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E X PE RT O P I N I O N

Airway management in obese patient


O. LANGERON, A. BIRENBAUM, F. LE SACH, M. RAUX
Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Piti-Salptrire, Assistance PubliqueHpitaux de Paris, Universit Pierre et Marie Curie (Paris 6), Paris, France

ABSTRACT
Oxygenation maintenance is the cornerstone of airway management in the obese patient related to anatomic and
pathophysiologic issues. Difficult mask ventilation (DMV) risk is increased in obese patients according recognized
predictors (Body Mass Index [BMI]>26 kg/m2, age >55 years, jaw protrusion severely limited, lack of teeth, snoring,
beard, Mallampati class III or IV) and should systematically search. Difficult tracheal intubation (DTI) risk may
be increased and risk should be assessed in a careful manner. Increased neck circumference and high BMI (>35 kg/
m2) should be added to standard preoperative airway assessment including:Mallampati class, mouth opening and
thyromental distance. In obese patients, preoxygenation is mandatory by 25 head-up position achieving better gas
exchange than in supine position. In addition, to prevent early arterial oxygen desaturation related to a reduced
functional residual capacity (FRC), atelectasis formation during anesthetic induction and after tracheal intubation,
non invasive positive pressure ventilation and application of PEEP throughout this period are recommended. Airway
management in obese patients has to consider: the anesthesia technique with maintenance or not of spontaneous
ventilation, the available oxygenation technique in case of anticipated DMV, and the appropriate tracheal intubation technique (fiberoptic intubation technique or videolaryngoscope) according to the patient status and will. In
unexpected difficult airway, the very first priority is oxygenation and a predefined strategy has to be implemented
with oxygenation devices first (supraglottic devices or ILMA). Lastly, the final step of the obese airway management
is tracheal extubation and recovery. A strategy with a fully awake patient, without residual paralysis, and a 25 headup position is mandatory.
(Minerva Anestesiol 2014;80:382-92)
Key words: Airway management - Obesity - Ventilation - Intubation, intratracheal.

erioperative management in obese patient,


including airway management, is an increasing and a worldwide concern for the anesthesiologist. Indeed, excess bodyweight is the sixth
most important risk factor contributing to the
overall burden of disease worldwide, with 1.1
billion adults and 10% of children now classified as overweight or obese.1 This phenomenon
is even qualified as epidemic.1 Obesity should
be distinguished from the metabolic syndrome,
despite a frequent overlap. This syndrome includes also dyslipidemia, hyperglycemia, insulin
resistance, hypertension, and carries different
risk profiles by predisposing to coronary artery
disease, congestive heart failure, obstructive

382

sleep apnea (OSA), pulmonary dysfunction,


and deep venous thrombosis.2 Another consequence of obesity is the obesity hypoventilation
syndrome (OHS) defined by the combination
of obesity (body mass index 30 kg/m2), daytime awake hypercapnia (partial pressure of arterial carbon dioxide 45 mmHg) and hypoxemia (partial pressure of oxygen 70 mmHg).3
These comorbidities are important to take into
account for the adequate perioperative management by the anesthesiologist, and are sometime
cumulative with specific obesity comorbidities.
Nevertheless, obesity is a technical challenge
for the anesthesiologist for basic but sometimes
vital considerations, like venous access or air-

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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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AIRWAY MANAGEMENT IN OBESE PATIENT

way management. Since obese patients have


an increased fatty tissue distributed in a truncal fashion, obesity may have an important and
negative impact on the airway patency and respiratory function. Difficulties or failure in airway
management are still important factors in morbidity and mortality related to anesthesia, and
obese patients are involved in about 40% of the
ASA closed claims analysis for a difficult airway
management in the perioperative period: from
induction to recovery including maintenance of
anesthesia and tracheal extubation periods.4
Maintenance of patients oxygenation is the
cornerstone of difficult airway management,
and is highlighted in algorithms from various
airway management guidelines.5-9 Therefore, we
will discuss specific problems in obese patients
for the airway management related to: difficult
mask ventilation (DMV) and difficult tracheal
intubation (DTI) risk assessment, preoxygenation and ventilation techniques, some airway
control techniques which may be performed to
solve a difficult airway, and specificities for anesthesia recovery including tracheal extubation.
Obesity definition requires a Body Mass Index
(BMI) above 30 kg/m2 and morbid obesity is
usually defined with a BMI>35 kg/m2.
Difficult airway prediction
DMV
DMV risk assessment is mandatory in the
preanesthetic evaluation whatever the patient
status or BMI is, and particularly in case of an
increased BMI or obesity. Indeed, in the anticipated difficult airway anesthetic strategy, one
of the very first question will be maintenance
or not of the spontaneous ventilation according to the anesthetic technique during airway
management.5-9 Because patients oxygenation is
the very first priority of difficult airway management, DMV was specifically studied and independent predictors of DMV identified.10, 11 Five
features (aged >55 years, BMI>26 kg/m2, lack
of teeth, presence of beard, history of snoring)
were independent risk factors for DMV, and
the presence of two of these criteria indicated
at best a DMV.10 These results were also found

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LANGERON

on a larger sample size population (14,369 patients) study, confirming the previous identified
DMV risk factors (aged >57 years, BMI>30 kg/
m2, presence of beard, history of snoring, Mallampati class III or IV), except the lack of teeth,
and providing another independent DMV predictor, the limited mandibular protrusion.11 The
slight increased of BMI, from 26 to 30 kg/m2,
was even associated in the Kheterpal et al. study,
with a better sensitivity and specificity for DMV
prediction, indicating that BMI is the most important risk factor for DMV.11 Obesity is associated with decreased posterior airway space
behind the base of the tongue, impaired airway
patency during sleep, and is a risk factor for obstructive sleep apnea syndrome.12 Upper airway
obstruction can occur after induction of general
anesthesia with posterior displacement of the
soft palate, base of tongue and epiglottis. Thus,
attempts at inspiratory phase during anesthesia
cause collapse of the pharynx with obstruction at
several sites, similar to obstructive sleep apnea.13
Moreover, increased BMI and history of snoring
are clearly identified as DMV risk factors.10, 11
Consequently, patients having these both criteria
are also high risk patients for OSA. In addition,
obesity is a common feature of OSA patients.14
Because of the increasing prevalence of obesity in
the general population,1, 14 therefore prevalence
of OSA is also increasing.14 It seems there are
close linkages between obesity and OSA, with
clear but not linear interactions (i.e., above a
weight threshold a small weight increase may enhance OSA severity), but no definite explanation
or conclusive evidence for the causality has been
provided to date.14 Probably different mechanisms are involved in OSA pathogenesis related
to obesity. Fat deposits surrounding the pharyngeal airway may participate to a local mechanism
of narrowing the upper airway creating anatomical imbalance within a normal bony enclosure
size formed by the cervical vertebrae, maxilla
and mandible.14 Obesity and craniofacial abnormalities with anatomical imbalance contribute
synergistically to increases in collapsibility of
the passive pharyngeal airway, narrowing the
upper airway in patients with OSA.14, 15 Obesity is also associated with a significant decrease
of lung volumes like the functional residual ca-

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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.

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AIRWAY MANAGEMENT IN OBESE PATIENT

pacity (FRC).14, 16 Tagaito et al.17 demonstrated


that in anesthetized and paralyzed OSA patients,
lung inflation decreased closing pressures of the
passive (i.e. without neuromuscular factors) velopharyngeal airway, and improved in obese OSA
patient the airway patency due to an increased
distensibility specifically at the velopharyngeal
site. Consequently, for a given lung inflation, a
more important closing pressure was observed in
obese patients and was related to increased BMI,
suggesting the dependence of pharyngeal airway
collapsibility according to lung volume.17 Thus,
decrease in lung volume in obese OSA patients
may contribute to pharyngeal airway obstruction, impairing mask ventilation during anesthesia. Lastly, during inspiration the trachea moves
a little caudally (<1 cm) and this displacement
leads a traction during lung inflation increasing
longitudinal tension of the pharyngeal airway
wall, stiffening the airway, and making a better airway patency.14 Profound reduction of the
longitudinal tracheal traction is speculated to occur on significant lung volume decrease in obese
OSA patients.14, 17 Thus, decrease lung volume
like in obese patient impair tracheal traction on
pharyngeal airway and might also decrease the
airway patency, suggesting an another mechanism of DMV in obese patient.
Impossible mask ventilation (IMV) has been
reported as a low incidence event (0.16%).18
Nevertheless, obesity was not associated with
an increased IMV risk, and five independent
predictors of impossible mask ventilation were
identified: neck radiation changes (strongest risk
factor), male sex, OSA, Mallampati class III or
IV, and presence of beard.18
Lastly, to summarize the relationship between
obesity and OSA: DMV assessment should take
into account in obese patient the independent
DMV predictors,10, 11 particularly the history of
snoring. In case of snoring, due to high prevalence of undiagnosed OSA in the surgical population (nearly 25%) and in obese patients,14 OSA
screening has to be performed with STOP-Bang
questionnaire,19 and diagnosis should be confirmed by polysomnography,14, 19 not only for
the airway management purpose, but also for the
patient perioperative care. Higher is the STOPBang questionnaire (3) greater is the probability

384

of having OSA. In contrast a STOP-Bang questionnaire <3 will rule out the OSA diagnosis.19
Because of close causal links between obesity and
OSA, as reported above to explain part of the
OSA pathophysiology in obese patients, despite
without to date any explanation for the causality, OSA obese patient should be considered by
definition as a definite DMV risk patient and a
greater risk patient for postoperative upper airway obstruction during recovery.14
DTI
There are some controversies in the literature
to demonstrate that obesity per se is associated
with an increase risk of DTI. Indeed, some studies failed to associate obesity or BMI with intubation difficulties.20, 21 In contrast, other studies concluded that obesity increased the DTI
risk.22-25 This lack of consensus about obesity
and DTI may have some explanations: first the
lack of universal definition of DTI may be one
reason, and difficult laryngoscopy, defined according the Cormack and Lehane grades III or
IV,26 is often used as a surrogate outcome for
DTI;20, 21 second the relationship between BMI
and DTI risk may be not linear with controversies about the cut-off values stratifying the risk
related to BMI.24, 27 In a large cohort study,27
obesity was associated with different odds ratio
(OR) according the level of BMI: OR was 1.42
for DTI with BMI of 35 kg/m2 or above, and the
OR was 1.24 with BMI between 25-35 kg/m2.
The authors concluded that high BMI (>35 kg/
m2) is a weak but statistically significant predictor of DTI and may be more appropriate than
weight in multivariate models for DTI prediction.27 This assertion that only high BMI were
independently correlated to DTI was also previously reported, suggesting again a non linear
interaction between BMI and DTI risk.24
A good predictor of a difficult airway in obese
patient is the neck circumference (NC). Large
NC has been reported to be associated with a
DTI and should be specifically assessed in obese
patient to predict a DTI.21, 24 Excessive fat tissue
in the velopalate, retropharynx, and submandibular regions in obese patients may increase the
difficulty in laryngoscopy by reducing anterior

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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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AIRWAY MANAGEMENT IN OBESE PATIENT

mobility of pharyngeal structures. Quantification of fat tissue in specific neck areas, especially
the anterior neck at the level of the vocal cords,
assessed by ultrasound techniques may provide
good prediction of difficult intubation, with no
overlap in values for the difficult and easy laryngoscopies.28
As seen previously, in obese patients, the
DMV risk is increased.10,11 Moreover, it has
been reported that in DMV patients the risk of
DTI was also significantly increased.10,11,18 In
the selected patients with IMV (0.15% of general population), 25% of them demonstrated
difficult intubation, and the incidence of the
worst difficult airway scenario, cannot intubate
cannot ventilate (CICV), was 5% among this
IMV population.18 Thus, the most important
benefit in DTI prediction, is to think to a potential difficult airway to anticipate it, avoiding
the most dangerous situation in difficult airway
management when tracheal intubation is difficult or impossible and where mask ventilation is
or becomes inadequate, thereby creating a CICV
scenario. Indeed the risk of difficult or impossible mask ventilation starts to increase yet after 3
unsuccessful tracheal intubation attempts.29
Consequently, DTI risk assessment should be
performed in a careful manner and with some
specificities in obese patients. In a meta-analysis
of bedside screening tests usually performed to
predict difficult tracheal intubation, a poor to
moderate discriminative power was reported
when test used alone.25 Combinations of individual tests or risk factors add some incremental diagnostic value in comparison to the value
of each test alone, the best combination was
Mallampati classification and thyromental distance.25 Mouth opening measured by interincisor distance is also recommended in DTI screening.8 In obese patient, high BMI (>35 kg/m2)
and increased NC (43 cm) should be specifically searched in preoperative airway assessment,
indicating an increased DTI risk when they occur.24, 27
Preoxygenation and ventilation techniques
Preoxygenation is the first step for the induction of anesthesia and is always mandatory

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LANGERON

from any airway management guidelines.6-9 This


procedure is essential in airway management
whatever the patient status is, and particularly
in obese patients. Optimization of preoxygenation allows to tolerate a longer period of apnea
without oxygen desaturation (usually defined
by SpO2<90%), and consequently increased the
desaturation safety period (DSP) to control the
airway.30 The respiration function and lung volumes are affected by obesity.16 A reduced FRC
is observed in obese patients inducing a reduced
oxygen stocks and decreases preoxygenation efficacy with more rapidly oxygen desaturation during apnea than in non obese patient.30-33 Thus, a
shorter DSP is observed and the margin of safety
to perform tracheal intubation without oxygen
desaturation is reduced.30-33 There is a non linear relationship between the increasing BMI and
the decreasing DSP, morbidly obese patients had
even desaturation before the end of induction of
anesthesia including the onset of complete relaxation and tracheal intubation.32, 33 Another consequence of a reduced FRC in obese patients is a
shorter time to reach maximum end tidal oxygen
concentration (ETO2) during preoxygenation as
the weight is increasing.30 The combination of
a decreased FRC and increased airway closure
make the obese patient prone to atelectasis formation in the dependent zones of the lung with
ventilation-perfusion mismatch, increasing the
risk to develop hypoxemia when apneic during
the induction of anesthesia.16, 34, 35
Various preoxygenation techniques before
induction of anesthesia have been advocated,
including tidal volume breathing 100% oxygen
for 3-5 min, four deep vital capacity breaths of
oxygen taken within 30 seconds (4DB method),
and eight deep vital capacity breaths of oxygen
taken within 60 seconds (8DB method).36, 37
Comparison of these different preoxygenation
techniques have often been conflicting, because
of the various regimens of preoxygenation depending on the oxygen flow and the type of anesthetic system, and because of various endpoints
as maximum arterial oxygen tension, maximum
ETO2, and time taken for hemoglobin to desaturate.36, 37 In obese patients, preoxygenation
efficiency is improved by 25 head-up position,
achieving better gas exchange by reducing at-

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AIRWAY MANAGEMENT IN OBESE PATIENT

electasis and decreasing ventilation-perfusion


mismatch related to a less reduced FRC in that
position, with a longer DSP: time to reach oxygen saturation of 92% decreased from 20156
to 15570 sec, in 25 head-up and supine positions respectively.38 In a prospective randomized
study in morbidly obese patients, it has been
demonstrated that oxygen administration during facemask ventilation with non invasive positive pressure (8 cmH2O pressure support and
6 cmH2O PEEP) provided a safe and efficient
preoxygenation technique, achieving in a shorter
time, a higher ETO2 than in the spontaneous
ventilation group (96.91.3% vs. 94.12.0%,
P<0.001).39 In addition, when PEEP (+10 cmH2O) was applied during anesthetic induction,
a greater safety margin to control the airway in
morbidly obese patients was observed in comparison without PEEP, increasing the nonhypoxic apnea duration.40 Indeed, in morbidly
obese patients (BMI>35 kg/m2), atelectasis formation, assessed by CT scans performed before
and after induction of anesthesia, is significantly
prevented by application of PEEP (+10 cmH2O)
throughout this period, and is associated with a
better oxygenation.35 Lastly, during the apneic
period following anesthetic induction and preoxygenation, it has been demonstrated that nasopharyngeal oxygen insufflation (5 L/min) in
morbidly obese patients placed in a 25 head-up
position was able to delay significantly oxygen
desaturation in comparison with patients without apneic oxygenation.41
Airway control techniques
General principles
To perform the adequate airway control technique, it is important to distinguish the two main
clinical situation of difficult airway management
according prediction of DMV and DTI, making
an anticipated or unanticipated difficult airway
management. In case of anticipated DTI some
issues are raised and are really challenging in the
obese patient: is mask ventilation anticipated as
difficult? How to maintain patients oxygenation? (consider intubating laryngeal mask or
supraglottic devices use, or invasive airway ac-

386

cess) and lastly at induction of anesthesia, should


we preserve spontaneous ventilation or apnea is
safe? After considering these points, awake or
general anesthesia intubation techniques could
be decided depending answers to previous issues.
In case of unanticipated DTI, a predefined algorithm should be used to minimize improvisation, considering oxygenation as the main goal
of the difficult airway management as mentioned
in guidelines.5-9 Lastly, the CICV scenario often
results from an inappropriate airway management with repeated unsuccessful and traumatic
tracheal intubation attempts. This should be
prevented by changing the operator and/or the
technique of tracheal intubation, reminding the
possibility to awake the patient if there is no lifethreatening situation.
Basic airway management
While preparations for airway control are
planned, basic maneuvers should be implemented: preoxygenation techniques in 25 head-up
position, including relieved of airway obstruction by chin lift and jaw thrust, and insertion
of a nasal or oral airway. Mask ventilation with
the use of an oropharyngeal or nasopharyngeal
airway can be a difficult skill to master, and is
best performed by two individuals with a more
efficient mask seal and jaw thrust, but can easily
inflate the stomach.42 Moreover, techniques that
use one hand to squeeze the bag give significantly smaller tidal volumes than two-handed techniques, with no significant difference in peak or
average airway pressure.42 The second component of optimal mask ventilation is the use of
large oral or nasal pharyngeal airways specially
in obese patients. Lastly, in comparison to circle system, ventilation pressure-controlled during mask ventilation reduced inspiratory peak
flow rates and airway pressures, providing additional patient safety by decreasing the risk of
gastric inflation, regurgitation and subsequent
pulmonary aspiration.43 Obesity predispose to
gastro-oesophageal reflux, increasing the risk of
pulmonary aspiration while the airway remains
unprotected, and improvement of mask ventilation without gastric inflation is mandatory.
In basic airway management, the sniffing po-

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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.

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AIRWAY MANAGEMENT IN OBESE PATIENT

sition has been advocated as the standard head


position to improve direct laryngoscopy. In this
position, the neck must be flexed on the chest,
by elevating the head with a cushion under the
occiput and extending the head on the atlantooccipital joint. In a prospective randomized
study comparing the sniffing position with
simple head extension for laryngoscopic view
in elective surgery patients, Adnet et al. demonstrated that only in case of reduced neck mobility and obesity (BMI>30 kg/m2), the laryngoscopic view, assessed by Cormack-Lehane grade,
was significantly improved with application of
the sniffing position.44 In addition, it has also
been reported that in obese patients scheduled
for bariatric surgery, difficult tracheal intubation, when performing in a beach chair position,
was rare (1%) in contrast to the higher prevalence encountered (14%) without beach chair
positioning; moreover increased BMI did not
worsen laryngoscopic view in this position.45
Rao et al. demonstrated that in obese patients
by positioning their head elevated above their
shoulders on the operating table, on a ramp created by placing blankets under their upper body
or by reconfiguring the operating room table in a
beach chair position, were two equivalent methods regarding direct laryngoscopy assessed by the
Cormack and Lehane grade and time to achieve
tracheal intubation.46
Advanced airway management
Several advanced airway management techniques may be implemented to overcome a difficult airway in obese patients.
The fiberoptic intubation (FOI) is a well
documented technique in anticipated difficult
airway patient. Guidelines on anticipated difficult airway management emphasized the importance of the FOI technique when a difficult
airway is predicted.6-9 Then, awake intubation
has to be considered to maintain oxygenation of
the patient with a predicted DMV, and remains
a gold standard for this scenario. Nevertheless,
in a retrospective analysis of the obese airway
management, the FOI technique has been reported as the first line airway control technique
in only 4% of obese patients, selected mainly in

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LANGERON

case of a male gender, a Mallampati class III or


IV and a BMI 60 kg/m2.47
Supraglottic devices like the laryngeal
mask airway (LMA) and the intubating laryngeal mask airway (ILMA) represent a major
advance in airway management and have been
incorporated into difficult airway algorithms as
oxygenation and oxygenation combining tracheal intubation devices respectively.5-9 Because
the airway seal pressure of the Proseal LMA
(PLMA) is greater than the one of LMA, and
a drainage tube is integrated to provide access
directly or by means of a gastric tube to the gastrointestinal tract, PLMA has been proposed as
an interesting supraglottic ventilatory device for
obese patients.48, 49 In addition, in obese patients
a greater cuff pressure is needed for the LMA
to obtain a minimal leak in comparison to the
PLMA.48 Moreover, PLMA has been reported
as an effective temporary ventilatory device before laryngoscope-guided tracheal intubation
in obese or morbidly obese patients, and could
be safely used in case of an unanticipated difficult airway in these patients.49 The LMA Supreme is the latest LMA device, combining the
ILMA shape and allowing gastric drainage. It
has been reported that LMA Supreme provided
effective and easier ventilation performed by
novices in anesthetized and paralyzed morbidly
obese patients with DMV predictors than facemask ventilation, suggesting its use as a rescue
ventilatory device in an unanticipated difficult
airway in obese patients.50 Nevertheless, to completely secure the airway, tracheal intubation is
mandatory and the ILMA has been designed for
this purpose. In morbidly obese patients, ILMA
has been demonstrated to be a safe and effective
technique for the airway management with a
high success rate (96.7%) for tracheal intubation
without any difference in patients according the
Cormack-Lehane grade (low 1 or 2 versus high 3
or 4).51 In addition, in a prospective randomized
study comparing ILMA in obese and lean patients, the authors demonstrated that ILMA was
an efficient airway device for both groups with a
similar success rate for tracheal intubation (96%
and 94% respectively) and that the numbers
of failed blind tracheal access attempts and patients who required airway adjustment maneu-

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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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AIRWAY MANAGEMENT IN OBESE PATIENT

vers were significantly reduced in obese patients


in comparison to lean patients.52 Consequently,
ILMA is an appropriate airway device in difficult
obese airway management, anticipated or not,
allowing either satisfactory ventilation and tracheal intubation, and emphasize the impact of
this airway device in algorithms and guidelines
from many anesthesiology societies.6-9
Videolaryngoscopes have a high success
rate in morbidly obese patients.53-56 In addition, some authors reported that by shortening
the duration of tracheal intubation in comparison with standard laryngoscopic technique with
Macintosh laryngoscope, the Airtraq prevented
oxygen arterial desaturation in these high risk patients.53 In contrast, in another study a significant
increased duration of tracheal intubation with
the Glidescope videolaryngoscope has been reported in comparison with direct laryngoscopy:
48 (22-148) sec versus 32 (17-209) sec as median
(range).54 Nevertheless, no clinical relevant consequences were observed during tracheal intubation with the Glidescope videolaryngoscope in
relation with the increased tracheal intubation
duration, moreover it provided better laryngoscopic views according lower Cormack-Lehane
grades and a decreased Intubation Difficult Scale
(IDS) score compared to direct laryngoscopy
technique.54 In a prospective randomized study
performed in morbidly obese (>35 kg/m2), the
benefit of videolaryngoscopy on the laryngoscopic grade patients was demonstrated in a study
comparing the use (video group) or not (control
group) of the screen of the videolaryngoscope.55
In addition, awake tracheal intubation was performed in morbidly obese patients (BMI>40 kg/
m2), and assisted by videolaryngoscopy (Glidescope videolaryngoscope) in 50 patients with a
overall success rate of 96% (95% CI 86-100%),
27 success on the first attempt, 15 on the second
attempt, and 6 on the third and last attempt.56
Consequently, considering the risk of arterial
oxygen desaturation during anesthetic induction
despite effective preoxygenation and the better
laryngeal view provided by video-assisted laryngoscopy compared to conventional Macintosh
direct laryngoscopy, awake videolaryngoscopy
may also be useful for the tracheal intubation of
the morbidly obese patient.

388

Lastly, the awake FOI technique is considered


as the gold standard when a difficult airway is
anticipated.6-9 It has been reported that in anticipated difficult airway patients, no difference was
found in time to perform tracheal intubation
between two awake advanced difficult airway
techniques performed by experienced anesthesiologists, FOI and video-assisted laryngoscopy
with the McGrathTM videolaryngoscope.57 Intubation success on the first attempt was 79%
versus 71% for FOI technique and videolaryngoscope intubation respectively.57 Thus, in obese
patients videolaryngoscopes may be proposed as
useful devices in anticipated DTI management
without anticipated DMV, to overcome rapidly
this difficulty and prevent serious arterial oxygen
desaturation, and video-assisted laryngoscopy
has been included in that algorithm scenario
in updated difficult airway management ASA
guidelines.6
When the airway is compromised and
attempts at intubation have failed, cricothyroidotomy should be considered. This technique
involves different methods, including surgical
cut-down to the cricothyroid membrane and insertion of an appropriately sized tracheal tube.
This allows effective ventilation and overcomes
the limitations of percutaneous transtracheal
needle ventilation most of the time difficult in
obese patient. Several cricothyroidotomy kits are
available. Possible complications such as intratracheal bleeding, pneumothorax, pneumomediastinum or oesophageal puncture, are reduced
if the Seldinger technique is used in contrast
to direct puncture, but technical difficulties are
increased in obese patients for anatomical reasons. Correct needle placement through the
cricothyroid membrane is essential for cannula
cricothyroidotomy. However in a simulation
study performed in volunteer subjects, with the
mid-central point of the cricothyroid membrane
previously determined by ultrasound, it has
been reported that only 30% of anesthesiologist
participants accurately identified the skin over
the cricothyroid membrane.58 The authors reported that cartilages and cricothyroid muscles
were easily identified providing accurate dimensions for the median cricothyroid ligament, ultrasound providing an ease in identifying ana-

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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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AIRWAY MANAGEMENT IN OBESE PATIENT

tomical landmarks for cricothyroidotomy.58 In


addition, in female patients misidentification of
the cricothyroid membrane is common and its
localization is less precise when they are obese
making cricothyroid membrane puncture also
more difficult.59 Lastly, during trantracheal jet
ventilation (TTJV) through the cricoid membrane, obesity is considered as a risk factor for
carbon dioxide retention and hypoxemia, which
may be explained by a decreased airway patency
and a reduced FRC respectively.60
Recovery and tracheal extubation techniques
In the ASA closed claims study analysis related
to difficult airway management, 73% of the claims
from extubation or recovery were associated with
a difficult intubation on induction, obesity and/
or sleep apnea.4 As for the induction of anesthesia, obese patients are high risk patients for airway
obstruction and oxygen desaturation after tracheal
extubation and recovery. This risk increased a lot if
they are also OSA patients with a decreased pharyngeal tone related to more sensitive effects of residual anesthesia and opioids, resulting an airway
collapse and obstruction.61 Difficult airway society
guidelines for the management of tracheal extubation promoted the necessity of a stepwise approach to better estimate the risk and to perform a
safer tracheal extubation.61 Obese patients may be
considered as at-risk tracheal extubation patients
because of pathophysiological issues related to
obesity: depletion of oxygen stores (reduced FRC,
OHS, atelectasis), potential pre-existing airway
difficulties mainly related to DMV, and reduced
airway reflexes.61 Thus, to prevent serious respiratory events in the postoperative period, tracheal
extubation requires full cooperation of the patient,
in a proclive position enabling a better respiratory
mechanics than in a supine position, and the absence of residual paralysis by monitoring the neuromuscular blockade with a train-of-four (TOF)
above 0.9. In morbidly obese patients, it has been
reported that administration of sugammadex in
comparison to neostigmine provides faster and
more complete recovery of neuromuscular function (TOF>0.9) and better prevents postoperative residual curarization.62 Nevertheless, use of
sugammadex in obese patients raises some issues

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LANGERON

related to the dose adjusted to the ideal body


weight (IBW) by reversing the neuromuscular
blockades only in 60% and 77% of patients who
had deep and moderate neuromuscular blockades
respectively, with the requirement of a second
IBW-based sugammadex dose in the 40% and
23% remaining patients.63 Therefore, administration of sugammadex cannot be safely based only
on the IBW-calculated dose in obese patients, but
its adjustment should be performed according to
the level of the TOF ratio at spontaneous recovery
and its efficacy (or not) should be assessed with
objective neuromuscular monitoring to emphasize
insufficient antagonization with a single sugammadex administration 63 and/or to prevent a delayed reoccurrence neuromuscular blockade after
an inadequate dose of sugammadex according the
rocuronium one administered.64
In OSA patients, the imbalance between forces
that narrow and those dilate the upper airway patency is increased during the recovery period due
to residual effects of the sedative drugs, leading to
postextubation upper airway obstruction. After
tracheal extubation, continuous positive airway
pressure or non-invasive ventilation must be available for obese patients, including those with OSA,
to prevent airway obstruction and arterial oxygen
desaturation.65 Opioid-induced ventilatory impairment (OIVI) is an induced central respiratory
depression with a decreased level of consciousness
and increased upper airway obstruction related to
opioid administration. In the postoperative period,
patients with OHS are at higher risk of OIVI in
relation to their increased susceptibility to upper
airway obstruction, depressed central respiratory
drive and impaired pulmonary mechanics.3 Consequently, these patients have to be monitored with
continuous oximetry and non invasive ventilation
should be available and implemented as requested.
In case of difficult airway management, anticipated or not during the induction, a strategy with a stepwise approach for tracheal extubation should be implemented to prevent
arterial oxygen desaturation and preventable
tracheal reintubation in obese patients. When
performing tracheal extubation, a continue
oxygenation supplementation is mandatory in
a monitored patient and an airway exchange
catheter (AEC) assisted extubation could be

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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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AIRWAY MANAGEMENT IN OBESE PATIENT

Table I.Proposition of simple predefined strategies used in difficult airway management.


Anticipated difficult tracheal intubation

Unanticipated difficult tracheal intubation

Preliminary questions
Is DMV anticipated?
Anesthesia technique: spontaneaous ventilation or not?
Oxygenation maintenance techniques available? (consider intubating
laryngeal mask or laryngeal mask use, or invasive airway access)
Actions
Consider awake or general anesthesia intubation techniques

implemented.61 This device inserted into the


trachea though the tracheal tube before extubation enables in patients for whom reintubation is likely to be difficult an easy and quick
reintubation procedure with a continuous airway access and a guided intubation technique.
Moreover, AEC can be used to oxygenate the
patients lungs in case of respiratory distress
ensuring a barotrauma prevention by checking
correct expiratory patients flow in case of jet
ventilation and/or a limited continuous oxygen flow delivery (below 2 L.min). 61
Conclusions
Oxygenation maintenance is the cornerstone
of the airway management of the obese patient
according anatomic and pathophysiologic issues, mainly due to respiratory function changes
as a reduced FRC and atelectasis formation in
dependent parts of the lungs. DMV assessment
should be done searching the independent DMV
predictors. OSA screening has to be performed
due to high prevalence of undiagnosed OSA generally and specifically in this obese population.
The snoring obese patient should be considered
as a DMV patient. DTI risk assessment should be
also performed in a careful manner and with some
specific risk factors related to obesity, like high
BMI (>35 kg/m2) and increased neck circumference (43 cm). Preoxygenation is mandatory by
25 head-up position (RAMP position) achieving
better gas exchange by reducing atelectasis and decreasing ventilation-perfusion mismatch related
to a less reduced FRC in that position. Moreover
to prevent atelectasis formation during anesthetic
induction and after tracheal intubation, non invasive positive pressure ventilation and application

390

Preliminary questions
None: use of a predefined algorithm

Actions
Consider oxygenation as first priority
Consider tracheal intubation as second priority
Call for help

of PEEP (+10 cmH2O) throughout this period


are recommended for a better oxygenation. Management of airways in obese patients, as for any
patient, have to consider several points including
(Table I): the anesthesia technique with maintenance or not of spontaneous ventilation, the available oxygenation technique in case of anticipated
difficult mask ventilation, and the appropriate
tracheal intubation techniques (fiberoptic intubation technique or videolaryngoscope) according to the patient status and will. The RAMP or
the beach chair positions allowed a better laryngoscopic view improving tracheal intubation. In
unexpected difficult airway (Table I), the very first
priority is oxygenation and a predefined strategy
or algorithm has to be implemented in that way
with oxygenation devices first as supraglottic devices or ILMA. Lastly, the final step of the obese
airway management is tracheal extubation and
recovery requiring a strategy with a fully awake
patient without any residual paralysis in a 25
head-up position.
Key messages
In obese patient, DMV risk and difficulties encountered during preoxygenation
are increased making the oxygenation maintenance the cornerstone of airway management.
Increased neck circumference (>43
cm) and high BMI (>35 kg/m2) are specific
DTI predictors related to obesity and should
be added to standard preoperative airway
assessment for DTI prediction.
Airway management in obese patients
has to consider: the anesthesia technique with

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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
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AIRWAY MANAGEMENT IN OBESE PATIENT

maintenance or not of spontaneous ventilation, the available oxygenation technique in


case of anticipated DMV, the appropriate
tracheal intubation technique in sniffed or
beach chair position, and finally the management of tracheal extubation has to promote
the necessity of a stepwise approach because
obese patient may be considered as at-risk
for tracheal extubation.
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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Conflicts of interest.The authors certify that there is no conflict of interest with any financial organization regarding the material discussed
in the manuscript.
Received on October 8, 2012. - Accepted for publication on September 3, 2013.
Corresponding author:O. Langeron, Dpartement dAnesthsie-Ranimation, Hpital de la Piti-Salptrire, 47 Boulevard de lHpital,
75651 Paris Cedex 13, France. E-mail: olivier.langeron@psl.aphp.fr

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