Association between body mass index and difficult intubation with a double lumen tube: A retrospective cohort study

Anand R Mehta; Yasdet Maldonado; Mohamed Abdalla; Julian Roessler; Marc Schmidt; Xuan Pu; Nikolaos J Skubas; Kurt Ruetzler

doi:10.1016/j.jclinane.2022.110980

Association between body mass index and difficult intubation with a double lumen tube: A retrospective cohort study

J Clin Anesth. 2022 Dec:83:110980. doi: 10.1016/j.jclinane.2022.110980. Epub 2022 Oct 8.

Authors

Anand R Mehta¹, Yasdet Maldonado¹, Mohamed Abdalla¹, Julian Roessler², Marc Schmidt², Xuan Pu³, Nikolaos J Skubas¹, Kurt Ruetzler⁴

Affiliations

¹ Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
² Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
³ Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, OH, USA.
⁴ Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address: ruetzlk@ccf.org.

PMID: 36219977
DOI: 10.1016/j.jclinane.2022.110980

Abstract

Study objective: Obesity, defined by the World Health Organization as body mass index (BMI) ≥ 30.0 kg/m², is associated with adverse outcomes and challenges during surgery. Difficulties during endotracheal intubation, occur in 3-8% of procedures and are among the principal causes of anesthetic-related morbidity and mortality. Endotracheal intubation can be challenging in obese patients due to an array of anatomic and physiologic factors. Double lumen tubes (DLTs), the most commonly used airway technique to facilitate anatomic isolation of the lungs for one lung ventilation. However, DLTs can be difficult to properly position and are also more likely to cause airway injuries and bleeding when compared to conventional single lumen tubes. We investigated the association between BMI and difficult tracheal DLT intubation.

Design: Retrospective cohort study.

Setting: Operating room.

Patients: We analyzed electronic records of adults having cardiac and thoracic surgery requiring general anesthesia and endotracheal intubation with DLT at the Cleveland Clinic between 2008 and 2021.

Measurements: BMI, preoperative airway abnormalities and difficult intubation, defined as more than one intubation attempt, was assessed using multivariable logistic regression.

Main results: Among 8641 analyzed anesthetics requiring DLT, 1459 (17%) were difficult intubations. After adjusting for confounders, each 5 kg/m² increase in BMI was associated with a marginal increase of difficult intubation, odds ratio (OR) 1.06 (95% Confidence Interval [CI]: 1.002, 1.11; P = 0.040). Difficult intubation was not associated with airway abnormalities, estimated OR 0.85 (95% CI: 0.62, 1.17; P = 0.321). There was no interaction between known airway abnormalities and BMI (P = 0.894).

Conclusions: Difficult intubations with DLT remain common, but BMI is a weak predictor thereof. For example, an increase in BMI from 20 to 40 kg/m² corresponds to an increase in average absolute risk for difficult intubation from 16 to 19%, which probably is not clinically meaningful.

Keywords: Airway; Body mass index; Difficult intubation; Double lumen tube; Intubation; Obesity.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Body Mass Index
Humans
Intubation, Intratracheal* / adverse effects
Intubation, Intratracheal* / methods
Lung
Obesity / complications
One-Lung Ventilation* / methods
Retrospective Studies