Ultrasound-measured cutaneous-epiglottic distance for predicting difficult laryngoscopy: an observational study
Distância cutâneo-epiglótica medida por ultrassom para predição de laringoscopia difícil: um estudo observacional
Luis Henrique Cangiani, Rodrigo Leal Alves, Glenio B. Mizubuti, Rodrigo Moreira e Lima, Lais Helena Navarro e Lima
Abstract
Introduction
Ultrasound (US) allows for rapid bedside airway assessment. We aimed to evaluate the US-measured cutaneous-epiglottic distance (CED) in predicting difficult laryngoscopy (Cormack-Lehane grades 3‒4). We also evaluated the potential association between CED, sex, patient’s body mass index (BMI), and the independent associations between CED and increased odds for Cormack-Lehane grades 3‒4 (secondary outcomes).
Methods
Patients aged 18‒70 years scheduled for elective surgeries under general anesthesia with tracheal intubation were included. Those with a BMI > 35 kg.m-2 and/or previous history of difficult intubation were excluded. CED was measured with patients anesthetized before tracheal intubation. Age, sex, BMI, type of surgery, and number of attempts until successful tracheal intubation were recorded. Receiver operator characteristic (ROC) curve analysis was performed to evaluate CED’s clinical relevance. Secondary analyses compared the association between CED and BMI in patients with Cormack-Lehane grades 1‒2 versus those with grades 3‒4. The relationship between CED and BMI was assessed using multiple linear regression. Binary logistic regression was employed for predicting Cormack-Lehane grades 3‒4 as a dichotomous outcome with CED and BMI as a covariate.
Results
ROC curve analysis revealed an area under the curve of 0.899 (p < 0.001). The maximum CED cut-off point (by Youden index) was 25.6 mm. CED and BMI were positively correlated, and both were independently associated with an increased odds for difficult laryngoscopy [odds ratio for CED = 1.81, 95% confidence interval (CI) 1.35‒2.41; BMI = 1.30, 95% CI 1.05‒1.59].
Conclusion
US-measured CED has a high discriminatory capability for predicting lower (1‒2) and higher (3‒4) Cormack-Lehane grades during direct laryngoscopy. CED was positively correlated with BMI and was independently associated with higher odds for difficult laryngoscopy.
Keywords
Resumo
Introdução
O ultrassom (US) permite avaliação rápida da via aérea à beira do leito. Nosso objetivo foi avaliar a Distância Cutâneo-Epiglótica (CED) medida por US na predição de laringoscopia difícil (graus 3‒4 de Cormack-Lehane). Também avaliamos a possível associação entre CED, sexo, Índice de Massa Corporal (IMC) do paciente, e as associações independentes entre CED e o aumento das chances para graus 3‒4 de Cormack-Lehane (desfechos secundários).
Métodos
Pacientes com idades entre 18‒70 anos, programados para cirurgias eletivas sob anestesia geral com intubação traqueal, foram incluídos. Foram excluídos pacientes com IMC > 35 kg.m⁻² e/ou histórico prévio de intubação difícil. A CED foi medida com os pacientes anestesiados antes da intubação traqueal. Foram registrados idade, sexo, IMC, tipo de cirurgia e número de tentativas até a intubação traqueal bem-sucedida. A análise da curva ROC (Receiver Operator Characteristic) foi realizada para avaliar a relevância clínica da CED. Análises secundárias compararam a associação entre CED e IMC em pacientes com graus 1‒2 versus graus 3‒4 de Cormack-Lehane. A relação entre CED e IMC foi avaliada por regressão linear múltipla. A regressão logística binária foi usada para predizer graus 3‒4 de Cormack-Lehane como desfecho dicotômico, considerando CED e IMC como covariáveis.
Resultados
A análise da curva ROC revelou uma área sob a curva (AUC) de 0,899 (p < 0,001). O ponto de corte máximo para CED (índice de Youden) foi 25,6 mm. CED e IMC apresentaram correlação positiva, e ambos foram independentemente associados ao aumento das chances de laringoscopia difícil (OR para CED = 1,81, IC 95% 1,35‒2,41; IMC = 1,30, IC 95% 1,05‒1,59).
Conclusão
A CED medida por US apresenta alta capacidade discriminatória para predizer graus baixos (1‒2) e altos (3‒4) de Cormack-Lehane durante laringoscopia direta. A CED mostrou correlação positiva com IMC e foi independentemente associada a maiores chances de laringoscopia difícil.
Palavras-chave
References
1. Fulkerson JS, Moore HM, Anderson TS, et al. Ultrasonography in the preoperative difficult airway assessment. J Clin Monit Comput. 2017;31:513−30.
2. Dong F, Wang Y, Wang X, et al. Changes in the upper airway following induction of anaesthesia: a prospective observational study protocol to determine the use of ultrasound in the assessment of a difficult airway in China. BMJ Open. 2019;9:e029782.
3. Benavides-Zora D, Jaramillo MC, Townsley MM, et al. Diagnostic performance of airway ultrasound for the assessment of difficult laryngoscopy: A systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2023;37:1101−9.
4. Kundra P, Mishra SK, Ramesh A. Ultrasound of the airway. Indian J Anaesth. 2011;55:456−62.
5. Osman A, Sum KM. Role of upper airway ultrasound in airway management. J Intensive Care. 2016;4:52.
6. Yadav NK, Rudingwa P, Mishra SK, et al. Ultrasound measurement of anterior neck soft tissue and tongue thickness to predict difficult laryngoscopy - An observational analytical study. Indian J Anaesth. 2019;63:629−34.
7. Kristensen MS, Teoh WH, Graumann O, et al. Ultrasonography for clinical decision-making and intervention in airway management: from the mouth to the lungs and pleurae. Insights Imaging. 2014;5:253−79.
8. Dabo-Trubelja A. Point-of-care ultrasound: A review of ultrasound parameters for predicting difficult airways. J Vis Exp. 2023;194. https://doi.org/10.3791/64648.
9. Pinto J, Cordeiro L, Pereira C, et al. Predicting difficult laryngoscopy using ultrasound measurement of distance from skin to epiglottis. J Crit Care. 2016;33:26−31.
10. Simel DL, Rennie D, Bossuyt PM. The STARD statement for reporting diagnostic accuracy studies: Application to the history and physical examination. J Gen Intern Med. 2008;23:768−74.
11. Ezri T, Szmuk P, Warters RD, et al. Difficult airway management practice patterns among anesthesiologists practicing in the United States: Have we made any progress? J Clin Anesth. 2003;15:418−22.
12. Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: A closed claims analysis. Anesthesiology. 2005;103:33−9.
13. Combes X, Jabre P, Margenet A, et al. Unantecipated difficult airway management in the prehospital emergency setting: Prospective validation of an algorithm. Anesthesiology. 2011;114: 105−10.
14. Stringer KR, Bajenov S, Yentis SM. Training in airway management. Anaesthesia. 2002;57:967−83.
15. Alessandri F, Antenucci G, Piervincenzi E, et al. Ultrasound as a new tool in the assessment of airway difficulties: An observational study. Eur J Anaesthesiol. 2019;36:509−15.
16. Abdallah FW, Yu E, Cholvisudhi P, et al. Is ultrasound a valid and reliable imaging modality for airway Elevaluation? An observational computed tomographic validation study using submandibular scanning of the mouth and oropharynx. J Ultrasound Med. 2017;36:49−59.
17. Prathep S, Jitpakdee W, Woraathasin W, et al. Predicting difficult laryngoscopy in morbidly obese Thai patients by ultrasound measurement of distance from skin to epiglottis: A prospective observational study. BMC Anesthesiol. 2022;22:145.
18. Martins MP, Ortenzi AV, Perin D, et al. Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in adults. Braz J Anesthesiol. 2024;74:744477.
19. Falcetta S, Cavallo S, Gabbanelli V, et al. Evaluation of two neck ultrasound measurements as predictors of difficult direct laryngoscopy: A prospective observational study. Eur J Anaesthesiol. 2018;35:605−12.
20. Giordano G, Alessandri F, Zulian A, et al. Pre-operative ultrasound prediction of difficult airway management in adult patients: A systematic review of clinical evidence. Eur J Anaesthesiol. 2023;40:313−25.
21. Altun D, Kara H, Bozbora E, et al. The Role of indirect laryngoscopy, clinical and ultrasonographic assessment in prediction of difficult airway. Laryngoscope. 2021;131:e555−e60.
22. Vidhya S, Swain BP, Dash A, et al. Ultrasound-guided airway evaluation: Is it a game changer for predicting difficult endotracheal intubation? Cureus. 2024;16:e52557.
23. Fernandez-Vaquero MA, Charco-Mora P, Garcia-Aroca MA, et al. Preoperative airway ultrasound assessment in the sniffing position: A prospective observational study. Braz J Anesthesiol. 2023;73:539−47.
24. Carsetti A, Sorbello M, Adrario E, et al. Airway ultrasound as predictor of difficult direct laryngoscopy: A systematic review and meta-analysis. Anesth Analg. 2022;134:740−50.
25. De Luis-Cabezon N, Ly-Liu D, Renedo-Corcostegui P, et al. A new score for airway assessment using clinical and ultrasound parameters. Front Med (Lausanne). 2024;11:1334595.
Submitted date:
11/07/2024
Accepted date:
04/29/2025
Facebook
Google+
Twitter
LinkedIn
Mendeley
StumbleUpon
CiteULike
Reddit
Email