SciELO - Scientific Electronic Library Online

vol.55 issue2Morbidly Obese Patients and Tracheal Intubation author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Revista Brasileira de Anestesiologia

On-line version ISSN 1806-907X

Rev. Bras. Anestesiol. vol.55 no.2 Campinas Mar./Apr. 2005 



Tracheal intubation of morbidly obese patients: a useful device



Obese population has considerably increased almost everywhere. In Brazil, incidence on female population is 13.3% and on male population is 7%. In Europe and the USA, prevalences are 20% and 22.5%, respectively. Ascension rate varies from 0.5% to 1% a year in developed countries. Only Japan and The Netherlands have stable ascension rates 1.

Due to these figures, it is to be expected that increasingly more obese patients will be seen in our clinical practice, not only for gastroplasties and gastric bands, but also for different types of procedures. Several anesthetic peculiarities should be understood to manage such patients. It can be said that cardiovascular, respiratory and pharmacokinetic changes are some of the most important. However tracheal intubation (TI) and airway maintenance were the focus of recent discussions during the latest ASA meeting in October 2004.

Mallampati index would not be the most effective factor to predict difficult TI in obese patients. Most successful test for such evaluation would be neck circumference measurement. So, obese patients would have 30% probability of difficult TI when neck circumference would be above 60 cm. Only for these cases tracheal intubation with awaken patients would be recommended 2,3.

It has also been discussed that morbid obesity/difficult TI ratio is being overvalued 4. Two studies, one with 764 and the other with 100 morbidly obese patients, were unable to show evident correlation between body mass index (BMI) and difficult TI 5,6. However, when obese patients presented obstructive sleep apnea, there has been strong correlation with difficult TI7. A study has shown the presence of large amounts of weak paratracheal connective tissue in these patients 8.

This same meeting has stressed that most times when TI was impossible with direct laryngoscopy, the problem was inadequate patients' position 3,4 (Figure 1).

Some authors have shown in our journal (Bras J Anesthesiol) cares to be taken before direct laryngoscopy. Thorough airways evaluation, pads under shoulders and table bending were considered effective maneuvers to adequately position these patients, providing thoracic column extension and cervical column flexion favoring atlanto-occipital joint 9,10 (Figure 2).

Observing recent illustrations published by Bras J Anesthesiol and after the latest ASA 2004 Refresher Course, I have developed a single trapezoidal pad. Device was manufactured with density 33 foam and was wrapped in washable canvas, the measures of which are shown in Figure 5 (Figure 3, Figure 4 and Figure 5).

Note that to correctly position obese patients, an imaginary line should be drawn between external acoustic meatus and sternum, and such line should be parallel to the ground 3 (Figure 6).

This single trapeze-shaped device eliminates the need for numerous folded sheets, blankets and different pillows which would be needed to obtain such effect. Minor variations could be achieved with small pillows placed under patient's head (Figure 7).

After careful observation, this TI position may be also obtained by bending the operating table with headrest parallel to ground. However not all tables have this facility and for some very obese patients two tables would have to be adapted to perform the proposed operation.

With our pad, not only TI is made easier, but also morbidly obese patients' ventilation is more effective as result of distal shift of breasts and abdomen. Patients themselves, when placed in this position, very often report easier ventilatory movements.

Yours truly.


Ricardo Francisco Simoni, TSA, M.D.
Member of CET/SBA do Instituto Penido Burnier and Centro Médico de Campinas
Address: Rua Cel.Francisco Andrade Coutinho, 222/12
ZIP: 13025-190 City: Campinas, Brazil



01. Mancini MC - Diagnóstico e Classificação da Obesidade, em: Garrido Júnior AB - Cirurgia da Obesidade, São Paulo: Atheneu, 2002;1-7.

02. Ogunnaike BO, Jones SB, Jones DB et al - Anesthetic considerations for bariatric surgery. Anesth Analg, 2002;95:1793-1805.

03. Brodsky JB - Anesthesia for Bariatric Surgery, em: Refresher Course ASA, 2004;506.

04. Neligan PJ - Bariatric Medicine: Clinical Implications of Morbid Obesity, em: Refresher Course ASA, 2004;121.

05. Ezri T, Waters RD, Szmuk P et al - The incidence or class "zero" airway and the impact of  Mallampati score, age, sex, and body mass index on prediction of laringoscopy grade. Anesth Analg, 2001;93:1073-1075.

06. Brodsky JB, Lemmens HJ, Brock-Utne JG et al - Morbid obesity and tracheal intubation. Anesth Analg, 2002;94:732-736.

07. Erzi T, Medalion B, Weisenberg M et al - Increased body mass index per se is not a predictor of difficult laryngoscopy. Can J Anaesth, 2003;50:179-183.

08. Erzi T, Gewurtz G, Sessler DI et al - Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesthesia, 2003;58:1111-1114.

09. Souza LR, Porsani DF, Branco A - Posicionamento do paciente com obesidade mórbida para intubação traqueal. Rev Bras Anestesiol, 2000;50:484-485.

10. Braga AFA, Silva ACM, Cremonesi E - Obesidade mórbida: considerações clínicas e anestésicas. Rev Bras Anestesiol, 1999;49:201-212.

10. Braga AFA, Silva ACM, Cremonesi E - Obesidade mórbida: considerações clínicas e anestésicas. Rev Bras Anestesiol, 1999;49:201-212.

All the contents of this site, except where otherwise noted, is licensed under a Creative Commons Attribution License.