title: Near-zero difficult tracheal intubation and tracheal intubation failure rate with the "Besta Airway Algorithm" and "Glidescope® in morbidly obese" (GLOBE).
abstract: Unpredicted Difficult Tracheal Intubation (DTI) with Macintosh occurs frequently in obese patients. We investigated the incidence of DTI using an algorithm based on preoperative assessment with the El-Ganzouri Risk Index (EGRI) and Glidescope® routine use.
  
  
  
  We prospectively enrolled morbidly obese patients undergoing abdominal surgery. Patients were scheduled for Glidescope® intubation under general anesthesia if EGRI was <7 or awake Flexible Fiber-optic Intubation if EGRI was ≥7. The primary outcome was the DTI rate, defined as Cormack and Lehane grades ≥III, Intubation Difficulty Scale >5 and modified Intubation Difficulty Scale >5. Secondary outcomes included intubation success on the first attempt, the Time to Cormack, the time to intubation, failure to intubate, oxygen desaturation and difficult ventilation.
  
  
  
  Of the 214 patients enrolled, 212 (99%) were intubated with Glidescope® and 2 (1%) with awake Flexible Fiber-optic Intubation (one electively, one after a Glidescope® failure). There were no cases of DTI assessed using Cormack and Lehane and Intubation Difficulty Scale, and 3 cases (1.4%; 95% CI 0.45-4.29%) assessed using modified Intubation Difficulty Scale. Of the 213 patients intubated with Glidescope®, 185 (87%) had successful intubation on the first attempt. Mean Time to Cormack and time to intubation were 13.1 (SD 9.6) and 38.1 seconds (SD 21.1) respectively. We had one case (0.5%) of failed Glidescope® intubation and no cases of clinically significant complications.
  
  
  
  The incidence of DTI and Intubation Failure was reduced to near-zero using Glidescope® and the Besta Airway Algorithm in this sample of morbidly obese patients.
authors.affiliation: Department of Anesthesia, Critical Care Medicine and Emergency, Spedali Civili University Hospital, Brescia, Italy - elenacagnazzi@gmail.com.
authors.forename: Elena
authors.initials: E
authors.lastname: Cagnazzi
authors.forename: Alessandro
authors.initials: A
authors.lastname: Mosca
authors.forename: Federico
authors.initials: F
authors.lastname: Pe
authors.forename: Tiziana
authors.initials: T
authors.lastname: Togazzari
authors.forename: Ottavia
authors.initials: O
authors.lastname: Manenti
authors.forename: Francesco
authors.initials: F
authors.lastname: Mittempergher
authors.forename: Elena
authors.initials: E
authors.lastname: Raffetti
authors.forename: Francesco
authors.initials: F
authors.lastname: Donato
authors.forename: Nicola
authors.initials: N
authors.lastname: Latronico
mesh_terms: D000465:Algorithms; D004867:Equipment Design; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000379:methods / Q000706:statistics & numerical data; D020704:Laryngoscopes / Q000706:statistics & numerical data*; D007828:Laryngoscopy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D011446:Prospective Studies