British Journal of Anaesthesia, 120 (5): 1110e1116 (2018)

doi: 10.1016/j.bja.2018.01.019
Advance Access Publication Date: 21 March 2018
Respiration and Airway

Degree of obesity is not associated with more than

one intubation attempt: a large centre experience
W. Saasouh1,2, K. Laffey3, A. Turan1,2, R. Avitsian2, A. Zura2, J. You1,4,
N. M. Zimmerman1,4, L. Szarpak5, D. I. Sessler1 and K. Ruetzler1,2,*
1
Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, OH, USA, 2Department of
General Anaesthesiology, Anaesthesiology Institute, Cleveland Clinic, OH, USA, 3Department of General
Anaesthesiology, Fairview Hospital, Cleveland, OH, USA, 4Department of Quantitative Health Sciences,
Cleveland Clinic, Cleveland, OH, USA and 5Department of Emergency Medicine, Medical University of
Warsaw, Warsaw, Poland

*Corresponding author. E-mail: RUETZLK@ccf.org

This article is accompanied by an editorial: Big data for big patients: gaining insight into risks for tracheal intubation in obese patients by
J. Hinkelbein, Br J Anesth 2018:120:901e903, doi: 10.1016/j.bja.2018.02.006.

Abstract
Background: The role of obesity as a risk factor for difficult intubation remains controversial. We primarily assessed the
association between body mass index (BMI) and difficult tracheal intubation.
Methods: We analysed electronic records of more than 67 000 adults having elective non-cardiac surgery requiring
tracheal intubation at the Cleveland Clinic between 2011 and 2015. The association between BMI and difficult intubation,
defined as more than one intubation attempt, was assessed using multivariable logistic regression adjusting for pre-
specified confounders.
Results: Amongst 40 183 patients with BMI <30 kg m!2 and 27 519 with BMI "30 kg m!2, 9% required more than one
intubation attempt. Increasing BMI up to 30 kg m!2 was significantly associated with increased odds of more than one
intubation attempt [odds ratio (OR): 1.03; 97.5% confidence interval (CI): 1.02, 1.04] per unit increase in BMI, P < 0.001.
However, the odds of difficult intubation remained unchanged once BMI exceeded 30 kg m!2 (P ¼ 0.08). The results were
similar when analysis was restricted to patients without history of airway abnormalities in whom intubation was
attempted using a standard direct laryngoscope (OR: 1.03; 99.4% CI: 1.01, 1.04) per kg m!2 increase in BMI <30 kg m!2).
Conclusions: Increasing BMI was associated with increasing odds of difficult intubation in the lean range. At higher BMI,
the odds of difficult intubation remain elevated, but there is no additional increase in odds with further increase in BMI.
Obese patients were thus harder to intubate than lean ones, but difficult intubation was no more likely in morbidly obese
patients than in those who were only slightly obese.

Keywords: airway management; body mass index; laryngoscopy; obesity; morbid

Editorial decision: January 25, 2018; Accepted: January 25, 2018

© 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

1110

Editor’s key points
$ It is still not clear whether or not tracheal intubation is
more difficult in obese patients than in lean patients.
$ A single centre retrospective analysis of electronic data
was conducted to assess the relationship between
intubation difficulty and BMI in patients undergoing
non-cardiac surgery.
$ Tracheal intubation was more difficult with increasing
BMI, but the odds of difficult intubation remained un-
changed once BMI exceeded 30 kg m!2.
The World Health Organization defines obesity as a BMI
exceeding 30 kg m!2; by this definition two-thirds of the US
population may be obese.1 Obesity is associated with multiple
medical comorbidities such as metabolic syndrome, hyper-
tension, diabetes, and anatomical changes that can result in
gastro-oesophageal reflux and obstructive sleep apnoea. Each
contributes to the risk of perioperative morbidity and mor-
tality.2e4 Additional potential consequences of obesity are
difficulties during airway management (ventilation, intuba-
tion, or both).5e7
Airway management, including tracheal intubation, is a
cornerstone of perioperative anaesthesia and requires
considerable experience and skill. Difficulties encountered
during airway management increase the risk of perioperative
morbidity and mortality.5,6,8e10 Obese patients present with
varying degrees of fat deposition at key locations of the airway.
Consequently, morbidly obese patients are thought to be at
increased risk for difficult airway management. For example,
difficult intubations have been reported in up to 15% of seri-
ously obese patients11e13 compared with 2e6%12e14 in lean
patients. Obesity also reduces oxygen reserve, thereby
decreasing the time available for airway manipulations.
Whether obesity complicates intubation attempts remains
unresolved, with some studies reporting that obesity is a risk
factor9,15,16 and others not.11,17 However, based on clinical
experience and morphologic changes consequent to obesity,
we expected body mass to have little effect on intubation
difficulty in lean patients, and that intubation would become
progressively more difficult with increasing BMI. This is sup-
ported by reported difficult intubations in the obese popula-
tion both in and out of the operating room.6,7 Our goal was
thus to evaluate the relationship between BMI and difficult
tracheal intubation. Specifically, we tested the hypothesis that
there is an association between BMI and more than one intu-
bation attempt in obese surgical patients.
Methods
With approval of the Institutional Review Board of the Cleve-
land Clinic Foundation (16e474) and waived consent, this
retrospective cohort registry analysis included adults who had
elective non-cardiac surgery under general or combined
anaesthesia with tracheal intubation at the Cleveland Clinic
Main Campus between January 2011 and September 2015. Data
were obtained from the Cleveland Clinic Perioperative Health
Documentation System, an electronic registry including data
containing patient demographics and baseline characteristics,
the preoperative airway evaluation (including expected diffi-
culty and significant airway abnormalities as judged by an
attending anaesthesiologist), unexpected airway difficulties,
Difficult intubation in obese patients - 1111
and the number of intubation attempts. Patients were
excluded if they had missing intubation device data, received
fibreoptic or bronchoscopic intubation, received neither or
both regular direct or videolaryngoscopy or had incomplete
data on intubation attempts, BMI, or potentially confounding
characteristics. Only the first intubation attempt was consid-
ered for each patient.
The primary relationship of interest was the association
between BMI and difficult tracheal intubation, defined as
requiring more than one intubation attempt. To assess whether
the relationship between BMI and the probability of difficult
intubation is linear, we plotted the estimated probability of
requiring more than one intubation attempts across the
observed range of BMI, using a univariable logistic regression
incorporating a smooth (natural cubic spline with knots at 10th,
25th, 50th, 75th, and 90th percentile) term for BMI.18 As patterns
differed below and above a BMI of 30 kg m!2 and because BMI
>30 kg m!2 is the World Health Organization threshold for
obesity, we constructed separate multivariable logistic regres-
sion models for BMI values below and above 30 kg m!2.1,19
Each model was adjusted for the following pre-specified
potential confounding variables: age, gender, ASA physical
status, Mallampati score, significant airway abnormality,
short neck, small mouth opening, short thyromental distance,
beard present, rheumatoid arthritis, diabetes mellitus, cervical
spine surgery, type of surgery [US agency for healthcare
research and quality’s clinical classification software (AHRQ-
CCS) categories], and year of surgery.
Secondarily, we assessed the associations between
BMI and difficult intubation separately for regular and
videolaryngoscopy with and without any significant airway
abnormality (yes vs no) using the same approach as the pri-
mary analysis.
As a post hoc sensitivity analysis, we assessed the associa-
tion between BMI >30 kg m!2 with the odds of difficult intu-
bation using a multivariable logistic regression model
adjusting for the same potentially confounding factors as in
the primary analysis.
The significance criterion was adjusted using Bonferroni
corrections. Thus, P < 0.025 was considered statistically sig-
nificant for the two primary analyses, whereas P < 0$006 was
required for the eight secondary analyses.
Sample size considerations
We planned to use all available patients who met our inclusion
criteria (approximately 100 000 patients based on a recent
query of the Cleveland Clinic Perioperative Health Documen-
tation System). We have more than 99% power to detect an
odds ratio (OR) of 1.05 or more per kg m!2 increase in BMI at
the overall 0.05 significance level, assuming a mean (standard
deviation) BMI of 30 (8) kg m!2 and an 8% incidence of having
difficult intubation (based on a recent query of our registry).
SAS software version 9$4 (SAS Institute, Cary, NC, USA) was
used for all statistical analyses.
Results
Analyses included 67 702 eligible adults who had non-cardiac
surgery with general or combined anaesthesia with tracheal
intubation at the Cleveland Clinic Main Campus hospital be-
tween January 2011 and September 2015 (Fig. 1). Amongst
them, 56% were female, and the average age was 56 (16) yr. The
 1112 - Saasouh et al.
Fig 1. Study flow chart.
median BMI was 28 (Q1 24, Q3 34, minimum 12, maximum 100)
kg m!2. Demographic and perioperative characteristics are
summarised in Table 1.
Amongst 67 702 patients, 61 010 (90%) of tracheas were
initially intubated using regular (direct) laryngoscopy and 6692
(10%) were initially intubated using videolaryngoscopy. More
than one intubation attempt was required in 6055 (9%) pa-
tients, including 4420 (73%) patients’ tracheas intubated with
a regular laryngoscope and 1635 (27%) patients’ tracheas
intubated with a videolaryngoscope. Thus, 24% (i.e. 1635
of 6692) of patients’ tracheas which were intubated with a
videolaryngoscope and 7.2% (i.e. 4420 of 61 010) intubated with
direct laryngoscopy had difficult intubations. A total of 40 183
patients had a BMI <30 kg m!2 while 27 519 had a BMI
"30 kg m!2.
Increasing BMI was associated with increased odds of having
difficult intubation for patients with BMI <30 kg m!2 (P < 0.001),
with an estimated OR of 1.03 [97.5% confidence interval (CI):
1.02, 1.04] per kg m!2 increase in BMI (Table 2). Interestingly,
although the odds of difficult intubation for patients with
BMI >30 kg m!2 are higher than patients with lower BMI, the
odds of difficult intubation stopped increasing with increasing
BMI "30 kg m!2 (P ¼ 0.08, Fig. 2), with an estimated OR of 1.00
(97.5 CI: 0.99, 1.00) per kg m!2 increase in BMI.
Results persisted amongst patients with BMI <30 kg m!2
who did not have any significant airway abnormalities and
had tracheal intubation using a regular laryngoscope, with
increasing BMI <30 kg m!2 associated with increased odds of
difficult intubation (OR: 1.03; 99.4% CI: 1.01, 1.04) for 1 unit
increase in BMI, P < 0.001). This corresponds to an estimated
OR (97.5% CI) of 1.16 (1.10, 1.22) per 5 kg m!2 increase in BMI
and 1.34 (1.22, 1.48) per 10 kg m!2 increase in BMI, which we
consider to be a clinically important increase. However, there
was no significant association between BMI <30 kg m!2 and
difficult intubation amongst subgroups of patients with re-
ported airway abnormalities with or without the use of a
videolaryngoscope. Consistent with our primary analysis,
there was no significant association between BMI and difficult
intubation for patients with BMI "30 kg m!2 (Table 2) in any
subgroup.
 Difficult intubation in obese patients - 1113

Table 1 Patient characteristics summarised by BMI below and above 30 kg m!2. Summary statistics are presented as % of patients,
mean (standard deviation), or median [Q1, Q3], respectively. *Only most frequent 10 categories are reported because of limited space.
y
Absolute standardised difference (ASD): absolute difference in means or proportions divided by the pooled standard deviation; ASD of
0$2, 0$5, and 0$8 represent small, median, and large differences. GI, OR

Factor BMI < 30 kg m¡2 BMI ≥ 30 kg m¡2 ASDy

(n ¼ 40 183) (n ¼ 27 519)

Age (yr): mean (range) 56 (42e70) 56 (39e73) 0.03

Gender (female) (n, %) 54 59 0.09
ASA status (n, %) 0.35
I 5 2
II 36 25
III 49 63
IV 9 10
Mallampati score (n, %) 0.40
1 39 24
2 52 55
3 8 19
4 1 2
Airway evaluation (significant abnormalitiesdYes or No) (n, %) 12 30 0.45
Short neck (n, %) 2 21 0.60
Small mouth opening (n, %) 4 6 0.09
Short thyromental distance (n, %) 4 7 0.13
Beard present (n, %) 2 3 0.08
Rheumatoid arthritis (n, %) 2 2 0.02
Diabetes (n, %) 12 28 0.40
History of C-spine surgery (n, %) 1 1 0.01
Regular (vs video) laryngoscope (n, %) 93 86 0.25
Year of surgery (n, %) 0.03
2011 23 23
2012 21 21
2013 21 21
2014 20 20
2015 14 15
Type of surgery* (n, %)
Colorectal resection 7 4
Laminectomy; excision intervertebral disc 4 4
Hysterectomy; abdominal and vaginal 4 4
OR therapeutic procedures on skin and breast 4 3
Gastric bypass and volume reduction 0 8
Nephrectomy; partial or complete 3 3
OR lower GI therapeutic procedures 3 2
Thyroidectomy; partial or complete 2 3
Therapeutic endocrine procedures 2 3
Transurethral excision; drainage; or removal Urinary obstruction 2 2

In our post hoc sensitivity analysis, we found that BMI
>30 kg m!2 was significantly associated with difficult intuba-
tion, with an estimated OR (95% CI) of 1.10 (1.05, 1.17);
P ¼ 0.002.
Discussion
Our large retrospective cohort study reveals that the odds of
difficult intubation increase linearly with BMI up to 30 kg m!2
and remain constant thereafter. Obese patients were thus
more likely to have difficult intubation than lean patients, but
morbidly obese patients did not have higher odds than those
who were only slightly obese. More than one intubation at-
tempts were required in 9% of patients overall, which is more
than the 5.2e5.8% previously reported.9,14 However, even
accepting the lower limit of about 5%, more than one intuba-
tion attempts remain common. A way to reliably predict
difficult intubation would thus be clinically helpful. However,
the difference of risk for difficult intubation of 8% in lean
patients, 10% in those who were obese, and no greater in those
who were morbidly or even super-obese, was not convincing.
Generally, a BMI exceeding 25 kg m!2 is defined as over-
weight, while a BMI "30 kg m!2 is defined as obesity.20 The
threshold of BMI "30 kg m!2 is therefore of particular impor-
tance, which is interestingly also reflected in our study.
Overweight patients had linearly increased risk of difficult
intubation, while risk of obese patients remained constant.
This was in accordance with the increased incidence of
significant abnormalities in obese patients (12% vs 30%).
Consequently, videolaryngoscopy was more often used in
obese patients (7% vs 14%), which has been reported to be
superior in obese patients in order to minimise intubation
attempts, and was probably reducing the risk of difficult
intubation in obese patients.6,21,22
Our findings differ from recent studies and a meta-analysis
which reported increased BMI as an independent risk factor
for difficult intubation, especially within the obese popula-
tion.9,12,14 A meta-analysis by Shiga and colleagues,14 for
 1114 - Saasouh et al.

Table 2 Estimated association between BMI and difficult intubation. *Odds ratio of having difficult intubation (more than one attempt)
for one unit increase in BMI. yThe significant criterion was adjusted using Bonferroni correction (P<0.05 divided by number of esti-
mations); P<0.025 for the two estimations in the primary analysis and P<0.006 for the eight estimations in the secondary analysis. CI,
confidence interval

Analysis Number of patients Difficult intubation (%) Odds ratio* (97.5% CI)y P-valuey

Primary analysis
BMI < 30 kg m!2 40 183 8.2 1.03 (1.02, 1.04) <0.001
BMI " 30 kg m!2 27 519 10.0 1.00 (0.99, 1.00) 0.08
Secondary analysis (99.4% CI)y P-valuey
Regular laryngoscope, no significant airway abnormalities
BMI < 30 kg m!2 33 682 6.7 1.03 (1.01, 1.04) <0.001
BMI "30 kg m!2 17 529 7.6 1.00 (0.99, 1.01) 0.97
Regular laryngoscope, significant airway abnormalities
!2
BMI < 30 kg m 3788 8.5 1.02 (0.98, 1.06) 0.12
BMI " 30 kg m!2 6011 8.4 0.99 (0.98, 1.01) 0.30
Videolaryngoscope, no significant airway abnormalities
!2
BMI < 30 kg m 1727 28.1 1.02 (0.98, 1.06) 0.11
BMI " 30 kg m!2 1760 27.2 0.98 (0.97, 1.00) 0.03
Videolaryngoscope, significant airway abnormalities
BMI < 30 kg m!2 986 22.8 1.00 (0.95, 1.05) 0.93
BMI " 30 kg m!2 2219 20.1 1.00 (0.98, 1.01) 0.46

intubation was 5.2%, and there was a modest but significant

Fig 2. The univariable relationship between BMI and multiple
intubation attempts using a univariable logistic regression
incorporating a smooth term for BMI (natural cubic spline with
specified knots at 10th, 25th, 50th, 75th, and 90th percentile).
The solid line and the shaded region represent the estimated
probability of having difficult intubation and the corresponding
confidence interval as a function of the BMI. The histogram just
above the x-axis represents the distribution of the BMI.
example, included 35 studies with a total of 50 760 patients and
reported that obese patients were three times as likely to have
difficult intubations than lean patients (incidence of difficult
intubation 16% vs 6%). However, many of the included studies
had only a few hundred patients; furthermore, the definition
of difficult intubation and patient positioning differed
amongst the studies. In contrast, our results are broadly
consistent with the largest registry analysis, Lundstrom
and colleagues,9 which evaluated 91 332 patients who had
planned direct laryngoscopy. The overall incidence of difficult
association between BMI %35 kg m!2 and difficult intubation,
with an estimated OR of 1.34 (95% CI: 1.19e1.51, P ¼ 0.001).
Awake fibreoptic intubation is an accepted method of
intubation in patients with suspected or known difficult air-
ways. Several guidelines and experts further advocate that
patients with a BMI exceeding 30e35 kg m!2 have a high risk of
difficult intubation and that fibrotic awake intubation should
therefore at least be considered, even without any signs of
significant difficult airway beside of increased BMI.5,23e26
Neither our results, nor those of Lundstrom and colleagues,9
support this recommendation. Instead, we recommend that
the decision to use awake intubation should be based on a
thorough airway examination and other factors, rather than
BMI.2 In contrast, there is little question that high BMI makes
mask ventilation difficultda risk that should not be
underestimated.27,28
Our analysis included 67 702 patients, and was thus larger
than all but one previous study. The Cleveland Clinic is a large
academic hospital and all types of non-cardiac surgeries were
included in our cohort. A consequence of being a teaching
institution is that clinicians with various backgrounds, edu-
cation, and skill levels were involved, always under supervi-
sion of a staff anaesthesiologist. Presumably, the initial
success rate would have been better if airway management
would always be performed by more experienced staff mem-
bers. Successful airway management largely depends on per-
sonal skills and experience.29 Consequently, a highly skilled
difficult airway management team has been implemented in
our institution. However, our records do not detail exactly who
performed the initial or repeat laryngoscopies so we were
unable to analyse outcomes by provider type.
Our primary finding, that the BMI influences initial intu-
bation success only when BMI <30 kg m!2, is thus likely to be
generalisable, keeping in mind that for BMI "30 kg m!2, the
odds of more than one intubation attempts are persistently
higher than those for lean patients.
Our database does not provide reliable data of intubation
procedures requiring more than one intubation attempts.

Clinically important changes of anaesthesia providers, change
of intubation device used, or repositioning of the patient are
not reliably documented. We therefore a priori decided, to use a
simple, generous, and broad definition of difficult intubation;
namely the need for a second intubation attempt. This con-
servative measure allowed us to detect even a slight increase
in intubation difficulty. Absolute number of intubation at-
tempts are of clinical importance, as every single additional
intubation attempt may contribute to patient morbidity in
both adults and paediatrics.30,31
Others have used various definitions of difficult airways,
with many studies based on visualisation (such as the Cor-
mack and Lehane Score).14,32 It is likely that our results would
differ had we adopted another definition of difficult intuba-
tion. However, it seems unlikely that a different definition
would change the general shape of our results, or our overall
conclusion that obesitydand degree of obesitydis a poor
predictor of difficult intubation.
Proper positioning of the head during tracheal intubation
has been shown to affect the laryngoscopic view. The ‘ramped’
position significantly improves laryngoscopic view, especially
in obese patients.33,34 Positioning of the head was not stand-
ardised in our cohort, although the routine at the Cleveland
Clinic is to use ramp position in obese patients.
As a limitation, our data indicate that patients with BMI
"30 kg m!2 were more likely to be initially intubated using the
videolaryngoscope (14%), compared with patients with BMI
<30 kg m!2 (7%). However, this decision was solely based on
clinical judgment, and opens the possibility of selection bias.
Given the retrospective study design, residual confounding
may introduce error. For example, we were unable to adjust
for potentially confounding variables such as neck circum-
ference and CormackeLehane classification because of un-
available or unreliable data. As a result of missing data, almost
17% of our patients had to be excluded from our analysis.
Although this fraction represents a significant portion of our
patients, the data are generally reliable. Obesity is known to
decrease the functional residual capacity (FRC) and subse-
quently cause desaturation during intubation, which is clini-
cally most important. However, this study only focused on the
association between BMI and intubation attempts. Clinicians
should therefore always be aware that ease of intubation is
only one out of several cornerstones, including risk for desa-
turation and aspiration, during airway management.
In summary, 9% of all patients required more than one
intubation attempts. BMI was related to difficult intubation,
but only within the lean range. At higher BMIs, there was no
relationship between BMI and difficult intubation. Obese pa-
tients were thus harder to intubate than lean ones, but difficult
intubation was no more likely in morbidly obese patients than
in those who were only slightly obese. Obesity per se should
not be considered an indication for advanced airway man-
agement techniques, instead using direct laryngoscopy and
videolaryngoscopy.
Authors’ contributions
Made substantial contribution to conception and design: W.S.,
L.S., R.A., D.I.S., K.R.
Acquisition of data: W.S., J.Y., D.I.S., K.R.
Interpretation of data: all authors
Drafting the article and revising it critically for important in-
tellectual content: all authors.
Difficult intubation in obese patients - 1115
Analysis of data: J.Y., N.M.Z.
Approved the final version to be published and agreed to be
accountable for all aspects of the work thereby ensuring that
questions related to the accuracy or integrity of any part of the
work are appropriately investigated and resolved: all authors.
Declaration of interest
The authors do not have any personal, financial, or marketing
interests related to this manuscript.
References
1. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of
childhood and adult obesity in the United States,
2011e2012. JAMA 2014; 311: 806e14
2. Kristensen MS. Airway management and morbid obesity.
Eur J Anaesthesiol 2010; 27: 923e7
3. Domi R, Laho H. Anesthetic challenges in the obese pa-
tient. J Anesth 2012; 26: 758e65
4. Prospective Studies Collaboration, Whitlock G,
Lewington S, et al. Body-mass index and cause-specific
mortality in 900 000 adults: collaborative analyses of 57
prospective studies. Lancet 2009; 373: 1083e96
5. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice
guidelines for management of the difficult airway: an
updated report by the American society of anesthesiolo-
gists task force on management of the difficult airway.
Anesthesiology 2013; 118: 251e70
6. Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Video-
laryngoscopy versus direct laryngoscopy for adult pa-
tients requiring tracheal intubation. Cochrane Database
Syst Rev 2016; 11, CD011136
7. De Jong A, Molinari N, Pouzeratte Y, et al. Difficult intu-
bation in obese patients: incidence, risk factors, and
complications in the operating theatre and in intensive
care units. Br J Anaesth 2015; 114: 297e306
8. Hove LD, Steinmetz J, Christoffersen JK, Moller A,
Nielsen J, Schmidt H. Analysis of deaths related to anes-
thesia in the period 1996e2004 from closed claims regis-
tered by the Danish Patient Insurance Association.
Anesthesiology 2007; 106: 675e80
9. Lundstrom LH, Moller AM, Rosenstock C, Astrup G,
Wetterslev J. High body mass index is a weak predictor for
difficult and failed tracheal intubation: a cohort study of
91,332 consecutive patients scheduled for direct laryn-
goscopy registered in the Danish Anesthesia Database.
Anesthesiology 2009; 110: 266e74
10. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA,
Cheney FW. Management of the difficult airway: a closed
claims analysis. Anesthesiology 2005; 103: 33e9
11. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M,
Saidman LJ. Morbid obesity and tracheal intubation.
Anesth Analg 2002; 94: 732e6
12. Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intu-
bation is more common in obese than in lean patients.
Anesth Analg 2003; 97: 595e600 [table of contents]
13. Adnet F, Borron SW, Racine SX, et al. The intubation dif-
ficulty scale (IDS): proposal and evaluation of a new score
characterizing the complexity of endotracheal intubation.
Anesthesiology 1997; 87: 1290e7
14. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting
difficult intubation in apparently normal patients: a meta-
 1116 - Saasouh et al.
analysis of bedside screening test performance. Anesthe-
siology 2005; 103: 429e37
15. el-Ganzouri AR, McCarthy RJ, Tuman KJ, Tanck EN,
Ivankovich AD. Preoperative airway assessment: predic-
tive value of a multivariate risk index. Anesth Analg 1996;
82: 1197e204
16. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Pre-
dicting difficult intubation. Br J Anaesth 1988; 61: 211e6
17. Ezri T, Medalion B, Weisenberg M, Szmuk P, Warters RD,
Charuzi I. Increased body mass index per se is not a pre-
dictor of difficult laryngoscopy. Can J Anaesth 2003; 50:
179e83
18. Hastie T, Tibshirani R, Friedman J. The elements of statistical
learning. New York: Springer-Verlag; 2001
19. Obesity: preventing and managing the global epidemic.
Report of a WHO consultation. World Health Organ Tech
Rep Ser 2000; 894: iexii, 1e253
20. Sorensen TI, Virtue S, Vidal-Puig A. Obesity as a clinical
and public health problem: is there a need for a new
definition based on lipotoxicity effects? Biochim Biophys
Acta 2010; 1801: 400e4
21. Norris A, Heidegger T. Limitations of videolaryngoscopy.
Br J Anaesth 2016; 117: 148e50
22. Aziz MF, Bayman EO, Van Tienderen MM, Todd MM.
StAGE Investigator Group, Brambrink AM. Predictors of
difficult videolaryngoscopy with GlideScope(R) or C-
MAC(R) with D-blade: secondary analysis from a large
comparative videolaryngoscopy trial. Br J Anaesth 2016;
117: 118e23
23. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway
Society 2015 guidelines for management of unanticipated
difficult intubation in adults. Br J Anaesth 2015; 115:
827e48
24. Heidegger T. Videos in clinical medicine. Fiberoptic intu-
bation. N Engl J Med 2011; 364: e42
25. Collins SR, Blank RS. Fiberoptic intubation: an overview
and update. Respir Care 2014; 59: 865e78. discussion 78e80
26. Langeron O, Birenbaum A, Le Sache F, Raux M. Airway
management in obese patient. Minerva Anestesiol 2014; 80:
382e92
27. Kheterpal S, Han R, Tremper KK, et al. Incidence and
predictors of difficult and impossible mask ventilation.
Anesthesiology 2006; 105: 885e91
28. Langeron O, Masso E, Huraux C, et al. Prediction of diffi-
cult mask ventilation. Anesthesiology 2000; 92: 1229e36
29. Ruetzler K, Guzzella SE, Tscholl DW, et al. Blind intubation
through self-pressurized, disposable supraglottic airway
laryngeal intubation masks: an international, multicenter,
prospective cohort study. Anesthesiology 2017; 127: 307e16
30. Lee JH, Turner DA, Kamat P, et al. The number of tracheal
intubation attempts matters! A prospective multi-
institutional pediatric observational study. BMC Pediatr
2016; 16: 58
31. Mort TC. Emergency tracheal intubation: complications
associated with repeated laryngoscopic attempts. Anesth
Analg 2004; 99: 607e13 [table of contents]
32. Ruetzler K, Imach S, Weiss M, Haas T, Schmidt AR. Com-
parison of five video laryngoscopes and conventional
direct laryngoscopy: investigations on simple and simu-
lated difficult airways on the intubation trainer. Anaes-
thesist 2015; 64: 513e9
33. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG,
Levitan RM. Laryngoscopy and morbid obesity: a com-
parison of the “sniff” and “ramped” positions. Obes Surg
2004; 14: 1171e5
34. El-Orbany M, Woehlck H, Salem MR. Head and neck po-
sition for direct laryngoscopy. Anesth Analg 2011; 113:
103e9
Handling editor: T. Asai