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Thyromental Distance Ratio in Predicting Difficult Intubation

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Thyromental Distance Ratio in Predicting Difficult Intubation THE EFFECTIVENESS OF EXTENDED MALLAMPATI TEST, HYOMENTAL DISTANCE RATIO AND NECK CIRCUMFERENCE – THYROMENTAL DISTANCE RATIO IN PREDICTING DIFFICULT INTUBATION BY EZIKE AMECHI CHUKWUDUM DEPARTMENT OF ANAESTHESIA UNIVERSITY OF CALABAR TEACHING HOSPITAL CALABAR, NIGERIA A DISSERTATION SUBMITTED TO NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILLMENT OF THE FINAL FELLOWSHIP OF THE MEDICAL COLLEGE IN ANAESTHESIA (FMCA) EXAMINATION REQUIREMENT MAY 2017 1 SUPERVISORS ATTESTATION We hereby affirm that we supervised this study carried out by Dr. Amechi Chukwudum Ezike titled EFFECTIVENESS OF EXTENDED MALLAMPATI SCORE, HYOMENTAL DISTANCE RATIO AND NECK CIRCUMFERENCE- THYROMENTAL DISTANCE RATIO IN PREDICTING DIFFICULT INTUBATION , in partial fulfillment for the requirement of the award of the Fellowship of the National Postgraduate Medical College of Nigeria. First Supervisor……………………………………………… Date…………………………….. Prof. Atim I. Eshiet (MBBCh, DA, FMCA, FICS, FWACS) Consultant Anaesthetist, University of Calabar Teaching Hospital, Calabar, Nigeria. Second Supervisor …………………………………… Date……………………………… DR. Iniabasi Udoh Ilori (MBBCh; DA; FWACS). Consultant Anaesthetist, University of Calabar Teaching Hospital, Calabar, Nigeria. 2 CERTIFICATION I affirm that this dissertation titled ‘Effectiveness Of Extended Mallampati Score, Hyomental Distance Ratio And Neck Circumference-Thyromental Distance Ratio In Predicting Difficult Intubation’ was carried out by Dr. Ezike Amechi Chukwudum and supervised by consultants in the Department of Anaesthesiology, University of Calabar Teaching Hospital. This is in partial fulfillment of the requirement for the award of the Fellowship of the National Postgraduate Medical College of Nigeria. …………………………………………… Date………………………. DR. OBOKO OKU (MBBCh; DA; FWACS). The Head, Department of Anaesthesiology, University of Calabar Teaching Hospital (UCTH), Calabar, Nigeria. 3 DECLARATION I hereby declare that this work is original unless otherwise stated. It has neither been presented to any other College for Fellowship nor submitted for publication anywhere else. ---------------------- Date--------------- NAME: Dr. EZIKE AMECHI CHUKWUDUM 4 DEDICATION I dedicate this dissertation to God Almighty for His guidance and inspirations throughout the duration of this study. 5 ACKNOWLEDGEMENT I would like to express my gratitude to God for giving me the grace to see the conclusion of this work. I am also sincerely grateful to my supervisors and teachers; Prof. Atim I. Eshiet and Dr. Iniabasi Ilori, for their patience, wise counsel and excellent teaching skills. They made the conception and actualization of this project possible. I wish to sincerely thank my assessors for their insightful and invaluable guidance towards producing an acceptable research work. They have helped to make me a better researcher. I appreciate the help I received from Mrs. Fond Success, Dr. Affiong Oku and Dr. Augustine Bello, for their contributions in the study design and analysis. I am also very grateful to the Head of Department and Consultants in the Department of Anaesthesia for providing a suitable environment and to fellow residents for their invaluable help during the data collection. 6 TABLE OF CONTENTS PAGES Title Page i Supervisors Attestation ii Certification iii Declaration iv Dedication v Acknowledgement vi Table of Contents vii List of Tables ix List of Figures xi List of Appendices xii List of Abbreviations xiii Summary 1 CHAPTER ONE Introduction 3 Objectives 6 Hypothesis and Alternative Hypothesis 7 CHAPTER TWO Literature Review 8 7 CHAPTER THREE Methodology 23 CHAPTER FOUR Results 30 CHAPTER FIVE Discussion 45 Recommendations 51 Limitations of the study 52 References 53 Appendices 67 8 LIST OF TABLES PAGES Table I: Socio-demographic Characteristics of participants 30 Table II: Descriptive statistics of participants’ demography 31 Table III: BMI and Incidence of difficult laryngoscopy using IDS 31 Table IV: Age and gender showing ease of intubation using IDS 32 Table V: Predictors and findings at laryngoscopy 32 Table VI: Prediction of difficult intubation by the three predictors 33 Table VII: Agreement between IDS and the three predictors 33 Table VIII: Predictive profiles for EMT, HMDR and NC/TMDR 35 Table IX: Area under the Curve for the predictors 36 Table Xa: Risk Estimate for EMT/HMDR 37 Table Xb: Risk Estimate for EMT/NCTMDR 37 Table Xc: Risk Estimate for HMDR/NCTMDR 38 Table XI: Association between BMI and IDS 39 Table XIIa: Correlations 40 Table XIIb: Model Summary 41 Table XIIc: Anova 41 9 Table XIId: Coefficients 42 Table XIII: Multivariate Logistic regression forward Wald analysis 42 10 LIST OF FIGURES Figure 1: AUC for NCTMDR 43 Figure 2: AUC for HMDR 43 Figure 3: AUC for EMT 44 11 LIST OF APPENDICES PAGES Appendix I: Ethical Approval 67 Appendix II: Patient’s informed consent form 68 Appendix III: Questionnaire 71 Appendix IV: Grading for Comarck and Lehane / Intubation Difficulty Score 72 12 ABBREVIATIONS ASA: American Society of Anesthesiologists BP: Blood Pressure BMI: Body Mass Index cm: Centimeter CI: Confidence Interval CL Cormack and Lehane X2: Chi-square DI Difficult Intubation eg: Example EI Easy Intubation ECG: Electrocardiography EHN EMT+ HMDR+NCTMDR EMS/EMT: Extended Mallampati Score/ Test FN: False Negative FP: False Positive G: Gauge Ht: Height HMDR: Hyomental Distance ratio HMDe: Hyomental distance in neck extension position HMDn: Hyomental distance in neutral position 13 IL: Illinois IDS: Intubation Difficulty Score IV: Intravenous <: Less than mm: Millimeter MMT: Modified Mallampati Test >: More than ≥: More than or equal to NC/TMDR OR NCTMDR: Neck Circumference-Thyromental Distance Ratio OR: Odd Ratio SpO2: Peripheral oxygen saturation + : Plus PPV: Positive Predictive Value PACU: Post Anaesthesia Care Unit ROC curve: Receiver Operative Characteristic Curve RR: Relative Risk SPSS: Statistical Package for Social Sciences ie: That is TN: True negative TP: True positive TMD: Thyromental distance Wt: Weight 14 SUMMARY Laryngoscopy and intubation could become unexpectedly difficult and this is a significant source of morbidity and mortality in anaesthetic practice. Pre-operative airway assessment identifies those at risk of difficult laryngoscopy / intubation so as to adopt safer alternative strategies at induction of anaesthesia. This study evaluated the usefulness of Extended Mallampati Test (EMT), Hyomental distance ratio (HMDR) and Neck-circumference-thyromental distance ratio (NCTMDR) in isolation and in combinations in apparently normal patients and correlated these predictors with difficult intubation using Intubation Difficulty Score. Three hundred and fourteen ASA I & II adults scheduled for elective general anaesthesia with tracheal intubation were randomly selected. During pre-operative review, each patient’s weight (Wt), height (Ht), and neck circumference (NC) were measured and noted. The EMT, HMDR and NC/TMDR were also assessed for each patient and noted. EMT class ≥3, HMDR< 1.2 and NC/TMDR ≥ 5 were considered predictive of difficult intubation. Intraoperatively, laryngoscopy was performed and the Cormack and Lehane (CL) grading recorded for each patient. Grades 3 and 4 were considered difficult intubation in the CL grading. The Intubation difficulty score (IDS) was then calculated and noted. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and false positive (FP) values for each airway predictor in isolation and then in combinations were determined using a 2x2 contingency table. 15 Difficult intubation occurred in 5 out of 314 patients (1.6 %). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false positive and positive likelihood Ratio (PLR) for the three predictors were: EMT (50%, 99.7%, 80%, 98.7%, 1, 153.0), HMDR (4.05%, 99.1%, 60%, 77%, 2, 4.86), and NC/TMDR (33.3%, 99.7%, 80%, 97.4%, 1, 100.7) respectively. Although their low false positive values (1 for EMT, 2 for HMDR and 1 for NC/TMDR) and their areas under the curves (AUC) of receiver operator characteristic curve (ROC) showed they were all useful predictors, the EMT was the most accurate single predictor of difficult intubation with an AUC of ROC of 0.878 (p- value 0.000). Furthermore, the Univariate analyses also showed that though EMT, HMDR, and NC/TMDR were related to difficult intubation, the relationship was significant only for EMT and NC/TMDR. EMT however had the highest precision of this relationship with a kappa coefficient of 0.608 ( p-value < 0.001). The multivariate analysis odds ratios also estimated that EMT predicted difficult intubation about 12 times better than HMDR and also about 1.5 times better than NC/TMDR. Again, the combination of the anatomical distances (HMDR plus NC/TMDR) was less accurate than EMT alone ( AUC of 0.797 as against 0.878 for EMT). Combining the EMT to the anatomical distances increased their accuracy significantly at a p-value < 0.05. Both univariate analyses and Logistic regression showed that at a p-value of < 0.05, there was no relationship between age, gender, body mass index (BMI), neck circumference and difficult intubation. In conclusion, EMT had the greatest predictive profile of all the three predictors assessed singly. EMT improved the predictive values of the anatomical distances 16 (HMDR and NC/TMDR) in all the combinations. There was no relationship between age, gender, BMI, neck circumference and difficult intubation. CHAPTER ONE INTRODUCTION Difficult intubation remains
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