254   Airway Management
Mask ventilation (MV) Easy Difficult Impossible P value*
n= 487 n= 46 n= 10   determine the accuracy of ULBT and MT in predicting difficult endotracheal
SpO2< or = 92% 0 (0) 3 (6.5) 5 (50.0) 0.003**
Need to increase FGF > 15L/min 16 (3.3) 16 (34.8) 4 (40.0) NSS
No perceptible capnogram 39 (8.0) 29 (63.0) 9 (90.0) NSS
No perceptible chest movements 33 (6.8) 25 (54.3) 10 (100) 0.009
Need to perform a two-handed MV 12 (2.5) 39 (84.8) 9 (90.0) NSS
Change of operator required 9 (1.8) 9 (19.6) 3 (30.0) NSS  Ease or difficulty of laryngoscopy after the patient is being fully anesthetized
Cumulative frequency of PD/ pt 0.22 2.60 4.0   with standard technique and laryngoscopic view of first attempt was rated by
FGF: fresh gas flow, * Fisher’s exact test: paired comparisons between difficult MV and
impossible MV, **OR= 14.3
Conclusion(s): Absence of chest movements is always present during impos-
sible MV. Evaluation of desaturation alone, seems to underestimate the inci-
dence of inadequate MV.
References:
1 Langeron O etal. Anesthesioloy 2000;92:1229-36.
2 Kheterpal S etal. Anesthesiology 2006;105:885-91.
3 Yildiz TS etal. J Anesth 2005;19:7-11.
19AP4-6
The incidence of difficult laryngoscopy among patients with
difficult mask ventilation
M. Anagnostopoulou, K. Papamichael, H. Galazoula, C. Karanastasi, G.
Voyagis
Department of Anaesthesiology, “Sotiria” Chest Hospital, Athens, Greece
Background and Goal of Study: The ability to maintain an adequate airway
using bag and face mask in cases of difficult intubation is of critical importance.
However there is evidence that difficult direct laryngoscopy (DL) occurs more
frequently in patients with difficult mask ventilation (MV). The goal of this study
was to determine the incidence of difficult DL among patients with difficult
MV.
Materials and Methods: After IRB approval and written informed consent we
studied 543 anaesthetised paralysed adults (ASA 1-3, age 15-85 yr, weight
42-141 kg, M/F: 376/167). The efficiency of MV under general anaesthesia was
evaluated by using a four-point scale to grade difficulty. As criteria of inadequate
MV we defined the following: SpO2 ≤ 92%, need to increase gas flow to >15 L/
min, no perceptible chest movements or capnogram, need to perform a two-
handed MV, change of operator required. Adequate (not difficult) MV without or
with an oral airway was defined as grade (G) 1 or 2 respectively. According to
the number of criteria of inadequate MV the cases were ranked as difficult (G3:
two or three) or impossible (G4: four or more).The DL findings (as defined by the
modified five-grade Cormack & Lehane scoring system [1]) were recorded with
the patient in optimum sniffing position, by using a Macintosh 3 or 4 blade and
without applying any manipulation on the neck.
Results and Discussion:Chi-square test Yates corrected: comparisons
between LV grades 1 and 2a and 2b vs. 3 and 4: P= 0.015, OR= 2.5
LV grades No DMV D/I MV Total
n= 474 n= 56 n= 543
1 287 (60.5) 27 (48.2) 314 (57.8)
2a 77 (16.2) 6 (10.7) 6 (10.7)
2b 64 (13.5) 11 (19.6) 75 (13.8)
3 39 (8.2) 10 (17.9) 49 (9.0)
4 7 (1.5) 2 (3.6) 9 (1.7)
( ):%, D/I: difficult or impossible
Conclusion(s): The inability to visualise the larynx during DL appears twice
as frequent in patients with difficult MV, compared to the rest of the surgical
population.
References:
1 Yentis SM, Lee DJ. Anaesthesia 1998; 53: 1041-4.
19AP4-7
Comparison of upper lip bite test with Mallampati test in
prediction of difficult intubation in tertiary care hospital of a
developing country
M. Qamarul Hoda, A. Asghar, K. Samad
Department of Anaesthesiology, Aga Khan University Hospital, Karachi, Pakistan
Background and Goal of Study: Difficult or failed tracheal intubation has
been identified as one of the most important cause of death or permanent
brain damage during anesthesia. Many methods have been used to predict
difficult intubation. Upper lip bite test (ULBT) and Mallampati test (MT) are two
of them. MT is used to evaluate oropharyngeal structures while ULBT evalu-
ates the ability of a patient to reach the upper lip with the lower incisors. To
intubation.
Materials and Methods: After institutional ethical committee approval and
written informed consent, 324 patients were enrolled in this observational study
requiring endotracheal intubation for elective surgical procedure. ULBT and MT
were performed for the assessment of airway by specifically trained observer.
another anesthetist who remained blinded to the result of initial assessment.
Results and Discussion: Of the 324 patients included in the analysis, 56
(17.3%) were classified as difficult to intubate. ULBT showed significantly
higher accuracy, positive predictive valve and negative predictive valve than
MT. Comparison of specificity however did not reveal any significant difference
between these two tests. The discriminating power of ULBT was high 0.90
(95% confidence interval, 0.84-0.95) than MT 0.55 (95% confidence interval,
0.47-0.64) indicating that ULBT is a good predictor of difficult intubation.
Conclusion(s): ULBT is an acceptable option for prediction of difficult intuba-
tion as a simple, single test.
19AP4-8
Strategy to improve anaesthesiologists’ airway assessment
and management in Catalonia: QUAVA II
R. Valero, E. Massó, A. López, C. Orrego, S. Sabaté
Department of Anaesthesiology, Societat Catalana de Anestesiologia,
Reanimació i Terapèutica del Dolor, Barcelona, Spain
Background and Goal of Study: QUAVA study demostrated that a deeper
knowledge on Airway assessment(AA)and management(AM), continuous train-
ing on different AM techniques, as well as quick availability of AM devices is
needed among Catalan anaesthesiologists(1). QUAVA II collaborative project is
an study focused on the further improvement of AA and AM in Catalonia.
Materials and Methods: A prospective multicentre study is conducted
in 38 hospitals. In order to plan a continuous educational program, a ques-
tionnaire was sent. AA and AM details of each department were recorded.
Anesthesiologists were asked to anonymously rate their experience and avail-
ability of 8 AM techniques and their needs for continuous education.
Results and Discussion: Availability of different devices is shown in table 1.
76% hospitals have an AM cart. Preoperative AA is performed with a specific
checklist in 74% hospitals. 74% anaesthesiologists answered to the survey.
Degree of individual experience and availability of different AM techniques is
shown in Table 1. AA is performed routinely (85%), only when difficulty is sus-
pected (14%) or seldom (1%). Local or ASA guidelines are usually followed
(90%). In 2009, 78% of anaesthesiologists received some information/training
on AM but 94% of them demand training in invasive techniques (62%), fiberos-
copy (49%), videolaryngoscopy (46%), airway rescue devices (41%).
Devices Hospitals Experience* Availability perception**
availability. n(%)
Bougies 35 (92%) 15-23-43-7-13 67-17-6-2-7
Extraglotic devices 37 (97%) 42-41-13-2-2 77-12-5-2-3
LMA fastrach 37 (97%) 18-26-43-8-5 56-33-7-1-4
Videolaryngoscopes 17 (45%) 5-8-49-20-17 20-15-10-13-43
Fiberscope 31 (82%) 12-24-43-11-9 35-32-19-10-4
Non invasive rescue Airway 14 (37%) 3-2-17-38-40 15-17-13-14-41
Cricotiroidotomy set 33 (87%) 2-1-15-39-44 26-24-23-16-10
*Percentage of anaesthesiologists’experience degree: 1=expert; 2=frequent user;
3=occasional user without help; 4=only in mannequins; 5=never used; **Percentage
of perceived availability degree by anaesthesiologists: 1=immediate availability;
2=available<5min; 3=available<15 min; 4=difficult availability; 5=not available.
Conclusion(s): From this results, a training programme is being developed
in Catalonia, starting with a Training of trainers course last Oct. A prospective
study of several AM quality clinical indicators is being conducted to assess
impact of a multifocal strategy focused in training developement.
References:
1 Eur J Anaesth 2008;25(supl44):245.
Acknowledgements: To all anesthesiologists participing in QUAVA study.
19AP4-9
Variability in the application of difficult airway predictor tests:
Is it affected by anesthesiologist’s experience?
I. Portero, J.A. Paz, A. Andueza, S. García del Valle, J.I. Gómez-Arnau
Department of Anaesthesiology, Hospital Universitario Fundación Alcorcón,
Madrid, Spain
 Airway Management   255

Background and Goal of Study: Multiple studies have attempted to identify 19AP5-1
patient characteristics predictive of difficult intubation and some of them are com-
A comparison of three endotracheal tubes for blind intubation
monly accepted to be admissible predictors when used all together; but these
characteristics are observer dependent. The goal of this study is to define the via LMA-FastrachTM disposable and the i-gel mask in an
influence of the degree of experience of the anaesthesiologist on the variability of airway management manikin
four defined predictors of difficult airway and on the global airway assessment. H. Francksen, J. Renner, M. Gruenewald, V. Doerges, B. Bein
Materials and Methods: Prior to study, an airway assessment protocol was Department of Anaesthesiology and Intensive Care, UK-SH, Campus Kiel,
designed, in wich a semiquantitative valuation (normal, limited or very lim- Kiel, Germany
ited) was defined for three predictors: mouth opening, thyromental distance
Background and Goal of Study: The study was split up in two parts: insertion
and cervical mobility; as well as Samsoong-Young modification of Mallampati
of the I-Gel and LFD in a manikin followed by blind intubation with three different
test. Once these tests were applied, a subjective difficult airway prediction
endotracheal tubes (ET) via both supraglottic airway devices(1).
was required (difficult, possible or not difficult). A total of 9684 patients were
Materials and Methods: 32 investigators (12 staff member, 10 anesthesia
assessed by 9 anesthesiologists; 3 had less than 5 years of experience (they
residents and 10 CRNA) with no previous experience in using neither the I-Gel
evaluated 2716 patients), 3 had between 5 and 10 (3053 patients), and 3 had
nor the LFD volunteered to participate in this study. The number of insertion
more than 10 (who evaluated 3915). Intragroup variability was calculated, as
attempts, time to achieve an effective airway and the handling of insertion
well as intergroup variability by analysis of Variance and Bonferroni test for
of both devices were recorded. Blind intubation via both devices was per-
multiple comparisons, for each of the test and for the final assessment.
formed using either an ID 7.0 mm Portex silicones tube (PT), an ID 7.0 mm
Results and Discussion: There was no statistically significant differences
Mallinckrodt PVC tube (MT) or an ID 7.0 mm LMA FastrachTM tube (LFT).
(p<0’05) between sex nor age of the patients in each group; and intragroup
Failure rate, attempts and time for successful intubation were obtained.
variability was discarded. There were statistically significant differences (p<0’01)
Results and Discussion: The I-gel was inserted successfully with the first
between the 3 groups for mouth opening, thyromental distance and cervical
attempt by all investigators, whereas the insertion of the LFD was successful in
mobility. No linearity was found; and the intermediate experience group was who
90% with the first attempt and in 10% with second attempt. Insertion time was
gave the worst score. Analyzing Mallampati and final assessment, we found sta-
significantly shorter in I-Gel group (p<0.0001). Intubation time via LFD was sig-
tistically significant differences (p<0’01) between the most experienced group
nificantly shorter for LFT (12±3 sec) compared to PT (14±3; p=0.001) and to MT
and the other two (but noy between these two) with a marked linearity. It was the
(14±6; p=0.043). Insertion time using LFT via I-gel was also significantly shorter
most experienced group who assessed a difficult intubation more frecuently.
compared with MT (12±3 vs. 16±8; p=0.0032) and with PT (12±3 vs. 19±10;
Conclusion(s): Statistically significant variability exists when difficult airway
p<0.001). There was no difference in the attempts needed for intubation using
predictive test are applied in a semiquantitative way. Anesthesiologist’s experi-
the different tubes in the both roup. Intubation time with PT was significantly
ence affects variability and subjective prediction of difficult airway.
shorter via LFD compared to I-Gel (p=0.02). The overall rate of successful intu-
bation via LFD was significantly higher compared to I-Gel with PT, and similar
19AP4-10 between MT and LFT.
Preoperative evaluation of difficult laryngoscopy using
predictive tests
S. Tur, A. Ozcan, N. Ozcan, B. Blataci, H. Basar
Department of Anaesthesiology, Ankara Training and Research Hospital,
Ankara, Turkey
Background and Goal of Study: Unanticipated difficult intubation increases
morbidity and mortality in patients undergoing general anesthesia. The aim of
this study was to assess the usefulness of preoperative tests to predict difficult
intubation.
Materials and Methods: After approval of ethics committee and patients’
informed consent, 235 adults aged 18-68 years who required tracheal intu-
bation as part of their anaesthetic were enrolled to study. The age, ­gender,
weight, height and body mass index (BMI) of patients were recorded.
The assessed tests were interincisor distance (IID), upper lip bite (ULB),
Mallampati, thyromental distance (TMD), sternomental distance (SMD). Ratio
of height to thyromental distance was also calculated. After induction of
anaesthesia and neuromuscular blocking drug administration, laryngoscopy
was performed after the loss of the forth twitch in the train-of-four. Glottic
visualization was assessed according to Cormack-Lehane classification. Figure 1. Insertion time to achieve an effective airway with I-Gel and LMA FastrachTM
Results and Discussion: Laryngoscopy was difficult in 15 (6,38%) patients but
there was no failed intubation. Incidence of difficult laryngoscopy was increased
with the increase in age, BMI and weight. There was a negative correlation
between difficult laryngoscopy and TMD, SMD, IID and a positive correlation
between difficult laryngoscopy and and RHTMD, ULB test and Mallampati classi-
fication. ULB test was found as the most sensitive test with sensitivity of 86,67%
in predicting difficult laryngoscopy. Area under curve (AUC) was largest for
Mallampati classification.There was no statistically significant difference between
the ROC curves of tests. Preoperative evaluation of anatomical landmarks and
clinical factors help identify potentially difficult laryngoscopies. Several studies
evaluated different tests, alone or in combination, to predict difficult intubation.

Table1. Accuracy of tests in predicting difficult laryngoscopy

Test Sensitivity Spesifisity +PV -PV %95 CI AUC

TMD 46,67 90,0 24,1 96,1 0,545-0,67 0,610

SMD 46,67 82,65 17,1 95,3 0,621-0,75 0,688
IID 66,67 65,10 13 96,2 0,601-0,73 0,670
RHTMD 46,67 91,36 26,9 96,2 0,574-0,70 0,639
ULB 86,67 43,64 9,5 98,0 0,627-0,74 0,690
Mallampati 73,33 95,45 54,2 98,1 0,780-0,87 0,834 Figure 2. Intubation tiem via I-Gel and LMA fastrachTM with 3 Ets. PT, Portex tube; MT,
Mallinckrodt tube; LFT, LMA fasttrach tube; LFD< LMA fastrach disposable.
PV: Predictive value

Conclusion(s): Our results suggested that ULB test and Mallampati clas- Conclusion(s): Significantly shorter insertion times suggest that the I-Gelâ may
sification could be useful bedside tests for preoperative prediction of difficult be advantageous to ensure oxygenation. For blind intubation, however, the
laryngoscopy. LMA FastrachTM proved to be superior.