Factors influencing difficult and failed intubation in patients undergoing gynecologic oncology surgery: a retrospective cohort study

Seyyid Furkan Kına; Zeynep Koç; Damla Usalan; Atakan Sezgi; Savaş Altınsoy; Julide Ergil

doi:10.18621/eurj.1629467

Research Article

Factors influencing difficult and failed intubation in patients undergoing gynecologic oncology surgery: a retrospective cohort study

Year 2025, Volume: 11 Issue: 4, 722 - 731, 04.07.2025

Seyyid Furkan Kına , Zeynep Koç , Damla Usalan , Atakan Sezgi , Savaş Altınsoy , Julide Ergil

https://doi.org/10.18621/eurj.1629467

Abstract

Objectives: Difficult and unsuccessful intubation is a leading cause of anesthesia-related morbidity and mortality. This study aimed to investigate the incidence and contributing factors of difficult and unsuccessful intubation in patients undergoing gynecologic oncology surgery, particularly those with significant comorbidities and obesity.

Methods: The study included 653 patients over 18 years of age who underwent gynecologic oncology surgery with planned intubation under general anesthesia between January 1 and July 1, 2024. Data collected included demographic information, number of intubation attempts, personnel involved in intubation, auxiliary methods employed, intubation duration, complications, mouth opening, sternomental distance, thyromental distance, neck mobility, upper lip bite test results, presence of retrognathia or micrognathia, obstructive sleep apnea, and mobile dentures.

Results: The incidence of difficult intubation in our cohort was 7.5%, with no cases of failed intubation. Significant factors associated with increased risk of difficult intubation included body mass index (P=0.008), obstructive sleep apnea (P<0.001), Mallampati score (P<0.001), and mouth opening <4 cm (P<0.001). Among patients with difficult intubation, statistically significant differences were observed for age (P=0.001), ASA score (P=0.002), presence of comorbid conditions(P=0.004), Cormack-Lehane score(P<0.001), sternomental distance <12 cm (P<0.001), thyromental distance <6 cm (P<0.001), limited neck mobility (P<0.001), upper lip bite test results (P<0.001), retrognathia/micrognathia (P<0.001), and presence of dentures (P<0.001).

Conclusions: This study demonstrated that preoperative assessments of body mass index, obstructive sleep apnea, Mallampati score, and mouth opening are significant risk factors for difficult intubation. To reduce the risk of airway-related complications, patients undergoing gynecologic oncology surgery should undergo thorough and careful preoperative evaluation.

Keywords

Gynecologic oncology, airway management, difficult intubation, predictive, general anesthesia

Ethical Statement

This study was approved by the Ankara Etlik City Hospital Scientific Research Evaluation and Ethics Committee (Decision no. AEŞH-BADEK-2024-528, date: 05.06.2024).

Thanks

We would like to thank Dr. Hatice Mediha Kına for her contributions to the statistical analysis of the study.

References

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2. Chrimes N. The Vortex: a universal 'high-acuity implementation tool' for emergency airway management. Br J Anaesth. 2016;117 (Suppl 1):i20-i27. doi: 10.1093/bja/aew175.
3. Endlich Y, Lee J, Culwick MD. Difficult and failed intubation in the first 4000 incidents reported on webAIRS. Anaesth Intensive Care. 2020;48(6):477-487. doi: 10.1177/0310057X20957657.
4. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012;109(Suppl 1):i68-i85. doi: 10.1093/bja/aes393.
5. Roth D, Pace NL, Lee A, et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018;5(5):CD008874. doi: 10.1002/14651858.CD008874.pub2.
6. Crosby ET, Cooper RM, Douglas MJ, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth. 1998;45(8):757-776. doi: 10.1007/BF03012147.
7. Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet. 2022;399(10333):1412-1428. doi: 10.1016/S0140-6736(22)00323-3.
8. Ayhan A, Bakhshandehpour A, Khan I, et al. [Comparison of predictable and unpredictable difficult airway cases in gynecologic-oncology surgery patients]. Turk J Clin Lab. 2023;14(3):557-563. doi: 10.18663/tjcl.1344158. [Article in Turkish]
9. De Jong A, Pouzeratte Y, Sfara T, Jaber S. Difficult airway management: is prevent by using routine videolaryngoscopy better than cure. Ann Transl Med. 2022;10(21):1183. doi: 10.21037/atm-22-3883.
10. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103(2):429-437. doi: 10.1097/00000542-200508000-00027.
11. Siddiqui KM, Hameed F, Ali MA. Diagnostic Accuracy of Combined Mallampati and Wilson Score to Predict Difficult Intubation in Obese Patients: A Descriptive Cross-sectional Study. Anesth Pain Med. 2021;11(6):e118626. doi: 10.5812/aapm.118626.
12. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth. 2021;68(9):1405-1436. doi: 10.1007/s12630-021-02008-z.
13. Piepho T, Cavus E, Noppens R, et al. [S1 guidelines on airway management]. Anaesthesist. 2015;64(11):859-873. doi: 10.1007/s00101-015-0087-6. [Article in German]
14. Ezri T, Warters RD, Szmuk P, et al. The incidence of class "zero" airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade. Anesth Analg. 2001;93(4):1073-1075. doi: 10.1097/00000539-200110000-00055.
15. Schnittker R, Marshall SD, Berecki-Gisolf J. Patient and surgery factors associated with the incidence of failed and difficult intubation. Anaesthesia. 2020;75(6):756-766. doi: 10.1111/anae.14997.
16. Thota B, Jan KM, Oh MW, Moon TS. Airway management in patients with obesity. Saudi J Anaesth. 2022;16(1):76-81. doi: 10.4103/sja.sja_351_21.
17. Mehta AR, Maldonado Y, Abdalla M, et al. Association between body mass index and difficult intubation with a double lumen tube: A retrospective cohort study. J Clin Anesth. 2022;83:110980. doi: 10.1016/j.jclinane.2022.110980.
18. Wang T, Sun S, Huang S. The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis. BMC Anesthesiol. 2018;18(1):79. doi: 10.1186/s12871-018-0534-4.
19. Felix AS, Addison D. The intersection of gynecologic cancer, obesity, and cardiovascular disease. Gynecol Oncol. 2022;165(3):403-404. doi: 10.1016/j.ygyno.2022.05.004.
20. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768-775. doi: 10.1093/bja/aes022.
21. Lee YL, Lim ML, Leong WL, Lew E. Difficult and failed intubation in Caesarean general anaesthesia: a four-year retrospective review. Singapore Med J. 2022;63(3):152-156. doi: 10.11622/smedj.2020118.
22. Köhl V, Wünsch VA, Müller MC, et al. Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airway management: a randomised controlled trial. Anaesthesia. 2024;79(9):957-966. doi: 10.1111/anae.16326.
23. Koirala S, Shakya BM, Marhatta MN. Comparison of Upper Lip Bite Test with Modified Mallampati Test and Thyromental Distance for Prediction of Difficult Intubation. Nep J Med Sci. 2020;5(1):2-9. doi: 10.3126/njms.v5i1.36792.
24. Kar S, Senapati LK, Samanta P, Satapathy GC. Predictive Value of Modified Mallampati Test and Upper Lip Bite Test Concerning Cormack and Lehane's Laryngoscopy Grading in the Anticipation of Difficult Intubation: A Cross-Sectional Study at a Tertiary Care Hospital, Bhubaneswar, India. Cureus. 2022;14(9):e28754. doi: 10.7759/cureus.28754.
25. Iohom G, Ronayne M, Cunningham AJ. Prediction of difficult tracheal intubation. Eur J Anaesthesiol. 2003;20(1):31-6. doi: 10.1097/00003643-200301000-00006.
26. Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology. 2013;119(6):1360-1369. doi: 10.1097/ALN.0000435832.39353.20.
27. Onda M, Inomata S, Satsumae T, Tanaka M. [The efficacy of the "BURP" maneuver during laryngoscopy and training period necessary for residents in anesthesiology]. Masui. 2012;61(4):444-447. [Article in Japanese]
28. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev. 2022;4(4):CD011136. doi: 10.1002/14651858.CD011136.pub3.
29. Jaber S, Rolle A, Jung B, et al. Effect of endotracheal tube plus stylet versus endotracheal tube alone on successful first-attempt tracheal intubation among critically ill patients: the multicentre randomised STYLETO study protocol. BMJ Open. 2020;10(10):e036718. doi: 1136/bmjopen-2019-036718.
30. Russotto V, Lascarrou JB, Tassistro E, et al.; INTUBE Study Investigators. Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study. Br J Anaesth. 2023;131(3):607-616. doi: 10.1016/j.bja.2023.04.022.

Year 2025, Volume: 11 Issue: 4, 722 - 731, 04.07.2025

Seyyid Furkan Kına , Zeynep Koç , Damla Usalan , Atakan Sezgi , Savaş Altınsoy , Julide Ergil

https://doi.org/10.18621/eurj.1629467

Abstract

References

1. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022 ;136(1):31-81. doi: 10.1097/ALN.0000000000004002.
2. Chrimes N. The Vortex: a universal 'high-acuity implementation tool' for emergency airway management. Br J Anaesth. 2016;117 (Suppl 1):i20-i27. doi: 10.1093/bja/aew175.
3. Endlich Y, Lee J, Culwick MD. Difficult and failed intubation in the first 4000 incidents reported on webAIRS. Anaesth Intensive Care. 2020;48(6):477-487. doi: 10.1177/0310057X20957657.
4. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012;109(Suppl 1):i68-i85. doi: 10.1093/bja/aes393.
5. Roth D, Pace NL, Lee A, et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018;5(5):CD008874. doi: 10.1002/14651858.CD008874.pub2.
6. Crosby ET, Cooper RM, Douglas MJ, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesth. 1998;45(8):757-776. doi: 10.1007/BF03012147.
7. Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet. 2022;399(10333):1412-1428. doi: 10.1016/S0140-6736(22)00323-3.
8. Ayhan A, Bakhshandehpour A, Khan I, et al. [Comparison of predictable and unpredictable difficult airway cases in gynecologic-oncology surgery patients]. Turk J Clin Lab. 2023;14(3):557-563. doi: 10.18663/tjcl.1344158. [Article in Turkish]
9. De Jong A, Pouzeratte Y, Sfara T, Jaber S. Difficult airway management: is prevent by using routine videolaryngoscopy better than cure. Ann Transl Med. 2022;10(21):1183. doi: 10.21037/atm-22-3883.
10. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103(2):429-437. doi: 10.1097/00000542-200508000-00027.
11. Siddiqui KM, Hameed F, Ali MA. Diagnostic Accuracy of Combined Mallampati and Wilson Score to Predict Difficult Intubation in Obese Patients: A Descriptive Cross-sectional Study. Anesth Pain Med. 2021;11(6):e118626. doi: 10.5812/aapm.118626.
12. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth. 2021;68(9):1405-1436. doi: 10.1007/s12630-021-02008-z.
13. Piepho T, Cavus E, Noppens R, et al. [S1 guidelines on airway management]. Anaesthesist. 2015;64(11):859-873. doi: 10.1007/s00101-015-0087-6. [Article in German]
14. Ezri T, Warters RD, Szmuk P, et al. The incidence of class "zero" airway and the impact of Mallampati score, age, sex, and body mass index on prediction of laryngoscopy grade. Anesth Analg. 2001;93(4):1073-1075. doi: 10.1097/00000539-200110000-00055.
15. Schnittker R, Marshall SD, Berecki-Gisolf J. Patient and surgery factors associated with the incidence of failed and difficult intubation. Anaesthesia. 2020;75(6):756-766. doi: 10.1111/anae.14997.
16. Thota B, Jan KM, Oh MW, Moon TS. Airway management in patients with obesity. Saudi J Anaesth. 2022;16(1):76-81. doi: 10.4103/sja.sja_351_21.
17. Mehta AR, Maldonado Y, Abdalla M, et al. Association between body mass index and difficult intubation with a double lumen tube: A retrospective cohort study. J Clin Anesth. 2022;83:110980. doi: 10.1016/j.jclinane.2022.110980.
18. Wang T, Sun S, Huang S. The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis. BMC Anesthesiol. 2018;18(1):79. doi: 10.1186/s12871-018-0534-4.
19. Felix AS, Addison D. The intersection of gynecologic cancer, obesity, and cardiovascular disease. Gynecol Oncol. 2022;165(3):403-404. doi: 10.1016/j.ygyno.2022.05.004.
20. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768-775. doi: 10.1093/bja/aes022.
21. Lee YL, Lim ML, Leong WL, Lew E. Difficult and failed intubation in Caesarean general anaesthesia: a four-year retrospective review. Singapore Med J. 2022;63(3):152-156. doi: 10.11622/smedj.2020118.
22. Köhl V, Wünsch VA, Müller MC, et al. Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airway management: a randomised controlled trial. Anaesthesia. 2024;79(9):957-966. doi: 10.1111/anae.16326.
23. Koirala S, Shakya BM, Marhatta MN. Comparison of Upper Lip Bite Test with Modified Mallampati Test and Thyromental Distance for Prediction of Difficult Intubation. Nep J Med Sci. 2020;5(1):2-9. doi: 10.3126/njms.v5i1.36792.
24. Kar S, Senapati LK, Samanta P, Satapathy GC. Predictive Value of Modified Mallampati Test and Upper Lip Bite Test Concerning Cormack and Lehane's Laryngoscopy Grading in the Anticipation of Difficult Intubation: A Cross-Sectional Study at a Tertiary Care Hospital, Bhubaneswar, India. Cureus. 2022;14(9):e28754. doi: 10.7759/cureus.28754.
25. Iohom G, Ronayne M, Cunningham AJ. Prediction of difficult tracheal intubation. Eur J Anaesthesiol. 2003;20(1):31-6. doi: 10.1097/00003643-200301000-00006.
26. Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology. 2013;119(6):1360-1369. doi: 10.1097/ALN.0000435832.39353.20.
27. Onda M, Inomata S, Satsumae T, Tanaka M. [The efficacy of the "BURP" maneuver during laryngoscopy and training period necessary for residents in anesthesiology]. Masui. 2012;61(4):444-447. [Article in Japanese]
28. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev. 2022;4(4):CD011136. doi: 10.1002/14651858.CD011136.pub3.
29. Jaber S, Rolle A, Jung B, et al. Effect of endotracheal tube plus stylet versus endotracheal tube alone on successful first-attempt tracheal intubation among critically ill patients: the multicentre randomised STYLETO study protocol. BMJ Open. 2020;10(10):e036718. doi: 1136/bmjopen-2019-036718.
30. Russotto V, Lascarrou JB, Tassistro E, et al.; INTUBE Study Investigators. Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study. Br J Anaesth. 2023;131(3):607-616. doi: 10.1016/j.bja.2023.04.022.

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Details

Primary Language	English
Subjects	Anaesthesiology
Journal Section	Original Articles
Authors	Seyyid Furkan Kına 0000-0002-2083-3339 Zeynep Koç 0000-0001-7588-7097 Damla Usalan 0000-0001-5614-3017 Atakan Sezgi 0000-0003-4566-3521 Savaş Altınsoy 0000-0002-3588-7145 Julide Ergil 0000-0002-4580-7866
Early Pub Date	June 1, 2025
Publication Date	July 4, 2025
Submission Date	January 31, 2025
Acceptance Date	March 26, 2025
Published in Issue	Year 2025 Volume: 11 Issue: 4

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AMA	Kına SF, Koç Z, Usalan D, Sezgi A, Altınsoy S, Ergil J. Factors influencing difficult and failed intubation in patients undergoing gynecologic oncology surgery: a retrospective cohort study. Eur Res J. July 2025;11(4):722-731. doi:10.18621/eurj.1629467

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