We read Shiga et al. ’s meta-analysis of predictors of difficult tracheal intubation.1They analyzed four studies involving obese patients2–5and concluded that intubation problems are three times more likely to occur in this patient population compared with normal-weight patients.

Although the standard sniffing position for tracheal intubation is achieved in nonobese patients by raising the occiput 8 to 10 cm with a pillow or head rest, obese patients require much greater elevation of their head, neck, and shoulders to produce the same alignment of axes for intubation. We demonstrated that elevating the upper body and head of morbidly obese patients to align their sternum and ear in a horizontal line (head-elevated laryngoscopy position) results in significant improvement in laryngoscopic view.6In two of Shiga et al. ’s four references, head position was described only as sniffing and may therefore have been suboptimal. Suboptimal positioning would result in a higher incidence of grade 3 and 4 Cormack-Lehane laryngoscopy views, making direct laryngoscopy and hence tracheal intubation more challenging. Until a standard intubating position for obese patients is adopted for research purposes, comparing studies using different positions will continue to confound the issue.

Shiga et al.  defined difficult intubation as a Cormack-Lehane grade 3 or 4 view during direct laryngoscopy using a standard laryngoscopy blade. However, they used a different definition for two of the four studies, although each of the original references included standard grading of laryngoscopy. For example, they incorrectly cited a 12% incidence of problematic intubations in our study rather than the actual 9% incidence of grade 3 views we encountered.4Similarly, in another study the actual incidence of grade 3 or 4 views was 10%, but they listed difficult intubation as 15% based on their own intubation difficulty scale.3Such inconsistencies contributed to their conclusions.

We would like to emphasize that difficult laryngoscopy is not synonymous with difficult intubation. The American Society of Anesthesiologists Task Force on the management of the difficult airway defines a difficult airway as the “clinical situation in which a conventionally trained anesthesiologist experiences problems with (a) face mask ventilation  of the upper airway or (b) tracheal intubation , or both.”7The airways of morbidly obese patients are more difficult to ventilate by mask, but whether they are more difficult to laryngoscope is not substantiated by Shiga et al. ’s study. There were a total of 378 obese patients in the studies they reviewed, and every patient except one was intubated successfully by direct laryngoscopy. All four of the studies they analyzed specifically stated that the magnitude of obesity does not influence laryngoscopy difficulty.2–5 

Based on both our clinical experience at an active bariatric surgical center and on the few prospective studies that have addressed this issue, we question the validity of the general statement that obese patients are three times more difficult to intubate than their slimmer counterparts. The tracheas of a smaller subgroup of morbidly obese patients, that is, those with obstructive sleep apnea, high Mallampati class (III and IV), and large neck circumferences, are more difficult to intubate.2,4 

The incidence of obesity in the adult population is growing. More obese and morbidly obese patients are undergoing surgery. As with any patient, the anesthesiologist must always be prepared to manage airway problems. However, there is no evidence that obesity per se  is a risk factor for difficult laryngoscopy and tracheal intubation.

*Stanford University Medical Center, Stanford, California. jeremycollins@stanford.edu

Shiga T, Wajima Z, Inoue T, Sakamoto A: Predicting difficult intubation in apparently normal patients: A meta-analysis of bedside screening test performance. Anesthesiology 2005; 103:429–37
Ezri T, Gewurtz G, Sessler DI, Medalion B, Szmuk P, Hagberg C, Susmallian S: Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesthesia 2003; 58:1111–4
Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, Desmonts JM: Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg 2003; 97:595–600
Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ: Morbid obesity and tracheal intubation. Anesth Analg 2002; 94:732–6
Voyagis GS, Kyriakis KP, Dimitriou V, Vrettou I: Value of oropharyngeal Mallampati classification in predicting difficult laryngoscopy among obese patients. Eur J Anaesthesiol 1998; 15:330–4
Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: A comparison of the “sniff” and ramped positions. Obes Surg 2004;14:1171–5.
American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269–77.
American Society of Anesthesiologists Task Force on Management of the Difficult Airway