Emergency airway management in the morbidly obese patient
- Christian Arbelaez, MD, MPH
Christian Arbelaez, MD, MPH
- Assistant Professor of Medicine
- Harvard Medical School
- Susan Bartels, MD, MPH
Susan Bartels, MD, MPH
- Clinician Scientist
- Queen’s University
- Affiliate Faculty
- Harvard Humanitarian Initiative
- Calvin A Brown, III, MD, FAAEM
Calvin A Brown, III, MD, FAAEM
- Assistant Professor of Emergency Medicine
- Harvard Medical School
- Section Editor
- Ron M Walls, MD, FRCPC, FAAEM
Ron M Walls, MD, FRCPC, FAAEM
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Adult Resuscitation
- Neskey Family Professor of Emergency Medicine
- Harvard Medical School
- Brigham and Women's Hospital
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
In patients presenting with acute respiratory or ventilatory failure, the emergency clinician's first responsibilities are to ensure oxygenation and secure the airway. Obesity-related anatomic and physiologic changes make airway management more difficult, and studies have shown a correlation between obesity and difficulty with endotracheal intubation [1-4].
This topic will review emergency airway management in obese and morbidly obese patients outside of the operating room. Other aspects of airway management and care of the obese patient are discussed separately. (See "Approach to the difficult airway in adults outside the operating room" and "Rapid sequence intubation for adults outside the operating room" and "Advanced emergency airway management in adults" and "Basic airway management in adults" and "Anesthesia for the obese patient" and "Obesity in adults: Overview of management".)
OBESITY'S EFFECTS ON THE AIRWAY
Definitions — The evaluation and classification of obesity is discussed in detail separately. A brief overview and aspects of obesity of particular relevance to airway management are reviewed here. (See "Obesity in adults: Prevalence, screening, and evaluation", section on 'Measurements'.)
Overweight is defined as weight above the normal range. Obesity is defined as an abnormally high percentage of body weight as fat. Body mass index (BMI) is used to distinguish between the two terms and also determines the degree of excess weight.
BMI = body weight (in kg) ÷ height (in meters) squared
- Benumof JL. Obstructive sleep apnea in the adult obese patient: implications for airway management. Anesthesiol Clin North America 2002; 20:789.
- Levi D, Goodman ER, Patel M, Savransky Y. Critical care of the obese and bariatric surgical patient. Crit Care Clin 2003; 19:11.
- Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992; 77:67.
- Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth 1994; 41:372.
- Ogunnaike, BO, Whitten, CW. Anesthetic management of morbidly obese patients. Semin Anesth 2002; 21:46.
- Varon J, Marik P. Management of the obese critically ill patient. Crit Care Clin 2001; 17:187.
- Behringer EC. Approaches to managing the upper airway. Anesthesiol Clin North America 2002; 20:813.
- Bercault N, Boulain T, Kuteifan K, et al. Obesity-related excess mortality rate in an adult intensive care unit: A risk-adjusted matched cohort study. Crit Care Med 2004; 32:998.
- O'Brien JM Jr, Phillips GS, Ali NA, et al. Body mass index is independently associated with hospital mortality in mechanically ventilated adults with acute lung injury. Crit Care Med 2006; 34:738.
- Ray DE, Matchett SC, Baker K, et al. The effect of body mass index on patient outcomes in a medical ICU. Chest 2005; 127:2125.
- Passannante AN, Rock P. Anesthetic management of patients with obesity and sleep apnea. Anesthesiol Clin North America 2005; 23:479.
- Blouin RA, Warren GW. Pharmacokinetic considerations in obesity. J Pharm Sci 1999; 88:1.
- Cheymol G. Effects of obesity on pharmacokinetics implications for drug therapy. Clin Pharmacokinet 2000; 39:215.
- Butler KH, Clyne B. Management of the difficult airway: alternative airway techniques and adjuncts. Emerg Med Clin North Am 2003; 21:259.
- Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229.
- Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009; 110:891.
- Brown 3rd CA, Walls RM. Identification of the difficult and failed airway. In: Walls Manual of Emergency Airway Management, 5th ed, Brown 3rd CA (Ed), Lippincott, Williams and Wilkins, Philadelphia 2018. p.9.
- Grant P, Newcombe M. Emergency management of the morbidly obese. Emerg Med Australas 2004; 16:309.
- Voyagis GS, Kyriakis KP, Dimitriou V, Vrettou I. Value of oropharyngeal Mallampati classification in predicting difficult laryngoscopy among obese patients. Eur J Anaesthesiol 1998; 15:330.
- Lundstrøm LH, Møller AM, Rosenstock C, et al. High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology 2009; 110:266.
- Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg 2003; 97:595.
- Lavi R, Segal D, Ziser A. Predicting difficult airways using the intubation difficulty scale: a study comparing obese and non-obese patients. J Clin Anesth 2009; 21:264.
- Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg 2002; 94:732.
- Holmberg TJ, Bowman SM, Warner KJ, et al. The association between obesity and difficult prehospital tracheal intubation. Anesth Analg 2011; 112:1132.
- Barak M, Assalia A, Mahajna A, et al. The use of VivaSight™ single lumen endotracheal tube in morbidly obese patients undergoing laparoscopic sleeve gastrectomy. BMC Anesthesiol 2014; 14:31.
- Aslani A, Ng SC, Hurley M, et al. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg 2012; 114:987.
- Gerstein NS, Carey MC, Braude DA, et al. Efficacy of facemask ventilation techniques in novice providers. J Clin Anesth 2013; 25:193.
- Fei M, Blair JL, Rice MJ, et al. Comparison of effectiveness of two commonly used two-handed mask ventilation techniques on unconscious apnoeic obese adults. Br J Anaesth 2017; 118:618.
- Rao SL, Kunselman AR, Schuler HG, DesHarnais S. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg 2008; 107:1912.
- Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg 2004; 14:1171.
- Lee BJ, Kang JM, Kim DO. Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Br J Anaesth 2007; 99:581.
- Frappier J, Guenoun T, Journois D, et al. Airway management using the intubating laryngeal mask airway for the morbidly obese patient. Anesth Analg 2003; 96:1510.
- Neligan PJ, Porter S, Max B, et al. Obstructive sleep apnea is not a risk factor for difficult intubation in morbidly obese patients. Anesth Analg 2009; 109:1182.
- Navarro Martínez MJ, Pindado Martínez ML, Paz Martín D, et al. [Perioperative anesthetic management of 300 morbidly obese patients undergoing laparoscopic bariatric surgery and a brief review of relevant pathophysiology]. Rev Esp Anestesiol Reanim 2011; 58:211.
- Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016; 122:1101.
- Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997; 87:979.
- Delay JM, Sebbane M, Jung B, et al. The effectiveness of noninvasive positive pressure ventilation to enhance preoxygenation in morbidly obese patients: a randomized controlled study. Anesth Analg 2008; 107:1707.
- El-Khatib MF, Kanazi G, Baraka AS. Noninvasive bilevel positive airway pressure for preoxygenation of the critically ill morbidly obese patient. Can J Anaesth 2007; 54:744.
- Solis A, Baillard C. [Effectiveness of preoxygenation using the head-up position and noninvasive ventilation to reduce hypoxaemia during intubation]. Ann Fr Anesth Reanim 2008; 27:490.
- Altermatt FR, Muñoz HR, Delfino AE, Cortínez LI. Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea. Br J Anaesth 2005; 95:706.
- Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology 2005; 102:1110.
- Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth 2010; 22:164.
- Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2012; 59:165.
- Hanley MJ, Abernethy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clin Pharmacokinet 2010; 49:71.
- Lemmens HJ, Brodsky JB. The dose of succinylcholine in morbid obesity. Anesth Analg 2006; 102:438.
- Rose JB, Theroux MC, Katz MS. The potency of succinylcholine in obese adolescents. Anesth Analg 2000; 90:576.
- Pühringer FK, Keller C, Kleinsasser A, et al. Pharmacokinetics of rocuronium bromide in obese female patients. Eur J Anaesthesiol 1999; 16:507.
- Pühringer FK, Khuenl-Brady KS, Mitterschiffthaler G. Rocuronium bromide: time-course of action in underweight, normal weight, overweight and obese patients. Eur J Anaesthesiol Suppl 1995; 11:107.
- Leykin Y, Pellis T, Lucca M, et al. The pharmacodynamic effects of rocuronium when dosed according to real body weight or ideal body weight in morbidly obese patients. Anesth Analg 2004; 99:1086.
- Levitan RM. Patient safety in emergency airway management and rapid sequence intubation: metaphorical lessons from skydiving. Ann Emerg Med 2003; 42:81.
- Levitan RM, Chudnofsky C, Sapre N. Emergency airway management in a morbidly obese, noncooperative, rapidly deteriorating patient. Am J Emerg Med 2006; 24:894.
- Marrel J, Blanc C, Frascarolo P, Magnusson L. Videolaryngoscopy improves intubation condition in morbidly obese patients. Eur J Anaesthesiol 2007; 24:1045.
- Dhonneur G, Abdi W, Ndoko SK, et al. Video-assisted versus conventional tracheal intubation in morbidly obese patients. Obes Surg 2009; 19:1096.
- Maassen R, Lee R, Hermans B, et al. A comparison of three videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesth Analg 2009; 109:1560.
- Abdelmalak BB, Bernstein E, Egan C, et al. GlideScope® vs flexible fibreoptic scope for elective intubation in obese patients. Anaesthesia 2011; 66:550.
- Moore AR, Schricker T, Court O. Awake videolaryngoscopy-assisted tracheal intubation of the morbidly obese. Anaesthesia 2012; 67:232.
- Andersen LH, Rovsing L, Olsen KS. GlideScope videolaryngoscope vs. Macintosh direct laryngoscope for intubation of morbidly obese patients: a randomized trial. Acta Anaesthesiol Scand 2011; 55:1090.
- Gaszynski T, Pietrzyk M, Szewczyk T, Gaszynska E. A comparison of performance of endotracheal intubation using the Levitan FPS optical stylet or Lary-Flex videolaryngoscope in morbidly obese patients. ScientificWorldJournal 2014; 2014:207591.
- Ndoko SK, Amathieu R, Tual L, et al. Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes. Br J Anaesth 2008; 100:263.
- Ranieri D Jr, Filho SM, Batista S, do Nascimento P Jr. Comparison of Macintosh and Airtraq™ laryngoscopes in obese patients placed in the ramped position. Anaesthesia 2012; 67:980.
- Zoremba M, Aust H, Eberhart L, et al. Comparison between intubation and the laryngeal mask airway in moderately obese adults. Acta Anaesthesiol Scand 2009; 53:436.
- Combes X, Sauvat S, Leroux B, et al. Intubating laryngeal mask airway in morbidly obese and lean patients: a comparative study. Anesthesiology 2005; 102:1106.
- Dhonneur G, Ndoko SK, Yavchitz A, et al. Tracheal intubation of morbidly obese patients: LMA CTrach vs direct laryngoscopy. Br J Anaesth 2006; 97:742.
- Arslan ZI, Özdamar D, Yildiz TS, et al. Tracheal intubation in morbidly obese patients: a comparison of the Intubating Laryngeal Mask Airway™ and Laryngeal Mask Airway CTrach™. Anaesthesia 2012; 67:261.
- Wender R, Goldman AJ. Awake insertion of the fibreoptic intubating LMA CTrach in three morbidly obese patients with potentially difficult airways. Anaesthesia 2007; 62:948.
- Della Puppa A, Pittoni G, Frass M. Tracheal esophageal combitube: a useful airway for morbidly obese patients who cannot intubate or ventilate. Acta Anaesthesiol Scand 2002; 46:911.
- Banyai M, Falger S, Röggla M, et al. Emergency intubation with the Combitube in a grossly obese patient with bull neck. Resuscitation 1993; 26:271.
- Kovacs G, Law AJ, Petrie D. Awake fiberoptic intubation using an optical stylet in an anticipated difficult airway. Ann Emerg Med 2007; 49:81.
- Wieczorek PM, Schricker T, Vinet B, Backman SB. Airway topicalisation in morbidly obese patients using atomised lidocaine: 2% compared with 4%. Anaesthesia 2007; 62:984.
- Heffner, DeBlieux P. Anesthesia and sedation for awake intubation. In: Walls Manual of Emergency Airway Management, 5th ed, Brown 3rd CA (Ed), Lippincott, Williams and Wilkins, Philadelphia 2018. p.273.
- Abdellatif AA, Ali MA. GlideScope videolaryngoscope versus flexible fiberoptic bronchoscope for awake intubation of morbidly obese patient with predicted difficult intubation. Middle East J Anaesthesiol 2014; 22:385.
- King DR. Emergent cricothyroidotomy in the morbidly obese: a safe, no-visualization technique. J Trauma 2011; 71:1873.
- Duggan LV, Law JA. Is bougie-aided cricothyrotomy really "extremely fast and safe" in the morbidly obese patient? J Trauma Acute Care Surg 2012; 73:779.
- Dinsmore J, Heard AM, Green RJ. The use of ultrasound to guide time-critical cannula tracheotomy when anterior neck airway anatomy is unidentifiable. Eur J Anaesthesiol 2011; 28:506.
- Siddiqui N, Arzola C, Friedman Z, et al. Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial. Anesthesiology 2015; 123:1033.
- OBESITY'S EFFECTS ON THE AIRWAY
- Physiologic and anatomic changes
- AIRWAY ASSESSMENT
- Obesity and airway difficulty
- Bag-mask ventilation
- Tracheal intubation
- Surgical airway
- AIRWAY MANAGEMENT
- Bag-mask ventilation
- Tracheal intubation
- - Positioning
- - Preoxygenation
- - Medication dosing
- - Rapid sequence intubation
- - Devices for airway management
- - Awake intubation
- Mechanical ventilation
- SUMMARY AND RECOMMENDATIONS