Difficult Airway Clinical Trial
Official title:
F.R.O.N.T. Formula for Pre-operative Airway Assessment and Documentation
The F.R.O.N.T. formula for pre-operative airway assessment and documentation
Background:
Prediction of difficult airway is one of the most important challenges before general
anesthesia. Although in recent decades different scoring systems have been for the
preoperative assessment of their sensitivity and specificity in predicting a difficult
airway remains moderate. Recently, the calculation of composite scores using different
formulae has been proposed as the most sensitive one. The aim of the present work was to
test the clinical usefulness of the FRONT score, a recently developed scoring system.
Methods:
This study was a multi-center, inter-observer, prospective and double-blind investigation
that included 976 patients from two university centers: 250 from the University of
Cluj-Napoca, Romania, and 726 from the University of Debrecen, Hungary.
The preoperative evaluation of the patients was performed by a preoperative team of
anesthesiologists (team A) who evaluated and scored the expected difficulty of the
management of the airway. An intraoperative team of evaluators (team B) working
independently from team A, performed the actual instrumentation of the airway and scored the
actual findings. Both teams used the FRONT scoring system and worked independently from each
other to ensure blinded assessment. Statistical analysis of the preoperative and
intraoperative FRONT scores were performed post hoc.
Criteria for preoperative assessment and grading for all five levels "F" 0 Normal level of
difficulty or no difficulty to be expected
1. Difficulty to apply air tight the facial mask ventilation by one person (difficulty to
maintain SpO2 above 92% with 100% O2), or inability to prevent the decrease in SpO2
during facial mask ventilation.
2. Increased ventilation difficulty, requiring the presence of two anesthetists in order
to maintain the patient's oxygenation, or inability to ventilate the patient with the
facial mask.
"R" 0 Normal level of difficulty or no difficulty to be expected
1. Incomplete teeth, loose teeth, edentulous status, incisor protrusion, prognathia,
micrognathia, limited opening of the mouth but still more than 3 cm., expected
difficulty with direct laringoscopy and/or insertion of a supraglottic device.
2. Mobile teeth, mouth opening less than 3 cm, laryngoscopy or insertion of a supraglottic
airway device impossible "O"
0 Normal level of difficulty or no difficulty to be expected
1 Laryngoscopy and intubation difficult expected by intaroral mass, abscess, anatomical
anomalies (large tongue) 2 Laryngoscopy and tracheal intubation expected to be extremely
difficult or impossible "N" 0 Normal level of difficulty or no difficulty to be expected
1. Reduced mobility of the cervical spine, short neck, bulky chest, special positioning of
the patient necessary (roll under the shoulders)
2. Immobile cervical spine "T"
0 Normal level of difficulty or no difficulty to be expected
1. Expected trouble for passing the tube through the glottis (polyp, tumor, abscess), and
tube with smaller diameter necessary
2. Severe obstruction in the upper airway (polyp, tumor, abscess, paralysis of the vocal
cords), tracheal stenosis, tracheomalacia
Criteria for intraoperative assessment and grading for all five levels. "F" 0 Normal level
of difficulty or no difficulty
1. Difficulty to seal the face mask accordingly by one person in order to maintain SpO2
above 92% by ventilating with oxygen.
2. Inability to maintain SpO2 above 92% by ventilating with oxygen with handling the face
mask by two persons.
"R" 0 Normal level of difficulty or no difficulty
1. Incomplete dentition, protruding incisives, prognathia, micrognathia, a reduced
interincisive gap above 3 cm thus explicitly hampering (but not completely preventing)
intubation or supraglottic device insertion.
2. Incomplete dentition, protruding incisives, prognathia, micrognathia, a reduced
interincisive gap below 3 cm limiting intubation or supraglottic device insertion.
"O" 0 Normal level of difficulty or no difficulty
1. Macroglossia, presence of tumours or other findings with increased oral tissue mass,
tongue base processes which hamper the performance of direct laryngoscopy
(Cormack/Lehane grades up to 3°), conventional intubation or the insertion of a
supraglottic airway. Final success could be achieved after two attempts to secure the
airway with any adopted technique.
2. Macroglossia, presence of tumours or other findings with increased oral tissue mass,
tongue base processes which prevent the performance of direct laryngoscopy
(Cormack/Lehane grade 4°), conventional intubation or the insertion of a supraglottic
airway. Tracheal intubation could be achieved only after recurring to a visualizing
technique (e.g. flexible fiberoptic).
"N" 0 Normal level of difficulty or no difficulty
1. Reduced cervical spine mobility, short neck, risk of spinal cord damage by certain head
positions that hamper direct laryngoscopy and conventional means of tracheal
intubation. Successful intubation possible by 2 or more attempts. Supraglottic airway
insertion is not affected.
2. Reduced cervical spine mobility, short neck, risk of spinal cord damage by certain head
positions that prevent direct laryngoscopy and conventional means of tracheal
intubation. Tracheal intubation could be achieved only after recurring to a visualizing
technique (e.g. flexible fiberoptic). Supraglottic airway insertion may have been
affected.
"T" 0 Normal level of difficulty or no difficulty
1. Difficult forwarding of a tracheal tube with regular diameter to a mid-tracheal
position. Supraglottic airway insertion is not affected.
2. Impossible forwarding of a tracheal tube even with a reduced diameter to a mid-tracheal
position. Supraglottic airway insertion is not affected but ventilation is difficult or
impossible. Necessity to apply jet ventilation or to bypass the oro-tracheal route by
performing a trans-tracheal access.
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