Hilal ERDEM SOLAK, Canan YILMAZ, Derya KARASU, Isra KARADUMAN, Gülşen KORFALI, Ümran KARACA, Çağdaş BAYTAR, Ayşe Neslihan BALKAYA

Gebelerde zor laringoskopinin belirlenmesinde ön boyun yumuşak doku kalınlığının ultrasonografi ile ölçümü

Amaç: Bu çalışmanın birincil amacı, zor laringoskopi ile boyun ön yumuşak doku kalınlığı ölçümü arasındaki ilişkiyi genel anestezi altındaki sezaryenlerde incelemektir. İkincil amacımız, gebe kadınlarda zor laringoskopiyi saptamak için diğer prediktif testlerin ve indüksiyon sonrası göstergelerin etkinliğini belirlemektir. Gereç ve Yöntem: Yüz elli iki gebe hasta (18-45 yaş, Amerikan Anesteziyologlar Derneği Fiziksel Durum Sınıf II) dahil edildi. Cormack ve Lehane skalası skoruna (I-II: kolay laringoskopi, III-IV: zor laringoskopi) göre hastalar iki gruba ayrıldı. Deriden trakeanın ön yüzüne kadar olan mesafe ultrasonografi ile 5 farklı seviyede (hyoid kemik, tirohyoid membran, vokal kord, tiroid istmus ve suprasternal çentik) ölçüldü. Zor laringoskopiyi önceden belirlemek için diğer öngörücü testler ve indüksiyon sonrası belirteçler kaydedildi. Bulgular: Gruplar arasında boyun ön yumuşak dokusunun ultrasonografi ölçümlerinde anlamlı fark yoktu. Ağız açıklığının kısıtlı olması (4.80±0.51cm), sek dişleri (%20), Wilson Risk Skoru yüksek (0.73±0.82), boyun çevresi geniş (41.40±2.96cm), üst dudağı ısıramama (%43), ve yüksek Modifiye Mallampati Skoru (%33), zor laringoskopi grubunda istatistiksel olarak anlamlı derecede daha yaygın görüldü. Ayrıca “Geri, Yukarı, Sağa Basınç” manevrası, sakız elastik buji kullanımı, yüksek Entübasyon Zorluk Skoru ve >2 entübasyon girişimi zor laringoskopi grubunda daha sık bulundu. Sonuç: Gebelerde boyun ön yumuşak dokusunun ultrasonografi ile ölçülmesi zor laringoskopiyi belirlemede etkili bir yöntem değildir. Ancak Mallampati Skoru, üst dudak ısırma testi, ağız açma, boyun çevresi, çıkık ön diş ve Wilson Risk Skoru gebelerde zor laringoskopinin belirlenmesinde faydalı olabilir.

Ultrasound measurements of anterior neck soft tissue thickness to predict difficult laryngoscopy in pregnant patients

Purpose: The aim of this study is to examine the relationship between the measurement of anterior neck soft tissue thickness and the difficult laryngoscopy in which cesarean section under general anesthesia. Our secondary aim is to determine the efficacy of the other predictive tests and post-induction indicators to detect difficult laryngoscopy in pregnant women. Materials and Methods: One hundred fiftytwo pregnant women (18-45 years old, American Society of Anesthesiologists Physical Status Class II) were included. According to Cormack and Lehane’s scale (Grade I-II: easy laryngoscopy, Grade III-IV: difficult laryngoscopy) patients were divided into two groups. The distance from the skin to the anterior aspect of the trachea was measured at five different levels (hyoid bone, thyrohyoid membrane, vocal cords, thyroid isthmus, and suprasternal notch) with ultrasound. In addition, the other predictive tests and post-induction indicators for predetermining difficult laryngoscopy were recorded. Results: There was no significant difference in the anterior neck soft tissue ultrasound measurements between the groups. Having limited mouth opening (4.80±0.51cm), buck teeth (20%), high Wilson's Risk Score (0.73±0.82), large neck circumference (41.40±2.96cm), inability to bite the upper lip (43%), and high Modified Mallampati Score (33%) were seen statistically significantly more common in the difficult laryngoscopy group. In addition, ‘‘Backward, Upward, Rightward Pressure’’ maneuver, use of gum elastic bougie, high Intubation Difficulty Score, and >2 intubation attempts were more frequently found in the difficult laryngoscopy group. Conclusion: Measuring the anterior neck soft tissue with ultrasound is ineffective for determining difficult laryngoscopy in pregnant women. On the other hand, Mallampati Score, upper lip bite test, mouth opening, neck circumference, buck teeth, and Wilson's Risk Score can be helpful in the determination of difficult laryngoscopy in pregnancies.

PDF

___

1. Kuczkowski KM, Reisner LS, Benumof JI. The difficult airway: Risk, prophylaxis and management. In Chestnut's Obstetric Anesthesia: Principles and Practice. 3rd edn. Mosby Inc, 2004; 535-62.
2. Hagberg CA. Handbook of Difficult Airway Management. Philadelphia:Churchill Livingstone, 2000; 301-18.
3. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology 2005;103:429-37. https://doi.org/10.1097/00000542-200508000-00027.
4. Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand 2011;55(10):1155-73. https://doi.org/10.1111/j.1399-6576.2011.02518.x.
5. Singh M, Chin KJ, Chan VW, Wong DT, Prasad GA, Yu E. Use of sonography for airway assessment: an observational study. J Ultrasound Med 2010;29(1):79-85. https://doi.org/ 10.1097/ALN.0b013e31827773b2.
6. Apfelbaum JL, Hagberg CA, Caplan RA et al. Practice guidelines for management of difficult airway: an updated report by the American society of anesthesiologists task force on management of the difficult airway. Anesthesiology 2013;118:251-70.
7. Yentis SM, Lee DJH. Evaluation of an improved scoring system for the grading of direct laryngoscopy. Anaesthesia 1998;53(11):1041-4. https://doi.org/ 10.1046/j.1365-2044.1998.00605.x.
8. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth 2012;109(1):68-85. https://doi.org/ 10.1093/bja/aes393.
9. Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177,088 patients. Br J Anaesth 2011;107(5):659-67. https://doi.org/ 10.1093/bja/aer292.
10. Prasad A, Yu E, Wong DT, Karkhanis R, Gullane P, Chan VW. Comparison of sonography and computed tomography as imaging tools for assessment of airway structures. J Ultrasound Med 2011;30(7):965-72. https://doi.org/10.7863/jum.2011.30.7.965.
11. Lakhal K, Delplace X, Cottier J-P et al. The feasibility of ultrasound to assess subglottic diameter. Anesth Analg 2007;104(3):611-4. https://doi.org/10.1213/01.ane.0000260136.53694.f
12. Ezri T, Gewürtz G, Sessler DI et al. Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesthesia 2003;58(11):1111-4. https://doi.org/ 10.1046/j.1365-2044.2003.03412.x
13. Adhikari S, Zeger W, Schmier C et al. Pilot study to determine the utility of point-of-care ultrasound in the assessment of difficult laryngoscopy. Acad Emerg Med 2011;18(7):754-8. https://doi.org/ 10.1111/j.1553-2712.2011.01099.x.
14. Wu J, Dong J, Ding Y, Zheng J. Role of anterior neck soft tissue quantifications by ultrasound in predicting difficult laryngoscopy. Med SciMonit 2014;18;20:2343-50. https://doi.org/ 10.12659/MSM.891037.
15. Pinto J, Cordeiro L, Pereira C, Gama R, Fernandes HL, Assunc J. Predicting difficult laryngoscopy using ultrasound measurement of distance from skin to epiglottis. J Crit Care 2016;33:26-31. https://doi.org/ 10.1016/j.jcrc.2016.01.029.
16. Parameswari A, Govind M, Vakamudi M. Correlation between preoperative ultrasonographic airway assessment and laryngoscopic view in adult patients: A prospective study. J Anaesthesiol Clin Pharmacol 2017;33(3):353-8. https://doi.org/ 10.4103/joacp.JOACP_166_17.
17. Rana S, Verma V, Bhandari S, Sharma S, Koundal V, Chaudhary SK. Point of care ultrasound in the airway assessment: A correlation of ultrasonography-guided parameters to the Cormack–Lehane Classification. Saudi J Anaesth 2018;12(2):292-6. https://doi.org/10.4103/sja.SJA_540_17 .
18. Komatsu R, Sengupta P, WadhwaA et al. Ultrasound quantification of anterior soft tissue thickness fails to difficult laryngoscopy in obese patients. Anaesth Intensive Care. 2007;35(1):32-7. https://doi.org/10.1177/0310057X0703500104
19. Aydogmus MT, Erkalp K, Sinikoglu SN, Usta TA, Ulger OG, Alagol A. Is ultrasonic investigation of transverse tracheal air shadow diameter reasonable for evaluation of difficult airway in pregnant women: a prospective comparative study. Pak J Med Sci 2014;30(1):91-5. https://doi.org/10.12669/pjms.301.3972.
20. Mohammadi SS, Saliminia A, Nejatifard N, Azma R. Usefulness of Ultrasound View of Larynx in Pre-Anesthetic Airway Assessment: A Comparison With Cormack-Lehane Classification During Direct Laryngoscopy. Anesth Pain Med 2016;6(6):39566. https://doi.org/10.5812/aapm.39566.
21. Craig P, Halavatau V, Comino E, Caterson I. Differences in body composition between Tongans and Australians: time to rethink the healthy weight ranges? Int J Obes Relat Metab Disord 2001;25(12):1806-14. https://doi.org/10.1038/sj.ijo.0801822.
22. Zillikens MC, Conway JM. Anthropometry in blacks: applicability of generalized skinfold equations and differences in fat patterning between blacks and whites. Am J Clin Nutr 1990; 52(1):45-51. https://doi.org/10.1093/ajcn/52.1.45.
23. Fulkerson JS, Moore HM, Anderson TS, Lowe RF Jr. Ultrasonography in the preoperative difficult airway assessment. J Clin Monit Comput 2017;31(3):513-30. https://doi.org/ 10.1007/s10877-016-9888-7.
24. Harmer M. Difficult and failed intubation in obstetrics. Int. J. Obstetric Anaesth 1997;6: 25-31.
25. Alıç M, Birbiçer H, Kurku Ö. The Importance of Predictive Tests on Determination of Intubation Difficulties in Obese Pregnants. Turk J Anaesthesiol Reanim 2011;39:126-133. https://doi.org/10.5222/JTAICS.2011.126.
26. Min J.J, Kim G, Kim E, Lee J. The diagnostic validity of clinical airway assessments for predicting difficult laryngoscopy using a grey zone approach. J Int Med Res 2016;44(4):893-904. https://doi.org/ 10.1177/0300060516642647.
27. Siriussawakul A, Rattana-arpa S, Jirachaipitak S, Chatsiriphattana A, Nim-mannit A, Wong-in N. The Performance of the Neck Circumference for a Difficult Laryngoscopy in Obese Patients. J Med Assoc Thai 2016;99(5):484-90. https://doi.org/10.1016/j.ijoa.2017.01.011.
28. Gonzalez H, Minville V, Delanoue K et al. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg 2008;106(4):1132-6. https://doi.org/ 10.1213/ane.0b013e3181679659.
29. Hester CE, Dietrich SA, White SW, Secrest JA, Lindgren KR, Smith T. A comparison of preoperative airway assessment techniques: the modified Mallampati and the upper lip bite test. AANA J 2007;75(3):177-82.
30. Honarmand A, Safavi MR. Prediction of difficult laryngoscopy in obstetric patients scheduled for Caesarean delivery. Eur J Anaesthesiol 2008;25(9):714-20. https://doi.org/10.1017/S026502150800433X.