title: A new difficult airway management algorithm based upon the El Ganzouri Risk Index and GlideScope® videolaryngoscope. A new look for intubation?
abstract: An El Ganzouri risk index test (EGRI) score of seven and the ability to achieve difficult laryngeal exposure with the GlideScope® may represent a highly predictive decisional threshold. Hence, we hypothesized that a new difficult airways algorithm that is EGRI- and GlideScope®-based may enable tracheal intubation in every patient.
  
  
  
  Thirteen staff practitioners trained in videolaryngoscopic intubation followed the algorithm from 2008 through 2010. Elective and emergency neurosurgical patients assessed as having an EGRI score of seven and higher underwent flexible fiberoptic bronchoscopy (FFB) intubation while conscious. Those with a score of six and lower were intubated with the GlideScope®, excluding patients with morbid obesity or pharyngo-laryngeal or neck tumors. A decision to perform alternative procedures, difficult laryngeal exposure [Cormack and Lehane (CL) grades III-IV], difficult ventilation and failure to intubate were recorded.
  
  
  
  The decisional rule was applied in 6,276 patients and resulted in six FFB intubations in conscious patients. The overall incidence of CL grade III-IV views was 0.2%. Difficult videolaryngoscopy was found in 14 patients (0.14%) with a score of 6 and lower. Post-hoc examinations of FFB intubations revealed five difficult laryngeal exposures. The positive predictive value was 85.7%, while the negative predictive value was 99.9%. The incidence of difficult ventilation and difficult laryngeal exposure was 0.03%. Two patients with neck tumors were assigned to alternative procedures.
  
  
  
  Adherence to the decisional process of the algorithm and to GlideScope® videolaryngoscopy achieved successful tracheal intubation in our cohort of patients.
authors: Department of Neuroanesthesia and Intensive Care, Neurologic Institute Carlo Besta, Milan, Italy. dcaldiroli@istituto-besta.it
authors: D
authors: D
authors: Caldiroli
authors: P
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authors: Cortellazzi