Anesthesia & Clinical Research
Open Access

Abstract

Grading of Bag-Mask Ventilation Difficulty and Association with Unanticipated Difficult Laryngoscopy/Intubation in Children at a Training Center University Hospital: A Prospective Cohort Study

Maliwan Oofuvong*, Tidarut Sangkaew, Kanjana Nuanjun and Edward B. McNeil

Objective: In children, the grading of Bag-Mask Ventilation (BMV) difficulty and its association with difficult laryngoscopy/intubation has not been well established. This study aimed to evaluate the grading for BMV difficulty and determine its association with difficult laryngoscopy/intubation in a normal airway pediatric population.

Methods: This prospective cohort study was conducted in children aged ≤9 years who underwent general anesthesia and oroendotracheal tube intubation between September 2008 and December 2012. Difficult laryngoscopy was defined as a Cormack–Lehane laryngoscopic view grade of 3 or 4. Difficult intubation was defined as the occurrence of at least two of the following: 1) at least three intubation attempts using direct laryngoscopy by experienced personnel (excluding first intubation attempts); 2) intubation time >300 s; and 3) occurrence of desaturation (SpO₂<95%). The use of open airway maneuvers, including continuous positive airway pressure (CPAP), oropharyngeal airway (OPA), and two-person ventilation (TPV), or unsuccessful BMV were also considered. The association between BMV difficulty and difficult laryngoscopy/intubation was assessed using multivariate logistic regression with adjusted odds ratios (OR), 95% confidence intervals (CIs), and area under the receiver operating characteristic curve (AUC).

Results: The incidence of difficult laryngoscopy/intubation was 6.4% (49/765). The categories of BMV difficulty were grade 0 (easy BMV without requiring an open airway maneuver, n=308), grade 1 (easy BMV after applying CPAP, n=368), grade 2 (successful BMV after inserting an OPA, n=16), grade 3 (successful BMV after applying TPV, n=71), and grade 4 (unsuccessful BMV after applying all airway maneuvers, n=2). Difficult BMV was defined as a BMV grade of 3 or 4 (v/s grades 0-2). After adjusting for age, body weight, history of snoring, type of operation, use of neuromuscular blocking agents, and first laryngoscopist, BMV difficulty was significantly associated with difficult laryngoscopy/intubation (adjusted OR [95% CI]=2.5 [1.1-5.5], sensitivity 0.59, specificity 0.74, AUC=0.70).

Conclusion: A BMV grade of 3 (requiring TPV) or 4 (unsuccessful BMV) was associated with difficult laryngoscopy/ intubation in a pediatric population.

Published Date: 2020-02-28; Received Date: 2020-02-07