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3DLaryGard=
Airway Demographics in Morbidly Obese Patients Undergoing Weight Reduction Surgery
Aaron J. Wolkoff, Andrew K. Alshab MD MPH & Donald M. Voltz MD
University Hospitals of Cleveland and Case Western Reser= ve University, Cleveland, Ohio
INTRODUCTION
Patients with morbid obesity may be more difficult to intubate than normal weight cohorts, but this has not been our experience at an academic center perfor= ming bariatric surgery. To further elucidate the airway presentation in patients undergoing weight reduction surgery, we designed a retrospective chart review.
Obesity is a prevalent disease in developed countries with an incidence of obesity (BMI ≥30) as high as 30% in the US population and 4.9% for morbid obesity (BMI≥40)1. Securing the airway in pati= ents undergoing elective general anesthesia is of paramount importance. Morbidly obese patients desaturate during general anesthesia due to higher metabolic requirements and limited ventilatory reserve when compared to a normal wei= ght cohort2. In addition to higher incidents of desaturation, several studies have reported an increase difficulty with endotracheal intubation<= /span>3,4,5. In situations requiring emergent airway control in obese patients outside the OR environment, Mort found BMI measurements to correlate with difficulty in intubation6. A number of studies looking= at morbid obesity and tracheal intubations have not found obesity to be predictive of intubation difficulties6,7,8.
Management of the morbidly obese patient airway in our institution relies on the stan= dard airway assessment tools that are outlined in the ASA difficult airway guidelines10. Our experience has been that the ASA guidelines supersede BMI measurement in the assessment and management of the morbidly obese airway. We present retrospective data on a cohort of morbidly obese patients presenting to the operating room for both open and laparoscopic gastric bypass surgery.
METHODS
After IRB approval of our data collection proposal, we identified 227 morbidly o= bese patients who underwent elective gastric bypass surgery from January 2003 to December 2004. Standard patient demographic information and airway examina= tion data were collected as well as the method and difficulty for endotracheal = tube placement.
The variables assessed include sex, body mass index (BMI), Mallampati class, thyro-mental distance, temporo-mandibular joint (TMJ) function, neck range= of motion, presence or absence of obstructive sleep apnea (OSA), method of intubation, and the number of attempts to secure an airway. In addition, we looked at post-operative airway complications in our patient cohort. This = data is presented as mean ± standard deviation to summarize the airway demographics for our institution.
RESULTS
The patients in this retrospective study were mainly female (83.3%) with an average BMI of 50.47 kg/m2 ± 8.55 kg/m2. Obstructive sleep apnea was noted in 51.5% of these patients with 42.2% we= re currently using CPAP. General anesthesia with neuromuscular paralysis was = used in 92.5% of the cases, and successful placement of an endotracheal tube was done with direct laryngoscopy 96.5% of the time. Fiberoptic bronchoscopic placement of an endotracheal tube occurred in 2.2% of the patients. None of these patients underwent awake fiberoptic intubation or required emergency management of the airway following the induction of anesthesia.
Post-operatively, there were 7 cases (3.1%) of post-operative desaturation, all of which resolved with increasing FiO2 with 1 (0.44%) requiring re-intuba= tion in the operating room.  Six patients (2.6%) were taken to the PACU intubated and extubated shortly aft= er arrival. There were no reported intraoperative desaturations or inability = to secure the airway. No patient was cancelled due to airway related issues.&= #13;
CONCLUSION
Difficult intubation in the obese patient population has been debated. In this retrospective analysis of morbidly obese patients, we outline the airway demographics and the mode of intubation in a cohort of 227 patients. Our retrospective study has not demonstrated an increased incidence of difficu= lt intubation when compared to previously reported data on difficult laryngos= copy and tracheal intubation9.
Since we did not have any patient in this cohort who we could not intubate, we a= re unable to draw a link between BMI, or pre-operative airway evaluation and airway difficulty in morbidly obese patients. A larger Prospective evaluat= ion normalizing airway evaluation and comparing them with a normal weight coho= rt would help to delineate some of these problems.
The conclusions drawn from this research are limited by its retrospective natu= re. Many of the earlier studies that found obesity as a risk factor for diffic= ult intubation did not differentiate between difficult intubation and difficult laryngoscopy, not necessarily the same thing. Our review did not account f= or this problem since few of the charts recorded the laryngeal view obtained = by the laryngoscopist. The purpose of this study was to define the demographi= cs for a large group of morbidly obese patients undergoing gastric bypass surgery.
REFERENCES
1. Hedley AA, Og= den CL, Johnson, CL, Carroll MD, Curtin, LR, Flegal, KM. Prevalence of overwei= ght and obesity US children, adolesc= ents, and adults, 1999–2002. JAMA 2004;291:2847 – 50. 2. Kabon B, Nagele A, Reddy D, Eagon C, Fleshman JW, Sessler DI, Kurz A. Obesity decreases perioperative <= span style=3D'position:absolute;top:77.11%;left:68.95%;width:27.61%;height:1.56= %'> tissue oxygenation. Anesthesiology. 2004 Feb;100(2):274-80.
3. Fisher A, Waterhouse, TD, = Adams, AP. Obesity: its relation to anaesthesia. Anaesthesia 1975; 30:633-47.
4. Benumof JL. Obstructive sleep apnea in the adult obese patient: implications for airwa= y management. J Clin Anesth 2001; 13:144-56. 5. Voyagis GS, Kyriakis KP, Dimitriou V, Vrettou I. Vale of oropharyngeal Mallampati classification in prediciting difficult laryngoscopy among obese patien= ts. Eur J Anaesthesiol 1998; 15:330-4.
6. Mort TC. Morbid Obesity: Difficulties in Managing the Emergent Airway. ASA Abstract, 2005, A1145. &= #13;
7. Brodsky, JB, Lemmens, HJM, Brock-Utne, JG, Vierra, M, Saidman, LJ. Morbid obesity and tracheal intubation. Anesth = Analg 2002;94:732–6.
8. Bond A. Obesity and diffic= ult intubation. Anaesth Intensive Care 1993;21:828–30.
9. Jacobsen J, J= ensen E, Waldau T, Poulsen TD. Preoperative evaluation of intubation conditions = in patients scheduled for elective surgery. Acta Anaesthesiol Sca= nd 1996;40:421–4. 10. American Society of Anesthesiologists Task For= ce on Management of the Difficult Airway. Practice guidelines <= span style=3D'position:absolute;top:93.73%;left:68.95%;width:32.67%;height:1.56= %'> for management of the difficult airway: an updated re= port by the American Society= of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003 May;98(5):1269= -77.
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