ISSN: 2320-5407 Int. J. Adv. Res.

11(04), 767-774

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/16725
DOI URL: http://dx.doi.org/10.21474/IJAR01/16725

RESEARCH ARTICLE
OBESITY AND ANTICIPATED DIFFICULT AIRWAY- A COMPREHENSIVE APPROACH WITH
VIDEOLARYNGOSCOPY, RAMP POSITION, SEVOFLURANE AND OPIOID FREE ANAESTHESIA

Dr. Vinayak Panchgar1, Dr. Shivaraddi Bhandi2 and Dr. Anagha S.3
1. Professor and Head, Department of Anaesthesiology, Gadag Instituite of Medical Sciences.
2. Assistant Professor, Department of Anaesthesiology, Gadag Instituite of Medical Sciences.
3. Post-Graduate in Anaesthesiology, Gadag Instituite of Medical Sciences.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background: Anaesthetic management of obese patient can be
Received: 25 February 2023 challenging because of altered anatomy and physiology. Safe apnea
Final Accepted: 30 March 2023 period is extremely short and videolaryngoscope is believed to reduce
Published: April 2023
the number of failed intubation attempts. Slow emergence with fat-
soluble volatile agents may be due to delayed release from adipose
stores. Use of opioids in the presence of obesity increases the occurrence
of obstructive sleep apnea, hypoxia and upper airway obstruction. The
aim is to provide safe airway management in obesity by reducing the
number of intubation attempts and the time taken for intubation with
reduced post-operative respiratory depression.
Methods: 25 patients with the BMI of >30kg/m2 were selected. Standard
technique for induction of anaesthesia using Inj. Dexmedetomidine
1mcg/kg 10 mins before intubation with patient in RAMP position was
done. HugeMed videolaryngoscope with appropriate sized blade was
used and maintainance of anaesthesia with Sevoflurane and Inj.
Dexmedetomidine 0.5mcg/kg/hr. Assessment consisted of number of
intubation attempts, time required for intubation, visualisation of glottis,
hemodynamic stress response to laryngoscopy and intubation and post-
operative respiratory depression.
Results: Among 25 patients, 18 patients had intubation at the first
attempt, the maximum attempts taken were three in 2 patients. In
majority of the patients i.e, 10, time taken for intubation was 13-15 secs.
The maximum time to intubate was 18-20 secs in 2 patients. The
visualisation if glottic structures assessed by Percentage Of Glottic
Opening (POGO) score was 80-100% in majority of 20 patients. Most of
the patients had a saturation of 96-100% post-operatively. There was a
significant fall in the above hemodynamic parameters from baseline to
intubation and 5mins later. The mean reduction in HR was 28.42%, SBP-
28.72%, DBP- 38.85% and MAP- 34.69%.
Conclusion: This study emphasises on the use of advanced airway tools,
standard intubation techniques and careful drug selection in order to
prevent and minimise the risk of airway complication in obesity.

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....

Corresponding Author:- Dr. Anagha S. 767

Address:- Post-Graduate in Anaesthesiology, Gadag Instituite of Medical Sciences.
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 767-774

Introduction:-
The World Health Organization (WHO) in 1997 declared obesity as a major public health problem and a
global epidemic.1 Based on this source, in 2016, approximately 13% of the world’s population were labeled
as obese.2 WHO defines obesity as a condition with excess body fat to the extent that health and well-being
are adversely affected. The definition of obesity includes the presence of excessive body weight for the
patient’s age, gender and height and is estimated on calculation of the following-
1. Lean Body Weight (LBW)
2. Predicted Body Weight (PBW)
3. Ideal Body Weight (IBW)
4. Body Mass Index (BMI)3

Obesity is an accepted risk factor for difficult airway and these patients are prone for respiratory depression induced
by opioids. Laryngoscopy may be difficult in obese patients because of elevated chest diameter giving limited space
for the laryngoscope positioning, limited neck mobility, and increased amount of adipose tissue in the upper airway,
including a larger tongue. Because of these challenges, it is recommended to properly position obese patients for
intubation. Although obesity alone is not a risk factor for difficult intubation, the use of videolaryngoscopes should
improve laryngeal view in morbidly obese patients.4

Collins et al suggested placing morbidly obese patients in a ramped position rather than in the standard sniffing
position. The ramped position is achieved by arranging blankets under the patient’s upper body and head to obtain
a horizontal alignment between the external auditory meatus and sternal notch. This position produces proper
alignment of the oral, pharyngeal, and laryngeal axes (the three axes of intubation) in obese patients, similar to the
sniffing position in lean patients.11

Obesity leads to a restrictive lung disease, causing reduction in functional residual capacity and total lung
compliance. Further, when an obese patient is supine and anaesthetized, the depressant effects of many
anesthetic agents and analgesics, particularly opioids, further decrease the lung compliance, leading to
increased hypoxemia. Opioid‐based general anesthesia in these patients increases the incidence of post-
operative respiratory depression, atelectasis, and pneumonia.5

Obesity related conditions including diabetes, cardiovascular disease, obstructed sleep apnea (OSA), non-alcoholic fatty
liver disease, osteoarthriitis and some cancers are leading causes of morbidity and mortality. Surgery in this patient
population is considered high risk but careful planning, pre-operative risk assessment, adequate anaesthetic
management, thromboembolic prophylaxis and adequate post-operative analgesia can help reduce the risk. In order to
prevent the above complications and to provide a safe anaesthesia the above study was conducted. The objective of this
observational study was to-

1. Provide safe airway management in obese patients.

2. Reduce the number of intubation attempts and the time taken for intubation.
3. Reduce the incidence of post-operative respiratory depression.

Methods:-
After obtaining approval and clearance from institutional ethical committee, 25 patients were included in the study
with proper consent from patients and patient attenders. A detailed history, complete physical examination and routine
investigations were done for all the patients. 18G intravenous (IV) line was secured and all cases were induced with
standard technique.

Patients were pre-medicated with inj.Glycopyrolate 0.004mg/kg IV, inj.Midazolam 0.05mg/kg IV and
inj.Dexmedetomidine 1mcg/kg IV started 10minutes before intubation with patient in Rapid Airway
Management positioner (RAMP) position. Patients were induced with inj. Propofol 2-2.5mg/kg IV and
intubation was facilitated by inj.Scoline 2mg/kg IV. HugeMed videolaryngoscope with appropriate size
blade was used and after getting proper visualisation of glottis, an appropriate size cuffed Endotracheal
Tube (ETT) was secured. Anaesthesia was maintained with oxygen, air and sevoflurane with intermittent
Inj.Atracurium IV and inj.Dexmedetomidine 0.5mcg/kg/hr.

768
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 767-774

Here, assessment consisted of-

1. Number of intubation attempts.
2. Time required for intubation.
3. Visualisation of glottic structures.
4. Hemodynamic stress response to laryngoscopy and intubation.

Intraoperative analgesia supplemented with inj. Paracetamol 15mg/kg IV. Towards the end of the procedure, inj.
Dexmedetomidine was stopped approximately 30min before extubation and after return of normal tone, power,
reflexes and regular breathing, patient was extubated. Patients were then shifted to the SICU and assessed for post-
operative respiratory depression by monitoring saturation and respiratory rate.

Figure 2:- Videolaryngoscopic view of glottis.

Inclusion criteria-
ASA I and II patients aged between 25-50 years of both gender with BMI>30kg/m2 posted for elective surgeries under
general anaesthesia (GA) were included.

Exclusion criteria-
Patients of ASA grade III, IV, V who denied consent and those posted for emergency surgeries under GA were
excluded.

Results:-
This present observational study on obese patients using videolaryngoscope and opioid free anaesthesia to reduce the
number and duration of intubation attempts and to reduce the incidence of post-operative respiratory depression was
conducted in Gadag Institute of medical sciences.

Among 25 patients, 18 patients had intubation at the first attempt, the maximum attempts taken were three in 2 patients.

In majority of the patients i.e, 10, time taken for intubation was 13-15 secs. The maximum time to intubate was 18-20
secs in 2 patients.

The visualisation if glottic structures assessed by Percentage Of Glottic Opening (POGO) score was 80-100% in
majority of 20 patients.

Most of the patients had a saturation of 96-100% post-operatively.

769
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 767-774

Table 1:- Number of intubation attempts.

No.Of intubations 1 2 3
No.Of patients 18 5 2

No.Of Intubation attempts

Figure 2:- Number of intubation attempts.

Table 2:-Time taken for intubation.

Time taken for 10- 12 13- 15 118 >18
Intubation (secs)
No.Of patients 5 10 8 2

No.Of patients

>18

16 to18

13 to15

10 to12

0 2 4 6 8 10 12

Figure 3:- Time taken for intubation.

770
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 767-774

Table 3:- Visualisation of glottic structures.

POGO score 0-30 30-50 50-80 80-100
No.Of patients 0 0 5 20

No.Of patients

Figure 4:-Visualisation of glottic structures.

Table4:-Post-operative respiratory depression.

Postop Spo2(%) 90-95 ≥96
No.Of patients 3 22

25

20

15

10

0
90-95 96-100

Figure 5:- Post-operative respiratory depression.

771
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 767-774

Table 5:- Hemodynamic responses to laryngoscopy and intubation.

PARAMETERS HR SBP DBP MAP

BASELINE 101.2 141.6 87.2 105.6
PREMEDICATION 82.6 146 90 108.8
INDUCTION 88 130.4 77.6 96
INTUBATION 93.6 124.8 72.4 89.8
1MIN 82.8 113.2 68.4 83.2
5MIN 78.8 110 62.8 78.4
ANOVA test value 33.13597 8.5891 12.87002 12.37116
pvalue <0.00001 0.00008 <0.00001 0.00001
Significance Significant Significant Significant Significant

Hemodynamics was monitored and charted. Mean values of heart rate (HR), systolic blood pressure (SBP), diastolic
blood pressure (DBP) and mean arterial pressure (MAP) at each event is calculated. There was a significant fall in the
above hemodynamic parameters from baseline to intubation and 5mins later. The mean reduction in HR was 28.42%,
SBP- 28.72%, DBP-38.85% and MAP- 34.69%.

MEAN VALUE
160

140

120

100

80
0 BASELIN PREMEDI INDUCTI INTUBAT 1MIN 5MIN
E CATION ON ION
HR 101.2 82.6 88 93.6 82.8 78.8
SBP 141.6 146 130.4 124.8 113.2 110
DBP 87.2 90 77.6 72.4 68.4 62.8
MAP 105.6 108.8 96 89.8 83.2 78.4

Figure6:-Hemodynamic responses to laryngoscopy and intubation.

772
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 767-774

mean reduction%

34.69
28.42 28.72

HR SBP DBP MAP

Figure7:-Mean reduction in hemodynamic parameters.

Discussion:-
The incidence of difficult laryngoscopy in morbidly obese patients is 8.1%–31%.7 Oxygenation maintenance is the
cornerstone of airway management in the obese patient related to anatomic and pathophysiologic issues.6 Obesity is a
multisystem disease affecting all organs, there are a number of implications relevant to the conduct of anaesthesia.

Fat accumulation on the thorax and abdominal wall leads to reduced compliance reduction in functional residual
capacity (FRC), vital capacity (VC) and total lung capacity (TLC). Increased metabolic rate with increased oxygen
consumption leads to chronic hypoxaemia. Worsening of the above respiratory problems with the use of opioids results
in hypoxia. They are also more susceptible to cardiovascular diseases including systemic hypertension, biventricular
failure and myocardial ischaemia.3

Our study showed that, in anticipated difficult airways, using videolaryngoscope as the first tool for intubation
significantly reduced the number of intubation attempts and the time taken for intubation which reduces the risk of
hypoxia and desaturation during laryngoscopy and intubation. Also, the hemodynamic stress response to laryngoscopy
and intubation was reduced preventing intra-operative major acute cardiac events. Our results were similar to the
systematic review and metanalysis done by Hiroshima Hoshijimaetal 10 on videolaryngoscope versus Macintosh
laryngoscope for tracheal intubation in obese patients where eleven articles were reviewed. They extracted data on
success rate, intubation time and glottic visualisation and concluded that videolaryngoscopes were superior to
macintosch laryngoscope for tracheal intubation in patients with obesity. Seongheon Lee et al11 conducted a
prospective randomized study in patients with morbid obesity to compare ramped versus sniffing position in
videolaryngoscopy-guided tracheal intubation. They found that compared with the sniffing position, the ramped
position reduced intubation time inmorbidly obese patients and effectively facilitated both mask ventilation and
tracheal intubation using videolaryngoscopy which was similar to our study.

There was a significant fall in the hemodynamic parameters from baseline to intubation and 5mins later. The mean
reduction in HR was 28.42%, SBP- 28.72%, DBP-38.85% and MAP- 34.69%. The hemodynamic parameters of our
study was comparable to the study done by Tomas Gaszynski et al12 on 42 morbidly obese patients between
dexmedetomidine and fentanyl for attenuating hemodynamic response to intubation stimuli in low-opioid technique
showed no significant difference between the groups. But, dexmedetomidine group demonstrated lesser degree of
variation in hemodynamic parameters providing a greater degree of hemodynamic stability on exposure to painful
stimulus during laryngoscopy with dexmedetomidine.

773
ISSN: 2320-5407 Int. J. Adv. Res. 11(04), 767-774

The use of opioid free anaesthesia significantly reduced post-operative respiratory depression thus reducing the need
of post-operative ventilator support. Roger E Hofer et al13 reported a 433kg morbidly obese patient using
dexmedetomidine without narcotics. It was observed that dexmedetomidine had narcotic sparing effects and is useful
for patients who are susceptible to narcotic induced respiratory depression. Tomasz Gaszynski et al4, observed in super
obese patients with suspected difficult intubation that Dexmedetomidine for awake intubation and an opioid free
general anesthesia helped to reduce or eliminate intra-operative use of opioids and recommended the use of
videolaryngoscope and awake intubation in morbidly obese patients. In a Cochrane systematic review By S R Lewis
et al9 on videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation concluded that
videolaryngoscopes reduced the number of failed intubations, particularly among patients presenting with a difficult
airway. They improve the glottic view and may reduce laryngeal/ airway trauma. Insufficient sample size for statistical
measurements was the limitation in our study.

Conclusion:-
In conclusion, use of videolaryngoscope with RAMP position reduced the intubation time and intubation attempts in
obese patients and dexmedetomidine is a useful anaesthetic adjunct for patients susceptible to opioid induced
respiratory depression. This study emphasises the use of advanced airway tools, standard intubation techniques and
careful drug selection in order to prevent and minimise the risk of airway complication in obesity.

References:-
1. HaththotuwaRN, WijeyaratneCN, SenarathU. World wide epidemic of obesity.
2. In Obesity and obstetrics. 2020Jan1(pp.3-8).Elsevier.
3. Seyni-Boureima R, Zhang Z, Antoine MM, Antoine-Frank CD. A review on the anesthetic management of obese
patients undergoing surgery. BMC anesthesiology. 2022 Dec;22(1):1-3.
4. Ana Fernandez-Bustamante, Sharma E Joseph. Anaesthesia and Obesity. In: Paul GBarash, Bruce F Cullen,
th

Robert K Stoelting,Micheal K Cahalan (Eds). ClinicalAnaesthesia.8 Edition.NewDelhi:WolterKluwer

Publishing;2017.p1277-297.
5. GaszynskiT, GaszynskaE, SzewczykT. Dexmedetomidine for awake intubation and an opioid-free general
anesthesia in a superobese patient with suspected difficult intubation. Drug design, development and therapy.
2014;8:909.
6. Bhardwaj S, Garg K, Devgan S. Comparison of opioid-based and opioid-free TIVA for laparoscopic urological
procedures in obese patients. Journal of Anaesthesiology, Clinical Pharmacology.2019Oct;35(4):481.
7. LangeronO, BirenbaumA, LeSachéF, RauxM. Airway management in obese patient. MinervaAnestesiologica.
2014Mar;80(3):382-392.PMID:24122033.
8. Bindu HM, Dogra N, Makkar JK, Bhatia N, Meena S, Gupta R. Limitedcondylar mobility by ultrasonography
predicts difficult direct laryngoscopy in morbidly obese patients: An observational study. Indian Journal of
Anaesthesia.2021Aug;65(8):612.
9. RooneyKD,WerrettGC. Obesity&Anaesthesia.AnaesthUK.Article.2006;100620.
10. Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct
laryngoscopy for adult patients requiring tracheal intubation: A CochraneSystematicReview. BrJAnaesth.2017
Sep 1;119(3):369-383.doi:10.1093/bja/aex228. PMID:28969318.
11. Hoshijima, H.Denawa, Y.Tominaga, A.Shiga & NagasakaH. (2018). Videolaryngoscope versus Macintosh
laryngoscope for tracheal intubation in adults with obesity: A systematic review and meta-analysis. Journal of
clinical anesthesia,44,69-75.
12. Lee, S., Jang, E. A., Hong, M., Bae, H. B., & Kim, J. (2022). Ramped versus sniffing position in the
videolaryngoscopy-guided tracheal intubation of morbidly obese patients: a prospective randomized study.
Korean Jounal of Anesthesiology.
13. Gaszyński,T.,Czarnik,K.,Łaziński,Ł.,&Gaszyński,W.(2016). Dexmedetomidine for attenuating haemodynamic
response to intubation stimuli in morbidly obese patients anaesthetised using low-opioid technique: comparison
with fentanyl-based general anaesthesia. Anaesthesiology Intensive Therapy,48(5),275-279.
14. Hofer, R. E., Sprung, J., Sarr, M. G., &Wedel, D. J. (2005). Anesthesia. for a patient with morbid obesity using
dexmedetomidine without narcotics. Canadian Journal ofAnesthesia,52(2),176.

774