Airway sonography fails to detect difficult laryngoscopy in an adult Veteran surgical population

Fulkerson, Justin S.; Moore, Heather M.; Lowe, Rachel; Anderson, Tristan; Lucas, Lisa L.; Reed, Jonathan W.

doi:10.1016/j.tacc.2019.07.003

“…Patient selection bias was the most common bias encountered in the reviewed studies. Four studies were judged to have a high risk for patient selection bias due to their convenience sampling method [ 9 ], unclear recruitment method and small sample size [ 29 ], unknown recruitment method, too many exclusion criteria, and undisclosed excluded cases [ 31 ], or unknown recruitment method and including only parturient women [ 10 ]. Sixteen studies were deemed to have an unclear risk of patient selection bias due to their unclear recruitment strategy [ 8 , 11 – 18 , 20 – 22 , 24 , 27 , 28 , 30 ].…”

Section: Resultsmentioning

confidence: 99%

Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis

Sotoodehnia

¹

,

Rafiemanesh

²

,

Mirfazaelian

³

et al. 2021

View full text Add to dashboard Cite

Background Ultrasonography (US) is recently used frequently as a tool for airway assessment prior to intubation (endotracheal tube (ETT) placement), and several indicators have been proposed in studies with different reported performances in this regard. This systematic review and meta-analysis reviewed the performance of US in difficult airway assessment. Methods This systematic review and meta-analysis was conducted according to the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane book. All the studies that had carried out difficult airway assessments using US, had compared the indicators in difficult and easy groups, and had published the results in English by the time we conducted our search in April 28, 2020, were included. Results In the initial search, 17,156 articles were retrieved. After deleting the duplicate articles retrieved from multiple databases, 7578 articles remained for screening based on the abstracts and titles. Finally, the full text of 371 articles were assessed and the data from 26 articles were extracted, which had examined a total of 45 US indicators for predicting difficult intubation. The most common US index was the “thickness of anterior neck soft tissue at the vocal cords level”. Also, “skin to epiglottis” and “anterior neck soft tissue at the hyoid bone level” were among the most common indicators examined in this area. Conclusion This systematic review showed that US can be used for predicting difficult airway. Of note, “skin thickness at the epiglottis and hyoid levels”, “the hyomental distance”, and “the hyomental distance ratio” were correlated with difficult laryngoscopy in the meta-analysis. Many other indicators, including some ratios, have also been proposed for accurately predicting difficult intubation, although there have been no external validation studies on them.

show abstract

“…A further source of potential heterogeneity was the application of external laryngeal manipulation during laryngoscopy. The backward-upward-rightward-pressure (BURP) maneuver was applied in 3 studies, 28,40,43 12 did not use it, 29,32,34,37,[44][45][46][47][48][49][50][51] and 17 did not mention if any external laryngeal manipulation was applied to improve laryngeal view. 30,31,33,35,36,38,39,41,42,[52][53][54][55][56][57][58][59] Some studies reported sensitivity, specificity, and area under the curve receiver operating characteristic (AUC-ROC) for each UA-US index test, whereas other studies only compared the mean values of UA-US index test between the patients' groups (Supplemental Digital Content 1, Table 1, http://links.lww.com/AA/D759).…”

Section: Study Selection and Study Characteristicsmentioning

confidence: 99%

“…Seventeen studies have been considered for secondary outcome. [28][29][30][31][32][33]38,41,44,46,[48][49][50][51]53,59,64 Patients with difficult direct laryngoscopy had higher DSE, DSVC, and DSHB values than patients with easy laryngoscopy, with MD of 0.38 cm (95% confidence interval [CI], 0.17-0.58 cm; P = .0004), 0.18 cm (95% CI, 0.01-0.35 cm; P = .04), and 0.23 cm (95% CI, 0.08-0.39 cm; P = .004), respectively (Figure 3; Supplemental Digital Content 1, Figures 4 and 5, http://links.lww.com/AA/D759). However, the level of heterogeneity was very high.…”

Section: Secondary Outcomementioning

confidence: 99%

Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis

Carsetti

¹

,

Sorbello

²

,

Adrario

³

et al. 2021

Anesthesia &Amp; Analgesia

View full text Add to dashboard Cite

BACKGROUND: Despite several clinical index tests that are currently applied for airway assessment, unpredicted difficult laryngoscopy may still represent a serious problem in anesthesia practice. The aim of this systematic review and meta-analysis was to evaluate whether preoperative airway ultrasound can predict difficult direct laryngoscopy in adult patients undergoing elective surgery under general anesthesia. METHODS: We searched the Medline, Scopus, and Web of Science databases from their inception to December 2020. The population of interest included adults who required tracheal intubation for elective surgery under general anesthesia without clear anatomical abnormalities suggesting difficult laryngoscopy. A bivariate model has been used to assess the accuracy of each ultrasound index test to predict difficult direct laryngoscopy. RESULTS: Fifteen studies have been considered for quantitative analysis of summary receiver operating characteristic (SROC). The sensitivity for distance from skin to epiglottis (DSE), distance from skin to hyoid bone (DSHB), and distance from skin to vocal cords (DSVC) was 0.82 (0.74–0.87), 0.71 (0.58–0.82), and 0.75 (0.62–0.84), respectively. The specificity for DSE, DSHB, and DSVC was 0.79 (0.70–0.87), 0.71 (0.57–0.82), and 0.72 (0.45–0.89), respectively. The area under the curve (AUC) for DSE, DSHB, DSVC, and ratio between the depth of the pre-epiglottic space and the distance from the epiglottis to the vocal cords (Pre-E/E-VC) was 0.87 (0.84–0.90), 0.77 (0.73–0.81), 0.78 (0.74–0.81), and 0.71 (0.67–0.75), respectively. Patients with difficult direct laryngoscopy have higher DSE, DSVC, and DSHB values than patients with easy laryngoscopy, with a mean difference of 0.38 cm (95% confidence interval [CI], 0.17–0.58 cm; P = .0004), 0.18 cm (95% CI, 0.01–0.35 cm; P = .04), and 0.23 cm (95% CI, 0.08–0.39 cm; P = .004), respectively. CONCLUSIONS: Our study demonstrates that airway ultrasound index tests are significantly different between patients with easy versus difficult direct laryngoscopy, and the DSE is the most studied index test in literature to predict difficult direct laryngoscopy. However, it is not currently possible to reach a definitive conclusion. Further studies are needed with better standardization of ultrasound assessment to limit all possible sources of heterogeneity.

show abstract

“…Ultrasound is a safe, fast, convenient, real-time, and repeatable imaging technology [ 13 ]. In recent years, bedside ultrasound technology has been developed day by day.…”

Section: Introductionmentioning

confidence: 99%

“…Other scholars believe that ultrasonic examination of the thickness of the anterior soft tissue in the neck at the level of the hyoid and thyrohyoid membrane can be adopted to distinguish difficult laryngoscope exposure. A number of studies have indicated that the ultrasonic measurement of the distance from the epiglottis to skin and the thickness of the pre-epiglottic space can better predict the occurrence of difficult laryngoscope exposure [ 13 , 14 ]. In addition, ultrasonic measurement of tongue thickness, tongue longitudinal cross-sectional area, and tongue volume are also good indicators for predicting difficult laryngoscope exposure.…”

Section: Introductionmentioning

confidence: 99%

Diagnostic Efficacy and Clinical Value of Ultrasonography in Difficult Airway Assessment: Based on a Prospective Cohort Study

Wu

¹

,

Wang

²

2022

Contrast Media & Molecular Imaging

9

0

View full text Add to dashboard Cite

Objective. A case-control study was conducted to explore the diagnostic efficacy and clinical value of ultrasound in difficult airway assessment. Methods. A total of 220 patients undergoing elective surgery under general anesthesia were prospectively enrolled in our hospital from April 2018 to April 2021. General data were collected one day before operation, including sex, age, height, weight, body mass index (BMI), modified Mallampati test (MMT), inter-incisor distance (IID) and thyromental distance (TMD), the upper lip bite test (ULBT), and thyromental height (TMH). DSH, DSE, DSV, HMD, and tongue width and thickness were measured by ultrasound in the supine position before anesthesia induction on the day of operation. The above data were measured by the same anesthesiologist. After anesthesia, the patients were exposed to laryngoscope by the same senior doctor who did not participate in the data analysis, and the Cormack–Lehane (CL) grade was recorded and endotracheal intubation was completed. The relationship between DSE, DSH, DSV, HMD, and tongue width and thickness and laryngoscope exposure difficulty and tracheal intubation difficulty was analyzed. The critical value of each index for predicting laryngoscope exposure difficulty and tracheal intubation difficulty was obtained by the receiver operating characteristic curve (ROC) and Jordan index. According to the critical value, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of each index were calculated. Results. On comparing the general conditions of the four groups, this study prospectively included 220 patients undergoing elective surgery under general anesthesia for tracheal intubation in our hospital from April 2018 to April 2021, of which 8 cases were excluded from the study because of loss of incisors, 5 cases were excluded from the study due to unclear development of the anterior vocal cords under ultrasound, 7 cases were excluded from the study, and finally 200 patients were included in the study, including 104 males and 96 females. Among the 200 patients, difficult laryngoscope exposure was found in 26 cases (13.00%) and difficult tracheal intubation in 17 cases (8.50%). Tracheal intubation was performed in 17 patients with a visual laryngoscope and light rod, respectively. The weight and BMI of patients in the DL group were higher than in the NDL group, and the difference was statistically significant ( P < 0.05 ); the weight and BMI of patients in the DI group were higher than in the NDI group, and the difference was statistically significant ( P < 0.05 ); there was no significant difference in sex, age, and height between the DL group and the NDL group and the DI group and the NDI group ( P > 0.05 ). Compared with the NDL group, IID, TMD, and TMH in the DL group were lower, and the difference was statistically significant ( P < 0.05 ); there was no significant difference in ULBT ( P > 0.05 ). DSE, DSH, and DSV were higher than in the NDL group, and the difference was statistically significant ( P < 0.05 ), the HMD was lower than in the NDL group, and the difference was statistically significant ( P < 0.05 );the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant ( P < 0.05 ). On comparing the DI NDI groups, the IID, TMD, and TMH in group DI were lower than in group NDI, and the difference was statistically significant ( P < 0.05 ), but there was no significant difference in ULBT ( P > 0.05 ); DSE, DSH, and DSV were higher than in the NDI group, and the difference was statistically significant ( P < 0.05 ); the HMD was lower than in the NDI group, and the difference was statistically significant ( P < 0.05 ); the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant ( P < 0.05 ). The AUC of BMI, TMH, DSE, DSV, HMD, and tongue width and thickness all ranged from 0.70 to 0.9. Laryngoscope exposure difficulty diagnostic value was medium. The AUC of TMD, MMT, ULBT, IID, and DSH ranged from 0.5 to 0.7. The diagnostic value of laryngoscope exposure difficulty was low. According to the ROC curve, the AUC value of HMD, DSE, and tongue thickness in ultrasonic indicators was higher than that of traditional indicators and the AUC value of TMH was the highest in traditional indicators. When the HMD cutoff value was 5.29 cm; the accuracy, sensitivity, specificity, PPV, and NPV were 73.6%, 96.7%, 71.6%, 31.8%, and 97.4%, respectively. Compared with tongue width, tongue thickness has a better predictive performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult laryngoscope exposure was lower than HMD and the difference was statistically significant ( P < 0.05 ). The patients in the DI and NDI groups indicated that the AUC of ULBT, TMD, and IID was between 0.5 and 0.7, the diagnostic values of BMI, MMT, TMH, DSE, DSH, DSV, HMD, and tongue width and thickness were between 0.7 and0.9, and the diagnostic value for tracheal intubation difficulty was moderate. According to the ROC curve, HMD, DSE, and tongue thickness in ultrasonic indexes were higher compared to traditional indexes. Among the traditional indexes, the AUC value of TMH is the largest. In ultrasonic indexes, when the critical value of HMD DSE is 4.85 cm, the AUC value is 0.893, and its accuracy, sensitivity, specificity, PPV, and NPV are 81.6%, 93.8%, 80.6%, 30.2%, and 99.5%, respectively. In ultrasonic indexes, the prediction performance is better, followed by the tongue thickness prediction performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult tracheal intubation was lower than in HMD, and the difference was statistically significant ( P < 0.05 ). Conclusion. Ultrasonic measurements such as DSH, DSE, DSV, HMD, and tongue width and thickness have predictive value for difficult airway;when the ultrasonic measurement of HMD is ˂5.29 cm, we should pay attention to the difficulty of laryngoscope exposure, and when DSE is ˂4.85 cm, we should watch out for difficult tracheal intubation. In terms of other ultrasound indexes, HMD is more valuable in predicting difficult airway.

show abstract

Airway sonography fails to detect difficult laryngoscopy in an adult Veteran surgical population

Cited by 8 publications

References 35 publications

Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis

Ultrasonography indicators for predicting difficult intubation: a systematic review and meta-analysis

Airway Ultrasound as Predictor of Difficult Direct Laryngoscopy: A Systematic Review and Meta-analysis

Diagnostic Efficacy and Clinical Value of Ultrasonography in Difficult Airway Assessment: Based on a Prospective Cohort Study

Contact Info

Product

Resources

About