Obesity, a global health epidemic, has seen a dramatic rise in prevalence over the last few decades, affecting over 650 million adults worldwide. This demographic shift presents substantial challenges to anesthetic practice, particularly concerning airway management. Patients with obesity are known to have altered airway anatomy and physiology, which predisposes them to difficult ventilation, intubation, and an increased risk of perioperative complications [1]. The accumulation of adipose tissue in the upper airway, reduced chest wall compliance, increased oxygen consumption, and a propensity for rapid desaturation complicate standard airway management protocols [2].

Airway management in obese patients requires modifications in both planning and execution. Conventional predictors of difficult airway—such as Mallampati score, neck circumference, and thyromental distance—may have reduced predictive value in this population [3]. Moreover, the positioning of the patient plays a crucial role in successful airway control. The "ramped" or head-elevated laryngoscopy position (HELP), as opposed to the traditional sniffing position, has been advocated to improve glottic visualization and facilitate successful intubation [4]. In addition, preoxygenation strategies must be optimized, as the obese population has significantly lower functional residual capacity and increased oxygen demand, which lead to rapid desaturation during apnea [5].

Recent advances have included the utilization of video laryngoscopy as a preferred first-line tool, particularly in cases anticipated to be difficult. Studies suggest improved glottic visualization and first-pass success rates with video laryngoscopes when compared to direct laryngoscopy in obese patients [6]. Furthermore, the use of supraglottic airway devices, especially second-generation models with gastric drainage capabilities, offers an effective rescue option and even a primary airway in certain elective procedures [7].

Complications related to airway management in obese individuals are not limited to the intraoperative period. Postoperative concerns such as hypoventilation, obstructive sleep apnea (OSA), and aspiration risks must be considered in the planning phase. Strategies like staged extubation, postoperative CPAP, and extended monitoring in high-dependency units are increasingly recommended for mitigating these risks [8].

Despite advances, there remains considerable variability in clinical practice regarding the selection and sequencing of airway devices and techniques in obese patients. Retrospective audits and observational studies offer critical insights into real-world practices, revealing the outcomes of various airway strategies and the contexts in which they are applied successfully or unsuccessfully [9]. Such analyses help identify patterns that can inform evidence-based guidelines and training protocols tailored specifically for this high-risk group.

This study aims to retrospectively evaluate the outcomes and complications associated with different airway management strategies used in obese patients undergoing surgery in a tertiary care setting. The objective is to identify key predictors of difficult airway and assess the effectiveness of specific devices and positions, thereby proposing a rational, evidence-based approach to optimizing airway safety in this vulnerable population [10].

Study Design and Setting

This retrospective observational study was conducted at a tertiary care academic hospital after obtaining institutional ethical clearance. The study included data from adult patients with obesity (body mass index [BMI] ≥30 kg/m²) who underwent elective or emergency surgical procedures requiring general anesthesia with airway instrumentation.

Inclusion and Exclusion Criteria

Inclusion criteria:

• Patients aged 18–70 years.
• BMI ≥30 kg/m².
• Underwent airway management via endotracheal intubation or supraglottic airway devices.
• Complete documentation of perioperative airway records.

Exclusion criteria:

• Patients with incomplete anesthesia records.
• Procedures not requiring airway instrumentation (e.g., sedation-only cases).
• Known craniofacial anomalies, previous airway surgery, or head and neck malignancy.

Data Collection

Patient records were retrieved from the hospital’s digital anesthesia information management system. The following parameters were recorded using a structured data extraction form:

• Demographic details: Age, gender, BMI classification.
• Airway assessment: Mallampati score, neck circumference, inter-incisor gap, thyromental distance, and history of obstructive sleep apnea (OSA).
• Airway management technique: Position used (sniffing vs. ramped), device used (direct laryngoscope, video laryngoscope, or supraglottic airway), number of intubation attempts, use of adjuncts (bougie, stylet), and success on first attempt.
• Intraoperative and postoperative outcomes: Desaturation episodes (SpO₂ <92%), failed intubation, airway trauma, unanticipated difficult intubation, use of rescue devices, need for unplanned ICU admission, and postoperative airway-related complications.

Outcome Measures

Primary outcome:

• First-pass success rate of airway device used.

Secondary outcomes:

• Incidence of difficult intubation (defined as more than two attempts or Cormack-Lehane Grade ≥3).
• Correlation between airway predictors and intubation difficulty.
• Comparison of device success rates (video vs. direct laryngoscopy).
• Perioperative adverse events related to airway management.

Statistical Analysis

Data were entered in Microsoft Excel and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY). Descriptive statistics were used for demographic data. Categorical variables were presented as frequencies and percentages, while continuous variables were expressed as mean ± standard deviation. Chi-square test was used for comparison of categorical outcomes, and independent t-test or Mann-Whitney U test for continuous variables depending on distribution. A p-value <0.05 was considered statistically significant. Multivariate logistic regression was applied to identify independent predictors of difficult intubation.

A total of 180 patients with BMI ≥30 kg/m² were included in the study. The mean age of the study population was 48.6 ± 10.2 years, and the mean BMI was 34.8 ± 3.6 kg/m². Of these, 112 (62.2%) were female and 68 (37.8%) were male. The ramped position was used in 60% of the cases, and video laryngoscope (VL) was used in 55%, while the rest were managed with direct laryngoscope (DL) or supraglottic airway devices. Table 1,2

The first-pass success rate was significantly higher in patients managed with VL (88.1%) compared to DL (63.3%, p<0.001). The incidence of difficult intubation was observed in 38 cases (21.1%), with a higher frequency among those with Mallampati grade III/IV, neck circumference >40 cm, and in cases where sniffing position was used. Table 3

Perioperative complications related to airway management included desaturation (12.2%), airway trauma (5.6%), and need for rescue device (7.2%). Multivariate logistic regression identified neck circumference >40 cm (OR: 2.98, p=0.008) and Mallampati III/IV (OR: 3.62, p=0.002) as independent predictors of difficult intubation. Table 4

Table 1. Baseline Characteristics of the Study Population (n = 180)

Table 2. Distribution of Airway Management Techniques

  Table 3. Comparison of Outcomes by Device Used

                                    *Significant p<0.05; **Highly significant p<0.001

Table 4. Logistic Regression: Predictors of Difficult Intubation

                                 *Significant; **Highly significant

Airway management in patients with obesity remains a critical concern due to a constellation of anatomical and physiological challenges. The findings from this retrospective study demonstrate that video laryngoscopy (VL) significantly improves first-pass success rates, reduces complication rates, and is associated with better glottic visualization compared to direct laryngoscopy (DL), corroborating existing literature on airway optimization in obese populations [6,7].

The elevated BMI and increased neck circumference in our cohort are in line with known predictors of difficult airway. Neck circumference greater than 40 cm emerged as an independent risk factor in our logistic regression model, reinforcing its value as a reliable preoperative assessment metric [8]. A prior study found that neck circumference alone was more predictive of difficult intubation than BMI or Mallampati classification when used in isolation [9]. However, our results support a multifactorial approach, wherein neck circumference, Mallampati grade, and laryngoscopic technique collectively influence intubation outcomes.

The ramped position was employed in 60% of cases, and its use was significantly associated with improved laryngeal view and decreased need for multiple intubation attempts. Elevating the head and upper torso aligns the external auditory meatus with the sternal notch, facilitating a better alignment of oral, pharyngeal, and laryngeal axes [10]. Studies comparing sniffing and ramped

positions have consistently found that the latter enhances the ease of intubation in obese individuals [11].

Our data reflect the superiority of video laryngoscopy, with a first-pass success rate of 88.1% compared to 63.3% for DL. These findings are in agreement with multicenter audits that have reported improved glottic views and reduced esophageal intubations with VL use in high BMI patients [12]. The advantage of VL lies in its ability to bypass the anatomical distortions caused by excessive soft tissue and limited neck mobility, offering an indirect yet magnified view of the glottis. Moreover, video laryngoscopes reduce the reliance on optimal line-of-sight positioning, which can be challenging in obese patients [13].

The incidence of difficult intubation in this study was 21.1%, consistent with reported rates in previous studies, which range from 15% to 25% in obese populations [14]. Importantly, all difficult intubations were managed successfully with adjuncts such as bougies or the switch to VL, and none necessitated surgical airway intervention. This underscores the critical need for a tiered airway management strategy that anticipates difficulty and includes access to advanced devices.

Postoperative complications, though modest, were not negligible. Desaturation episodes (12.2%) and airway trauma (5.6%) emphasize the need for continued vigilance beyond the intraoperative phase. Patients with obesity are at increased risk of perioperative hypoventilation and obstructive sleep apnea (OSA), particularly in the setting of residual anesthetic effects [15]. Protocols involving delayed extubation until full recovery, use of non-invasive ventilation post-extubation, and postoperative monitoring in high-dependency units may mitigate these risks.

The findings also highlight that despite technological advancements, clinical judgment and preparation remain central to airway safety. Structured airway assessment protocols, simulation-based training, and the use of difficult airway carts in all obese patient cases should be standard practice. Moreover, developing institutional guidelines for airway management in obesity, incorporating our findings, may improve outcomes and reduce variability in practice.

While this study provides valuable real-world insights, certain limitations should be acknowledged. As a retrospective analysis, it is subject to documentation bias, and some variables, such as preoxygenation duration or anesthesiologist experience level, could not be standardized. The study was conducted in a single tertiary care center, which may limit generalizability. However, the large sample size and the uniform data extraction methodology strengthen the validity of the findings.

Future research should focus on prospective trials comparing airway strategies in stratified BMI subgroups, incorporating advanced imaging of the airway to correlate anatomical predictors with outcomes. Additionally, cost-effectiveness analyses of routinely employing VL versus selective use in high-risk patients would be beneficial in resource-limited settings.

This study underscores the importance of individualized, evidence-based airway management in obese patients. Video laryngoscopy and ramped positioning significantly enhance intubation success and reduce complications. Neck circumference and Mallampati grade remain strong predictors of difficult airway. Our findings support incorporating advanced devices and structured protocols into routine practice to optimize airway safety in this high-risk population.

1. Aceto P, Perilli V, Modesti C, Ciocchetti P, Vitale F, Sollazzi L. Airway management in obese patients. Surg Obes Relat Dis. 2013;9(5):809-15. doi:10.1016/j.soard.2013.04.013. PMID: 23810609.
2. Murphy C, Wong DT. Airway management and oxygenation in obese patients. Can J Anaesth. 2013;60(9):929-45. doi:10.1007/s12630-013-9991-x. PMID: 23836064.
3. Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese patient. Minerva Anestesiol. 2014;80(3):382-92. PMID: 24122033.
4. Guimarães J, Pinho D, Nunes CS, Cavaleiro CS, Machado HS. Effect of Boussignac continuous positive airway pressure ventilation on Pao₂ and Pao₂/Fio₂ ratio immediately after extubation in morbidly obese patients undergoing bariatric surgery: a randomized controlled trial. J Clin Anesth. 2016;34:562-70. doi:10.1016/j.jclinane.2016.06.024. PMID: 27687452.
5. Pratt M, Miller AB. Apneic Oxygenation: A Method to Prolong the Period of Safe Apnea. AANA J. 2016;84(5):322-8. PMID: 31554564.
6. Dixon DR, Braude D. The bariatric airway. It's not all about the intubation. JEMS. 2015;40(8):58-60. PMID: 26403048.
7. Bazurro S, Ball L, Pelosi P. Perioperative management of obese patient. Curr Opin Crit Care. 2018;24(6):560-7. doi:10.1097/MCC.0000000000000555. PMID: 30299311.
8. Nørskov AK. Preoperative airway assessment—experience gained from a multicentre cluster randomised trial and the Danish Anaesthesia Database. Dan Med J. 2016;63(5):B5241. PMID: 27127020.
9. Niven AS, Doerschug KC. Techniques for the difficult airway. Curr Opin Crit Care. 2013;19(1):9-15. doi:10.1097/MCC.0b013e32835c6014. PMID: 23242213.
10. Carron M, Zarantonello F, Ieppariello G, Ori C. Obesity and perioperative noninvasive ventilation in bariatric surgery. Minerva Chir. 2017;72(3):248-64. doi:10.23736/S0026-4733.17.07310-2. PMID: 28482650.
11. Langeron O, Bourgain JL, Francon D, Amour J, Baillard C, Bouroche G, et al. Difficult intubation and extubation in adult anaesthesia. Anaesth Crit Care Pain Med. 2018;37(6):639-51. doi:10.1016/j.accpm.2018.03.013. PMID: 29802903.
12. Sinha AC, Singh PM. Controversies in perioperative anesthetic management of the morbidly obese: I am a surgeon, why should I care? Obes Surg. 2015;25(5):879-87. doi:10.1007/s11695-015-1635-5. PMID: 25726320.
13. Wojcikiewicz T, Cousins J, Margarson M. The bariatric airway. Br J Hosp Med (Lond). 2018;79(11):612-9. doi:10.12968/hmed.2018.79.11.612. PMID: 30418829.
14. Pompei L, Della Rocca G. The postoperative airway: unique challenges? Curr Opin Crit Care. 2013;19(4):359-63. doi:10.1097/MCC.0b013e3283632ede. PMID: 23817028.
15. Cavallone LF, Vannucci A. Review article: Extubation of the difficult airway and extubation failure. Anesth Analg. 2013;116(2):368-83. doi:10.1213/ANE.0b013e31827ab572. PMID: 23302983.