Airway management and morbid obesity

Abstract

Morbidly obese patients present with excess fatty tissue externally on the breast, neck, thoracic wall and abdomen and internally in the mouth, pharynx and abdomen. This excess tissue tends to make access (intubation, tracheostomy) to and patency (during sedation or mask ventilation) of the upper airway and the function of the lungs (decreased residual capacity and aggravated ventilation perfusion mismatch) worse than in lean patients. Proper planning and preparation of airway management is essential, including elevation of the patient's upper body, head and neck. Preoxygenation is mandatory in morbidly obese patients and should be followed by actions to counteract atelectasis formation. The decision as to weather to use a rapid sequence induction, an awake intubation or a standard induction with hypnotics should depend on the thorough airway examination and comorbidity and should not be based solely on whether morbid obesity is present or not. It is important to ensure sufficient depth of anaesthesia before initiating manipulation of the airway because inadequate anaesthesia depth predisposes to aspiration if airway management becomes difficult. The intubating laryngeal mask airway is more efficient in the morbidly obese patients than in lean patients and serves as a rescue device for both failed ventilation and failed intubation. In the 24 h following anaesthesia, morbidly obese patients experience frequent oxygen desaturation periods that can be counteracted by continuous positive airway pressure, noninvasive ventilation and physiotherapy.

The New Maneuver for Difficult Intubation

“…Difficult intubation, sometimes defined as inadequate glottis exposure to direct laryngoscopy, is more prevalent in patients with high BMI [1]. Theories to explain difficult intubation in obese patients include: fatty tissue in the neck, chest, abdomen, and pharynx may compromise intubation [5]; limited neck extension, anatomic abnormality, and tissue reactivity [6]; fat distribution [7]; large necks [8]; diabetes mellitus [9]. These factors are believed to impress laryngoscopy and therefore tracheal intubation [3].…”

Does the Future Belong to Bronchial Blockers?

“…Obez hastalarda akciğer izolasyon teknikleri havayolu idamesi süresince komplikasyon gelişimi için risk oluşturabilir [51,52] . ÇLT ile entübasyon TLT'ye göre daha zor olabilir çünkü özel şekillleri ve daha büyük olmaları nedeniyle direkt laringoskopi sırasında glottisin görünümünü engelleyebilirler [53] .…”

Challenges in the surgical management of spine trauma in the morbidly obese patient: a case series

“…Immediate postoperative continuous positive airway pressure and early chest physiotherapy are recommended. 13,30,38 There may be a greater indication for surgical tracheostomy in these patients.…”

“…8 Obesity is generally defined in terms of the BMI as measured by weight in kilograms divided by height in meters squared. 49 According to the definitions of the WHO, a BMI of 18-24.99 is normal, 25-29.99 is overweight, [30][31][32][33][34][35][36][37][38][39].99 is obese, and ≥ 40 is morbidly obese. 49 In addition to the well-recognized medical, social, and economical consequences, this increasing level of obesity poses significant challenges for health care professionals in the multitrauma setting.…”

“…5,13 Postoperatively, obese patients with obstructive sleep apnea, who have undergone a procedure while prone, are more susceptible to developing airway edema and obstruction. 30 A planned extubation is performed in the intensive care unit with the patient awake and able to respond to commands. Immediate postoperative continuous positive airway pressure and early chest physiotherapy are recommended.…”