How fat for FOI?

[deleted547339]

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Is there a BMI at which you would prefer awake FOI over putting someone asleep? If so, how high?

Yes, I realize that there is a lot more that goes into how you induce someone than simply whether they are rail thin or orca fat/no neck, but how big makes you at least pause and reconsider your options?

(I wonder how many posts before someone says prop sux tube)

 

[Psai]

Just ramp them and have glide in the room imo

 

[Robotic Wis-Hipple]

I don’t think BMI alone has ever made me say, you know, I’m gonna AFOI this patient.

In my opinion, it’s small mouth opening and a short TMD that makes my radar tingle.

But the real answer is it’s a true total picture assessment that leads to an AFOI, typically you can tell from the door and it’s not typically because they’re large.

 

[dchz]

prop roc tube

It's not the BMI that worries me, it's the airway and retrognathia. Our average BMI is around 35. Fat people don't scare me, it's the skinny guy with no chin that gives me pause.

 

[Arch Guillotti]

Pent sux tube

 

[deleted547339]

I don’t think BMI alone has ever made me say, you know, I’m gonna AFOI this patient.

In my opinion, it’s small mouth opening and a short TMD that makes my radar tingle.

But the real answer is it’s a true total picture assessment that leads to an AFOI, typically you can tell from the door and it’s not typically because they’re large.

I mean, 600 lbs, 5’2” wouldn’t give you pause?

 

[Robotic Wis-Hipple]

I mean, 600 lbs, 5’2” wouldn’t give you pause?

Pause? Sure. But I’d evaluate the cervical ROM, mouth opening, size of teeth, TMD, and mallampati/tongue size. I’ve put multiple >60 BMI patients to sleep before securing the tube. BMI alone just doesn’t correlate as strongly as you think imo. If anything masking them sucks but a glidescope intubation is a chipshot.

 

[deleted547339]

Pause? Sure. But I’d evaluate the cervical ROM, mouth opening, size of teeth, TMD, and mallampati/tongue size. I’ve put multiple >60 BMI patients to sleep before securing the tube. BMI alone just doesn’t correlate as strongly as you think imo. If anything masking them sucks but a glidescope intubation is a chipshot.

Yea. I had a guy so fat today that I’m not sure how he talked - he had so much neck fat he couldn’t really open his mouth. He was mega-fat even for someone who has spent significant time in the South and Midwest. Also not sure how he could breathe as he had 100+ lbs of tissue on his chest. Made me wonder if there was a BMI/weight that y’all would consider.

And you know how some people are super fat but their anatomy of the mouth, chin and neck are normal and they end up being a chip shot airway? He wasn’t that. His chin rolls had rolls. Probably BMI 70-80.

 

[dchz]

I think we need a picture. Your words aren't doing it justice.

Just put the black bar thing across the eyes.

 

[nimbus]

Yea. I had a guy so fat today that I’m not sure how he talked - he had so much neck fat he couldn’t really open his mouth. He was mega-fat even for someone who has spent significant time in the South and Midwest. Also not sure how he could breathe as he had 100+ lbs of tissue on his chest. Made me wonder if there was a BMI/weight that y’all would consider.

And you know how some people are super fat but their anatomy of the mouth, chin and neck are normal and they end up being a chip shot airway? He wasn’t that. His chin rolls had rolls. Probably BMI 70-80.

I would afoi that guy.

Same size woman would prob get a glidescope.

 

[ethilo]

We call that "buried head"

 

[getdown]

If you're a writer for UBP anything outside of a normal, skinny airway will make you consider doing a FOI.

 

[Aether2000]

Predictive performance of a multivariable difficult intubation model for obese patients. - PubMed - NCBI

The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis. - PubMed - NCBI

Associations of obesity with tracheal intubation success on first attempt and adverse events in the emergency department: An analysis of the multic... - PubMed - NCBI

 

[DM27]

I generally go by appearance, where the weight is distributed, etc. I wouldn't say I have a specific number where above that the person is AFOI from the get go.

 

[coffeebythelake]

do an airway exam and assess
i think my only other consideration is that they can desat very quickly
ramp them up in best position possible. i prefer to have HOB up instead of using a bunch of blankets
i like to have a glidescope around just in case
also like to use suxx to intubate b/c potentially increased aspiration risk, and less time to intubate so less likely to desat with suboptimal masking

 

[deleted162650]

i prefer to have HOB up instead of using a bunch of blankets

THIS!!!!

For the life of me I can’t figure out why people feel the need to stack blankets under the patient. Put the head of the bed up. Put an extra pillow or one of those nice foam blocks under the head. Accomplishes the exact same thing and now you don’t need to go spelunking to dig out 37 blankets from underneath Jabba when the surgeon needs them flat.

 

[coffeebythelake]

Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial. - PubMed - NCBI

study showing equivalency between intubating by ramping blankets vs HOB up technique

 

[Psai]

THIS!!!!

For the life of me I can’t figure out why people feel the need to stack blankets under the patient. Put the head of the bed up. Put an extra pillow or one of those nice foam blocks under the head. Accomplishes the exact same thing and now you don’t need to go spelunking to dig out 37 blankets from underneath Jabba when the surgeon needs them flat.

Cause that's how I am trained. Maybe you guys should be training me.

 

[deleted162650]

Cause that's how I am trained. Maybe you guys should be training me.

Pay attention, we're trying. 😉

I was lucky enough to be an intern/resident in the glory days of @jetproppilot, @militarymd, @Tenesma, @zippy2u, @UTSouthwestern, @Noyac (you know, before he became the sad empty shell of the man he used to be ). I'd say a good 1/2 of my anesthetic education was SDN.

 

[anbuitachi]

I am not getting this. why is putting HOB up equivalent to putting blankets underneath the shoulders? with HOB up the entire back is going up (or are you guys talking about tables that only elevate the head portion and not the back?)

 

[GravelRider]

I’m a fan of the awake glidescope as the poor man’s awake FOI, especially in these “not that scary, but that little twinge of hesitation” airway scenarios. An example would be if Shamu shows up with a Santa Claus beard, I might spray him with some lidocaine and take a peek with the glide-a-scope. Patients seem to tolerate this pretty well.

 

[sevoflurane]

Just because someone is super morbidly obese doesn’t mean they need an AFO (might actually add unnecessary drama).
A BMI of 75 a few years back comes to mind.
DLx1. Grade one view.
She was obese from the neck down.
AW was easy cheese.

 

[deleted162650]

I am not getting this. why is putting HOB up equivalent to putting blankets underneath the shoulders? with HOB up the entire back is going up (or are you guys talking about tables that only elevate the head portion and not the back?)

Yes, back of the bed goes up then with doubled up pillow or foam block to elevated the head. This is identical positioning to a blanket ramp.

 

[anbuitachi]

Yes, back of the bed goes up then with doubled up pillow or foam block to elevated the head. This is identical positioning to a blanket ramp.

need to try this next time. sounds way easier than putting 22 blankets

 

[coffeebythelake]

 

[coffeebythelake]

Positioning The Head For Intubation - The Airway Jedi

 

[Psai]

Our beds don't have that extra step to make the head flat.

 

[deleted162650]

Our beds don't have that extra step to make the head flat.

Doesn't matter. I never tilt the head portion back flat like that.

 

[coffeebythelake]

Our beds don't have that extra step to make the head flat.

the ones we have don't either. doesn't matter. still works well.
have the angle of mandible line up horizontally with sternal notch
like when u ramp pts

 

[cchoukal]

I do a fair number of these, and for me, it's simply a matter of whether they will be one of the following:

1) Predicted to be difficult to mask AND intubate

or

2) Predicted to be difficult to intubate + have risk factors for harm from prolonged mask ventilation (aka severe, significant reflux, achalasia, etc.)

or

3) Severe achalasia with daily aspiration alone.

 

[Mman]

My incidence of needing AFOI is < 1:1000 cases and that is at a tertiary care center in the fat stroke belt. Weight is not much of a consideration. I mean I notice it, but if you have a great looking airway I really don't care how big your belly or thighs are. It's mouth opening, neck circumference, etc that are infinitely more important to airway management than simply the gross tonnage.

 

[nimbus]

My incidence of needing AFOI is < 1:1000 cases and that is at a tertiary care center in the fat stroke belt. Weight is not much of a consideration. I mean I notice it, but if you have a great looking airway I really don't care how big your belly or thighs are. It's mouth opening, neck circumference, etc that are infinitely more important to airway management than simply the gross tonnage.

Pears are no problem.

Sometimes one AFOIs with a weak indication for kicks or to test out the new disposable FOB.

 

[Arch Guillotti]

The funny thing is that I have had to ventilate some incredibly obese patients unexpectedly over the years and they are usually not that bad to mask.

 

[T-burglar]

Barring very abnormal anatomy ( airway cancer , previous airway surgery, airway radiation ). You should be able to mask ventilate almost anyone regardless of weight with an oral airway, tight mask strap, and two strong anesthesiologists

 

[coffeebythelake]

My incidence of needing AFOI is < 1:1000 cases and that is at a tertiary care center in the fat stroke belt. Weight is not much of a consideration. I mean I notice it, but if you have a great looking airway I really don't care how big your belly or thighs are. It's mouth opening, neck circumference, etc that are infinitely more important to airway management than simply the gross tonnage.

tbh i don't know how many GA cases I do in a year
usually 2-3 times a year AFOI
i work in a large tertiary care center
i also tend to be a bit conservative

 

[Ronin786]

99.7 BMI was a grade 1 glidescope a few years back for me. Males with big beards give me a little pause, but I think there's an overblown fear of obesity from an intubation standpoint.

Also, best thing I heard about mask ventilation: "If you can't mask someone, try harder."