Authors: Hrushikesh A et al.
Journal: Cureus, Volume 18, Issue 1, Article e102515, 10.7759/cureus.102515
Summary
This prospective observational study in an emergency department evaluated whether a simple bedside score using five noninvasive findings could help predict a difficult airway quickly and more reliably than relying on any single test. The investigators enrolled 200 conscious adults and assessed five predictors at the bedside: BMI >30 kg/m², retrognathia, inability to perform the upper lip bite test, thyromental distance <7 cm, and hyomental distance ≤6 cm. Each item scored 1 point (0–5 total).
For their initial validation, the authors used Modified Mallampati class 3/4 as the reference definition of “difficult airway.” By that definition, 41% of the cohort was classified as difficult (82/200). Among the single predictors, BMI >30 had the highest sensitivity, while the upper lip bite test had the highest specificity. No single variable performed well enough to be used alone as a dependable screening test.
The combined five-parameter score performed better than the individual predictors, with sensitivity about 79% and specificity about 71% at a cutoff of at least 1 point. The ROC curve showed good discrimination (AUC about 0.75). The score’s main practical strength was its higher negative predictive value (about 83%), suggesting it may be most useful as a fast “rule-out” screen in awake ED patients when you need to decide early whether to escalate preparation (extra equipment, additional expertise, backup plan) before medications are given.
Important limitations are that the reference standard was Mallampati (not actual intubation difficulty), unconscious/sedated patients were excluded, and the assessment was performed by a single evaluator at one center. The authors position the tool as a preliminary, practical bedside score that needs multicenter validation and comparison against laryngoscopic view and real-world intubation outcomes.
What You Should Know
This tool is best thought of as an early ED screening score for awake patients that may help you identify who is unlikely to be difficult (high NPV), prompting more deliberate planning when the score is positive. It does not replace laryngoscopy-based outcomes or a full difficult-airway strategy.
Key Points
• Design: prospective observational comparative study in a tertiary ED (India), 200 conscious adults
• Predictors (1 point each): BMI >30, retrognathia, ULBT unable, TMD <7 cm, HMD ≤6 cm
• Reference used for initial validation: Modified Mallampati 3/4
• Performance (cutoff ≥1): sensitivity ~79%, specificity ~71%, AUC ~0.75
• Main practical value: stronger rule-out than rule-in; multicenter validation and outcome-based testing still needed
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