|Year : 2022 | Volume
| Issue : 1 | Page : 39-43
The relationship between anthropometric measurements and modified mallampati test in patients with chronic obstructive pulmonary disease
Songul Cuglan1, Evren Köse2, Talat Kılıc3, Murat Ögetürk4, Deniz Senol5, Davut Özbağ2, Cemil Colak6, Hilal Irmak Sapmaz7
1 Departments of Anatomy, Faculty of Medicine, Beykent University, Istanbul, Turkey
2 Departments of Anatomy, Faculty of Medicine, Inönü University, Malatya, Turkey
3 Department of Chest Diseases, Faculty of Medicine, Inönü University, Malatya, Turkey
4 Department of Anatomy, Faculty of Medicine, Fırat University, ElazıAğ, Turkey
5 Department of Anatomy, Faculty of Medicine, Düzce University, Düzce, Turkey
6 Department of Bioistatistics and Medical Informatics, Faculty of Medicine, Inönü University, Malatya, Turkey
7 Department of Anatomy, Faculty of Medicine, Tokat Gaziosmanpaşa University, Tokat, Turkey
|Date of Submission||12-Sep-2021|
|Date of Decision||18-Jan-2022|
|Date of Acceptance||19-Jan-2022|
|Date of Web Publication||12-Jul-2022|
Dr. Songul Cuglan
Department of Anatomy, Faculty of Medicine, Beykent University, Buyukcekmece Campus, Beykent, 34550, Istanbul
Source of Support: None, Conflict of Interest: None
Context: The modified Mallampati test (MMT) is one of the most common examination methods to predict possible intubation problems. Aim: The present study aims to investigate the relationship between anthropometric measurements and the MMT in patients with chronic obstructive pulmonary disease (COPD) during the exacerbation period (COPD-E) and stable period (COPD-S). Materials and Methods: The present study included two groups of participants that consisted of 107 healthy individuals in the control group and 107 patients who were diagnosed with COPD (patient group). Two measurements were taken from the patients during the exacerbation and stable periods. The MMT, body mass index (BMI), face height, thyromental distance, and sternomental distance were measured and recorded. Statistical Analysis Used: Data collected were analyzed using the SPSS Statistics for Windows, version 22.0. Results: In the COPD-E period, the MMT score increased, whereas the face height value decreased (P = 0.030). During the COPD-S period, it was found that the higher BMI values were related to higher MMT scores (P = 0.025). The MMT score increased significantly during the COPD-S period, whereas the thyromental distance values decreased (P = 0.034). Conclusion: It is considered that the low face height value in the COPD-E period, the increase in the BMI, and the decrease in the thyromental distance in the COPD-S period could increase the difficult intubation possibility. The results of the present study which may lead to progression in the COPD database would contribute to the clinicians.
Keywords: Anthropometry, COPD, intratracheal, intubation, MMT score
|How to cite this article:|
Cuglan S, Köse E, Kılıc T, Ögetürk M, Senol D, Özbağ D, Colak C, Sapmaz HI. The relationship between anthropometric measurements and modified mallampati test in patients with chronic obstructive pulmonary disease. Niger J Basic Clin Sci 2022;19:39-43
|How to cite this URL:|
Cuglan S, Köse E, Kılıc T, Ögetürk M, Senol D, Özbağ D, Colak C, Sapmaz HI. The relationship between anthropometric measurements and modified mallampati test in patients with chronic obstructive pulmonary disease. Niger J Basic Clin Sci [serial online] 2022 [cited 2023 Feb 4];19:39-43. Available from: https://www.njbcs.net/text.asp?2022/19/1/39/350721
| Introduction|| |
Chronic obstructive pulmonary disease (COPD) is a disease manifested by both chronic bronchitis and emphysema. COPD is highly prevalent and leads to severe disability risk., Given such scope, data on COPD become significant each day. While the COPD-S (stable) period requires elective surgery, the COPD-E (exacerbation) period might require invasive intubation.
MMT scoring is one of the standard methods to determine difficult intubation., However, several studies in the literature reported that the sole use of MMT scoring was insufficient in determining difficult intubation., Accordingly, some studies evaluate the relationship between the face and neck anthropometric measurement parameters and MMT.
There is one study in the literature that has evaluated the MMT scores of the patients only with obstructive sleep apnea syndrome in the COPD-E period. To our knowledge, no study focused on all the patients in the COPD-E period. The literature review revealed no studies that investigated MMT scores in the COPD-S period and evaluated facial anthropometry in both COPD-E and COPD-S periods.
There is no report regarding examining the relationship between the MMT scores of the patients with COPD and their anthropometric values for the head and neck region. In the present study, we aimed to determine the relationship between the anthropometric values for the head and neck region head and MMT scores in the patients in both COPD-E and COPD-S periods.
| Methods|| |
Determination of the study group
In this prospective cohort study, patients with COPD who were admitted to the clinic of Pulmonary Medicine, Faculty of Medicine at the Inönü University between January 2016 and April 2016, and the healthy control group, were included. This study started after the ethics approval was obtained from the Malatya Clinical Research Ethics Committee of the Faculty of Medicine at the Inönü University, with the number 2016/34.
Written informed consent was obtained from all the participants in this study. COPD-E was evaluated as an acute increase or worsening of respiratory symptoms always present in the chronic and progressive course of COPD. The participants were included in this study based on receiving a COPD-E diagnosis and being above 40 years of age. The patients with asthma and acromegaly, with facial and neck surgery, or with congenital or structural chest deformities were excluded from the present study. The American Society of Anesthesiologists (ASA) score of the patients with COPD was evaluated first. The present study included a control group with 107 healthy subjects above 40 years of age and a patient group with 107 subjects diagnosed with COPD above 40 years of age. All the parameters were measured in the exacerbation period and control group.
Measurements were taken of the patients in the COPD-E period and an attempt was made to reach the same patients in the stable period. One patient was declared deceased during this period. Fifty-four patients did not participate in the second measurement due to different reasons, such as change of address, inaccessibility of the provided contact information, and being in a relapse period. Consequently, 52 patients were contacted in their stable period.
| Technical Information|| |
Digital calipers (Astor, 300 mm, Turkey), scales, and non-stretch cloth measuring tapes were used for the measurements based on the anthropological points of the head and neck region. All measurements were expressed in millimeters and centimeters.
Anthropometric measurements of the head and neck region were completed for each participant included in the present study. Measurements in the head area were carried out in the Frankfort horizontal plane by the same researcher. Subsequently, the MMT scores were evaluated. The modified Mallampati classification was evaluated with the tongue fully protruding and without phonating [Table 1] and [Figure 1]. Four standard anthropological measurements were obtained,,:
Facial height: The distance that connects the vertex with the gnathion points.
Jaw width (go-go): The distance between the gonion and gonion.
Thyromental distance: The distance between the prominentia laryngea and the mentum, when the anterior incisors are closed and the head is in full extension.
Sternomental distance (SMD): The distance between the sternal and the gnathion when the head is in a full extension position.
The power analysis yielded at least 214 units/case, with a minimum of 107 units/case for each group. Data were given as median (min-max). The compliance of the data to the normal distribution was made using the Shapiro–Wilk's or Kolmogorov–Smirnov test based on the number of subjects per group. IBM SPSS Statistics 22.0 software was used for data analysis. A P value of <0.05 was considered statistically significant.
| Results|| |
There was no difference between the MMT scores of the patient group obtained during the COPD-E period and the MMT scores of the control group (P = 0.324). A significant relationship was established between the low facial height during the COPD-E period and high MMT score [Table 2]. There was no difference between the MMT scores of the patient group obtained during the COPD-S period and the MMT scores of the control group (P = 0.954). The findings showed that the BMI values were higher when the MMT scores increased during the COPD-S period (P = 0.025). Furthermore, it was found that only the thyromental distances were lower when the MMT scores increased during this period (PP = 0.034) [Table 3]. No difference was found when the MMT scores of the COPD-E and COPD-S periods were compared (P = 0.317).
|Table 2: MMT scores and anthropometric measurement values for the COPD-E period|
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|Table 3: MMT scores and anthropometric measurement values for the COPD-S period|
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| Discussion|| |
The anthropometric measurements of the head and neck region and MMT scoring for the patients with COPD were evaluated in this study. In the COPD-E period, inflammation increases in the lung. In parallel, there is an increase in systemic inflammation. Edema is inevitable with systemic inflammation and also due to fluid retention, which is common in cases of exacerbation of respiratory failure., We think that edema may cause changes in the facial and neck anthropometric measurements in the COAH-E period. Therefore, anthropometric measurements of the head and neck region were made for the patients with COAH both in the exacerbation and stable periods. The objective was to evaluate how these measurements contributed to the prediction of difficult intubation in patients with COPD.
Obesity is one of the indicators of a difficult airway.,, It was found that patients with high MMT scores during the COPD-E period had high values of BMI. A previous study, conducted with obstructive sleep apnea syndrome patients who were in a COPD-E period, reported a statistically significant relationship between the increase in BMI and the MMT scores for the group with a BMI of 30 kg/m2. In the above-mentioned study, the BMI values were reported higher than in the present study (25.7 kg/m2). We consider that such difference stems from the diversities in population characteristics., To our knowledge, no study focused on the evaluation of the MMT scores during the COPD-S periods in the literature. Therefore, it is possible that the present study is the first to evaluate the MMT scores during the COPD-S period. We found a positive correlation between the BMI values and MMT scores determined in the COPD-S period. In the present study, the BMI values of the patients were above 25, both in the COPD-E and COPD-S periods. Therefore, we consider that increased dimensions and deterioration of the anatomical structure in the neck region resulted in a limitation in the neck extension, where the neck and, especially the pharynx fat tissue, might lead to difficult intubation.,,
We examined the relationship between facial height and MMT score and found that patients with a high MMT score during the COPD-E period had significantly lower facial height values. We also found that the facial height value was low in patients with high MMT scores during the COPD-S period. However, such a finding was not statistically significant. In a study conducted by Taskınalp et al., 250 people with an average age of 19.8 were examined and it was reported that the facial height was 200.0 mm in females and 213.2 mm in males. In another study conducted by Karaca et al., the total facial height was 205.6 mm in females and 222.8 mm in males, for the ages between 20 and 35. We consider that the younger participants in the two above-mentioned studies explain the facial height differences between the present study and those studies. The jaw width is related to the depth of the palatoglossal arch slope. It is acknowledged that an increase in this distance causes a decrease in the depth of the palatoglossal arch slope, thus, increasing the MMT score. In the present study, similarities were found between the control group values in the COPD-E period values for the jaw width. However, there was a decrease during the COPD-S period when compared to the control group. Yılmaz et al. reported that the jaw width was 122 mm in MMS 3 and 139.2 mm in MMS 4 and argued that a jaw width above 113 mm would contribute to the prediction of difficult intubation. In the present study, we determined that the jaw width value was 114.3 mm in the COPD-E period and 108.2 mm in the COPD-S period.
Another valued finding in clinical intubation is the thyromental distance. Thyromental distance indicates whether the displacement of the tongue by the laryngoscope blade will be simple or challenging. Different limit values for thyromental distance were reported in several studies in the literature, such as 6, 6.4, 7, 8, and 9.3 cm, for the prediction of difficult intubation.,,,,,,, We did not establish a relationship between the thyromental distance and the MMT scores during the COPD-E period. However, we found a relationship between the thyromental distance of 8 cm and high MMT scores during the COPD-S period. Acer et al. reported that a thyromental distance below 8 cm might lead to difficult intubation. However, it is still controversial. The normal value of the thyromental distance measurement is still controversial.
Sternomental distance is an indicator of head and neck mobility. In the present study, no significant relationship was found between a high MMT score and sternomental distance. There are many studies on sternomental distance in the literature. In those studies, different values ranging from 10.5 to 16.5 cm were reported for predicting difficult intubation via sternomental distance.,,,,, Several studies have claimed that the assessment of sternomental distance alone is insufficient to predict difficult intubation.,, The sternomental distance values determined in the present study were consistent with the studies that reported the insufficiency of sternomental distance in predicting difficult intubation.
As a result, the findings showed that the MMT scores evaluated both for the exacerbation and stable periods of the patients with COPD were not diverse for the control and COPD patient groups. To our knowledge, for the first time in the literature, lower facial height was found during the COPD-E period. This might be related to an increase in the possibility of difficult intubation. However, there was a lower facial height in the COAH-S period, even not statistically significant. Furthermore, the BMI increased and the thyromental distance decreased in the COPD-S period. Also, it can be speculated that this might be related to the possibility of increasing difficult intubation.
Our study has some limitations. First, the number patients in our study was small. Furthermore, we studied only the Turkish population, so our results may not be applicable to other ethnic groups.
In conclusion, the present study probably is the first to evaluate the MMT score in COPD patients. Given that the incidence of difficult intubation varies between populations, the results of the present study, which may lead to progression in the COPD database, would contribute to the clinicians, such as pulmonologists and anesthetists, who focus on patients with COPD. Further studies with larger sample groups in the patients with COPD are needed to clarify these results.
Preliminary findings of the study was prepared as poster in 9TH ISCAA World Congress, p-5, September 9-12 2017, Innsbruck, Tyrol, Australia.
Declaration of patient consent
All participants provided written informed consent before participation.
Financial support and sponsorship
This study was supported by Inönü University Scientific Projects Coordination Unit with the project number of TSA-2017-642.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pauwels RA, Rabe KF. Burden and clinical features of chronic obstructive pulmonary disease (COPD) Lancet 2004;364:613-20.
Yakar HI, Kanbay A. Could monocyte level/HDL cholesterol ratio predict cardiovascular diseases in patients with COPD? Niger J Clin Pract 2020;23:450-5.
] [Full text]
Ocal S, Topeli A. Kronik obstrüktif akciğer hastalığında güncel bilgiler. İç Hastalıkları Dergisi 2014;21:97-109.
Mallampati R, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al.
A clinical sign to predict difficult tracheal intubation; A prospective study. Can Anaesth Soc J 1985;32:429-34.
Adamus M, Fritscherova S, Hrabalek L, Gabrhelik T, Zapletalova J, Janout V. Mallampati test as a predictor of laryngoscopic view. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2010;54:339-43.
Lundstrom LH, Vester-Andersen M, Moller AM, Charuluxananan S, L'Hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: A meta-analysis involving 177 088 patients. Br J Anaesth 2011;107:659-67.
Turcani P, Skrickova J, Pavlik T, Janousova E, Orban M. The prevalence of obstructive sleep apnea in patients hospitalized for COPD exacerbation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2015;159:422-8.
Yetkin Ö, Günen H. KOAH Alevlenmelerinde Fizyopatolojik Değişiklikler. Solunum Dergisi 2009;11:11-3.
Farkas LG, Katic MJ, Forrest CR, Alt KW, Bagic I, Baltadjiev G, et al.
International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg 2005;16:615-46.
Karaca O, Gulcen B, Kus MA, Elmali F, Kus A. Morphometric facial analysis of Turkish adults. Balikesir Saglik Bil Derg 2012;1:7-11.
Çolak A, Yılmaz A, Memiş D, Süt N, Cigali BS, Kargı M, et al.
What can anthropometric measurements tell us about Mallampati classification? Balkan Med J 2012;29:68-72.
Deveci F, Tuğ T, Turgut T, Ogetürk M, Kirkil G, Kaçar C, et al
. Nutritional status, pulmonary functions, and exercise performance in COPD cases. Tuberk Toraks 2005;53:330-9.
Mador MJ, Kufel TJ, Magalang UJ, Rajesh SK, Watwe V, Grant BJ. Prevalence of positional sleep apnea in patients undergoing polysomnography. Chest 2005;128:2130-7.
Lee SL, Hosford C, Lee QT, Parnes SM, Shapshay SM. Mallampati class, obesity, and a novel airway trajectory measurement to predict difficult laryngoscopy. Laryngoscope 2015;125:161-6.
Voyagis GS, Kyriakis KP, Dimitriou V, Vrettou I. Value of oropharyngeal Mallampati classification in predicting difficult laryngoscopy among obese patients. Eur J Anaesthesiol 1998;15:330-4.
Kurtipek O, Isik B, Arslan M, Unal Y, Kizil Y, Kemaloglu Y. A study to investigate the relationship between difficult intubation and prediction criterion of difficult intubation in patients with obstructive sleep apnea syndrome. J Res Med Sci 2012;17:615-20.
Taskınalp O, Erdem N. Yetişkin Türklerde Yüz ile İlgili Bazı Vertikal Oranlar. Trakya Univ Tip Fak Derg 2009;26:49-52.
Karaca Saygili O, Cinar S, Gulcen B, Ozcan E, Kus I. The validity of eight neoclassical facial canons in the Turkish adults. Folia Morphol 2016;75:512-7.
Yilmaz A, Akcaalan M. What can anthropometric measurements tell us about obstructive sleep apnoea? Folia Morphol (Warsz) 2017;76:301-6.
Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: A meta-analysis of bedside screening test performance. Anesthesiology 2005;103:429-37.
Yildiz TS, Korkmaz F, Solak M, Toker K, Erciyes N, Bayrak F, et al.
Prediction of difficult tracheal intubation in Turkish patients: A multi-center methodological study. Eur J Anaesthesiol 2007;24:1034-40.
Ambesh SP, Singh N, Rao PB, Gupta D, Singh PK, Singh U. A combination of the modified Mallampati score, thyromental distance, anatomical abnormality, and cervical mobility (M-TAC) predicts difficult laryngoscopy better than Mallampati classification. Acta Anaesthesiol Taiwan 2013;51:58-62.
Kandemir T, Şavlı S, Ünver S, Kandemir E. Zor Entübasyonun Öngörülmesinde Mallampati Testinin Antropometrik Ölçümlerle Kombinasyonunun Seçiciliği ve Malignite Varlığı. Turk J Anaesth Reanim 2015;43:7-12.
Sharma S, Majumder K, Kishor K, Das R, Kishor S, Gulia S. Relevance of predictors in difficult ıntubation for patients undergoing maxillofacial surgery. Int J Clin Med 2014;5:1365-73.
Ittichaikulthol W, Chanpradub S, Amnoundetchakorn S, Arayajarernwong N, Wongkum W. Modified Mallampati test and thyromental distance as a predictor of difficult laryngoscopy in Thai patients. J Med Assoc Thai 2010;93:84-9.
Qudaisat IY, Al-Ghanem SM. Short thyromental distance is a surrogate for inadequate head extension, rather than small submandibular space, when indicating possible difficult direct laryngoscopy. Eur J Anaesthesiol 2011;28:600-6.
Acer N, Akkaya A, Tuğay BU, Öztürk A. A comparison of cormeck-lehane and Mallampati tests with mandibular and neck measurements for predicting difficult ıntubation. Balkan Med J 2011;2:157-63.
Wang B, Peng H, Yao W, Guo L, Jin X. Can thyromental distance be measured accurately?. J Clin Monit Comput 2018;32:915-20.
Prakash S, Mullick P, Bhandari S, Kumar A, Gogia AR, Singh R. Sternomental distance and sternomental displacement as predictors of difficult laryngoscopy and intubation in adult patients. Saudi J Anaesth 2017;11:273-8.
Fritscherovaa S, Adamus M, Dostalova K, Koutna J, Hrabalek L, Zapletalova J, et al
. Can difficult intubation be easily and rapidly predicted?. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2011;155:165-71.
Turkan S, Ates Y, Cuhruk H, Tekdemir I. Should we reevaluate the variables for predicting the difficult airway in anesthesiology? Anesth Analg 2002;94:1340-4.
Aftab S, Raja D, Rashdi S, Khalid A. Preoperative assessment of risk factors for difficult intubation. J Surg Pakistan 2008;24:60-4.
Tuzuner-Oncul AM, Kucukyavuz Z. Prevalence and prediction of difficult intubation in maxillofacial surgery patients. J Oral Maxillofac Surg 2008;66:1652-8.
[Table 1], [Table 2], [Table 3]