A Comparison of the Mallampati evaluation in neutral or extended cervical spine positions: a retrospective observational study of &gt;80 000 patients

Healy, David W.; Peoples, Emily; Jewell, Elizabeth S.; Bettendorf, R.J.; Ramachandran, Satya Krishna

doi:10.1093/bja/aew056

Cited by 18 publications

(9 citation statements)

References 32 publications

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“…When evaluating diagnostic tests a high sensitivity and specificity is desired, with the former being of greater importance [13]. Ultrasonography-derived indicators have been recently evaluated for the prediction of difficult airway.…”

Section: Discussionmentioning

confidence: 99%

Ultrasound-based assessment of hyomental distances in neutral, ramped, and maximum hyperextended positions, and derived ratios, for the prediction of difficult airway in the obese population: a pilot diagnostic accuracy study

Petrișor

Szabó

Constantinescu³

et al. 2018

Anaesthesiol Intensive Ther

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Background: Ultrasonography-assessed hyomental distance (HMD) ratio has been found to discriminate between obese patients with Cormack-Lehane grades 1 or 2 vs. those with grades 3 or 4. The aim of our study is to evaluate the performance of the HMD evaluated ultrasonographically in neutral, ramped, and maximum hyperextended positions, as well as for the ratios obtained by dividing the HMD in the ramped position to that in the neutral position (HMDR1) and by dividing the HMD in maximum hyperextension to that in the neutral position (HMDR2), in order to predict the occurrence of Cormack-Lehane grades 3 or 4 during direct laryngoscopy. Methods: Ultrasound measurements were performed preoperatively in 25 patients with morbid obesity, measuring the HMD in the neutral, ramped, and maximum hyperextended positions. Pre-epyglotic soft tissue thickness, Mallampati and upper lip bite test scores were recorded. Cormack-Lehane grading was considered as an outcome variable in the Receiver Operating Characteristics curve analysis. Results: HMD in the neutral, ramped and maximum hyperextended positions presented similar sensitivities, 100% [39.8-100.0]. For HMD, specificity was 42.86% [21.8-66.0] in the neutral position, 61.9% [38.4-81.9] in the ramped postion, and 71. 4% [47.8-88.7] in the maximum hyperextended position. For HMDR1, the cut-off value was 1.12. This threshold provides 75% [19.4-99.4] sensitivity and 76. 2% [52.8-91.8] specificity. For HMDR2, a cut-off value of 1.23 provides 100% [39.8-100.0] sensitivity and 90.5% [69.6-98.8] specificity. Conclusion: HMDR2 seems to have superior diagnostic accuracy in predicting difficult laryngoscopy in the obese population compared to HMDR1, as well as compared to the HMD in the neutral, ramped, and maximum hyperextended positions.

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Section: Discussionmentioning

confidence: 99%

Ultrasound-based assessment of hyomental distances in neutral, ramped, and maximum hyperextended positions, and derived ratios, for the prediction of difficult airway in the obese population: a pilot diagnostic accuracy study

Petrișor

Szabó

Constantinescu³

et al. 2018

Anaesthesiol Intensive Ther

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“…A thick neck 15 , 28 , 190 - 192 and OSA 167 are associated with difficult DL or intubation. Whether obesity alone predicts difficult laryngoscopy/intubation continues to be controversial, with some studies reporting an association, 15 , 29 , 31 , 39 , 192 - 195 and others not. 11 , 25 , 191 , 196 - 198 No studies have yet reported obesity to be a risk factor for difficult or failed VL-facilitated tracheal intubation, although one study has reported a thick neck to be associated with failed HA-VL-facilitated tracheal intubation.…”

Section: Special Situationsmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

101

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

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“…This binary risk assessment is then used to predict a research outcome of either difficult laryngoscopy or of difficult intubation. The commonly used standard for difficult laryngoscopy is a Cormack-Lehane direct laryngeal view classification of grade III or IV, 5,23,[25][26][27][28][29][30][31] although the percentage of glottic opening score has also been used. 32 When the chosen outcome is instead difficult intubation, this has been coded as either a numeric threshold (eg, 3 or more unsuccessful attempts 26 ) or a composite score based on the number of attempts and ultimate intubation failure.…”

Section: How Well Does the Mallampati Score Predict Difficult Laryngomentioning

confidence: 99%

“…Healy et al 26 performed the third largest Mallampati study, with 80,801 anesthetics, and found that a Mallampati score of III or IV was 43% sensitive and 83% specific in predicting difficult laryngoscopy. There were 14 false-positive warnings for each correct prediction of a difficult airway.…”

Section: How Well Does the Mallampati Score Predict Difficult Laryngomentioning

confidence: 99%

“…Other smaller studies also noted a low sensitivity for the Mallampati score. [41][42][43] In a 2018 Cochrane review (which did not include the study by Healy et al 26 discussed above), Roth et al 5 found 6 studies reporting data on the Mallampati score and difficult bag-valve-mask ventilation, totaling 56,232 participants with 493 cases of difficult ventilation. Among the studies, the sensitivity and specificity varied widely, with a summary sensitivity of 17% (95% CI 6% to 39%) and specificity of 90% (95% CI 81% to 95%).…”

Section: Adults Receiving General Anesthesiamentioning

confidence: 99%

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Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?

Green

Roback

2019

Annals of Emergency Medicine

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We review the literature in regard to the accuracy, reliability, and feasibility of the Mallampati score as might be pertinent and applicable to emergency department (ED) airway management and procedural sedation. This 4-level pictorial tool was devised to predict difficult preoperative laryngoscopy and intubation, but is now also widely recommended as a routine screening element before procedural sedation. The literature evidence demonstrates that the Mallampati score is inadequately sensitive for the identification of difficult laryngoscopy, difficult intubation, and difficult bag-valve-mask ventilation, with likelihood ratios indicating a small and clinically insignificant effect on outcome prediction. Although it is important to anticipate that patients may have a difficult airway, there is no specific evidence that the Mallampati score augments or improves the baseline clinical judgment of a standard airway evaluation. It generates numerous false-positive warnings for each correct prediction of a difficult airway. The Mallampati score is not reliably assessed because independent observers commonly grade it differently. It cannot be evaluated in many young children and in patients who cannot cooperate because of their underlying medical condition. The Mallampati score lacks the accuracy, reliability, and feasibility required to supplement a standard airway evaluation before ED airway management or procedural sedation. [

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A Comparison of the Mallampati evaluation in neutral or extended cervical spine positions: a retrospective observational study of >80 000 patients

Abstract: This retrospective observational study demonstrates that cervical extension improves the specificity but decreases sensitivity of Mallampati examination. The Mallampati evaluation should be performed with the cervical spine in the neutral position to maximize test sensitivity.

Cited by 18 publications

References 32 publications

Ultrasound-based assessment of hyomental distances in neutral, ramped, and maximum hyperextended positions, and derived ratios, for the prediction of difficult airway in the obese population: a pilot diagnostic accuracy study

Ultrasound-based assessment of hyomental distances in neutral, ramped, and maximum hyperextended positions, and derived ratios, for the prediction of difficult airway in the obese population: a pilot diagnostic accuracy study

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Is the Mallampati Score Useful for Emergency Department Airway Management or Procedural Sedation?

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