What is the best way to determine oropharyngeal classification and mandibular space length to predict difficult laryngoscopy?

Background: Previous studies have suggested that the degree of visibility of oropharyngeal structures (OP class) and mandibular space (MS) length can predict difficult laryngoscopy. However, those studies were either inconsistent or omit description of how to perform these tests with regard to body, head and tongue position, and the use of phonation, hyoid versus thyroid cartilage and inside versus outside of the mentum. The purpose of this investigation was to determine which method of testing best predicts difficult laryngoscopy.

Methods: In each of 213 consenting adults the OP class was determined in 24 method combinations: two body positions (sitting and supine), three head positions (neutral, sniff, and full extension), two tongue positions (in and out), and with and without phonation. In each patient MS length was measured in 24 method combinations: two body positions (sitting and supine), three head positions (neutral, sniff, and full extension), two distal end points (hyoid and thyroid cartilage), and two proximal end points (inside and outside of the mentum). In each patient the laryngoscopic grade was determined at the time of induction of anesthesia. We defined laryngoscopic grades III (n = 24) and 4 (n = 0) as difficult. The area under the receiver operating characteristic curve (ROC area) for each combination was used to compare the combinations and determine significant differences: ROC area = 0.5 implied a totally uninformative combination and ROC area = 1.0 a combination that predicted perfectly. Logistic regression analysis was used to calculate a predictor of difficult intubation that combined both OP class and MS length (the performance index). The performance index could then be used to calculate sensitivity, specificity, positive and negative predictive value, and probability of difficult intubation.

Results: The ROC areas for the different combinations used to assess OP class ranged from 0.78 to 0.94. The best combination was with the patient sitting, head in extension, tongue out, and with or without phonation. For MS length, the ROC areas ranged from 0.58 to 0.77; the best combination was the patient sitting, with the head in extension, with distance measured from the inside of the mentum to the thyroid cartilage. Combining the OP class and MS length (performance index = 2.5 X OP class - MS length in centimeters) significantly increased predictability of difficult intubation. At performance index = 0 and = 2, the probability of difficult intubation was 3.5% and 24%, respectively. With clinically relevant cutpoints for the performance index it was found that most difficult intubations could be predicted, but approximately half of those predicted to be difficult would in fact be easy.

Conclusions: Based on the above ROC areas and ease of performing the test for the patient, we recommend that these tests be performed with patients in the sitting position, with the head in full extension, the tongue out, and with phonation, and with distance measured from the thyroid cartilage to inside of the mentum. Nevertheless, it is clear that these two tests, either used alone or in combination, will fail to predict a few difficult laryngoscopies and that they will predict difficult laryngoscopy in a significant number of patients in whom the trachea is easy to intubate.