ANESTHETIC ACTIONS

SECTION

JOHN

AND

OUTCOMES

EDITOR

H. TINKER

Predicting Difficult
Patients Scheduled
Blind Study
Jimson C. Tse,
* Department
t Departments

MD,

PhD*,

Endotracheal
Intubation
for General Anesthesia:

Eric B. Rimm, sat, and Ayyaz Hussain,

of Anesthesiology,
St. Elizabeths
of Nutrition
and Epidemiology,

Medical
Harvard

FFARCS

(En@*

Center of Boston, Tufts University School of Medicine,

School of Public Health, Boston, Massachusetts

We conducted a prospective, blind study to determine

whether a difficult endotracheal
intubation
could be
predicted preoperatively
by evaluation of one or more
anatomic features of the head. In 471 adults presenting
for elective surgery, the size of the tongue relative to the
oral cavity was assessed according to the Mallampati
classification
(oropharyngeal
class), and the distance
between the chin and thyroid cartilage (thyromental
distance) and the angle at full extension of the head
(head extension) were measured. At laryngoscopy,
the
difficulty in visualizing the larynx was determined by a

ecause failed endotracheal intubation is a principal cause of morbidity and mortality in anesthetized patients (l), there is a need for accurate
tests to predict difficult intubation. When a difficult
intubation occurs unexpectedly in a patient after general anesthesia has been induced, there might be an
unfavorable outcome if the patients lungs cannot be
adequately ventilated by mask or an endotracheal
tube cannot be properly inserted with use of other
techniques. Unexpected difficult intubations are probably the result of a lack of accurate predictive tests for
difficult intubation and inadequate preoperative examinations of the airway.
During direct laryngoscopy, the vocal cords are visualized by placing the head in the sniffing position
(extension of the head at the atlantooccipital joint and
upper part of the cervical spine, with flexion of the
neck at the lower cervical spine). Three preoperative
tests for assessinga patients airway for difficult intubation have been proposed, and it has been suggested
Presented
in part at the 68th Clinical
and Scientific
Congress
of
the International
Anesthesia
Research
Society, Orlando,
FL, March
1994.
Accepted
for publication
February
24, 1995.
Address
correspondence
and reprint
requests to Ayyaz
Hussain,
FFARCS (Eng), Department
of Anesthesiology,
St. Elizabeths
Medical Center of Boston, 736 Cambridge
St., Boston, MA 02135.

254

in Surgical
A Prospective

different observer. Assignment to oropharyngeal

Class
3, a thyromental distance 57 cm, and a head extension
~80, considered either alone or in various combinations, had low sensitivity and positive predictive values
in identifying
patients with airways that were difficult
to intubate, but high specificity and negative predictive
values. We conclude that these three tests are of little
value in predicting
difficult intubation
in adults, although the likelihood
of an easy endotracheal
intubation is high when they yield negative results.
(Anesth Analg 1995;81:254-8)

that the most accurate results are obtained when findings from these evaluations are combined (2). The tests
are assignment to oropharyngeal class, an assessment
of the size of the tongue in relation to the size of the
oral cavity (3); measurement of the thyromental distance, an indicator of the mandibular space anterior to
the larynx (4); and measurement of the head (atlantooccipital) extension (5). No study has examined the
usefulness of these tests when used together. We
therefore conducted a prospective, blind study of their
accuracy, used alone and in various combinations, in
predicting difficult endotracheal intubation.

Methods
Approval for the study was obtained from our institutions human subjects committee, which did not
require informed patient consent to be obtained because the measurements performed were noninvasive
and had no monetary cost. Consecutive male and
female patients aged 18 yr and older scheduled to
undergo elective surgery under general anesthesia in
our general community hospital between December
1992 and June 1993 were considered for enrollment.
Patients with obvious malformations of the airway,
edentulous patients, and patients who required cricoid pressure for rapid-sequence intubation were
excluded from the study. Edentulous patients were
01995 by the International

An&h

Analg

1995;81:254-8

and

Anesthesia

Research Society

0003.2999/95/$5.00

ANESTH
ANALG
1995;81:254-8

ANESTHETIC
ACTIONS
AND
PREDICTING
DIFFICULT

OUTCOMES
TRACHEAL

TSE ET AL.
INTUBATION

that they did not lift their shoulders

tending the head.

,?
-----L
/____:

1,
\

Figure
1. Angle measured
with bubble goniometer
to obtain values
for degrees of head extension.
The angle assessed was that between
a line joining the angle of the mouth and tragus of the ear with the
horizontal.

excluded to avoid introduction

of a variable that may
independently
affect the predictability
of difficult
intubation.
The following
measurements
were obtained preoperatively by two members of the anesthesiology
department not subsequently
involved in intubating the
airways
of the patients they evaluated. In most patients, the measurements
of thyromental
distance and
head extension angle were performed
twice and the
results averaged for the data analysis. The Mallampati
sign was assessed once in each patient, except those in
whom two or more evaluations were required to confirm the classification
assignment.
1.

2.

3.

Classification
of the oropharyngeal
view was
done according to the Mallampati
criteria (31,
with slight modifications
to avoid ambiguity.
Thus, assignment
to oropharyngeal
Class 1 indicated that the faucial pillars, soft palate, and
uvula could be visualized; assignment to Class 2
indicated that the uvula was only partly visible;
and assignment
to Class 3 indicated that the
uvula was completely masked by the base of the
tongue and that the posterior pharyngeal
wall
was not visible. The examination to determine
oropharyngeal
class was done with the aid of a
flashlight. The patients were in a sitting position
with the tongue fully protruding;
they were not
asked to say ah.
The distance in centimeters between the thyroid
prominence
and the most anterior part of the
chin, with the head fully extended, was measured with a ruler.
The maximum
extension of the head was assessed as the size of the angle between a line
joining the angle of the mouth and tragus of the
ear with the horizontal line (Figure 1). A bubble
goniometer was used for this assessment. The
patients were in a supine position on a flat bed
without
a pillow, and care was taken to ensure

while

255

ex-

All measurements
were recorded on a form not seen
by the anesthesiologist
who subsequently
performed
the intubation.
Intubation
was done with the patient adequately
anesthetized and fully relaxed on the operating room
table. A peripheral nerve stimulator was used in cases
in which there was doubt about the relaxation. The
head was placed in the sniffing
position, and laryngoscopy was performed with a Macintosh No. 3 blade
by the anesthesiologist
assigned to the case. The laryngeal view was graded according to the method
described by Cormack and Lehane (6) as Grade I (full
view of the glottis), Grade II (glottis partly exposed,
anterior commissure
not seen), Grade III (only epiglottis seen), or Grade IV (epiglottis not seen). A grade of
I or II was considered to represent easy intubation and
a grade of III or IV to represent difficult intubation.
Intubations
were performed
by anesthesiology
residents with at least 6 mo of experience or by staff
anesthesiologists.
The preoperative
assessment data and the intubation findings were used to determine the accuracy of
the three tests in predicting
difficult intubation.
The
sensitivity,
specificity, and positive and negative predictive values of each of the evaluations
used alone
and together in various combinations
were calculated
(Appendix).

Results
A total of 471 patients (220 men and 251 women aged
18-89 yr) were enrolled in the study. Sixty-two
of
them were found at laryngoscopy
to have airways that
were difficult to intubate (laryngoscopy
Grade III or
IV). There were no failed intubations.
Assignment
to
oropharyngeal
Class 3, a thyromental
distance 57 cm,
and a head extension 580 were selected as indicators
of difficult intubation. Information
on the accuracy of
the tests used alone and together is given in Table 1
and Figures 2 and 3.
We found that all the tests had low sensitivity,
although each test used alone had a higher sensitivity than the combination
tests. The combination
using all three tests had the lowest sensitivity.
All the
tests and combinations
also had low positive predictive values (18%-38%).
Only one patient among
the 50 with a thyromental
distance ~10 cm had a
difficult
intubation,
as did only one of the 54 patients with a head extension
angle >lOO. All the
tests had high negative
predictive
values;
some
were highly specific.

256

ANESTHETIC
PREDICTING

Table

1. Tests

ACTIONS
DIFFICULT

for

Difficult

Test

OK

TMDs7cm
HE 5 80
OPC 3, TMD
OK 3, HE 5
TMD
5 7 cm,
OK
3, TMD
and HE 5

5 7 cm
80
HE I 80
I 7 cm,
80

AND OUTCOMES
TSE ET AL.
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INTUBATION

ANESTH ANALG
1995;81:254-8

Intubation
TP

FP

TN

J?N

41
20
6

145
82
27
33

264
327
382
376
399
398
404

21
42
56
49
58
59
59

13

4
3
3

10
11

Sens

(%)

66
32
10
21
6
5
5

Spec

(%)

65
80
93
92
98
97
99

TP = true positive; FP = false positive; TN = true negative; FN = false negative; Sens = sensitivity; Spec = specificity;
= negative predictive value; OK = oropharyngeal
class; TMD = thyromental
distance: HE = head extension.

PPV

(%)

NPV

22
20
18
28
29
21
38
PPV = positive

(%)

93
89
87
88
87
87
87
predictive

value; NPV

Figure
2. Sensitivity,
specificity,
and positive
predictive
value of
the thyromental
distance
used alone to predict difficult
intubation.
If, for example,
a thyromental
distance
of 9 cm is used as the
threshold
value for identifying
patients whose airways
will be difficult to intubate,
that screening
measure would have a sensitivity
of
97%, a specificity
of 18%, and a positive
predictive
value of 16%.

Figure
3. Sensitivity,
specificity,
and positive
predictive
value of
the head extension
angle used alone to predict difficult
intubation.
If, for example,
a head extension
angle of 85 is used as the threshold value for identifying
patients whose airways
will be difficult
to
intubate,
that screening
measure would have a sensitivity
of 32%, a
specificity
of 72%, and a positive
predictive
value of 19%.

Discussion

were highly specific. Our findings indicate that

these screening evaluations have little value in predicting difficult intubation, although when their results are negative there is a high probability
that
intubation will be easy.
The oropharyngeal Class 3 test had a sensitivity of
66%, that is, it preoperatively identified 41 of the 62
patients who later had a difficult intubation. The tests
positive predictive value was 22%; it identified 186
patients who would have a difficult intubation, but, in
fact, 145 of them had an easy intubation. Thus, if one
were dependent on the results of this test, and all
patients in whom difficult intubation was predicted
were considered for awake intubation, many patients
with easy-to-intubate airways would be unnecessarily
subjected to that procedure.
The oropharyngeal Class 3 test was useful when its
results were negative: of the 285 intubations predicted
to be easy, 264 actually were so. Therefore, if all the
patients identified by this test to have airways easy to

The incidence of difficult intubation is reported to

be 10/o-18% (7-ll), depending on the criteria used to
define it; that of failure to intubate is 0.05%-0.35%
(6,9). In our study, the rate of difficult intubation
was 13%, and there were no failures to intubate the
trachea.
A test to predict difficult intubation should have
high sensitivity, so that it will identify most patients
in whom intubation will truly be difficult. It should
also have a high positive predictive value, so that
only a few patients with airways actually easy to
intubate are subjected to the protocol for management of a difficult airway. In this study, we found
that the commonly used tests for forecasting intubation type had inadequate sensitivity and positive
predictive values in predicting difficult intubation,
used either alone or together. The assessments did
have high negative predictive values, and some

ANESTH
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1995;81:254--8

intubate were anesthetized,

only a few would unexpectedly be found to have difficult-to-intubate
airways after the induction of anesthesia.
Our findings contradict those of Mallampati
et al.
(31, who reported that assignment
to oropharyngeal
Class 3, as they defined it, was a good predictor
of
difficult intubation,
with a sensitivity
of 50% and a
positive predictive value of 93%. The discrepancy
between
their results
and ours has three possible
sources.
First, in the study by Mallampati et al. (3), the same
person who did the preoperative
evaluation
also
graded the laryngoscopy
view, thereby introducing
the possibility
of bias into the assessment. In our investigation,
a patients assignment
to an oropharyngeal class and the laryngoscopic
examination
were
always performed
by a different anesthesiologist.
Second, the description
of the three oropharyngeal
classes by Mallampati et al. (3) is imprecise in that it is
unclear whether Class 3 is defined by an inability to
see the faucial pillars or by masking of the uvula. We
placed patients who had complete masking
of the
uvula and no visualization
of the posterior pharyngeal
wall in Class 3 and those with incomplete masking of
the uvula in Class 2, but Mallampati
et al. (3) may
have classified such patients differently.
Third, the uncertainty
created by the ambiguous
definition of oropharyngeal
Class 3 increases with the
number of evaluators in a study as a result of interindividual variations in interpretation
(12). The investigation by Mallampati et al. (3) used 22 evaluators for
the preoperative
assessment; we had only two.
A finding of a thyromental
distance 17 cm was also
not a good predictor
of difficult intubation
in our
study, in which its sensitivity was 32% and its positive
predictive
value was 20%. When the oropharyngeal
Class 3 and thyromental
distance 57 cm assessments
were used together, the sensitivity
and positive predictive value were 21% and 28%, respectively.
These
findings do not support those of Frerk (lo), who reported that assignment to oropharyngeal
Class 3 or 4
had a sensitivity
of 81.2% and a specificity of 81.5% in
predicting difficult intubation. In his investigation,
the
sensitivity
and specificity
of a thyromental
distance
~7 cm were 90.9% and 81.5%, respectively.
When
Frerk used both tests, the sensitivity
and specificity
were 81.2% and 97.8%, respectively.
The discrepancy
between our findings and those of Frerk (10) can be
explained partly by the different definitions used for
difficult intubation in the two studies. Frerk defined
difficult intubation
as a need to use a gum elastic
bougie.
Bellhouse and Dare (51, in a .radiologic study of
assessments
of cervical and facial characteristics
in
predicting difficult intubation, calculated head extension by estimating the angle traversed by the occlusal

ANESTHETIC
ACTIONS
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257

surface of the maxillary

teeth when the head is extended from the neutral position. They found that
patients with a limitation in extension who were in
oropharyngeal
Class 4 had a 95% likelihood of having
a difficult intubation.
In our study, head extension
was measured with a bubble goniometer
to ensure
that the patients were completely horizontal
during
the assessment. We found that use of a head extension
angle ~80 to predict difficult intubation had a sensitivity of 8% and a positive predictive
value of 21%.
The results of our study and that of Bellhouse and
Dare cannot be compared directly because those authors included an oropharyngeal
Class 4 in their investigation and we did not.
The anatomic features of the head and neck used in
the tests we evaluated generally affected the laryngeal
view independently
of each other. As a result, the
combination tests had a lower sensitivity
and a higher
positive predictive value than some of the tests used
alone.
Designing a good predictive test for difficult intubation is problematic because many factors may affect
visualization
of the larynx at intubation,
such as the
maximum mouth-opening
distance, the circumference
and length of the neck, and several characteristics
that
cannot be quantified
accurately.
These include the
compressibility
of the tongue and soft tissues of the
floor of the mouth and the extent of subluxation of the
temporomandibular
joint during laryngoscopy.
In addition, the ability of the person performing
the intubation cannot be easily incorporated
into a standardized assessment.
We did not find that tests using an oropharyngeal
Class 3, a thyromental
distance 57 cm, a head extension angle 580, or any combination
of these factors
predicted difficult intubation reliably. Their sensitivities and positive predictive
values were too low for
them to be clinically useful. However,
the tests had
high specificities and negative predictive values, thus
providing
reassurance
that negative results indicate
truly easy endotracheal
intubation.
We therefore do
not recommend
that all patients in whom difficult
intubation is predicted with use of these tests have
awake intubation.
Instead, awake intubation
should
be done only in patients in whom ventilation might be
difficult, those at risk of regurgitation
of stomach contents, those with an obvious abnormality
predisposing
them to difficult intubation, or those with a history of
difficult intubation. Most patients in whom a difficult
intubation is suspected can have their airways intubated while asleep by means of any of the several
methods available.
The authors thank Mrs. Mary DiGiovanni
for technical
Ms. Ren6e J. Robillard
for editorial
assistance.

support

and

258

ANESTHETIC
PREDICTING

ACTIONS
DIFFICULT

Negative predictive
value = the percentage of correctly predicted easy intubations
as a proportion
of
all predicted easy intubations,
i.e.,

Appendix
Definition

ANESTH
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1995;81:254-8

AND OUTCOMES
TSE ET AL.
TRACHEAL
INTUBATION

of Terms

True positive = a difficult intubation that

predicted to be difficult.
= an easy intubation
that
False positive
predicted to be difficult.
that
True negative = an easy intubation
predicted to be easy.
False negative = a difficult intubation that
predicted to be easy.
Sensitivity
= the percentage of correctly
difficult intubations
as a proportion
of
tions that were truly difficult, i.e.,

had been

true negatives
true negatives-tfalse
negatives.

had been
had been

References
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had been
2.

predicted
all intuba-

true positives
true positives+false
negatives.
Specificity
= the percentage
of correctly
predicted
easy intubations
as a proportion
of all intubations
that were truly easy, i.e.,
true negatives
true negatives-tfalse
positives.
Positive predictive value = the percentage of correctly
predicted difficult intubations as a proportion
of all
predicted difficult intubations,
i.e.,

3.

4.
5.

6.
7.

8.

9.
10.
11.

true positives
true positives+false
positives.

12.

RA, Posner KL, Ward RJ, Cheney EW. Adverse

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