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Predicting Difficulty

NextGen Learning To Elevate Your Airway Practice

Overview

An airway assessment before any airway procedure is essential for safety reasons, but how good are we at this clinical skill? The study below suggests we really aren’t very good at it at all. While assessment should occur before every intubation, no method is foolproof. This is a critical insight because of what it means and how we must respond to keep our patients safe.

The Evidence

The study titled “Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188,064 patients registered in the Danish Anaesthesia Database” aimed to evaluate how accurately anesthesiologists can predict difficulties in airway management during routine clinical practice. The researchers analyzed data from the Danish Anaesthesia Database (DAD), focusing on the anesthesiologists’ preoperative assessments and the actual occurrences of difficult tracheal intubation and mask ventilation. (Anaesthetists Publications)

Key Findings

  • Incidence of Difficult Intubation:
  • Of 188,064 cases, 3,383 (1.86%) were identified as difficult tracheal intubations.
  • A significant majority, 3,154 cases (93%), were unanticipated by the anesthesiologists.
  • Predictive Accuracy for Difficult Intubation:
  • Positive Predictive Value: 25% (95% CI: 22–28%), meaning it occurred in only 25% of cases when difficult intubation was anticipated.
  • Incidence of Difficult Mask Ventilation:
  • Difficult mask ventilation occurred in 857 cases (0.66%).
  • Of these, 808 cases (94%) were unanticipated.
  • Predictive Accuracy for Difficult Mask Ventilation:
  • Positive Predictive Value: 22% (95% CI: 17–29%), meaning that when difficult mask ventilation was anticipated, it actually occurred in only 22% of those cases.
  • Combined Difficulties:
  • In 424 cases (0.33%), both difficult intubation and difficult mask ventilation occurred.
  • Of these, only 16 cases (3.8%) were correctly anticipated by the anesthesiologists.
  • (Anaesthetists Publications)

More Evidence for Our Inability to Predict Difficulty

Some of our prediction tools, like LEMON, have been shown not to translate well to settings outside of elective OR procedures where they were designed.

The Bottom Line

Our ability to predict difficult airway management is limited and many unanticipated difficulties occur. This underscores the importance of always being prepared for unexpected airway management challenges, regardless of pre-intubation assessments.

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