support system for clinic aided tracheal intubation

predication with multiple features
Qing Yan a, Hongmei Yan a,*, Fei Han a, Xinchuan Wei b, Tao Zhu b
a
School of Life Science and Technology, University of Electronic Science and Technology of China, No. 4, Section 2, North Jianshe Road, Chengdu 610054, PR China
b
Department of Anaesthesiology, West China Hospital of Sichuan University, Chengdu 610064, PR China

a r t i c l e i n f o a b s t r a c t

Keywords: During routine anaesthesia, an airway physical examination should be conducted in all patients to
Tracheal intubation prediction estimate whether tracheal intubation is easy or difficult. In clinic, some anaesthetists usually do this
Medical decision support system by examining single item although most of the specialists agree that full consideration of multiple fea-
Support vector machines tures of airway physical examination rather than single one would enable anaesthetists to improve the
Multiple features
prediction accuracy when encountering a difficult airway. The application of machine learning tools
has shown its advantage in medical aided decision. The purpose of this study is to construct a medical
decision support system based on support vector machines with 13 physical features for tracheal intuba-
tion predication ahead of anaesthesia. A total of 264 medical records collected from patients suffering
from a variety of diseases ensure the generalization performance of the decision system. Moreover, the
robustness of the proposed system is examined using 4-fold cross-validation method and results show
the SVM-based decision support system can achieve average classification accuracy at 90.53%, manifest-
ing its great application prospect of supporting clinic aided diagnosis with full consideration of multiple
features of airway physical examination.
Ó 2008 Elsevier Ltd. All rights reserved.

1. Introduction prediction, which describes the laryngeal inlet by direct laryngos-

During routine anaesthesia, an airway physical examination
should be conducted in all patients to estimate whether tracheal
intubation is easy or difficult, which is prior to the initiation of
anaesthetic care and airway management. In clinic, some anaes-
thetists usually do this by examining single item such as Mallam-
pati’s screening test (Mallampati, Gatt, Gugino, et al., 1985),
thyromental distance, measurement (Patil, Stehling, & Zaunder,
1983), sternomental distance measurement (Savva, 1994), protru-
sion measurement of the mandible, craniocervical movement test
and so on, or by combining some of them, for example, modified
Mallampati’s screening test (Samsoon & Young, 1987) associated
with thyromental distance measurement (Frerk, 1991). Although
the majority of difficult intubation cases can be identified by this
way, some would be wrongly estimated due to the diversity of pa-
tients. In fact, most of the specialists agree that prediction of a dif-
ficult airway may be improved by assessment of multiple features
of airway physical examination rather than single one.
Cormack and Lahane classification (Cormack & Lehane, 1984) is
acknowledged as a decisive golden indicator for difficult airway
* Corresponding author. Tel.: +86 28 83201018; fax: +86 28 83208838.
E-mail addresses: elaine_yan@163.com (Q. Yan), hmyan@uestc.edu.cn (H. Yan),
hf364872@163.com (F. Han), weixinchuan@163.com (X. Wei), xwtao_zhu@yahoo.
com (T. Zhu).
copy as follows: Class I: the vocal cords are visible; Class II: the vo-
cals cords are only partly visible; Class III: only the epiglottis is
visible; and Class IV: the epiglottis cannot be observed. Usually,
it is easy when conducting intubation for Class I and Class II, while
it is difficult for Class III and Class IV. Clinically, Class III may re-
quire some airway manoeuvres (i.e. gum elastic bougie, cricoid
pressure) and Class IV may be impossible to intubate (Ambrose &
Taylor, 2004). An accurate estimation and prediction of Cormack
classification and preparatory efforts would enhance intubation
success and minimize risks when a difficult airway is encountered.
In this research, 13 basic and anthropometrical features in total
were taken into consideration instead of single or several features.
Support vector machine (SVM) was applied to build an aided deci-
sion support system to estimate the Cormack classification for
anaesthetists. Here for convenience, we merged Cormack Class I
and Class II into one kind as they were easy for anaesthetists to
conduct tracheal intubation (we called easy tracheal intubation,
ETI), while merged Class III and Class IV into the other kind because
they demanded anaesthetists’ careful preparations and operations
(we called difficult tracheal intubation, DTI). Furthermore, 4-fold
cross-validation method was used to test the robustness of the
proposed system and results showed that the SVM-based decision
support system with 13 features could achieve high classification
accuracy at 90.53%, manifesting its application prospect of sup-
porting clinic aided tracheal intubation predication.

0957-4174/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.eswa.2008.07.076
 Q. Yan et al. / Expert Systems with Applications 36 (2009) 6588–6592 6589

The remaining parts of this study are organized as follows: Sec- 1 XN

tion 2 reviews some basic SVM concepts. Section 3 describes the minimize Jðw; w0 ; nÞ ¼ jjwjj2 þ C ni
2 i¼1
methods of building the decision support system based on SVM.
Section 4 presents the experimental results and discussions. Final- subject to yi ðwT xi þ w0 Þ P 1  ni and ni P 0; i ¼ 1; 2; . . . ; N
ly, Section 5 concludes with a summary and some future work. ð6Þ
where C is the penalty parameter on training errors determined by
2. Basic concepts of SVM classifier users.
The dual Lagrangian of non-separable class is
In this section, we will briefly review the basic concepts of SVM
(Burges, 1998; Theodoridis & Koutroumbas, 2003) for a typical two X
N
1X N

class problem (as shown in Fig. 1). max LD ðaÞ ¼ ai  ai aj yi yj xTi xj

a
i¼1
2 i;j¼1
Considering a linearly separable binary classification problem ð7Þ
X
N

fðxi ; yi ÞgNi¼1 and yi ¼ fþ1; 1g ð1Þ subject to ai yi ¼ 0 and 0 6 ai 6 C; i ¼ 1; . . . ; N

i¼1
where xi is an n-dimension feature vector belonging to either of two
classes w1, w2, and yi is the corresponding class indicator (+1 for w1, Moreover, SVM can also achieve solving the non-linear case
1 for w2). SVM separates the two classes of points by an optimal when we map the input feature space into a higher-dimension lin-
hyperplane (with the maximum margin) ear feature space via kernels. In the dual Lagrangian (7), the inner
products are placed by the kernel function K(xi, xj), and the non-lin-
DðxÞ ¼ wT x þ w0 ¼ 0 ð2Þ ear dual Lagrangian LD(a) (8) is similar with that in the linear gen-
where w is an input vector, x is an adaptive weight vector and w0 is eralized case
a bias. SVM finds the parameters w and w0 to maximize the geomet- X
N
1X N
ric margin 2/||w|| by solving the following optimization problem: max LD ðaÞ ¼ ai  ai aj yi yj Kðxi ; xj Þ
a
i¼1
2 i;j¼1
1 ð8Þ
minimize jjwjj2
JðwÞ ¼ X
N
2 ð3Þ subject to ai yi ¼ 0 and 0 6 ai 6 C; i ¼ 1; . . . ; N
subject to yi ðwT xi þ w0 Þ  1 P 0; i ¼ 1; . . . ; N i¼1

To solve the quadratic optimization task, the Lagrangian func- Typical examples of kernels used in SVM are polynomials, radial
tion Lp(w, w0, a) is defined as basic functions and hyperbolic tangent. In the study, the polyno-
mial kernel function has been adopted
1 XN
Lp ðw; w0 ; aÞ ¼ jjwjj2  ai ½yi ðwT xi þ w0 Þ  1 ð4Þ Polynomials : Kðx; zÞ ¼ ðxT z þ 1Þq ; q>0 ð9Þ
2 i¼1

where ai P 0; i ¼ 1; 2; . . . ; N, denotes Lagrange multipliers.

3. Experiments and methodologies
The solution can be found through a Wolfe dual problem
X
N
1X N
3.1. Data collection and data process
max LD ðaÞ ¼ ai  ai aj yi yj xTi xj
a
i¼1
2 i;j¼1
ð5Þ A total of 264 medical records collected from patients suffering
X
N
from a variety of diseases ensure the generalization performance of
subject to ai yi ¼ 0 and ai P 0; i ¼ 1; . . . ; N
i¼1
the decision system. The data is collected from West China
Hospital of Sichuan University in Chengdu, China. All the records
Notice that we have now marked the Lagrangians different la- including 13 anthropometrical parameters related to Cormack
bels (P for primal and D for dual). Support vector training therefore classification were categorized into two classes: easy tracheal intu-
amounts to maximizing LD(a) with respect to the non-negative ai. bation (ETI, consisted of Cormack Class I and Class II) and difficult
In the case where the classes are not separable, we add slack vari- tracheal intubation (DTI, consisted of Cormack Class III and Class
ables ni into formula (1) and the goal function becomes IV). Each class includes 132 samples.
The 13 parameters of each sample were divided into three cat-
egories: (1) the basic information about patients such as age and
sex; (2) static metrical information (7 factors in total) including
body mass index, bigonial width (Lux, Conradt, Burden, & Kom-
posch, 2004), mandibular angle, mandibular length, neck circum-
ference, neck length and thromenatal distance; and (3) dynamic
metrical information (4 factors in total) including extension of
atlantoaxial joint, interincisor gap (IIG), modified Mallampati test
and upper lip bite test (Khan, Kashfi, & Ebrahimkhani, 2003).
Here, body mass index (BMI) was calculated by weight and
height as

BMI ¼ Weight in kilograms=ðHeight in metersÞ2 ð10Þ

Fig. 1. The sketch map of two class problem with SVM.
Bigonial width was the distance between left gonion and right
gonion.
Mandibular angle was the angle of the triangular region from
left gonion to right gonion through gnathion.
Mandibular length was the distance between gonion and
gnathion.
6590 Q. Yan et al. / Expert Systems with Applications 36 (2009) 6588–6592

Neck circumference (NC) was measured around the middle of

the neck, over cricoid cartilage.
Neck length was the distance from superior thyroid notch to
suprasternal notch with head hypsokinesis.
Thyromental distance (TMD) was a measurement taken from
the thyroid notch to the tip of the jaw with the head extended.
Extension of atlantoaxial joint (EAJ) h was defined as
h ¼ h 2  h1 ð11Þ
where h1 denoted the angle between horizontal plane and the line
of external-auditory-canal to angulus oris when the patient was
asked to lie supinely and h2 was the same angle but the patient
was requested to lift gnathion as much as possible.
Interincisor gap (IIG) was the maximum space between upper
and lower incisors.
Modified Mallampati test (MMT) provided a screening test in
which classification of oropharyngeal view was assessed with the
Fig. 2. System architecture of the SVM-based decision support system for clinic
patient in sitting position with the neck in neutral position and aided tracheal intubation predication with 13 input diagnostic parameters.
tongue fully protruded without phonation. Grade I: tonsils, pillars
and soft palate are clearly visible; Grade II: the uvula, pillars and
upper pole are visible; Grade III: only part of the soft palate is vis-
ible; the tonsils, pillars and base of the uvula could not be seen; (2) Variables with only two attributes such as sex were coded in
and Grade IV: only the hard palate is visible. binary values (0, 1) where 1 denoted male and 0 denoted
Upper lip bite test criterion was described as follows: Grade I: female.
lower incisors can bite the upper lip above the vermilion line; (3) Variables with three independent attributes such as upper
Grade II: lower incisors can bite the upper lip below the vermilion lip bite test were coded in ternary values (0, 0.5, 1). Take
line; and Grade III: lower incisors cannot bite the upper lip. upper lip bite test for example, Grade I was coded as 0, Grade
Each parameter corresponded to an input variable which consti- II was coded as 0.5 and Grade III was coded as 1.
tuted the input nodes of the SVM-based structure shown in Fig. 2. (4) Variables with four attributes such as modified Mallampati
In the system, the 13 input diagnostic parameters were normal- test were coded in four-value ordinal scales (0, 0.33, 0.67,
ized using the following schemes shown in Fig. 3 (Yan, Jiang, Zhen, 1) with 0 representing Grade I, 0.33 representing Grade II,
Peng, & Li, 2006): 0.67 representing Grade III and 1 representing Grade IV.

(1) Numerical variables such as age and neck length were scaled
to the normalized range [0, 1] so that every input parameter
played an equal role in training. For example, patients’ age
may range from 0 to 100 and thereby the age of a 45-year-
old patient could be scaled to the normalized value of 45/
100 (0.45). The scaling formulation was
xi  xmin
xi ¼
xmax  xmin
where xi represented the value of an input variable, xmin
meant the minimum of the data range and xmax meant the
maximum of the data range.
3.2. Data partition
The advantage of k-fold cross-validation (Written & Frank,
2006) is that all the examples in the dataset are eventually used
for both training and testing. Furthermore, the impact of data
dependency is minimized and the reliability of the results can be
ð12Þ improved. To guarantee precise prediction and good generalization
performance, the dataset was randomly divided into training and
testing samples via 4-fold cross-validation. Sequentially one subset
was tested as an independent holdout test using the classifier
trained on the remaining three subsets. The following illustrates

Fig. 3. List of 13 variables relevant to Cormack classification and their encoding schemes. BMI is the abbreviation for body mass index, TMD is thyromental distance, EAJ is
extension of atlantoaxial joint, IIG is interincisor gap, and MMT is modified Mallampati test.
 Q. Yan et al. / Expert Systems with Applications 36 (2009) 6588–6592 6591

how the four subsets (Fold 1, Fold 2, Fold 3, and Fold 4) in training tem. At the same time, 24 DTI were mistaken as ETI and 6 ETI were
had been performed: mistaken as DTI. Therefore, the user accuracy and the producer
accuracy (Story & Congalton, 1986) can be calculated.
(1) Model #1: training: Fold 1 + Fold 2 + Fold 3; testing: Fold 4; The user accuracy is given as follows:
(2) Model #2: training: Fold 1 + Fold 2 + Fold 4; testing: Fold 3;
DTI : 113=132 ¼ 85:6%
(3) Model #3: training: Fold 1 + Fold 3 + Fold 4; testing: Fold 2; ð14Þ
(4) Model #4: training: Fold 2 + Fold 3 + Fold 4; testing: Fold 1. ETI : 126=132 ¼ 95:5%
The producer accuracy is presented as follows:
In the study, each subset only contained 66 medical data.
DTI : 113=119 ¼ 95:0%
ð15Þ
3.3. Grid-search approach ETI : 126=145 ¼ 86:9%

When using SVM classifiers, there are two problems often con-
fronted: how to choose the optimal features and how to set the 5. Summary
best kernel function parameters. It is beneficial to limit the number
of input features in order to construct an intensive model with In this paper, we have presented a medical decision support
good predictive performance and less computational burdens system based on SVM for tracheal intubation predication before
(Zhang, 2000). Clinically, according to Cormack classification crite- anaesthesia. In particular, the system has been developed with
rion in this study, 13 feasible relative features were considered to 13 input features related with tracheal intubation predication
construct the system. rather than single one. A tracheal intubation database consisting
To improve the classification accuracy, a SVM-based strategy of 264 medical cases collected from patients suffering from a
using grid search (Basrak, 1987) was adopted to optimize the pen- variety of diseases ensured generalization performance of the
alty parameter C and the polynomial function parameter q. Pairs of decision system. Furthermore, the robustness of the proposed sys-
(C, q) were picked out until the best cross-validation accuracy was tem was examined using 4-fold cross-validation method and re-
obtained. Finally, the training parameters C = 100 and q = 3.5 were sults showed that the SVM-based decision support system could
adopted in this system. achieve average classification accuracy at 90.53%, manifesting its
great application prospect of supporting clinic aided diagnosis
4. Experiments results and discussion with full consideration of multiple features of airway physical
examination.
4.1. Classification accuracy For difficult intubation cases, it is greatly helpful if a decision
support system can achieve high prediction accuracy for anaesthe-
The 4-fold cross-validation accuracy of each subset and mean tists. Nevertheless, the prediction accuracy depends on many fac-
accuracy are listed in Table 1. tors. In this study, the number of the dataset, the distribution of
samples and the anthropometric operation errors by different
4.2. Confusion matrix anaesthetists and so on may fluctuate the results. A better solution
for the issue is to get much more medical records to optimize the
The experimental results can also be presented as a confusion performance and stability of the system.
matrix (Table 2). Usually, a confusion matrix contains information
about actual and predicted classifications performed by a classifi- Acknowledgements
cation system. In this study, there are two diagnostic classes: easy
or difficult tracheal intubation. In the confusion matrix, the rows The author would like to thank West China Hospital of Sichuan
represent the test data, while the columns represent the labels as- University, Chengdu, China, for their support in the tracheal intu-
signed by the classifier. Several indices of classification accuracy bation database and valuable suggestions. This work was sup-
can be derived from the confusion matrix. The cross-validation ported by the National Science Foundation of China (Nos.
classification accuracy thus can be determined as 30400105 and 30400423), the National Basic Research Program
(973 Program, No. 2003CB716106), and Outstanding Youth Fund
113 þ 126 239
¼ ¼ 90:53% ð13Þ of China (No. 30525030).
264 264
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