Morbid Obesity and Supraglottic Airway Devices

REVIEW
Morbid Obesity and Supraglottic Airway
Devices
Ben Babu Kurien, Sampathila Padmanabha, Vincent Mathias

Dr Ben Babu Kurien is Post
Graduate in Anaesthesiology
Yenepoya Medical College,
Mangalore 575018,
Karnataka, India.
Dr Sampathila
Padmanabha is Professor &
H.O.D, Dept. of
Anaesthesiology
Yenepoya Medical College,
Mangalore 575018,
Karnataka, India.
Securing the airway in obese individuals is challenging both in the operation theatres as well
as in the intensive care. Laryngoscopy in morbidly obese is difficult due to the
pathophysiological changes in the upper airway and neck. Supraglottic airway device can be
used alone to maintain the airway during short surgical procedures or it can act as a conduit
for passage of endotracheal tube during major surgical procedures or in the intensive care.
Studies have shown there need not be any fear of airway related complications while using
supraglottic airway device in obesity. In this review, we emphasize how supraglottic airway
device is a saviour in difficult airway situation.
Keywords: Obesity, SAD, LMA, BMI.

Dr Vincent Mathias is
Professor, Dept. of
Anaesthesiology
Yenepoya Medical College,
Mangalore 575018,
Karnataka, India.

Corresponding Author:
Dr Ben Babu Kurien
E-mail:
benbabu@rediffmail.com

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44 March 2014 International Journal of Health and Rehabilitation Sciences Volume 3 Issue 1
 Morbid Obesity and Supraglottic Airway Devices

INTRODUCTION capacity and airway closure occurs. So these

Obesity is a condition in which excess individuals desaturate rapidly especially when
body fat has accumulated to the extent that it anesthetized.
may have an adverse effect on health, leading to OBESITY MEASUREMENT
reduced life expectancy and/or increased health Obesity is measured by certain indices
problems. The term is derived from Latin word
Obesus which means fattened by eating. 1. Ideal body weight = height (cm) x
Airway of an obese individual is a major (x is 100 for adult males and 105 for
concern for an anaesthesiologist while providing adult female).
general anaesthesia or securing the airway in the 2. An individual can be called obese if his
intensive care unit (ICU). With an incidence of weight> 20% of ideal body weight
11 % of the global population according to 3. Body Mass Index (BMI) or Quetelet
world health organization (WHO) being obese, Index
an anaesthesiologist will encounter obese BMI is calculated as Body
patients quite often1. Endotracheal intubation is weight (kg) / height(m).
usually done in most surgeries but incidence of 4. Waist circumference exceeding 102 cm
difficult intubation in an obese patient is much (40 in) in men and 89 cm (35 in) in
higher than normal weight patients2-4. women indicates increased risk in
Why the Obese have a Difficult Airway? overweight.
Obese have a limited neck movement 5. Waist to height ratio > 0.5 is critical at
due to restriction of atlantoaxial joint and age below 40yrs and > 0.6 above 40yrs.
cervical spine by upper thoracic and lower 6. Waist-to-hip ratio (WHR) >0.9 in
cervical fat pads. Obese individuals usually have women and >1.0 in men is associated
short thick neck. The excessive tissue fold in with a higher risk of morbidity and
mouth may be missed during routine mortality
preanaesthetic check-up. They also have CLASSIFICATION OF OBESITY
suprasternal, presternal and posterior cervical fat
BMI is simple easy and very useful
and a very thick submental fat pad. All these
index in differentiating an individual in to
factors contribute to a difficulty in laryngoscopy
underweight, normal, overweight, severe obese,
and tracheal intubation.
morbidly obese and super obesity as given in
PATHOPHYSIOLOGICAL CHANGES Table 1.
IN OBESITY
About 5% of obese individuals present Table 1 Classification of Obesity
with obstructive sleep apnoea characterized by
BMI Category
episodes of apnoea or hypopnoea during sleep5.
This occurs when pharyngeal airway collapses < 18.5 Underweight
due to decreased tone and leads to narrowing of
18.524.9 Normal weight
airway causing turbulent airflow and snoring.
Due to the added thoracic cage and abdominal 25.029.9 Overweight
weight there is a reduction in the motion of the 30.034.9 Class I Obesity
diaphragm. Functional residual capacity,
expiratory reserve volume and total lung 35.039.9 Class II Obesity
capacity are also reduced in these patients. 40.0 Class III Obesity
Obese patients also have systemic as well as
pulmonary hypertension and are at high risk for 40 49.9 Morbid Obesity
IHD. Due to the increased blood volume and 50 Super Obesity
risk of ischaemic heart disease they are also
prone for right and left ventricular hypertrophy
leading to biventricular failure. Among the
obese, tidal breathing falls within the closing
45 March 2014 International Journal of Health and Rehabilitation Sciences Volume 3 Issue 1
 Morbid Obesity and Supraglottic Airway Devices
THE CHOICE OF SUPRAGLOTTIC
AIRWAY DEVICE IN OBESE
Since its invention by Archie Brain,
Laryngeal mask airway (LMA) has found its
place on the anaesthesia cart. In 2011, 20 years
after its invention, 56% of anesthetics in UK
were done using supraglottic airway device6.
The growing researches and modifications on
this device truly suggests that supraglottic
airway device (SAD) can be considered as a
valuable equipment in the hands of an
anesthetist. Laryngeal mask airway (LMA) is a
great choice for morbidly obese individuals.
Widad Abdi et al showed that LMA Supreme
could be considered as a standard airway
management tool for both elective and rescue
airway management of morbidly obese patients7.
RESPIRATORY PROBLEMS
Obese individuals being at a greater risk
for desaturation and reduced respiratory
compliance, plan to secure the airway should be
foolproof. Zoremba et al. suggests that using an
LMA and avoiding muscle relaxation reduce
post-operative deterioration of lung function,
compared with tracheal intubation, in
moderately obese patients undergoing a minor
surgery8. A study by Yu and Beirne, reported
that the use of the LMA resulted in a statistically
and clinically significant lower incidence of
laryngospasm, postoperative hoarse voice and
coughing than when using an endotracheal
tube(ETT)9. Laryngeal mask airway could
replace ETT in obese individuals as the latter is
known to cause bronchoconstriction and
atelectasis especially during induction of
anaesthesia10,11. The NAP4 project also states
that SADs were associated with a lower reported
incidence of major airway complications per
million than other devices in UK during 2010-
1112.
CARDIOVASCULAR RESPONSE
Obese patients are prone for several
cardiovascular complications. LMA can be
identified as better option in them as it reduces
the pressor response and provide better
haemodynamic stability compared to
laryngoscopy and intubation13,14. An intubating
LMA can be used if intubation is required
46 March 2014 International Journal of Health and Rehabilitation Sciences
especially when they come for cardiovascular
surgeries15.
SAD IN DIFFERENT SURGERIES
The low frequency of coughing during
emergence may be beneficial to patients
following open eye or ENT surgery where
excessive straining is potentially harmful16. Intra
ocular and Intracranial tension caused due to
SAD is lesser compared to endotracheal
intubation which makes it ideal for neuro
surgeries as well as ophthalmic surgeries such as
glaucoma or cataract operations. ProSeal can
be used as a temporary ventilatory device before
tracheal intubation in obese individuals17,18.
SECURING THE AIRWAY WITH SAD
Obesity predisposes to difficult airway
scenario. Emergency as well as elective
situations of obese should be handled using an
SAD by skilled individuals or paramedical staff,
as its ease in securing and ventilating the airway
is good19. The time spent on securing the airway
using an SAD is also lesser19. Laryngeal mask
anaesthesia is also fundamental skill, required by
all anaesthetists. The subject should be taught
with the same attention to detail as tracheal
intubation. This involves patient selection,
indications and contraindications for use and
practicalities such as insertion, confirmation of
correct positioning, management during
maintenance and removal of SADs. Positive
pressure ventilation is possible using SADs in
patients with low respiratory compliance. The
NAP4 report in 2011 had made a number of
recommendations pertaining to the use of
SAD12.
THE FEAR OF ASPIRATION WITH
SAD
Since the advent of SAD, there has been
the fear of aspiration associated with its use. A
metaanalysis involving 12,901 patients with
LMA usage, showed that clinical evidence of
pulmonary aspiration using the LMA was
comparable to anesthesia administered with an
endotracheal tube (ETT) (2.3 per 10000)20. The
2011 NAP4 project done in United Kingdom,
shows only a 4% chance of aspiration associated
with second generation airway devices,
compared to 35% chance seen with tracheal
tube. This makes SAD a superior choice21.
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 Morbid Obesity and Supraglottic Airway Devices
OTHER ADVANTAGES OF SAD
The reduced anaesthetic requirement for
airway tolerance makes supraglottic airway
device cost effective. Joseph Brimacombe has
found 13 advantages of LMA over ETT and four
over Face mask based on a number of articles,
which proves without doubt the superiority of
SADs over other airway management devices22.
It is possible to maintain the airway in case of a
failed intubation, especially using a ProSeal
LMA without regret.
COMPARISON WITH
ENDOTRACHEAL INTUBATION
Despite many studies supporting SADs,
many anaesthesiologists prefer control of airway
with endotracheal intubation in obese. This
could be because positive end expiratory
pressure (PEEP) and vital capacity(VC)
manouvers can be applied better with
endotracheal intubation10. But complications like
oesophageal intubation, bronchial intubation,
trauma, spinal cord/ vertebral injury due to neck
positioning can occur during intubation23.Of the
supraglottic airway devices ProSeal would be
a safer option in obese individuals due to the
better seal and the esophageal vent17. ProSeal
is a better choice before intubating as compared
to other SADs18,24,25.
CONCLUSION
Difficult laryngoscopy and difficulty in
intubation are the common problems that an
anaesthesiologist will face when an obese
patient comes to the emergency department,ICU
or for surgery. In such situations supraglottic
airway device should be made available.
ProSeal would be the best option in such
individuals.
CONFLICTS OF INTEREST
None declared
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