Too Obese to Intubate?



Anesthesia in morbidly obese patient can present many challenges.

The overriding concern of most anesthetist however, is airway management, as difficult tracheal intubation remains a relatively constant and significant source of morbidity and mortality in anesthesia


The incidence of difficult intubation appears to be more common in morbidly obese patients (12%) as compared to nonobese patients.

Obesity in Bahrain is higher than predicted and is increasing at a rate higher than the global average. Approximately 32% of Bahraini women and 25% of Bahraini men are obese (BMI _30.0 kg/m2).




Our primary objective was to establish the incidence of difficult intubation in patients undergoing elective Bariatric Surgery using Intubation difficulty scale (Table 1).

The secondary objective was to find any independent correlation between preoperative predictors for Difficult Airway and Difficult Intubation.


76 Patients undergoing elective Laparoscopic Bariatric Surgery with BMI > 35kg/ m2 with ASA Grade 1-3 were enrolled in this prospective observational study. Preoperatively, Body Mass index, Neck circumference, Mallampatti score, Mouth opening, Thyromental distance, Teeth Abnormalities and medical history were recorded in data collection form Rapid sequence induction (RSI) technique was used for all patients while in ramped position.

An IDS > 5 is categorized as Difficult Intubation while IDS 2-5 is categorized as slight difficulty and 0-1 is described as easy intubation (Table 2).


A total of 76 patients have been recruited in the study so far with 24 more to be recruited to make sample size of 100. Mean BMI was 53.95 with highest recorded as 86.8 and 33 (43%) were super obese. Mean neck circumference in our study population is 45.9 while maximum measured neck circumference was 58.5.Among those only 3 (3.94%) patients had IDS > 5, 10 (13.1%) had IDS 2-5 while 63 (82.57%) patients had IDS of (0-1).


Our study shows that a high proportion (96%) of obese patients are easy to intubate, however all these patients must have an individualized management plan and the chosen technique must be familiar to all involved with clear back up plan.


1. Cheney et al, Trends in anaesthesia related deaths and brain damage. A closed claims analysis Anesthesiology 2006; 105:1081-1086
2. Juvin et al, Difficult tracheal intubation is more common in obese than in lean patients, Anesth Analg 2003; 97:595-600
3. Amal R Hubail*, Kevin G Culligan, BSc, PhD, Current Prospectus on Obesity in Bahrain and Determination of Percentage Body Fat Range, Bahrain Medical Bulletin, Vol. 34, No. 1, March 2012.
4. Adnet, Frederic et al, The Intubation Difficulty Scale (IDS): Proposal and Evaluation of a New Score Characterizing the Complexity of Endotracheal Intubation Anesthesiology: December 1997 – Volume 87 – Issue 6 – p 1290–1297
5. Collins JS, Lemmens HJ, Brodsky JB. Obesity and difficult intubation: where is the evidence? Anesthesiology. 2006 Mar; 104(3):617.


1500 calories / day and favor foods rich in vitamin C, vitamin E, selenium, flavonoids, essential fatty acids, in particular omega-3. Regular physical exercise, for example 45 minutes of daily walking, improves endothelial function through the synthesis of NO and therefore has a favorable action on both the arterial and venous walls. There is an undeniable relationship between physical activity and quality of life

It is also recommended to limit trampling and prolonged standing, which has demonstrated its role in the progression of venous disease. Active vascular gymnastics promotes venous return.

Functional rehabilitation, performed by a physiotherapist, aims to strengthen the muscles of the calves and facilitate ankle mobility. Thus, it promotes venous return with increased efficiency of the muscular pump. In the obese with IVC, the exercise is useful both for the strengthening of the muscles of the calves and also to increase energy expenditure.

Spa treatments specialized in weight loss often has a favorable action to initiate weight loss. In patients with venous insufficiency, cures with warm baths or wraps should not be used.

Bariatric surgery may be considered in cases of morbid obesity. Weight loss can lead to a clear improvement in VMC symptoms

Management of Chronic Venous Disease in Overweight and Obesity: Medical compression is indicated at all stages of chronic venous disease. A poorly prescribed compression, without explanation of its benefits and its roles on the return traffic will end up in a drawer! Recent recommendations specify indications of the type of compression depending on the clinical context. The prescription must indicate the desired pressure in mmHg and possibly the class. In the overweight patient, custom pantyhose and / or compression socks are often used. Using a slip-on can be helpful. There is no particular contraindication to compression in obese patients. Systolic pressure indices (ABI) should be systematically checked by Doppler ultrasound, knowing that an ABI <0.6 contraindicates compression.

Treatment of varicose veins in obese or overweight patients:

The sclerotherapy of varicose veins and telangiectasia is not particularly problematic and echo-guided sclerotherapy is a guarantee of better results. The results of the surgical treatment of varicose veins are considered less good in the overweight patient, whatever the procedure. The risk of recurrence after stripping-ligation of the butt is increased in cases of BMI> 30. Endovenous procedures are also less effective. In a French series of more than 1000 radiofrequency varicose patients, each weight increase of 1 kg / m² (based on a BMI of 25 kg / m²) is associated with a risk of failure of the procedure plus 1.4 with increased risk of varicose recurrence. A slimming treatment before the procedure and especially a stricter phlebological follow-up postoperatively are recommended.

Although it has not been established that overweight and obesity are risk factors independent of chronic venous disease, the association of these two pathologies is extremely common in our populations and in particular in aging populations. Daily experience confirms the role of even moderate weight gain on onset or enhancement of symptoms of venous disease. Simple lifestyle rules combining diet, physical activity, and optimized management of chronic venous disease are effective in overweight patients. Venous disease in morbidly obese patients can only be managed in a specialized setting, without neglecting any pathology that is often intricate and whose respective responsibility is often difficult to specify.







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