Comparison of Upper Lip Bite Test with Modified Mallampati Score in Predicting Difficult Intubation

Background and Aims: Identifying a patient with a difficult airway is important in planning anaesthetic management so that endotracheal intubation can be achieved safely. This study aims to compare modified Mallampati score with Upper Lip Bite Test to predict difficult intubation using intubation difficulty scale. Materials and methods: A prospective study was carried on 104 patients, both sexes aged between 18 to 60 years scheduled for elective surgeries under general anaesthesia fulfilling inclusion and exclusion criteria. Patient airway was evaluated by MMT and ULBT preoperatively. Predictors of difficult endotracheal intubation were assigned to MMT class III and IV, ULBT class III. After premedication and induction laryngoscopy was performed. After successful intubation Intubation difficulty score was noted down based on the sum of seven assessing parameters. A score >5 was considered difficult intubation. Results: The incidence of difficult intubation in the study was 10.6% (i.e. 11 out of 104 patients). In this study ULBT had a higher sensitivity (90.9% v/s 18.20%), specificity (95.7% v/s 75.3%) PPV (71.4% v/s 8%) and NPV (98.9% v/s 88.6%) than that of MMT Conclusion: Upper lip bite test is better at predicting difficult intubation with higher accuracy when compared to Modified Mallampati test. Both the tests are good predictors of easy intubation. Keywords: Upper Lip Bite Test (ULBT), Modified Mallampati test (MMT), Intubation Difficulty scale (IDS), airway assessment. Difficult intubation prediction, Difficult airway

The Comparison of Duration Endotracheal Tube Insertion Using Aerosol Box And without Aerosol Box in Elective Surgery Patients in the Covid-19 Pandemic

Introduction. The aerosol box can reduce the risk of droplet and aerosol transmission from the patient to the operator when performing intubation, but in practice, an aerosol box makes the glottis visualization less evident, and the operator moves less space with less space the aerosol box. This study aimed to compare ETT duration using an aerosol box and without an aerosol box using a video laryngoscope. Methods: This study was a clinical trial with a post-test-only control design. The study was carried out from February 2021 to May 2021 at the Central Operating Theater of dr. Mohammad Hoesin General Hospital Palembang. The sample in this study was all patients who underwent elective surgery under general anesthesia using intubation at the Central Surgical Installation of dr. Mohammad Hoesin Palembang. After the data is collected, it is analyzed using the SPSS 22.0 program with the appropriate test. Results. There were no differences in subject characteristics (age, sex, BMI, Mallampati score, TMD, Cormack Lehane, limited mouth opening, short neck, limited mouth movement) between the group using the aerosol box and the group without the aerosol box. The duration of intubation without an aerosol box is 30.67 + 2.63 seconds, and using an aerosol box is 44.53 + 2.89 seconds. There was a significant difference between the two groups in the duration of patient intubation (p < 0.001). However, there was no significant difference in complications in the two groups (p >0.05). Conclusion. The duration of the endotracheal tube insertion using an aerosol box is more extended than without an aerosol box in elective surgery patients.

Risk of adverse events in gastrointestinal endoscopy: Zero-inflated Poisson regression mixture model for count data and multinomial logit model for the type of event

Background and aims We analyze the possible predictive variables for Adverse Events (AEs) during sedation for gastrointestinal (GI) endoscopy. Methods We consider 23,788 GI endoscopies under sedation on adults between 2012 and 2019. A Zero-Inflated Poisson Regression Mixture (ZIPRM) model for count data with concomitant variables is applied, accounting for unobserved heterogeneity and evaluating the risks of multi-drug sedation. A multinomial logit model is also estimated to evaluate cardiovascular, respiratory, hemorrhagic, other AEs and stopping the procedure risk factors. Results In 7.55% of cases, one or more AEs occurred, most frequently cardiovascular (3.26%) or respiratory (2.77%). Our ZIPRM model identifies one population for non-zero counts. The AE-group reveals that age >75 years yields 46% more AEs than age <66 years; Body Mass Index (BMI) ≥27 27% more AEs than BMI <21; emergency 11% more AEs than routine. Any one-point increment in the American Society of Anesthesiologists (ASA) score and the Mallampati score determines respectively a 42% and a 16% increment in AEs; every hour prolonging endoscopy increases AEs by 41%. Regarding sedation with propofol alone (the sedative of choice), adding opioids to propofol increases AEs by 43% and adding benzodiazepines by 51%. Cardiovascular AEs are increased by age, ASA score, smoke, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. Respiratory AEs are increased by BMI, ASA and Mallampati scores, emergency, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. Hemorrhagic AEs are increased by age, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. The risk of suspension of the endoscopic procedure before accomplishment is increased by female gender, ASA and Mallampati scores, and in-hospital, and it is reduced by emergency and procedure duration. Conclusions Age, BMI, ASA score, Mallampati score, in-hospital, procedure duration, other sedatives with propofol increase the risk for AEs during sedation for GI endoscopy.

Airway Management in Substernal Goiter Surgery

Objective(s): To review the experience of 3 hospitals with airway management during surgery for substernal goiter and identify preoperative factors that predict the need for advanced airway management techniques. Methods: A retrospective chart review between 2009 and 2017 of patients with substernal goiter treated surgically at 1 of 3 hospitals was performed. Results: Of the 179 patients included in the study, 114 (63.7%) were female, the mean age was 55.1 years (range 20-87). Direct laryngoscopy or videolaryngoscopy was successful in 162 patients (90.5%), with fiberoptic intubation used for the remaining 17 patients. Thirty-one patients (17.4%) required >1 intubation attempt; these patients had larger thyroids (201.3 g, 95% CI 155.3-247.2 g) than those intubated with 1 attempt (144.7 g, 95% CI 127.4-161.9 g, P = .009). Those who required >1 attempt had higher BMI (38.3, 95% CI 34.0-42.6 vs. 32.9, 95% CI 31.5-34.3, P = .02). Mallampati score was found to be a predictor of >1 attempt, though tracheal compression and tracheal shift were not found to be predictors of >1 attempt, nor was the lowest thyroid extent. BMI was the only independent factor on multivariable logistic regression of needing >1 attempt (odds ratio 1.056, 95% CI 1.011-1.103, P = .015). Conclusions: The majority of patients undergoing surgery for substernal goiter can be intubated routinely without the need for fiberoptic intubation. Thyroid-specific factors such as lowest thyroid extent and mass effect of the gland on the trachea do not appear to be associated with difficult intubation, whereas classic patient factors associated with difficulty intubation are. Level of evidence: VI

823 Apparent seizure activity in a 9 year old female presenting as hypnopompic hallucinations

Introduction The presence of hypnopompic hallucinations raises concerns for narcolepsy. However, sleep-related hallucinations may occur in other settings. Dreams at sleep-wake transitions may be difficult for patients to differentiate from sleep-related hallucinations. Sleep-related hallucinations are predominantly visual, although they can be auditory, tactile and/or kinetic. However, they are generally not olfactory in nature. Report of case(s) Here we present a case of a 9-year-old female with a history of tonsillectomy and adenoidectomy, ADHD, ODD, nocturnal enuresis, nocturia, aggressive behaviors and emotional outbursts who presented with EDS, frequent nocturnal awakenings, involuntary dozing, prolonged naps and a one year duration of hypnopompic hallucinations. Initially, the hallucinations occurred 2–3 times per week, but then decreased in frequency to 2–3 times per month. The frequency of episodes apparently decreased after tonsillectomy. She states that she wakes up and sees dots, and “she looks scary” when she looks at herself. She describes a variety of hallucinations including: seeing dots (including her mother being covered in dots), a cupcake, a strange woman walking, her hands looking strange--they had enlarged or hearing noises (a single loud bang). Pertinent physical exam findings included: BMI 66th percentile, Mallampati score 2/4, and a mildly enlarged tongue. The polysomnogram demonstrated mild obstructive sleep apnea by pediatric criteria, and, most notably, demonstrated an EEG with spike and wave formations in the central and frontal leads bilaterally. These were seen during NREM sleep and most prominently during sleep-wake transitions. There was also a more focal brief run of a regular 2 Hz rhythm in the central and frontal leads bilaterally. A referral was placed to Pediatric Neurology who ordered a full EEG which is pending at this time. Conclusion Sleep-related hallucinations may occur in narcolepsy, other sleep disorders, a mental disorder, a medical disorder, a medication effect or secondary to substance use. This case suggests that seizure activity may present as hypnopompic hallucinations as well. Support (if any):

Comparison of intra-oral mask and classic face mask in terms of ventilation success and practitioners’ work load assessments: a randomized crossover study

Aim: Providing effective ventilation of the unconscious patient is an essential skill in every specialty dealing with airway management. In this randomized cross-over study aimed to compare intra-oral and classic face mask in terms of ventilation success of patients, practitioners’ workload and anxiety assessments. Also we analyzed potential risk factors of difficult mask ventilation for both masks. Methods: 24 anesthesiology residents and 12 anesthesiologists participated in the study. Each of the practitioners ventilated 4 patients with both masks at settled pressure and frequency. Practitioners rated their workload and anxiety related to masks with National Aeronautics and Space Administration Task Load Index score and State Trait Anxiety Inventory scale. Ventilation success was evaluated with Han scale, expiratory tidal volume and leak volume. We analyzed potential risk factors of difficult mask ventilation with anthropometric characteristics and STOP-BANG score. Results: Ventilation success rate was superior with intraoral mask comparing to classic face mask in terms of Han Scale (Easy mask ventilation percentage 84/144 (58.3%); 123/144 (85.4%); respectively) and tidal volume (481.92±173.99; 430.85±154.87mL; respectively). Leak volume in intraoral mask ventilation was significantly lower than classic face mask (71.50±91.17 /159.38±146.31 respectively). Diffucult mask ventilation risk factors were high weight, neck circumference, Mallampati score and STOP-BANG score>3 for classic face mask (at the utmost neck circumference 95% CI, OR=1.180, p= 0.002) Risk factors were high body mass index and Mallampati score for intraoral mask (at the utmost Body mass index 95% CI, OR=1.162 p=0.006). The anxiety ratings of practitioners were similar between two masks. The work-load rating is higher with intraoral mask comparing to classic face mask. Conclusion: Intraoral mask may be an effective alternative device for bag-valve mask ventilation.

The Usefulness of Modified Mallampati Score and CT Upper Airway Volume Measurements in Diagnosing OSA among Patients with Breathing-Related Sleep Disorders

Background: Obstructive sleep apnea (OSA) is a condition causing restriction of the airflow through the upper airways during sleep, despite preserved inspiratory muscle activity. This may lead to the development of secondary hypertension, ischemic heart disease, myocardial infarction, and arrhythmia. Moreover, the prevalence of OSA is on the rise. Methods: Comparison of scores from the Berlin Questionnaire, modified Mallampati scores (MMP), pulse oximetry readings and Upper Airway Volume (UAV) data obtained from CBCT (Cone Beam Computed Tomography). The study group of 129 patients of both sexes reporting sleep-related breathing problems completed the Berlin Questionnaire, had their oxygen saturation (SpO2) measured with a PO40 pulse oximeter, and oropharyngeal tissues assessed according to MMP. CBCT scans were put into 3D Amira TM 3D computer analysisto obtain UAV values. Results: Snoring was associated with significantly higher BMI compared to non-snoring patients. Furthermore, snoring patients had higher heart rate, modified Mallampati score, and lower UAV than the non-snoring group. The multifactorial analysis showed MMP as a useful indicator of the risk of snoring (OR = 7.468 (3863–14, 507, p < 0.001)). Conclusions: The composition of MMP together with UAV and the Berlin questionnaire might be reliable indicators to assess the risk of snoring.

Obstructive Sleep Apnea High-Risk Prevalence, Symptoms and Sleepiness among Patients with Uncontrolled Type 2 Diabetes Mellitus Seen at the Out-Patient Department of Philippine General Hospital

Objectives. We determined the prevalence of patients at risk for obstructive sleep apnea (OSA) with uncontrolled type 2 diabetes mellitus (T2DM) at the out-patient department (OPD) of the University of the Philippines-Philippine General Hospital (UP-PGH) from December 1, 2018 - February 28, 2019. We described the demographic characteristics of patients with uncontrolled T2DM and compared them with high and low OSA risk, its association, and correlation with the quality of sleep. Methods. This is a prospective cross-sectional study among uncontrolled T2DM. The questionnaires were Berlin Questionnaire (screen OSA-HR) and Epworth Sleepiness Score (level of sleepiness). Clinicodemographic profile and significant laboratory data were obtained. Descriptive statistics utilized. Chi-square test was used to compare categorical variables between patients with high vs low OSA risk and to determine if an association exists between OSA-HR and sleep quality. Results. A total of 240 participants, 88 males and 151 females, were included in the study. The overall prevalence of OSA-HR among patients with uncontrolled type 2DM is 58.33%. The majority of the OSA–HR patients (105 /140) was 46 years old and above. There is a significant association of tonsillar grade, Mallampati score, BMI, HbA1c, hypercholesterolonemia, and Epworth sleepiness on OSA High risk. There is also a substantial association with age, BMI, Mallampati score, tonsillar grade, hypertension, asthma, HbA1c, and hypercholesterelonemia on the level of sleepiness of OSA-HR. Conclusion. There is a high prevalence of high OSA-risk among patients with uncontrolled DM. Factors associated with high OSA-risk among uncontrolled diabetes mellitus include HbA1c, dyslipidemia, BMI, Mallampati score, tonsillar grade, and Epworth score.