• Giovanni Giordano, Francesco Alessandri, Aurora Zulian, Federico Bilotta, and Francesco Pugliese.
• From the Department of General Surgery, Surgical Specialties and Organ Transplantation 'Paride Stefanini', Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.
• Eur J Anaesthesiol. 2023 May 1; 40 (5): 313325313-325.

BackgroundPredicting a difficult airway, including difficult laryngoscopy, intubation or mask ventilation, is paramount in peri-operative management. As clinical predictors are only partially reliable, ultrasound-based measurements might be useful in evaluating anterior neck fat tissues depth.ObjectivesThe aim of this systematic review is to report clinical evidence on pre-operative ultrasound as a predictor of difficult laryngoscopy, difficult intubation or difficult mask ventilation.DesignA systematic review of randomised controlled trials and observational studies.Data SourcesThe MEDLINE, EMBASE and Google Scholar databases were queried from inception until 28 February 2022.Eligibility CriteriaStudies involving adult patients who had undergone orotracheal intubation after evaluation with airways ultrasound were considered suitable. Exclusion criteria were a clinical history of difficult airways, cancer or trauma, pregnancy, supraglottic airway devices, video-laryngoscopy. Parameters were classified by reporting their accuracy in discriminating 'difficult' vs. 'not difficult' laryngoscopy, intubation or mask ventilation.ResultsThirty-one observational studies were included and a total of 41 single parameters and 12 different combinations of clinical and ultrasound parameters were reported. The distance from skin to epiglottis midway with neutral position of head and neck, the distance from hyoid bone to skin surface with a neutral position of head and neck and the hyomental distance extended/neutral ratio are the most associated with difficult laryngoscopy or difficult intubation. A combination of clinical and ultrasound parameters (a modified Mallampati score, the distance from the skin to the epiglottis midway with neutral position of the head and neck, and the USED-MSH score) showed high accuracy. Only two studies reported the role of ultrasound in predicting difficult mask ventilation: the distance from hyoid bone to skin surface with neutral position of head and neck, the thickness of the base of the tongue with hyperextension of the head, and the hyomental distance with hyperextension of the head and active subluxation of the mandible are the parameters with the highest correlation.ConclusionsThe use of ultrasound parameters might be useful in predicting difficult laryngoscopy or difficult intubation. Several ultrasound parameters and combinations have been associated with difficult laryngoscopy or difficult intubation prediction. The use of scores combining clinical predictors and ultrasound measures are very promising. Data on difficult mask ventilation are scarce and the role of ultrasound is still controversial. Future studies are needed.Clinical Trial RegistrationCRD42021250574.Copyright © 2023 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.

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