Decision-making in awake fibre optic intubation for patients with severe dentofacial infection: which patients will require fibre optic intubation?

BACKGROUND

Risk factors for advanced airway intervention among patients with dentofacial infection (DFI) are poorly understood. The appropriate delivery of clinical care to this patient group raises challenging anaesthetic service provision issues. The purpose of this study was to identify factors which may predict a requirement for an awake fibre optic intubation (AFOI) technique for airway management in this patient population.

METHODS

A retrospective analysis of data for consecutive patients admitted with DFI were analysed at the Oral & Maxillofacial department at St James's Hospital, Dublin from July 2014-July 2015 was carried out. Receiver operating characteristic analysis determined optimal cut-off values predictive of AFOI, and multivariate logistic regression determined independent risk factors for AFOI.

RESULTS

One hundred and twenty-five patients (64 male, 61 female) were admitted with DFI. The mean age was 35.9 years (range 16-91). AFOI was carried out in 58 (67.4%) patients who required GA. Increasing age was associated with an increase likelihood of AFOI (P = 0.047 95% CI 1.07(1.00-1.14). Reduced mouth opening was significantly associated with requirement for AFOI (28.8 ± 8.6 vs. 14.8 ± 8.6 mm, P < 0.0001). On receiver operating characteristic (ROC) analysis, mouth opening predicted requirement for AFOI with 87% accuracy (AUC 0.87 [95% CI 0.80-0.95], P < 0.0001). Using a cut-off value of 16.5 mm predicted subsequent AFOI with 96.7% (95% CI 78.1-100.0%) specificity and 65.6% (95% CI 51.4-77.8%) sensitivity. Initial C-reactive protein (CRP) was significantly associated with requirement for AFOI (60.1 ± 40.0 vs. 121.3 ± 89.8, P = 0.002). A CRP value of over 110 mg/L predicted subsequent AFOI with 95.8% (95% CI 78.9-100.0%) specificity.

CONCLUSION

Increasing age, reduced mouth opening < 16.5 mm, and an increased serum admission CRP > 100 mg/L on admission significantly increase the requirement for AFOI on multivariate and univariate regression analysis. The availability of anaesthetists experienced in AFOI is essential for safe management of these patients.