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Ultrasound as a new tool in the assessment of airway difficulties

An observational study

Alessandri, Francesco; Antenucci, Giuseppe; Piervincenzi, Edoardo; Buonopane, Costantino; Bellucci, Riccardo; Andreoli, Chiara; Alunni Fegatelli, Danilo; Ranieri, Marco V.; Bilotta, Federico

European Journal of Anaesthesiology (EJA): July 2019 - Volume 36 - Issue 7 - p 509–515
doi: 10.1097/EJA.0000000000000989
Airway management

BACKGROUND Prediction of difficult mask ventilation (DMV) is as challenging as difficult laryngoscopy. Ultrasound could be a helpful tool in the prediction of these difficulties.

OBJECTIVES The purpose of this study was to evaluate the ability of pre-operative ultrasound assessment of neck anatomy in predicting DMV and difficult laryngoscopy in patients undergoing during elective surgery requiring tracheal intubation.

DESIGN Prospective, single blind, observational study.

SETTING Operating theatre of a teaching hospital in Italy from April 2018 to July 2018.

PATIENTS A total of 194 patients aged more than 18 years, without neck masses, previous thyroid surgery or tracheotomy undergoing general anaesthesia and tracheal intubation for elective ear, nose and throat-surgery were included in the study.

OUTCOME MEASURES Ultrasound distances were recorded with a linear 6 to 13 MHz ultrasound transducer: measurements included the minimum distance from the thyroid isthmus to skin surface, the minimum distance from the hyoid bone to skin surface (DSHB), the minimum distance from skin to anterior commissure of the vocal cords, the minimum distance from skin to trachea at the level of the jugular notch and the distance from skin to epiglottis midway. The degree of DMV and difficult laryngoscopy was quantified.

RESULTS The mean (SD) of DSHB was 0.88 (0.3) cm in the easy mask ventilation group, 1.4 (0.19) cm in DMV group. The mean of DSHB and of the other ultrasound distances increased according to the DMV and difficult laryngoscopy level. The DSHB was correlated with an increase in the risk for DMV (0.61 [IQR 0.5 to 0.69]). DMV groups were associated with a greater ultrasound-measured DSHB.

CONCLUSION The prospective observational study confirms the relationship between ultrasound assessment of the anterior soft tissues of the neck and difficult laryngoscopy and DMV. DSHB and the other distances extend the available evidence, not only for difficult laryngoscopy but also for DMV.

TRIAL REGISTRATION identified NCT03592758.

From the Department of Anaesthesia and Critical Care Medicine (FA, GA, EP, CB, RB, MVR, FB), Department of Radiology (CA) and Department of Infectious Disease, Medical Statistics and Public Health, University of Rome ‘Sapienza’, Policlinico Umberto I, Rome, Italy (DAF)

Correspondence to Francesco Alessandri, MD, Department of Anaesthesia and Intensive Care Medicine, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy Tel: +39 064 997 8007; e-mail:

Published online 3 April 2019

© 2019 European Society of Anaesthesiology