Posted: November 9th, 2014

Evidence-based practice paper

Evidence-based practice paper

Critique of a research article related to physical assessment/preoperative evaluation in anesthesia: Comparison of Mallampati test with lower jaw protrusion
Margin, font, and page specification: 3 pages, 12-point font, 1” margins, double spacing, APA format

Introduction
•    the topic of the article clearly and concisely introduced
•    the introduction include a clear and concise summary statement
•    the information should forecast the remainder of the article critique for the reader

Body of the paper
•    Provide a brief synopsis of the article and provide a critical summary of the research drawn upon
•     What is the study problem? What is the study purpose?
•    Synthesize the material reviewed into a few main points
•    Provide excellent background, context and idea development
•    What are the study design, results, and conclusions
•    Critique the strengths and weaknesses of the article
•    What are the limitations of the study, if they are identified by the researcher
•     Discussion regarding implications for anesthesia practice
•    What suggestions are made for further studies?

Conclusion (a brief summary of what has been discussed)
References

Journal of Anaesthesiology Clinical Pharmacology | July-September 2013 | Vol 29 | Issue 3 313
Background: Failure to maintain a patent airway is one of the commonest causes of anesthesia -related morbidity and mortality.
Many protocols, algorithms, and different combinations of tested methods for airway assessment have been developed to
predict difficult laryngoscopy and intubation. The reported incidence of a difficult intubation varies from 1.5% to 13%. The
objective of this study was to compare Mallampati test   (MT) with lower jaw protrusion   (LJP) maneuver in predicting difficult
laryngoscopy and intubation.
Materials and Methods: Seven hundred and sixty patients were included in the study. All the patients underwent MT and LJP
maneuver for their airway assessment. After a standardized technique of induction of anesthesia, primary anesthetist performed
laryngoscopy and graded it according to the grades described by Cormack and Lehane. Sensitivity, specificity, accuracy, and
positive predictive value   (PPV) and negative predictive value   (NPV) were calculated for both these tests with 95% confidence
interval   (CI) using conventional laryngoscopy as gold standard. Area under curve was also calculated for both, MT and LJP
maneuver. A P < 0.05 was taken as significant.
Results: LJP maneuver had higher sensitivity  (95.9% vs. 27.1%), NPV   (98.7% vs. 82.0%), and accuracy   (90.1% vs. 80.3%)
when compared to MT in predicting difficult laryngoscopy and intubation. Both tests, however, had similar specificity and PPV.
There was marked difference in the positive and negative likelihood ratio between LJP and MT. Similarly, the area under the
curve favored LJP maneuver over MT.
Conclusion: The results of this study show that LJP maneuver is a better test to predict difficult laryngoscopy and tracheal
intubation. We recommend the addition of this maneuver to the routine preoperative evaluation of airway.
Key words:  Airway, difficult intubation, lower jaw protrusion maneuver, Mallampati test
Comparison of Mallampati test with lower jaw protrusion
maneuver in predicting difficult laryngoscopy and intubation
Muhammad Irfan Ul Haq, Hameed Ullah
Department    of     Anesthesiology,     Aga    Khan    University     Hospital,    Stadium    Road,    Karachi,    Pakistan
Address for correspondence:  Dr.  Muhammad Irfan Ul Haq,
Department of Anesthesiology, Aga Khan University Hospital,
Stadium Road, PO Box 3500, Karachi 74800, Pakistan.
E‑mail:  [email protected]
Introduction
Unanticipated difficult laryngoscopy and tracheal intubation
always remain a primary concern for the anesthesiologist, as the
failure to maintain a patent airway after the induction of general
anesthesia is one of the most common cause of anesthesia -related
morbidity and mortality.
[1]
Difficult laryngoscopy and tracheal
intubation can cause soft -tissue damage,
[2,3]
bronchial intubation,
laryngospasm, bronchospasm, inability to ventilate or intubate,
hypoxic brain injury, and even death.
[1,4,5]
The reported
incidence of a difficult laryngoscopy and tracheal intubation
varies     from      1.5%     to      13%      in      patients      undergoing     elective
surgery.
[6]
Because of potentially serious consequences of failed
tracheal intubation, considerable attention has been focused
on attempts to predict patients in whom laryngoscopy and
intubation might be difficult,
[5,7]
and in this regard combination
of different test and scores are developed, but none of them
have proven to be totally reliable.
[5,8,9]
Although difficult intubation is defined in a number of ways,
but visualization obtained during laryngoscopy remains the
mainstay of definition.
[10]
Cormack and Lehane defined the
grade of laryngoscopic view and they are widely used to label
the difficulty of tracheal intubation.
[11,12]
Modified Mallampati test
[13]
(MT) is the most widely used
tool in the armamentarium of an anesthesiologist for the
assessment and prediction of difficult airway. The pitfalls
associated with this MT are its low sensitivity
[14,15]
and poor
interobserver reliability.
[7,9,16]
Abstract
Access this article online
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DOI:
10.4103/0970-9185.117059
Original Article
Haq and Ullah: Comparison of mallampati with lower jaw protrusion
314 Journal of Anaesthesiology Clinical Pharmacology | July-September 2013 | Vol 29 | Issue 3
Lower jaw protrusion  (LJP) maneuver is a well -established
simple bedside maneuver for predicting difficult airways in
number of studies. It has a relatively simple grading system
in which patients were graded depending on the extent to
which they could translate their temporo -mandibular joint to
approximate their superior to inferior incisors.
[17 -19]
Although
the importance of jaw thrust during laryngoscopy has been
described    some     100    years     back,
[20]
there are number of studies
published in the last decade recommending the addition of
LJP maneuver in the routine evaluation of airway examination.
The objective of our study was to compare the sensitivity and
specificity of MT with LJP maneuver in predicting difficult
laryngoscopy and tracheal intubation using Cormack and
Lehane’s criteria of intubation as the gold standard.
Materials and Methods
After obtaining approval from Ethics Review Committee of the
hospital     (reference     number     703-Ane/ERC -07)    and    obtaining
informed     consent,     760    patients     were     enrolled     in     the    prospective
observational study, which was conducted at preoperative clinic,
preoperative waiting area, and operating rooms of a tertiary
care     hospital.    ASA    I-III     patients     aged     above    18    years     of     either
sex who were scheduled for elective surgeries under general
anesthesia requiring tracheal intubation were included in the
study. Patients who were bed bound, edentulous, having oral
pathology,      obesity      [body     mass      index      (BMI)      >     28     Kg/m
2
],
previous history of difficult intubations, Glasgow Coma Scale
(GCS)     14    or     below,    those     undergoing    obstetric    or     emergency
procedures, and those who refused consent were excluded
from the study.
Patient’s airway was assessed by the principal investigator at
either of the above -mentioned areas. Cormack and Lehane’s
criteria of laryngoscopy were taken as gold standard and
MT and LJP maneuvers as under study methods. The MT
was performed with the patient in the sitting position, head
neutral, mouth wide open, tongue protruded to its maximum,
and patient not phonating. Classification was assigned into
one     of      the     four      grades     [Table      1].     Out     of      the     four      grades     of
modified MT, grades I and II were considered as predictors
of “Easy” laryngoscopy and intubation, while grades III and
IV as predictors of “Difficult” laryngoscopy and tracheal
intubation. The LJP maneuver was performed by asking the
patient to protrude his or her lower jaw as much as possible
beyond the upper jaw. Patient was then assigned to one of
the three grades of mandibular protrusion
[16]
[Table     2].    LJP
grade A was considered as predictor of “Easy” and grade  B
and C as predictors of “Difficult” laryngoscopy and tracheal
intubation. Cormack and Lehane’s classification of difficult
intubation was also classified as “Easy”  (grades I and II)
or “Difficult”   (grades III and IV). All this information was
recorded in a prescribed proforma. Biometric patient data
including age, sex, weight, height, BMI, ASA status, and
surgical specialty was also noted.
Patient was then transferred to operating room and
head ring was placed below the head with routine
monitors [Electrocardiography (ECG), Non Invasive Blood
Pressure (NIBP), Pulse Oximetry (SpO
2
)]      were      applied.
After obtaining baseline readings, an intravenous access was
maintained with Lactated Ringer’s solution. Patient was
preoxygenated     with     100%     oxygen      for     3      min.     Anesthesia
was     induced      with     fentanyl      2     µg/kg,      propofol     2     mg/kg,     and
atracurium     0.5    mg/kg.    Patients’    were     then     manually    ventilated
for 3   min using circle system; during this period, anesthesia
was    maintained    with    50%     N
2
O in O
2
and    isoflurane     (≤0.5-1%).     An    anesthetist     with    an     experience     of     more     than     2    years,
blinded to the result of LJP maneuver, was asked to perform
laryngoscopy and intubation. This was graded according
to Cormack and Lehane’s criteria and was documented on
a separate form along with the duration of laryngoscopy
and number of attempts to successful tracheal intubation.
For laryngoscopy, Macintosh blade of size 3 was used,
while tracheal intubation was done using polyvinylchloride
orotracheal     tube      of      size      7-mm     ID     and     8-mm     ID     for     females
and males, respectively.
Sample     size     was    calculated     in     order     to     obtain    a    power    of     80%
and    level     of     significance    of     5%    using     area     under    curve     (AUC)
between     0.55      to      0.90      and     a     difference      of      0.1     in      the     area
considering     the     difficulty     of      10%.     All     the     relevant      data      were
analyzed     by      using      SPSS     version      14.0.     Percentages     were
generated for qualitative variable like gender and compared
by Chi-square test. For quantitative variables like age, height,
weight, and gender, mean and standard deviation were
computed and compared by using t-test. Sensitivity, specificity,
accuracy, and positive and negative predictive values were
calculated     for    MT    and    LJP    maneuver    with    95%     confidence
Table  1: Modified Mallampati test
[5,6]
Grade I Visualization of the soft palate, fauces; uvula, anterior and
the posterior pillars
Grade II Visualization of the soft palate, fauces and uvula
Grade III Visualization of soft palate and base of uvula
Grade IV Only hard palate is visible. Soft palate is not visible at all
Table  2: Lower jaw protrusion maneuver
[16]
Grade A Lower incisors can be brought anterior to the upper incisors
Grade B Lower incisors can only be protruded edge to edge with
upper incisors
Grade C Lower incisors cannot be protruded edge to edge with
upper incisors
Haq and Ullah: Comparison of mallampati with lower jaw protrusion
Journal of Anaesthesiology Clinical Pharmacology | July-September 2013 | Vol 29 | Issue 3 315
interval  (CI) using laryngoscopic view as gold standard. AUC
was also computed by receiving operative curve  (ROC).
A P    <    0.05     was    taken     as     significant.
Results
Seven hundred and sixty patients were enrolled and
completed the study. There was a predominance of female
participant     (55.5%     vs.     44.5%).    The    mean     values    of     weight,
height, and BMI of study patients were within normal range
with no significant effect on airway examination. Other
biometric details are shown in Table 3.
More     than     90%     of     participants     had    an     “Easy”     grade     of     Mallampati,
while     nearly    9%    have     a    “Difficult”     Mallampati    grade.    Similarly,
69.6%     of      the     patients      enrolled      in      the     study      had     “Easy”      grade
of     LJP    test    and    30.4%    patients     as     “Difficult”     grade     [Table    4].
There was no grade IV intubation. The mean intubation time
in     our    study     was    21.08    ±    7.57     s.
When the “Easy” grades of Mallampati were compared with
Cormack    and    Lehane’s    grades,     there     were     17.9%     participants
who have actually difficult laryngoscopic grades, i.e.,  grades
III     and    IV    of     Cormack    and    Lehane,    while     out    of     71    patients
that were predicted by MT as having difficult grades of
laryngoscopy     and    intubation,     only     32.2%     found    to     have     easy
grade    of     Cormack    and    Lehane     [Table     4].
Similarly, when “Easy” grades of LJP were compared with
Cormack     and     Lehane’s     grades      of      intubation,     only      1.3%
were found to have difficult grades of intubation, while out of
231     patients      that      were      predicted     to      have      difficult      intubation
grades,     nearly    29.4%    of     patients     were     actually     found    to     have     easy
grade according to Cormack and Lehane, as shown in Table 4.
Statistical measures used to describe the predictive values for
LJP maneuver and MT in predicting difficult intubations are
shown     in     Table    5.
Using     McNemar’s     test      and     with     a      95%      CI,     statistically
significant differences were observed between these two
predictive tests  ( P      <      0.05)     showing     higher      level      of
sensitivity     (95.9%)    and    accuracy    (90.1%)    for    LJP    maneuver
than     MT,    which    has    a    sensitivity     and    accuracy    of     27.1%     and
80.3%,     respectively.
Discussion
Prediction of difficult laryngoscopy and tracheal intubation
has been the primary focus of many research papers and many
time tested methods have been developed to avoid difficult
intubation and its related complications.
[6,13]
Problems with
tracheal intubation can range from minor complications as
mild soft-tissue damage, transient, and uncomplicated hypoxia
to more severe effects leading to severe airway damage
[5]

to hypoxic brain injury and death.
[1,4,5]
Because of these
potentially serious consequences of failed tracheal intubation,
considerable attention has been focused on attempts to
predict patients in whom laryngoscopy and intubation will
be difficult.
[15-19]
Difficult intubation is defined in a number of
ways, but an unanticipated poor laryngoscopic view is mainstay
of definition.
[10]
Although many advances have been made and
many time -tested methods, for example MT, sternomental
distance, interincisor gap, upper lip bite test, thyromental
distance alone or in combination, have been used to overcome
the conundrum of an unanticipated difficult laryngoscopy and
tracheal intubation but none of them are totally reliable.
[8,9,14]
Objective of our study was to compare the sensitivity and
specificity of MT with LJP maneuver in predicting difficult
Table  3: Demographic and anesthetic observations of the patients ( n=760)
Variables Overall statistics Cormack and Lehane’s P values
Easy (I and II)
n=590
Difficult (III and IV)
n=170
Age  (years) 43.44±14.93 40.97±14.22 52.03±14.18 0.0005
Weight (kg) 65.04±10.74 65.04±10.94 65.06±10.03 0.98
Height  (cm) 163.01±8.69 163.40±8.73 161.63±8.44 0.019
BMI  (kg/m
2
) 24.38±2.86 24.26±2.91 24.81±2.63 0.025
Duration of laryngoscopy  (min) 21.08±7.57 17.73±4.11 32.69±4.83 0.0005
Gender
†
(%)
Male 338  (44.5) 268  (45.4) 70 (41.2) 0.326
Female 422  (55.5) 322  (54.6) 100  (58.8)
Number of attempts
†
(%)
1 705  (92.8) 586  (99.3) 119  (70) 0.0005
2 53 (7) 4 (0.7) 49 (28.8)
3 02 (0.3) 0 (0) 2 (1.2)
Data are presented as mean±SD or number (%),
†
Chi‑square test used for qualitative, Independent t ‑test used for quantitative observation, BMI=Body mass index
Haq and Ullah: Comparison of mallampati with lower jaw protrusion
316 Journal of Anaesthesiology Clinical Pharmacology | July-September 2013 | Vol 29 | Issue 3
laryngoscopy and intubation using Cormack and Lehane’s
criteria of intubation as a gold standard. We could not find any
study in which MT has been compared with LJP maneuver
in nonobstetric and nonobese South Asian population.
The reported incidence of a difficult laryngoscopy and
endotracheal     intubation     varies    from     1.5%    to     13%     in     patients
undergoing surgery.
[6]
This variation in incidence might be
due to different reference standard for difficult intubation
among studies which were based on Cormack and Lehane’s
intubation grades, number of laryngoscopic attempts, and use
of backward upward rightward pressure  maneuver.
[6]
In      our     study,     we     examined      the     airway      of      760      patients      who
required general anesthesia and elective intubation and found
the     incidence      of      difficult      intubation      to      be      22.4%,      which     is
higher compared to previous studies. The probable reasons for
this may be the use of more strict criteria for difficult intubation,
as described by intubation grades III and IV of Cormack
and Lehane’s grading rather than using only grade   IV as
difficult intubation or relying upon Cook’s modification of
Cormack and Lehane’s grading.
[11]
Another reason for this
higher incidence could be the avoidance of external pressure
during     intubation.      Majority     of      intubations     (82.2%)     in      our
study were done by an anesthetist with an experience of more
than four years and none by an anesthetist with less than
two years experience. Nevertheless, our reported incidence
is quite comparable to the one reported by Bergler  et   al. ,
i.e.,     20.2%.
[12]
The high incidence of difficult LJP observed in our study can
be attributed to the different classification used in our study
wherein we collated grade B and grade C as difficult contrary
to the classification used by Eberhart  et   al .
[9]
However if we
also translate difficult as per Ebehart et  al ’s classification, the
incidence      of      difficult      LJP     in      our     study      would     also      be      8.2%
which is very similar to Eberhart et  al .
[9]
.
The    sensitivity     of     MT    in     our    study    is     22.4%     which    is     quite
comparable to that demonstrated by Vani  et   al.
[14]
who
found    it     to     be     25%.    Siddiqui    et  al.
[21]
found the sensitivity
of     MT    to     be     higher    (42%)     in     his    study,    while    other     authors
have found even higher sensitivities. This shows the wide
interobserver variability, an issue which has been confirmed
by Hilditch et   al.,
[7]
Eberhart  et   al .,
[9]
and      Karkouti
et   al .
[15]
who have shown poor interobserver reliability for
MT. Sensitivity of LJP maneuver in our study was very
high      (95.6%),      which     is      in      contradiction     with      the     work
by James  et   al .
[17]
and Sava et   al .
[18]
who have found the
sensitivity     to     be     14.9%     and    29.4%,     respectively.     This     wide
variation can also be attributed to interobserver variability
and needs further evaluation. The accuracy of both tests
is high and unchanged by their combination, similar to
James  et  al .
[17]
By    assessing    the    AUC,    Table    5,     LJP    comes
out to be a better predictor of difficult laryngoscopy and
tracheal intubation.
The main strength of our study was that the LJP maneuver
and MT were performed for the assessment of airway by
primary investigator, which reduced the risks of interobserver
variation and increased the reliability of the tests. We have not
evaluated obstetric patients in our study where the incidence of
unanticipated difficult intubation was quite high as compare
to general population and as such there is a need to develop a
more reliable predictive test in future in that specific specialty.
In conclusion, MT is the most commonly used test for the
prediction of difficult laryngoscopy and tracheal intubation but
with limited accuracy. We, therefore, recommend the addition
of LJP maneuver to the routine preoperative evaluation of
airway.
Table  4: Laryngoscopic view of all patients with respect to
Mallampati, LJP and Cormack (n=760)
Predictors Cormack and Lehane’s Total
(%)
Easy Difficult
I
n=522
II
n=68
III
n=170
Mallampati
I Easy 317 25 43 385  (50.7)
II 191 32 81 304  (40)
III Difficult 14 10 39 63 (8.3)
IV 0 1 7 8 (1.1)
Lower jaw protrusion grade
A Easy 490 32 7 529  (69.6)
B Difficult 32 32 105 169  (22.2)
C 0 4 58 62 (8.2)
Cormack and Lehane’s grade IV, not observed in patients. TP=46, FP=25,
FN=124, TN=565 for Mallampati, TP=163, FP=68, FN=7, TN=522 for LJP
Grade, LJP=Lower jaw protrusion
Table  5: Predictive values for MMT and LJP and their
combinations to predict the difficult laryngoscopy and
tracheal intubation
Mallampati LJP
Sensitivity 27.06% (20.94, 34.19) 95.88% (91.75, 97.99)
Specificity 95.76% (93.82, 97.11) 88.47% (85.65, 90.81)
PPV 64.79% (53.18, 74.88) 70.56% (64.39, 76.07)
NPV 82%  (79.96, 84.69) 98.56% (97.29, 99.36)
Accuracy 80.39% (77.42, 83.06) 90.13% (87.81, 92.05)
Likelihood ratio  (+) 6.38  (5.26, 7.74) 8.32  (8.08, 8.57)
Likelihood ratio  (–) 0.76  (0.74, 0.77) 0.046 (0.035, 0.061)
Area under the curve 61.4%  (0.56 to 0.66) 92.2%  (0.89 to 0.95)
95% confidence interval was computed by Wilson method, LJP=Lower jaw
protrusion, PPV=Positive predictive value, NPV=Negative predictive value,
MMT=Modified mallampati test
Haq and Ullah: Comparison of mallampati with lower jaw protrusion
Journal of Anaesthesiology Clinical Pharmacology | July-September 2013 | Vol 29 | Issue 3 317
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How to cite this article: Ul Haq MI, Ullah H. Comparison of Mallampati test
with lower jaw protrusion maneuver in predicting difficult laryngoscopy and
intubation. J Anaesthesiol Clin Pharmacol 2013;29:313-7.
Source of Support: Nil, Conflict of Interest: None declared.
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