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
cohort 2 . 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 intubation 6 . A number of studies looking=
at
morbid obesity and tracheal intubations have not found obesity to be
predictive of intubation difficulties 6,7,8.
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
guidelines 10 . 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/m 2 ± 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 FiO 2 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 intubation 9 .
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.
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span
style=3D'position:absolute;top:93.73%;left:68.95%;width:32.67%;height:1.56=
%'>
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