Obesity Clinical Trial
Official title:
Low Skill Fibreoptic Glottis View in Obese Patients: Ramp vs Supine Sniffing Air Position
Aims: The investigators are employing a feasibility study to determine whether fibreoptic view of the glottis (vocal cords) during low skill fibreoptic intubation (FOI) via a laryngeal mask airway (LMA) in obese and severely obese patients is appropriate and feasible for future full-scale research. Obese, and severely and morbidly patients in Asia are classed as body mass index (BMI) of ≥ 30, ≥35 and ≥40 kg/m2, respectively.
Aims: The investigators are employing a feasibility study to determine whether fibreoptic
view of the glottis (vocal cords) during low skill fibreoptic intubation (FOI) via a
laryngeal mask airway (LMA) in obese and severely obese patients is appropriate and feasible
for future full-scale research. Obese, and severely and morbidly patients in Asia are classed
as body mass index (BMI) of ≥ 30, ≥35 and ≥40 kg/m2, respectively.
Hypothesis: The glottis view during low skill FOI in obese and severely obese patients (BMI
≥30, and BMI ≥35 <40 kg/m2) is better in the ramp than in the standard supine 'sniffing air'
position. Low skill FOI is a term for FOI via an LMA.
Methodology: As a feasibility study, the investigators will recruit 18 adult patients
scheduled for elective surgery in obese and severely obese patients requiring tracheal
intubation. A non-randomized cross over design in selected. The investigators will assess
acceptability, implementation and practicality of such a study and also set criteria for
success of this feasibility study.
Importance of proposed research: Obese patients present many anaesthetic challenges. The ramp
position facilitates easier tracheal intubation and prolongs apnoea time. In cases of failed
intubation, guidelines recommend insertion of an LMA to faciliate ventilation and
oxygenation, allowing the option of low skill FOI to secure the airway. It may be performed
in unanticipated difficult airway ('rescue' intubation after failed intubation by
conventional techniques) and so may decrease patient morbidity and mortality. There is a
knowledge gap regarding whether the glottis view during low skill FOI is superior in the ramp
or standard supine sniffing position. It will help determine whether the study methodology
and protocol needs modification and assess what changes may occur, before implementing a
full-scale study. This will help form recommendations for future guidelines in difficult
airway management.
Primary outcome is to measure feasibility of this study. The areas of focus addressed by this
study are:
- the investigators will assess how many obese and severely obese patients we can recruit
in the Pre-Operative Evaluation Clinic (PEC)
1. Patient reaction and recruitment rate (accepting or declining invitation to the
study)
2. Patient dropout rate
Integration: Previous studies evaluating FOI via the LMA have proved less
straightforward than anticipated. Standard rostering of anaesthetic study members
does not allocate the latter to the operating theatre where study patients are
listed; this means the anaesthetic study team member needs to leave their own
operating list elsewhere to deliver the study intervention leading to poor
workflow. Also, the investigators used operating intubating fibrescopes, which had
priority allocation to other (nonstudy) patients due to clinical reasons. In
addition, the number of fibrescopes was greatly reduced due to maintenance and
repair work. As such, our study protocol incorporates different workflows. As soon
as a participant is recruited, the investigators will inform the roster consultant
to allocate one of the anaesthetic study member to the operating theatre where a
participant is listed to improve workflow. The investigators will also use grant
funded disposable fibrescopes and grant funded fibrescope monitor.
Assessment will be made of:
1. Percentage of lists that contain study participants that have an allocated
study team member, aiming for 80% allocation.
2. Any workflow availability.
Practicality: The investigators will assess for any difficulties when the patient
is changed from a ramp to standard supine sniffing position by a coordinated team
effort by theatre personnel.
Secondary outcome measures will evaluate the technique of FOI via the LMA in our
study population, comparing ramp and standard 'sniffing air' positions.
- Success of LMA insertion rate (after LMA insertion, an adequate capnography trace is
obtained under study ventilation parameters, whilst in ramp position)
- LMA insertion times (time from picking up the LMA for insertion until adequate
capnography trace is obtained, whilst in ramp position)
- Fibreoptic intubation times (time from picking up the fibrescope, after the patient has
been place in the standard supine sniffing position, until adequate capnography trace is
obtained)
- Airway manoeuvers to optimize glottis view
- Any complications
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