• Stefano Falcetta, Simona Cavallo, Vincenzo Gabbanelli, Paolo Pelaia, Massimiliano Sorbello, Ivana Zdravkovic, and Abele Donati.
• Clinic of Anaesthesia and Intensive Care Unit, Ospedali Riuniti Ancona (SF, SC, VG), Università Politecnica delle Marche, Ancona (PP, AD), Anaesthesia and Intensive Care, AOU Policlinico Vittorio Emanuele, Catania, Italy (MS) and Clinical Center Zvezdara, Belgrade, Serbia (IZ).
• Eur J Anaesthesiol. 2018 Aug 1; 35 (8): 605-612.

BackgroundUnpredictable difficult laryngoscopy remains a challenge for anaesthesiologists, especially if difficult ventilation occurs during standard laryngoscopy. Accurate airway assessment should always be performed, but the common clinical screening tests have shown low sensitivity and specificity with a limited predictive value. Ultrasound-based airway assessment has been proposed recently as a useful, simple, noninvasive bedside tool as an adjunct to clinical methods, but to date, few studies are available about the potential role of ultrasound in difficult airway evaluation, and these are mostly limited to specific groups of patients.ObjectivesThe aim of this study was to determine the correlation between the sonographic measurements of anterior cervical soft tissues thickness and Cormack-Lehane grade view at direct laryngoscopy in patients with normal clinical screening tests.DesignProspective, single blinded, observational study.SettingOperating theatre of a teaching hospital from May 2017 to September 2017.PatientsA total of 301 patients at least 18 years of age undergoing elective surgery under general anaesthesia with tracheal intubation were included in the study.Outcome MeasuresPre-operative evaluation was performed before surgery, demographic variables were collected and clinical screening tests to predict a difficult airway were performed. Patients with predicted difficult intubation were excluded. A 10 to 13-MHz linear ultrasound transducer was placed in the transverse plane and the thickness of the anterior cervical soft tissues was measured at two levels [thyrohyoid membrane (pre-epiglottic space) and vocal cords (laryngeal inlet)] with the patient's head in a neutral position. At each level, the distance from the skin in the median axis and the surrounding area was measured. The laryngoscopic view was graded by a different anaesthetist with more than 5 years of experience with direct laryngoscopy, blinded to the ultrasound assessments.ResultsThe 'pre-epiglottic space thickness' at the level of thyrohyoid membrane was measured as the median distance from skin to epiglottis (mDSE) and the pre-epiglottic area was calculated; the mDSE cut-off value of 2.54 cm (sensitivity 82%, specificity 91%) and the pre-epiglottic area cut-off value of 5.04 cm (sensitivity 85%, specificity 88%) were the best predictors of a Cormack-Lehane grade at least 2b at direct laryngoscopy and of difficult intubation. The cut-off value of mDSE showed greater sensitivity in female patients (94 vs. 86%) and greater specificity in male patients (92 vs. 83%). No correlation was found between difficult laryngoscopy and ultrasound assessments at the level of the vocal cords.ConclusionAirways ultrasounds might be considered as a predictor of restricted/difficult laryngoscopy and unpredicted difficult intubation.Trial RegistrationClinicalTrials.gov: NCT03547193.

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