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Published on: September 28, 2022
A clinical prediction rule to identify difficult intubation in children with Robin sequence requiring mandibular
Zhe Mao1, Na Zhang1, Yingqiu Cui2
1Guangzhou Women and Children's Medical Center, No 9, Jinsui Road, Guangzhou, 510623, Guangdong, China.
Insights
A new prediction rule using craniofacial computed tomography (CT) can identify difficult intubation in children with Robin sequence (RS) before mandibular distraction osteogenesis (MDO). This tool aids in planning airway management for these challenging cases.
Area of Science:
- Medical Imaging
- Pediatric Surgery
- Anesthesiology
Background:
- Airway management in children with Robin sequence (RS) undergoing mandibular distraction osteogenesis (MDO) presents significant challenges.
- Identifying children with RS at high risk for difficult intubation is crucial for safe MDO procedures.
Purpose of the Study:
- To derive and validate a prediction rule for difficult intubation in children with RS before MDO.
- To utilize craniofacial computed tomography (CT) imaging parameters for this prediction.
Main Methods:
- Retrospective study of 69 children with RS requiring MDO.
- Comparison of CT imaging parameters and clinicodemographic data between normal and difficult intubation groups (Cormack-Lehane classification).
- Development of a prediction rule and evaluation using receiver operating characteristic (ROC) curve analysis.
Main Results:
- Overall incidence of difficult intubation was 56.52%.
- Difficult intubation was associated with a shorter tongue-to-posterior pharyngeal wall distance, shallower mandibular angle, and smaller airway cross-sectional area at the epiglottis tip.
- A prediction rule based on airway cross-sectional area at the epiglottis tip (area < 36.97 mm² predicted normal intubation with 100% NPV; area > 36.97 mm² predicted difficult intubation with 100% sensitivity).
Conclusions:
- CT-derived measures can objectively assess upper airway morphology in RS patients to predict difficult intubation.
- The identified CT measures could be integrated into clinical airway assessment tools for guiding treatment decisions.
- Further validation in larger cohorts is recommended for broader clinical application.
Background:
Airway management is challenging in children with Robin sequence (RS) requiring mandibular distraction osteogenesis (MDO). We derived and validated a prediction rule to identify difficult intubation before MDO for children with RS based on craniofacial computed tomography (CT) images.
Method:
This was a retrospective study of 69 children with RS requiring MDO from November 2016 to June 2018. Multiple CT imaging parameters and baseline characteristic (sex, age, gestational age, body mass index [BMI]) were compared between children with normal and difficult intubation according to Cormack-Lehane classification. A clinical prediction rule was established to identify difficult intubation using group differences in CT parameters (eleven distances, six angles, one section cross-sectional area, and three segment volumes) and clinicodemographic characteristics. Predictive accuracy was evaluated by receiver operating characteristic (ROC) curve analysis.
Results:
The overall incidence of difficult intubation was 56.52%, and there was no significant difference in sex ratio, age, weight, height, BMI, or gestational age between groups. The distance between the root of the tongue and posterior pharyngeal wall was significantly shorter, the bilateral mandibular angle shallower, and the cross-sectional area at the epiglottis tip smaller in the difficult intubation group. A clinical prediction rule based on airway cross-sectional area at the tip of the epiglottis was established. Area > 36.97 mm2 predicted difficult intubation while area < 36.97 mm2 predicted normal intubation with 100% sensitivity, 62.5% specificity, 78.6% positive predictive value, and 100% negative predictive value (area under the ROC curve = 0.8125).
Conclusion:
Computed tomography measures can objectively evaluate upper airway morphology in patients with RS for prediction of difficult intubation. If validated in a larger series, the measures identified could be incorporated into airway assessment tools to guide treatment decisions. This was a retrospective study and was granted permission to access and use these medical records by the ethics committee of Guangzhou Women and Children's Medical Center.
Trials Registration:
Registration No. ChiCTR1800018252, NaZhang, Sept 7 2018.
