CD 008874

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Airway physical examination tests for detection of difficult airway
management in apparently normal adult patients (Review)
Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H
Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H.

Airway physical examination tests for detection of difficult airway management in apparently normal adult patients.
Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD008874.
DOI: 10.1002/14651858.CD008874.pub2.
www.cochranelibrary.com

Airway physical examination tests for detection of difficult airway management in apparently normal adult
patients (Review)
Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 7
OBJECTIVES.................................................................................................................................................................................................. 9
METHODS..................................................................................................................................................................................................... 9
Figure 1.................................................................................................................................................................................................. 11
RESULTS........................................................................................................................................................................................................ 12
Figure 2.................................................................................................................................................................................................. 13
Figure 3.................................................................................................................................................................................................. 14
Figure 4.................................................................................................................................................................................................. 14
Figure 5.................................................................................................................................................................................................. 14
Figure 6.................................................................................................................................................................................................. 16
Figure 7.................................................................................................................................................................................................. 17
Figure 8.................................................................................................................................................................................................. 18
Figure 9.................................................................................................................................................................................................. 19
Figure 10................................................................................................................................................................................................ 20
Figure 11................................................................................................................................................................................................ 21
Figure 12................................................................................................................................................................................................ 21
Figure 13................................................................................................................................................................................................ 22
Figure 14................................................................................................................................................................................................ 23
Figure 15................................................................................................................................................................................................ 24
DISCUSSION.................................................................................................................................................................................................. 24
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 25
ACKNOWLEDGEMENTS................................................................................................................................................................................ 25
REFERENCES................................................................................................................................................................................................ 26
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 37
DATA.............................................................................................................................................................................................................. 230
Test 1. Mallampati test: difficult laryngoscopy................................................................................................................................... 231
Test 2. Mallampati test: difficult tracheal intubation......................................................................................................................... 232
Test 3. Modified Mallampati test: difficult laryngoscopy.................................................................................................................... 232
Test 4. Modified Mallampati test: difficult face mask ventilation...................................................................................................... 232
Test 5. Modified Mallampati test: difficult tracheal intubation.......................................................................................................... 232
Test 6. Modified Mallampati test: failed intubation............................................................................................................................ 232
Test 7. Wilson risk score: difficult laryngoscopy................................................................................................................................. 232
Test 8. Wilson risk score: difficult tracheal intubation....................................................................................................................... 232
Test 9. Thyromental distance: difficult laryngoscopy......................................................................................................................... 232
Test 10. Thyromental distance: difficult face mask ventilation......................................................................................................... 232
Test 11. Thyromental distance: difficult tracheal intubation............................................................................................................. 232
Test 12. Sternomental distance: difficult laryngoscopy...................................................................................................................... 232
Test 13. Sternomental distance: difficult tracheal intubation............................................................................................................ 232
Test 14. Mouth opening: difficult laryngoscopy.................................................................................................................................. 232
Test 15. Mouth opening: difficult face mask ventilation.................................................................................................................... 233
Test 16. Mouth opening: difficult tracheal intubation........................................................................................................................ 233
Test 17. Upper lip bite test: difficult laryngoscopy............................................................................................................................. 233
Test 18. Upper lip bite test: difficult face mask ventilation................................................................................................................ 233
Test 19. Upper lip bite test: difficult tracheal intubation................................................................................................................... 233
Test 20. Combination of tests: difficult laryngoscopy........................................................................................................................ 233
Test 21. Combination of tests: difficult face mask ventilation........................................................................................................... 233
Test 22. Combination of tests: difficult tracheal intubation............................................................................................................... 233
Airway physical examination tests for detection of difficult airway management in apparently normal adult patients (Review) i
Informed decisions.

ADDITIONAL TABLES.................................................................................................................................................................................... 233

APPENDICES................................................................................................................................................................................................. 241
Figure 16................................................................................................................................................................................................ 243
Figure 17................................................................................................................................................................................................ 244
Figure 18................................................................................................................................................................................................ 246
Figure 19................................................................................................................................................................................................ 247
Figure 20................................................................................................................................................................................................ 248
Figure 21................................................................................................................................................................................................ 249
Figure 22................................................................................................................................................................................................ 251
Figure 23................................................................................................................................................................................................ 252
Figure 24................................................................................................................................................................................................ 253
Figure 25................................................................................................................................................................................................ 255
WHAT'S NEW................................................................................................................................................................................................. 256
HISTORY........................................................................................................................................................................................................ 256
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 257
DECLARATIONS OF INTEREST..................................................................................................................................................................... 257
SOURCES OF SUPPORT............................................................................................................................................................................... 258
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 258
INDEX TERMS............................................................................................................................................................................................... 258
Airway physical examination tests for detection of difficult airway management in apparently normal adult patients (Review) ii
Informed decisions.

[Diagnostic Test Accuracy Review]
Airway physical examination tests for detection of difficult airway

management in apparently normal adult patients
Dominik Roth1, Nathan L Pace2, Anna Lee3,4, Karen Hovhannisyan5, Alexandra-Maria Warenits1, Jasmin Arrich1, Harald Herkner1
1Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria. 2Department of Anesthesiology, University of Utah,
Salt Lake City, UT, USA. 3Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong. 4Hong
Kong Branch of The Chinese Cochrane Centre, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The
Chinese University of Hong Kong, Shatin, Hong Kong. 5Clinical Health Promotion Centre, Faculty of Medicine, Lund University, Malmö,
Sweden
Contact address: Harald Herkner, Department of Emergency Medicine, Medical University of Vienna, Währinger Gürtel 18-20, Vienna,
A-1090, Austria. harald.herkner@meduniwien.ac.at.
Editorial group: Cochrane Anaesthesia Group.

Publication status and date: Edited (no change to conclusions), published in Issue 3, 2019.
Citation: Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H. Airway physical examination tests for detection
of difficult airway management in apparently normal adult patients. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.:
CD008874. DOI: 10.1002/14651858.CD008874.pub2.
ABSTRACT
Background
The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully
managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to
identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear.
Objectives
The objective of this review was to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly
used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway
abnormalities. We performed this individually for each of the four descriptors of the difficult airway: difficult face mask ventilation, difficult
laryngoscopy, difficult tracheal intubation, and failed intubation.
Search methods
We searched major electronic databases including CENTRAL, MEDLINE, Embase, ISI Web of Science, CINAHL, as well as regional, subject
specific, and dissertation and theses databases from inception to 16 December 2016, without language restrictions. In addition, we
searched the Science Citation Index and checked the references of all the relevant studies. We also handsearched selected journals,
conference proceedings, and relevant guidelines. We updated this search in March 2018, but we have not yet incorporated these results.
Selection criteria
We considered full-text diagnostic test accuracy studies of any individual index test, or a combination of tests, against a reference standard.
Participants were adults without obvious airway abnormalities, who were having laryngoscopy performed with a standard laryngoscope
and the trachea intubated with a standard tracheal tube. Index tests included the Mallampati test, modified Mallampati test, Wilson risk
score, thyromental distance, sternomental distance, mouth opening test, upper lip bite test, or any combination of these. The target
condition was difficult airway, with one of the following reference standards: difficult face mask ventilation, difficult laryngoscopy, difficult
tracheal intubation, and failed intubation.
Airway physical examination tests for detection of difficult airway management in apparently normal adult patients (Review) 1
Informed decisions.

Data collection and analysis

We performed screening and selection of the studies, data extraction and assessment of methodological quality (using QUADAS-2)
independently and in duplicate. We designed a Microsoft Access database for data collection and used Review Manager 5 and R for data
analysis. For each index test and each reference standard, we assessed sensitivity and specificity. We produced forest plots and summary
receiver operating characteristic (ROC) plots to summarize the data. Where possible, we performed meta-analyses to calculate pooled
estimates and compare test accuracy indirectly using bivariate models. We investigated heterogeneity and performed sensitivity analyses.
Main results
We included 133 (127 cohort type and 6 case-control) studies involving 844,206 participants. We evaluated a total of seven different
prespecified index tests in the 133 studies, as well as 69 non-prespecified, and 32 combinations. For the prespecified index tests, we found
six studies for the Mallampati test, 105 for the modified Mallampati test, six for the Wilson risk score, 52 for thyromental distance, 18 for
sternomental distance, 34 for the mouth opening test, and 30 for the upper lip bite test. Difficult face mask ventilation was the reference
standard in seven studies, difficult laryngoscopy in 92 studies, difficult tracheal intubation in 50 studies, and failed intubation in two
studies. Across all studies, we judged the risk of bias to be variable for the different domains; we mostly observed low risk of bias for
patient selection, flow and timing, and unclear risk of bias for reference standard and index test. Applicability concerns were generally
low for all domains. For difficult laryngoscopy, the summary sensitivity ranged from 0.22 (95% confidence interval (CI) 0.13 to 0.33; mouth
opening test) to 0.67 (95% CI 0.45 to 0.83; upper lip bite test) and the summary specificity ranged from 0.80 (95% CI 0.74 to 0.85; modified
Mallampati test) to 0.95 (95% CI 0.88 to 0.98; Wilson risk score). The upper lip bite test for diagnosing difficult laryngoscopy provided the
highest sensitivity compared to the other tests (P < 0.001). For difficult tracheal intubation, summary sensitivity ranged from 0.24 (95% CI
0.12 to 0.43; thyromental distance) to 0.51 (95% CI 0.40 to 0.61; modified Mallampati test) and the summary specificity ranged from 0.87
(95% CI 0.82 to 0.91; modified Mallampati test) to 0.93 (0.87 to 0.96; mouth opening test). The modified Mallampati test had the highest
sensitivity for diagnosing difficult tracheal intubation compared to the other tests (P < 0.001). For difficult face mask ventilation, we could
only estimate summary sensitivity (0.17, 95% CI 0.06 to 0.39) and specificity (0.90, 95% CI 0.81 to 0.95) for the modified Mallampati test.
Authors' conclusions
Bedside airway examination tests, for assessing the physical status of the airway in adults with no apparent anatomical airway
abnormalities, are designed as screening tests. Screening tests are expected to have high sensitivities. We found that all investigated index
tests had relatively low sensitivities with high variability. In contrast, specificities were consistently and markedly higher than sensitivities
across all tests. The standard bedside airway examination tests should be interpreted with caution, as they do not appear to be good
screening tests. Among the tests we examined, the upper lip bite test showed the most favourable diagnostic test accuracy properties.
Given the paucity of available data, future research is needed to develop tests with high sensitivities to make them useful, and to consider
their use for screening difficult face mask ventilation and failed intubation. The 27 studies in 'Studies awaiting classification' may alter the
conclusions of the review, once we have assessed them.
PLAIN LANGUAGE SUMMARY
Bedside examination tests to detect beforehand adults who are likely to be difficult to intubate
Review question
We looked for the most suitable and accurate rapid screening test in adults with no obvious airway abnormalities, to identify those who
are likely to be difficult to intubate (i.e. insertion of a tube into the windpipe).
Background
Intubation ensures a patient’s airway is clear while they are heavily sedated, unconscious or anaesthetized, so their breathing can be
controlled by machine (ventilation), and appropriate levels of oxygen can be given during surgery, following major trauma, during critical
illness, or following cardiac arrest. Having an airway that is difficult to intubate is a potentially life-threatening situation.
Tube insertion is preceded by laryngoscopy (insertion of mini-camera to view route of tube insertion), requires advanced skills, and is
generally uneventful. Intubation is difficult in approximately 10% of patients, who require special equipment and precautions. Several
physical features are associated with difficult airways and failed intubation, so warning of potentially difficult airways would be helpful.
Several quick bedside tests are in routine clinical use to identify those at high risk for difficult airways, but how accurate these are remains
unclear.
Population
We included studies of adults aged 16 years or older without obvious airway abnormalities who were to receive standard intubation.
Test under investigation
We assessed the seven most common bedside tests, routinely used to detect difficult airways. These take only a few seconds to complete
and require no special equipment.
Informed decisions.

The index tests (diagnostic tests of interest) included:
- the Mallampati test (original or modified; asking a sitting patient to open his mouth and to protrude the tongue as much as possible so
that visibility can be determined);
- Wilson risk score (including patient's weight, head and neck movement, jaw movement, receding chin, buck teeth);
- thyromental distance (length between the chin and the upper edge of Adam's apple);
- sternomental distance (length between the chin and the notch between the collar bones);
- mouth opening test;
- upper lip bite test;
- or any combination of these tests.
Search date
The evidence is current to 16 December 2016. (We searched for new studies in March 2018, but we have not yet included them in the review.)
Study characteristics
We included 133 studies (844,206 participants) which investigated the accuracy of the seven tests above, plus 69 other common tests and
32 test combinations, in detection of difficult airways.
Key results
For difficult laryngoscopy, the average sensitivity (percentage of correctly identified difficult airways) ranged from 22% (mouth opening
test) to 63% (upper lip bite test). The average specificity (percentage of correctly classified patients without difficult airways) ranged from
80% (modified Mallampati test) to 95% (Wilson risk score). The upper lip bite test had the highest sensitivity of all tests considered.
For difficult tube insertion, the average sensitivity ranged from 24% (thyromental distance) to 51% (modified Mallampati test) and the
average specificity ranged from 87% (modified Mallampati test) to 93% (mouth opening test). The modified Mallampati test had the highest
sensitivity of all tests considered.
For difficult face mask ventilation (another indication of a difficult airway), there were only enough data to calculate average sensitivity of
17% and specificity 90% for the modified Mallampati test.
Quality of the evidence
Overall, the evidence from the studies was of moderate to high quality. The likelihood of the studies providing reliable results was generally
high, although in half of them, the intubating physician knew the result of the preceding test, which may have influenced results, but this
is the normal situation in routine clinical care. The characteristics of patients, tests, and conditions were comparable to those seen in a
wide range of everyday clinical settings. The results of this review should apply to standard preoperative airway assessments in apparently
normal hospital patients worldwide.
Conclusion
The bedside screening tests examined in this review are not well suited for the purpose of detecting unanticipated difficult airways because
they missed a large number of people who had a difficult airway.
Airway physical examination tests for detection of difficult airway management in apparently normal adult patients (Review)
SUMMARY OF FINDINGS

Summary of findings 1. Airway physical examination tests for detection of difficult airway management in apparently normal patients
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Patients or population: adults with no apparent anatomical airway abnormalities
Settings: operating theatres, intensive care units and emergency departments
Studies: total of 133 studies, mostly cohort type studies; six case-control studies. Each study can be present in more than one analysis
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Test Number of Summary Summary Prevalence Implications Quality and comments
participants sensitivity specificity median (IQR)
(studies) (95% confi- (95% confi-
dence inter- dence inter-
val) val)
Difficult laryngoscopy
Mallampati 2165 (6) 0.40 (0.16 to 0.89 (0.75 to 10% (5% to With a prevalence of 10%, 10 out of 100 patients Limited number of studies.
test 0.71) 0.96) 16%) will have difficult laryngoscopy. Of these, 6 will be
missed by the Mallampati test (60% of 10). Of the 90 Risk of bias mostly low in all
patients without difficult laryngoscopy 10 will be un- domains.
necessarily classified as having difficult airway.
Applicability concerns low.
Modified Mal- 232,939 (80) 0.53 (0.47 to 0.80 (0.74 to 10% (5% to With a prevalence of 10%, 10 out of 100 patients Risk of bias mostly unclear
lampati test 0.59) 0.85) 16%) will have difficult laryngoscopy. Of these, 5 will be in all domains.
missed by the modified Mallampati test (47% of 10).
Of the 90 patients without difficult laryngoscopy 18 Applicability concerns
will be unnecessarily classified as having a difficult mostly low.
airway.
Wilson risk 5862 (5) 0.51 (0.40 to 0.95 (0.88 to 10% (5% to With a prevalence of 10%, 10 out of 100 patients Limited number of studies.

score 0.61) 0.98) 16%) will have difficult laryngoscopy. Of these, 5 will be
missed by the Wilson risk score (49% of 10). Of the 90 Risk of bias unclear.
patients without difficult laryngoscopy 5 will be un-
Applicability concerns
necessarily classified as having a difficult airway.
mostly low in all domains.
Thyromental 33,189 (42) 0.37 (0.28 to 0.89 (0.84 to 10% (5% to With a prevalence of 10%, 10 out of 100 patients Risk of bias mostly low in all
distance 0.47) 0.93) 16%) will have difficult laryngoscopy. Of these, 6 will be domains.
missed by thyromental distance (63% of 10). Of the
90 patients without difficult laryngoscopy 10 will be Applicability concerns low.
unnecessarily classified as having a difficult airway.
4

Sternomental 12,211 (16) 0.33 (0.16 to 0.92 (0.86 to 10% (5% to With a prevalence of 10%, 10 out of 100 patients Risk of bias mostly low in all
distance 0.56) 0.96) 16%) will have difficult laryngoscopy. Of these, 7 will be domains.
missed by sternomental distance (67% of 10). Of the
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Mouth open- 22,179 (24) 0.22 (0.13 to 0.94 (0.90 to 10% (5% to With a prevalence of 10%, 10 out of 100 patients Risk of bias mostly low in all
ing test 0.33) 0.97) 16%) will have difficult laryngoscopy. Of these, 8 will be domains.
missed by the mouth opening test (78% of 10). Of the
Applicability concerns low.
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Trusted evidence.
90 patients without difficult laryngoscopy 5 will be
Upper lip bite 19,609 (27) 0.67 (0.45 to 0.92 (0.86 to 10% (5% to With a prevalence of 10%, 10 out of 100 patients Risk of bias mostly low in all
test 0.83) 0.95) 16%) will have difficult laryngoscopy. Of these, 3 will be domains.
missed by the upper lip bite test (33% of 10). Of the
Difficult tracheal intubation
Modified Mal- 191,849 (24) 0.51 (0.40 to 0.87 (0.82 to 11% (5% to With a prevalence of 11%, 11 out of 100 patients will Risk of bias mostly unclear
lampati test 0.61) 0.91) 13%) have difficult tracheal intubation. Of these, 5 will be in all domains.
missed by the modified Mallampati test (49% of 11).
Of the 89 patients without difficult tracheal intuba- Applicability concerns
tion 12 will be unnecessarily classified as having a mostly low in all domains.
difficult airway.
Thyromental 5089 (10) 0.24 (0.12 to 0.90 (0.80 to 11% (5% to With a prevalence of 11%, 11 out of 100 patients will Risk of bias mostly low in all
distance 0.43) 0.96) 13%) have difficult tracheal intubation. Of these, 8 will be domains.
missed by thyromental distance (76% of 11). Of the
89 patients without difficult tracheal intubation 9 Applicability concerns low.
will be unnecessarily classified as having a difficult
airway.

Mouth open- 6091 (9) 0.27 (0.16 to 0.93 (0.87 to 11% (5% to With a prevalence of 11%, 11 out of 100 patients will Risk of bias mostly low in all
ing test 0.41) 0.96) 13%) have difficult tracheal intubation. Of these, 8 will be domains.
missed by the mouth opening test (73% of 11). Of the
89 patients without difficult tracheal intubation 6 Applicability concerns low.
will be unnecessarily classified as having a difficult
airway.
Difficult face mask ventilation
Modified Mal- 56,323 (6) 0.17 (0.06 to 0.90 (0.81 to 11% (6% to With a prevalence of 11%, 11 out of 100 patients will Risk of bias mostly unclear
lampati test 0.39) 0.95) 28%) have difficult face mask ventilation. Of these, 9 will in all domains.
5

be missed by the modified Mallampati test (83% of Applicability concerns
11). Of the 89 patients without difficult face mask mostly low.
ventilation 9 will be unnecessarily classified as hav-
ing a difficult airway.
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CAUTION: the results on this table should not be interpreted in isolation from the results of the individual included studies contributing to each summary test accuracy mea-
sure. We have reported these in the main body of the text of the review. We calculated prevalences from the included studies by reference standard.
IQR: interquartile range.
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6

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BACKGROUND • Failed intubation: placement of the tracheal tube fails after

multiple intubation attempts.
Target condition being diagnosed
Current guidelines added difficult placement or functioning of
The difficult airway is a potentially life-threatening event during supraglottic devices as a dimension for the difficult airway (ASA
anaesthesia, following major trauma, with the onset of critical 2013). Difficult face mask ventilation is generally due to an
illness, and for resuscitation following cardiac arrest. While any inadequate mask fit or excessive resistance to gas ingress or egress;
part of the respiratory tract (through which air passes during face mask ventilation is usually facilitated by the insertion of
breathing) is considered to be part of the airway, the difficult an oral airway or by the administration of muscle relaxants (El-
airway is focused on the upper airway, that is, the portion of the Orbany 2009). Beside the signs of absent or inadequate chest
respiratory tract that extends from the nares or mouth to, and wall movement and breath sounds, difficult ventilation is also
including, the larynx. Thus subglottic stenosis, a type of airway recognized by falling oxygen saturation or increasing partial
obstruction, and other subglottic problems are not part of this pressure of carbon dioxide in the arterial blood (PaCO2), or both.
definition of the difficult airway. The upper airway must be patent Kheterpal and colleagues reported the risk of this difficult airway
(open and unblocked) to allow spontaneous lung ventilation by the event during anaesthesia in over 50,000 patients (Kheterpal 2009).
patient and for physician-, nurse- or therapist-managed assisted Using the descriptions "difficult ventilation (inadequate, unstable,
ventilation. Additionally, during severe illness or states of altered or requiring two providers) with or without muscle relaxant" and
consciousness the airway must be secured to prevent soiling of "unable to mask ventilate with or without muscle relaxant" the
the lower airway (trachea, bronchi, etc.) and lung parenchyma by prevalence was 2.2% (1141/53,401) for the former and 0.15%
gastric contents, oral secretions, infectious material and blood. (77/53,041) for the latter.
Without a patent airway, asphyxia develops within seconds to
minutes; without resolution of the loss of a patent airway, death The standard rigid laryngoscope typically consists of a handle
occurs quickly (ASA 2003). containing batteries and an interchangeable blade with a light
source. There are many types of laryngoscope blades. The two main
Most commonly, there is an orderly sequence of events in types are the curved Macintosh blade and the straight Miller blade.
the process of upper airway management by practitioners that The tip of the Macintosh blade is advanced into the vallecula, where
terminates with endotracheal intubation. The initial step is the it sits anterior to the epiglottis and raises the epiglottis out of the
application of a tight fitting face mask with the patient continuing visual pathway; the Miller blade is advanced further into the airway
to breath spontaneously. Typically, sedating and paralysing drugs with the tip sitting posterior to the epiglottis, trapping and elevating
are administered to facilitate airway access. This is followed by the the epiglottis while exposing the glottis and vocal folds. However,
application of positive airway pressure, generated manually with a both a curved and a straight blade can be used in either fashion with
breathing bag, to provide assisted ventilation. Next, a laryngoscope the tip of the blade in the vallecula or behind the epiglottis. Each
is inserted into the mouth and pharynx to allow visualization of the blade comes in several lengths and widths to accommodate patient
glottis and, finally, a tracheal tube is advanced through the glottis size (ASA 2003).
into the trachea (ASA 2003).
Cormack and Lehane (Cormack 1984), proposed a four-grade
The difficult airway is not a disease; neither is it just one scoring system to describe the view at direct laryngoscopy. using
particular anatomical characteristic of patient physiognomy. these standard laryngoscopes. The assigned grades are:
Strictly speaking, the difficult airway (or difficult airway event)
describes difficulty in or failure to complete one or more of the • full view of the glottis;
sequential steps in upper airway management. It is a complex • partial view of the glottis or arytenoids;
interaction of patient anatomy, clinical circumstances and clinician
• only epiglottis visible;
skill. Nevertheless, the usual focus of the difficult airway is
anatomical anomalies in contrast to functional airway obstruction • neither glottis nor epiglottis visible.
that can accompany inadequate anaesthesia (the struggling
This scoring system was extended by Yentis and Lee (Yentis 1998),
patient, coughing, laryngospasm, opioid induced skeletal muscle
by subdividing grade 2 into 2a) partial view of the glottis; and 2b)
and laryngeal rigidity, bronchospasm etc.). Thus, the difficult
arytenoids or posterior part of the vocal cords only just visible.
airway does not have a reference standard other than the result of
Other modifications of the Cormack and Lehane grades were
the actual attempted airway management for a patient. While there
proposed in the Cook 2000 study. Difficult laryngoscopy is usually
are no standardized definitions of a difficult airway event, the 2003
defined as a laryngeal exposure with a score of grade 3 or grade
practice guidelines from the American Society of Anesthesiologists
4. A systematic review (9 studies with 14,438 participants) found
(ASA), suggested using at least four descriptors of difficult airway
that the prevalence of difficult laryngoscopy ranged from 6% to
events (ASA 2003). In a simplified form, these are as follows.
27% (Lee 2006); in these nine studies the original Cormack and
• Difficult face mask ventilation: it is not possible to provide Lehane grades were almost uniformly used to classify difficult
adequate face mask ventilation. laryngoscopy.
• Difficult laryngoscopy: even with multiple attempts it is not Difficult tracheal intubation has been variously defined as a
possible to visualize any portion of the vocal cords during procedure requiring excessive time, multiple attempted passages
conventional laryngoscopy. of the tracheal tube, or having to resort to specialized equipment.
• Difficult tracheal intubation: tracheal intubation requires A quantitative intubation difficulty scale has been proposed (Adnet
multiple attempts. 1997). Lundstrom and colleagues defined a non-difficult tracheal
intubation as "intubated by direct laryngoscope by the first
Informed decisions.

anaesthetist and in two attempts maximally"; difficult tracheal • Modified Mallampati test.
intubation was any event with more than two anaesthetists, more • Wilson risk score.
than two attempts, use of specialized equipment or failed passage • Thyromental distance.
(Lundstrom 2009). In a cohort of over 90,000 patients having
• Sternomental distance.
anaesthesia, the prevalence of difficult tracheal intubation was
5.2% (4704/91,297) (Lundstrom 2009). • Mouth opening test.
• Upper lip bite test.
Failed intubation is the least common of the difficult airway events.
Lundstrom and colleagues reported a frequency of 0.15% in 91,297 See Table 1 for more details.
participants (Lundstrom 2009). Failed intubation may be defined
as "a maximum of three attempts at intubation; a fourth attempt Clinical pathway
by a more experienced colleague is permissible. If unsuccessful, a Before patients undergo surgery with general anaesthesia, it is
failed intubation should be declared and Plan B implemented" (DA common practice to screen for a difficult airway. This screening
Society 2015). includes taking a medical history and identifying overt flags for
the difficult airway, such as malformations or deformations. For
Because the definitions of the difficult airway are not standardized,
these individuals, alternative methods of airway management are
the prevalence depends on the definition. For example, the Rose
planned in advance. For the remaining apparently normal patients,
1996 study used three definitions for difficulties during intubation.
there is still a risk of unanticipated difficult airway.
These are: poor view at laryngoscopy (Cormack and Lehane grade
3 to 4); three or more direct laryngoscopy attempts before insertion To further reduce the number of individuals with an unanticipated
of the endotracheal tube; and failure to insert the endotracheal difficult airway, clinicians perform bedside airway physical
tube with direct laryngoscopy. The prevalence was 10.1%, 1.9%, examination tests. The results of these bedside tests help
and 0.1% respectively. The prevalence also depends on the healthcare providers to plan different levels of alternative airway
circumstances of medical management, being more difficult in a management. A difficult airway occurs in the early phases of
prehospital setting (Adnet 1997). The Combes 2006 study found the general anaesthesia when airway management takes place.
prevalence of difficult tracheal intubation in a prehospital setting
to be 7.4%. With the exception of the Wilson risk score, each of these tests
can be completed in five to 15 seconds; the Wilson risk score
Index test(s) also requires information about the patient's weight. Two tests,
The difficult airway may be the result of obvious upper airway Mallampati and thyromental distance, have been combined in
pathology or anatomical anomaly. When such upper airway some reports of screening tests. The performance of these tests
distortion is obvious, the prudent practitioner will choose alternate by different examiners can have large interobserver variability. The
plans for airway management. It is the unanticipated difficult Karkouti 1996 study had two observers independently perform an
airway in a patient without obvious airway pathology or anatomical airway physical examination with 10 characteristics in 59 patients,
anomaly that has fostered the search for diagnostic screening including some of the specific tests in Table 1. The poorest
tests. These have most commonly been extensions of the physical test performance was with the Mallampati, with classification of
examination of the patient, with a grading or scoring system for one patients having only a fair agreement between the observers
or more particular attributes of the head, neck and mouth. Some (Kappa coefficient 0.31). The difficulty in achieving repeatability
of these particular attributes that are thought to be relevant for of airway classification may explain some of the skepticism about
detection of the unanticipated difficult airway include the following using the index tests before surgery.
(ASA 2013).
Rationale
• Distance between upper and lower incisors. The serious morbidity and mortality associated with unsuccessfully
• Length of the upper incisors. managed upper airway was recognized decades ago. This
• Neck length. prompted the standard use of pulse oximetry and capnography
• Neck diameter. during anaesthesia and emergency care. In addition, learned
• Range of neck flexion and extension. societies, in particular the ASA and the Difficult Airway Society,
have promulgated guidelines for management of the difficult
• Shape of the palate.
airway (ASA 2013; DA Society 2015). There is indirect evidence
• Thyromental distance. from the ASA's closed claims analysis that claims for death
• Tissue compliance of the submandibular space. and brain damage during the induction of anaesthesia have
• Relationship of maxillary and mandibular incisors during decreased between the years 1985 to 1992 and 1993 to
normal jaw closure. 1999 (Peterson 2005). Also, the Berkow 2009 study reported
• Relationship of maxillary and mandibular incisors during a reduction in the need for an emergent surgical airway via
voluntary protrusion of mandible. tracheostomy through the introduction of a comprehensive
difficult airway programme. These improvements in outcomes
• Visibility of the uvula.
have been ascribed to standardized airway examination, improved
The most popular of these screening tests by airway physical monitoring, new airway devices and technology, and practice
examination include the following. guidelines. Specifically, significant advances in the availability of
robust video laryngoscopy equipment and other airway devices,
• Mallampati test. such as laryngeal mask airways, have dramatically increased the
Informed decisions.

techniques available for patients with a difficult airway (Luba 2010; index test other than bedside tests (for example, those involving
Pott 2008). radiological imaging).
The role of screening tests and their benefits are still uncertain. Participants
Four systematic reviews of airway examination tests have been
We included adults of either sex, aged 16 years or greater, without
published (ASA 2003; Lee 2006; Lundstrom 2011; Shiga 2005).
obvious airway abnormalities who were having laryngoscopy
The ASA Taskforce concluded that "There is insufficient published
performed with a standard laryngoscope (usually size 3 Macintosh
evidence to evaluate the predictive value of multiple features of the
blade) and the trachea intubated with a styletted or non-styletted
airway physical examination versus single features in predicting the
tracheal tube. We excluded studies performed in populations with
presence of a difficult airway" and "An airway physical examination
a high prevalence of abnormal airways (maxillofacial trauma,
should be conducted, whenever feasible, before the initiation of
cervical spine trauma, or otorhinolaryngology tumours) or those
anaesthetic care and airway management in all patients" (ASA
performed using specialized laryngoscopes or techniques (for
2013); this report did not present a meta-analysis. The Lee 2006
example, awake fibreoptic intubation).
systematic review and meta-analysis reported that "the Mallampati
tests have limited accuracy for predicting the difficult airway and Index tests
thus are not useful screening tests". The Lundstrom 2011 systematic
review and meta-analysis was limited to the modified Mallampati We included bedside tests used singly or in combination for
score only. Their conclusion was "that the modified Mallampati detection of a difficult airway. These include any version of the
score is inadequate as a stand-alone test of a difficult laryngoscopy Mallampati test (Ezri 2001; Mallampati 1985; Samsoon 1987),
or tracheal intubation". The Shiga 2005 systematic review and Wilson risk score (Wilson 1988), thyromental distance (Lewis 1994),
meta-analysis of six airway screening tests found that "the clinical sternomental distance (Ramadhani 1996), mouth opening test
value of bedside screening tests for predicting difficult intubation (Calder 2003), and upper lip bite test (Khan 2003), but were not
remains limited". Nevertheless, an airway physical examination limited to these tests. We collected information on the inter-
is still recommended (ASA 2003; ASA 2013). For example, airway or intraobserver correlation of the tests, or both, if reported or
examination may be useful in order to select the patients for which referenced in the study.
newer devices are most likely to be useful.
Target conditions
Since the previous systematic reviews, new statistical methods for The target condition was difficult airway. Although the difficult
the meta-analysis of diagnostic tests with correct handling of the airway does not have a reference standard other than the result of
dependency structure of such data are available. For example, the the actual attempted airway management for a patient, the 2003
variability of the predictive performance of a diagnostic test in practice guidelines of the American Society of Anesthesiologists
future patients can now be more correctly estimated. Additionally, (ASA), suggested using at least four descriptions of difficult airway
more studies of large sample size have been published. This review events (ASA 2003), as follows.
will incorporate an up-to-date literature search and new statistical
methods to establish the diagnostic properties of airway physical • Difficult face mask ventilation.
examination screening tests. • Difficult laryngoscopy.
OBJECTIVES • Difficult tracheal intubation.
• Failed intubation.
The objective of this review was to characterize and compare
the diagnostic accuracy of the Mallampati classification and other Reference standards
commonly used airway examination tests for assessing the physical As outline above in Target condition being diagnosed, the
status of the airway in adult patients with no apparent anatomical reference standards were: difficult face mask ventilation, difficult
airway abnormalities. We performed this individually for each of laryngoscopy, difficult tracheal intubation, and failed intubation.
the four descriptors of the difficult airway: difficult face mask As there were no standard definitions for the reference standards,
ventilation, difficult laryngoscopy, difficult tracheal intubation, and we accepted the authors' definition used for each study.
failed intubation.
Search methods for identification of studies
METHODS
We performed electronic searches and searched other resources.
Criteria for considering studies for this review
Electronic searches
Types of studies
The search is current to 16 December 2016. For identifying any
We considered diagnostic test accuracy studies (case-control or eligible studies, we searched the following electronic databases.
consecutive series) of any individual index test or a combination
of the tests listed in Table 1 against a reference standard. We • Cochrane Central Register of Controlled Trials (CENTRAL; 2016,
required studies to provide data for true positives, false positives, Issue 11), in the Cochrane Library (see Appendix 1).
false negatives and true negatives. We excluded studies that were • Cochrane Register of Diagnostic Test Accuracy Studies
reported only in abstract form, were uncontrolled reports (case • MEDLINE Ovid SP (1946 to 16 December 2016; see Appendix 2).
series, case reports), randomized controlled trials of test-treatment
• Embase Ovid SP (1874 to 16 December 2016; see Appendix 3).
design that are more appropriately analysed as intervention than
as diagnostic test accuracy studies, and studies that examined an • ISI Web of Science (1950 to 16 December 2016; see Appendix 4).
• CINAHL EBSCO host (1982 to 16 December 2016; see Appendix 5).
Informed decisions.

When searching the databases, we used both subject headings • British Journal of Anaesthesia (from 1995 to 29 December 2016).
and free text terms. We adapted our MEDLINE search strategy for • Canadian Journal of Anesthesia (from 1995 to 29 December
searching all other databases. 2016).
We also searched the following regional electronic bibliographic • Critical Care Medicine (from 1995 to 29 December 2016).
databases, subject-specific databases, and dissertation and theses • Intensive Care Medicine (from 1995 to 29 December 2016).
databases. • American Journal of Respiratory and Critical Care Medicine (from
1995 to 29 December 2016).
• IndMED • Abstracts from congresses of the European Society of
• KoreaMED Anaesthesiology (from 2004 to 29 December 2016).
• LILACS • Abstracts from the International Anesthesia Research Society
• Panteleimon (from 2000 to 29 December 2016).
• PASCAL • ATS international conference proceedings (from 2008 to 29
• Google Scholar December 2016).
• Turning Research into Practice (TRIP) database • International Symposium on Intensive Care and Emergency
• DissOnline Medicine proceedings (from 1997 to 29 December 2016).
• OpenSIGLE • American Society of Anesthesiologists Annual Meeting
proceedings (from 2000 to 29 December 2016).
We did not apply any language restrictions.
We also searched guidelines by the French, Italian, Spanish and
We performed a further search in March 2018. We have added those German Societies of Anaesthesiology and Intensive Care.
results to 'Studies awaiting classification' and we will incorporate
them into the review at the next update. Data collection and analysis
Selection of studies
Searching other resources
NLP, DR and HH independently, and in duplicate, performed
For identifying any additional published, unpublished and ongoing
selection of studies. We resolved disagreements by discussion or
studies, we searched the Science Citation Index and checked the
by involving AL as arbiter. We initially screened studies by the
references of all the relevant studies. We also handsearched the
title and abstract and then retrieved full reports for potentially
following journals and proceedings of the following conferences.
relevant studies. For these studies, we used a predefined electronic
• Acta Anaesthesiologica Scandinavica (from 1995 to 29 December spreadsheet to assess and document studies for inclusion and
2016). exclusion according to the above selection criteria. We documented
study selection in a flow chart (Liberati 2009; Figure 1).

Informed decisions.

Figure 1. Study flow diagram.

Data extraction and management Access. We resolved disagreements by discussion or by involving
AL or HH as arbiter. We then transferred data to Review Manager 5
We independently, and in duplicate, performed data extraction
(Review Manager 2014), Stata 14 (Stata 2015) and to R (R 2017), for
using a predefined electronic spreadsheet within the database, MS
further calculations.
Informed decisions.

Assessment of methodological quality results as sensitivity and specificity, as from the bivariate estimates
(logit transformed) with 95% CIs.
We independently, and in duplicate, performed assessment of
methodological quality using a predefined electronic spreadsheet. We produced a specificity versus sensitivity plot showing the study
We resolved disagreements by discussion or by involving AL or HH estimates of individual studies, the summary receiver operating
as arbiter. We used all four domains (Table 2), from the QUADAS-2 characteristic (ROC) point (summary values for sensitivity and
tool (Whiting 2011), a revision of the original QUADAS tool (Whiting specificity) and the 95% confidence region around the summary
2003), to assess the methodological quality of the included studies ROC point.
that is implemented in Review Manager 2014. This included the risk
of bias with signalling questions and applicability judgement. We We indirectly compared index tests and index test combinations
presented both a description and the judgement (coded 'yes', 'no', by including a covariate for test type in bivariate models
or 'unclear') for each signalling question. Additionally, we coded (i.e. meta-regression) using methods suggested by Partlett
risk of bias and applicability as 'high', 'low', or 'unclear'. and Takwoingi (Partlett 2016). For pairwise, between-index-
test difference comparisons, we used a bivariate mixed effects
We piloted the quality checklist independently on a sample of five regression model to test the joint null hypothesis of no difference
papers and refined the checklist before proceeding further. When in sensitivity and specificity between two index tests as calculated
necessary, we contacted authors of original studies for information in the models described above. We formally compared models
on unclear quality items. using a likelihood ratio test. If we rejected the joint null hypothesis,
we individually compared sensitivity and specificity. We present
We have presented the items on methodological quality
differences only for test comparison pairs where sufficient data
assessments in methodological quality summary figuress 12
were available and where models converged.
to 15 in the Results section. In addition, we have presented
methodological quality graphs showing the relative distribution Investigations of heterogeneity
of methodological quality assessments for each included study in
Appendix 6. To explore heterogeneity, we considered patient demographics
(e.g. age, sex, weight); the indication for airway management
Statistical analysis and data synthesis (e.g. elective surgery, emergent surgery, critical illness, trauma,
resuscitation); and different standards for declaring a difficult
For each included study, we treated the index test results
airway as potential covariates in a bivariate model (Whiting 2011).
as separate binary classifiers; we recorded the cutpoint for
dichotomization. The included studies reported one or more Sensitivity analyses
difficult airway events.
We assessed the impact of study design on our findings by
We separately tallied each type of reported difficult airway event. excluding case-control studies. We assessed the impact of the risk
We collected details on definitions of positive and negative of bias due to lack of blinding by excluding studies where the results
reference standard responses. We constructed 2×2 tables of test of the index tests were not blinded.
and reference standard results to show the cross-classification of
difficult airway status and test outcome. In studies where multiple Assessment of reporting bias
index tests were performed, we also constructed a series of 2×2 Testing for reporting bias and small study effects may not be
tables where the results of investigations were combined, provided especially useful in the context of studies of diagnostic tests (Begg
that they were derived from the total study population, and that the 2005), therefore, we did not present analyses on reporting bias.
definition of a positive result for combined tests was reported.
RESULTS
We used sensitivity and specificity of each test or test combination
as the underlying parameter in our calculations. As healthcare Results of the search
providers want to avoid false negatives, we considered sensitivity
as the most important property when comparing diagnostic We searched up to 16 December 2016. Our search yielded a total
accuracy between tests: overlooking a person at high risk for a of 12,277 papers after combining search results from all sources
difficult airway event may be potentially life-threatening during and after removing duplications. Based on independent title and
anaesthesia. False positives on the other hand, have less severe abstract evaluations, we excluded 11,779 references and retrieved
implications in this scenario. To describe and visualize the data, we the full text for 498 references. After careful evaluation, we excluded
produced forest plots showing pairs of sensitivity and specificity another 365 studies (Figure 1). The studies we excluded because
together with 95% confidence intervals (CIs) from each study in of insufficient data are reported in the 'Characteristics of excluded
Review Manager 2014. We presented data for all eligible studies studies' tables. After detailed assessments, we included 133 studies
on forest plots, but included only cohort type studies in the meta- involving 844,206 participants (Figure 1).
analyses to minimise the risk of bias. We meta-analysed pairs of
sensitivity and specificity using a generalized linear mixed model From an updated search in March 2018, we have added 27 study
approach to perform a bivariate meta-analysis of sensitivity and reports to 'Characteristics of studies awaiting classification' tables.
specificity (Chu 2006).
The 133 studies evaluated a total of seven different prespecified
We primarily performed meta-analyses for pooling estimates using test strategies, as well as 69 non-prespecified, and 32 combinations
the 'lme4' package in R (R 2017). From this package we used the (Table 3). For the prespecified index tests, we found six studies for
bivariate binomial method using the glmer function. We presented the Mallampati test, 105 for the modified Mallampati test, six for the
Wilson risk score, 52 for thyromental distance, 18 for sternomental
Informed decisions.

distance, 34 for the mouth opening test and 30 for the upper lip bite risk of bias domains and applicability concerns for each study in the
test. A total of 42 studies evaluated one individual test, 36 studies 'Characteristics of included studies' tables (Review Manager 2014).
evaluated two tests, 21 studies evaluated three tests, and 36 studies
evaluated four to 12 tests. Eberhart 2005 reported interobserver We judged the risk of bias to be variable, across all studies, for
correlation (IOC) for the upper lip bite test (IOC = 0.79), and for the the different domains; with mostly low risk of bias observed with
modified Mallampati test (IOC = 0.59). None of the studies reported patient selection, flow and timing, and mostly unclear risk of bias
intraobserver correlations. with reference standard and index test. We judged applicability
concerns to be low for all domains. Most of the included studies
Table 1 defines the cut-off thresholds for index tests. Details on were cohort type studies, only six of the included studies were
reported cut-offs are presented in the 'Characteristics of included case-control type studies (Connor 2011; Frerk 1996; Fritscherova
studies' tables. Overall, we did not consider variations of cut-offs to 2011; Naguib 1999; Naguib 2006; Nath 1997). Given the nature of
be clinically important. the setting, and the test, we did not observe partial or differential
verification in any of the studies.
Eighteen comparisons (7 studies) defined the target condition
as: difficult face mask ventilation; 218 comparisons (92 studies) For difficult laryngoscopy, the reference standard was performed
as difficult laryngoscopy; 72 comparisons (50 studies) as difficult blinded in 42, non-blinded in six, and blinding was unclear in 43
tracheal intubation; and two comparisons (two studies) as failed studies. For difficult tracheal intubation, the reference standard
intubation. was performed blinded in 11, non-blinded in eight, and blinding
was unclear in 29 studies. For difficult face mask ventilation, the
The median number of participants per study was 380, with reference standard was performed blinded in one, non-blinded in
an interquartile range (IQR) from 200 to 662. The median (IQR) one and blinding was unclear in five studies. For failed intubation,
percentage of females included in the studies was 53% (44% to the reference standard was performed blinded in none, non-
64%). The median (IQR) age of the participants was 45 years (39 blinded in none and blinding was unclear in three studies. The index
to 52). The median (IQR) body mass index (BMI) was 27.3 kg/ test was blinded in all studies investigating prespecified index tests
m2(24.8 to 30.0). All studies, apart from two (Freund 2012; Soyuncu as expected. Among alternative tests or test combinations, eight
2009), performed airway management in the operating theatre; the studies had non-blinded index tests (Fritscherova 2011; Gonzalez
Freund 2012 study involved airway management in ambulance cars 2008; Hagiwara 2015; Kim 2011; Langeron 2000; Nath 1997; Wilson
and the Soyuncu 2009 study in an emergency department. We did 1988; Wong 1999). All studies evaluated the index test before
not subgrouped studies according to where the study took place. the reference standard, except for the Fritscherova 2011 study,
The characteristics of the individual studies are described in the which performed the index test the day after intubation. Ninety-
'Characteristics of included studies' tables. five studies included all participants in the analysis. We found
incomplete or unclear reporting in 40 studies.
Methodological quality of included studies
For a graphical summary of the risk of bias and applicability, see
We report the details for individual study quality in the
the graphs in Appendix 6. For a summary for each difficult airway
'Characteristics of included studies' tables. Due to the complex
component, refer to Figure 2 for difficult laryngoscopy; Figure 3
structure of the review (multiple combinations of index tests and
for difficult tracheal intubation; Figure 4 for failed intubation; and
reference standards reported within individual studies), we were
Figure 5 for difficult face mask ventilation.
not able to use Review Manager 5 in-built features to report all the

Figure 2. Risk of bias and applicability concerns graph for difficult laryngoscopy: review authors' judgements about
each domain presented as percentages across included studies.

Informed decisions.

Figure 3. Risk of bias and applicability concerns graph for difficult tracheal intubation: review authors' judgements
about each domain presented as percentages across included studies.

Figure 4. Risk of bias and applicability concerns graph for failed intubation: review authors' judgements about each
domain presented as percentages across included studies.

Figure 5. Risk of bias and applicability concerns graph for difficult face mask ventilation: review authors'
judgements about each domain presented as percentages across included studies.

Findings Mallampati test, thyromental distance and mouth opening test for
difficult tracheal intubation; modified Mallampati test for difficult
The median (IQR) prevalence for difficult laryngoscopy, difficult face mask ventilation). We did not perform meta-analyses of
tracheal intubation, difficult face mask ventilation, and failed studies with the Mallampati test, Wilson risk score, sternomental
intubation was 11% (6% to 19%), 13% (5% to 16%), 6% (5% to 25%) distance or upper lip bite test for difficult tracheal intubation;
and 0.6% (0.3% to 0.9%), respectively. studies with thyromental distance, upper lip bite test or mouth
opening test for difficult face mask ventilation; or studies with the
We were able to perform meta-analyses for 11 comparisons (all
modified Mallampati test for failed intubation because only one
7 prespecified index tests for difficult laryngoscopy; modified
Informed decisions.

or two studies were available. For the remaining comparisons, we 0.98. We estimated a summary sensitivity of 0.40 (95% confidence
did not find any studies. All studies that we included in the meta- interval (CI) 0.16 to 0.71) and a summary specificity of 0.89 (95% CI
analyses used one clinically identical cut-off value per test. See 0.75 to 0.96).
Summary of findings 1 for key findings.
For the modified Mallampati test, there were 80 studies involving
Difficult laryngoscopy 232,939 participants with 10,545 cases of difficult laryngoscopy
(Data table 3). Both sensitivity and specificity varied from 0.00 to
For the Mallampati test, there were six studies involving 2165
1.00. We estimated a summary sensitivity of 0.53 (95% CI 0.47 to
participants with 153 cases of difficult laryngoscopy (Data table 1).
0.59) and a summary specificity of 0.80 (95% CI 0.74 to 0.85). See
Sensitivity varied from 0.05 to 0.85, and specificity from 0.65 to
Figure 6.

Informed decisions.

Figure 6. Forest plot of modified Mallampati test for difficult laryngoscopy, sorted by descending sensitivity.
Summary sensitivity 0.53 (95% confidence interval (CI) 0.47 to 0.59); summary specificity 0.80 (95% CI 0.74 to 0.85).
Informed decisions.


Figure 6. (Continued)

For the Wilson risk score, there were five studies involving 5862 For thyromental distance, there were 42 studies involving 33,189
participants with 145 cases of difficult laryngoscopy (Data table 7). participants with 2364 cases of difficult laryngoscopy (Data table 9).
Sensitivity varied from 0.00 to 0.75, and specificity from 0.86 to 0.99. Sensitivity varied from 0.03 to 1.00, and specificity from 0.08 to 0.99.
We estimated a summary sensitivity of 0.51 (95% CI 0.40 to 0.61) We estimated a summary sensitivity of 0.37 (95% CI 0.28 to 0.47)
and a summary specificity of 0.95 (95% CI 0.88 to 0.98). and a summary specificity of 0.89 (95% CI 0.84 to 0.93). See Figure 7.

Figure 7. Forest plot of thyromental distance for difficult laryngoscopy, sorted by descending sensitivity. Summary
sensitivity 0.37 (95% CI 0.28 to 0.47); summary specificity 0.89 (95% CI 0.84 to 0.93).

For sternomental distance, there were 16 studies involving 12,211 1.00. We estimated a sensitivity of 0.33 (95% CI 0.16 to 0.56) and a
participants with 762 cases of difficult laryngoscopy (Data table 12). specificity of 0.92 (95% CI 0.86 to 0.96).
Sensitivity varied from 0.00 to 0.84, and specificity from 0.71 to
Informed decisions.

For the mouth opening test, there were 24 studies involving 22,179 to 1.00. We estimated a summary sensitivity of 0.22 (95% CI 0.13 to
participants with 1220 cases of difficult laryngoscopy (Data table 0.33) and a summary specificity of 0.94 (95% CI 0.90 to 0.97). See
14). Sensitivity varied from 0.00 to 0.75, and specificity from 0.64 Figure 8.

Figure 8. Forest plot of mouth opening for difficult laryngoscopy, sorted by descending sensitivity. Summary

For the upper lip bite test, there were 27 studies involving 19,609 to 1.00. We estimated a summary sensitivity of 0.67 (95% CI 0.45 to
participants with 1998 cases of difficult laryngoscopy (Data table 0.83) and a summary specificity of 0.92 (95% CI 0.86 to 0.95). See
17). Sensitivity varied from 0.02 to 1.00, and specificity from 0.00 Figure 9.

Informed decisions.

Figure 9. Forest plot of upper lip bite test for difficult laryngoscopy, sorted by descending sensitivity. Summary

Forty-two studies reported non-prespecified index tests or index sensitivity compared to thyromental distance (P = 0.012) and mouth
test combinations involving 230,680 participants with 7197 cases opening (P < 0.001).
of difficult laryngoscopy (Data table 20). Both sensitivity and
specificity varied from 0.00 to 1.00. We did not perform a meta- Mouth opening had the highest specificity, which was significantly
analysis on these combinations, as outlined above. different from the modified Mallampati test (P < 0.001). The
modified Mallampati test had significantly lower specificity than
We were able to formally compare four index tests for difficult the upper lip bite test (P = 0.007), and thyromental distance (P =
laryngoscopy. The upper lip bite test had the highest sensitivity, 0.037). See Figure 10 for a graphical display. We were unable to
which was significantly different from mouth opening (P < 0.001). calculate test comparisons for other test combinations given the
The modified Mallampati test showed a significantly higher lack of data.

Informed decisions.

Figure 10. Summary receiver operating characteristic (ROC) plot of modified Mallampati test, thyromental
distance, mouth opening, and upper lip bite test for difficult laryngoscopy. For each index test, the summary point
with the 95% confidence region is displayed.
Informed decisions.


Difficult tracheal intubation For the modified Mallampati test, there were 24 studies involving
191,849 participants with 6615 cases of difficult tracheal intubation
For the Mallampati test, there was only one study (500 participants)
(Data table 5). Sensitivity varied from 0.19 to 0.91, and specificity
with 40 cases of difficult tracheal intubation (Data table 2).
from 0.62 to 0.98. We estimated a summary sensitivity of 0.51 (95%
Sensitivity in this study was 0.42 (95% CI 0.27 to 0.59), and
CI 0.40 to 0.61) and a summary specificity of 0.87 (95% CI 0.82 to
specificity was 0.93 (95% CI 0.90 to 0.95).
0.91). See Figure 11.

Figure 11. Forest plot of modified Mallampati test for difficult tracheal intubation, sorted by descending sensitivity.
Summary sensitivity 0.51 (95% CI 0.40 to 0.61); summary specificity 0.87 (95% CI 0.82 to 0.91).

For the Wilson risk score, there was only one study (123 from 0.63 to 0.90. We did not perform a meta-analysis on these
participants) with 17 cases of difficult tracheal intubation (Data combinations, as outlined above.
table 8). Sensitivity in this study was 0.47 (95% CI 0.23 to 0.72), and
specificity was 0.92 (95% CI 0.84 to 0.96). For thyromental distance, there were 10 studies involving 5089
participants with 437 cases of difficult tracheal intubation (Data
For sternomental distance, there were two studies (864 table 11). Sensitivity varied from 0.06 to 0.78, and specificity from
participants) with 115 cases of difficult tracheal intubation (Data 0.63 to 0.98. We estimated a summary sensitivity of 0.24 (95% CI
table 13). Sensitivity varied from 0.31 to 0.60, and specificity 0.12 to 0.43) and a summary specificity of 0.90 (95% CI 0.80 to 0.96).
See Figure 12.

Figure 12. Forest plot of thyromental distance for difficult tracheal intubation, sorted by descending sensitivity.
Summary sensitivity 0.24 (95% CI0.12 to 0.43); summary specificity 0.90 (95% CI 0.80 to 0.96).

For the upper lip bite test, there were two studies (598 participants) For mouth opening, there were 9 studies involving 6091
with 121 cases of difficult tracheal intubation (Data table 19). participants with 607 cases of difficult tracheal intubation (Data
Sensitivity varied from 0.34 to 0.91, and specificity from 0.93 to table 16). Sensitivity varied from 0.00 to 0.51, and specificity from
0.96. We did not perform a meta-analysis on these combinations, 0.76 to 0.99. We estimated a summary sensitivity of 0.27 (95% CI
as outlined above.
Informed decisions.

0.16 to 0.41) and a summary specificity of 0.93 (95% CI 0.87 to 0.96).

See Figure 13.

Figure 13. Forest plot of mouth opening for difficult tracheal intubation, sorted by descending sensitivity. Summary
sensitivity 0.27 (95% CI 0.16 to 0.41); summary specificity 0.93 (95% Cl 0.87 to 0.96).

Fifteen studies reported non-prespecified index tests or index test significantly different between mouth opening and thyromental
combinations involving 11,089 participants with 1030 cases of distance (P = 0.07).
difficult tracheal intubation (Data table 22). Sensitivity varied from
0.00 to 0.92, and specificity from 0.48 to 1.00. We did not perform a The mouth opening test showed the highest specificity, which was
meta-analysis on these combinations, as outlined above. higher than the thyromental distance and the modified Mallampati
test. Specificity was significantly different for all test comparisons
We were able to formally compare three index tests for difficult ( P < 0.001). See Figure 14 for a graphical display. We were unable
tracheal intubation. The modified Mallampati test had the highest to calculate test comparisons for other test combinations, given the
sensitivity. It was significantly higher than the mouth opening test lack of data.
(P < 0.001) and thyromental distance (P < 0.001). Sensitivity was not

Informed decisions.

Figure 14. Summary receiver operating characteristic (ROC) plot of modified Mallampati test, thyromental
distance, and mouth opening test for difficult tracheal intubation. For each index test the summary point with the
95% confidence region is displayed.
Informed decisions.


Difficult face mask ventilation (Data table 4). Sensitivity varied from 0.00 to 0.36, and specificity
from 0.80 to 0.99. We estimated a summary sensitivity of 0.17 (95%
For the modified Mallampati test, there were six studies involving
CI 0.06 to 0.39) and a summary specificity of 0.90 (95% CI 0.81 to
56,323 participants with 493 cases of difficult face mask ventilation
0.95). See Figure 15.

Figure 15. Forest plot of modified Mallampati test for difficult face mask ventilation, sorted by descending
sensitivity. Summary sensitivity 0.17 (95% CI 0.06 to 0.39); summary specificity 0.90 (95% CI 0.81 to 0.95).

For thyromental distance, there was only one study (53,041 DISCUSSION
participants) with 77 cases of difficult face mask ventilation (Data
table 10). Sensitivity in this study was 0.13 (95% CI 0.06 to 0.23), and Summary of main results
specificity was 0.94 (95% CI 0.94 to 0.95).
There was limited to moderate accuracy in commonly used airway
For the upper lip bite test, there was only one study (200 examination tests for assessing the physical status of the airway
participants) with 56 cases of difficult face mask ventilation (Data in adult patients with no apparent anatomical airway abnormality.
table 18). Sensitivity in this study was 0.75 (95% CI 0.62 to 0.86), and There was a consistent pattern of wide variability in the ranges
specificity was 0.60 (95% CI 0.51 to 0.68). around the 50% sensitivity point. On the other hand, specificity
was high with less variability across most of the tests. This applied
For mouth opening, there were two studies (53,469 participants) likewise for all reference standards. Standard airway examination
with 370 cases of difficult face mask ventilation (Data table 15). tests do not appear to work well as screening tests. The potential
Sensitivity was 0.06 in both studies, and specificity ranged from 0.91 high rate of false negatives could lead to disastrous situations
to 0.96. We did not perform a meta-analysis on these combinations, during induction of anaesthesia.
as outlined above.
Overall, the quality of the estimates was moderate to high. The
Four studies reported non-prespecified index tests or index test methodological quality was high for applicability and moderate to
combinations (10,819 participants) with 655 cases of difficult face high for the risk of bias in the individual studies.
mask ventilation (Data table 21). Sensitivity varied from 0.04 to
0.81, and specificity from 0.27 to 0.97. We did not perform a meta- Among the tests under investigation (Summary of findings 1), the
analysis on these combinations, as outlined above. upper lip bite test had the highest sensitivity to foresee difficult
laryngoscopy and was significantly better than the modified
Failed intubation Mallampati test and the mouth opening test. For difficult tracheal
intubation, there was insufficient information for the upper lip
For the modified Mallampati test, there were two studies (485
bite test. Here the modified Mallampati test had the highest
participants) with three cases of failed intubation (Data table 6).
sensitivity. For difficult tracheal intubation, there was no evidence
Sensitivity was 0.00 in one study and not estimable due to a lack of
of a difference in sensitivity between the mouth opening and
cases (reference standard positives) in the other study. Specificity
thyromental distance tests. For face mask ventilation and failed
varied from 0.80 to 0.94. We did not perform a meta-analysis on
intubation, there was insufficient information for test comparisons.
these combinations, as outlined above.
Strengths and weaknesses of the review
Sensitivity analyses
This review systematically summarized current evidence about
We performed sensitivity analyses for study design and lack of
standard bedside airway examination tests using up-to-date
blinding of index test results; we found no effect on our findings.
methodology from a total of 133 studies involving 844,206 patients.
Heterogeneity It updates the evidence described in a published systematic
review (Lee 2006), and expands the scope of index tests beyond
For non-prespecified index tests or index test combinations we the Mallampati test. We attempted to conduct a comprehensive
did not perform a meta-analysis because of the large clinical search for studies, but the fact that 27 studies have not yet been
heterogeneity in terms of differences in test properties. For all index incorporated may be a source of potential bias. We designed
tests where pooling was possible, we found high variability in the our review to cover the most common bedside tests used in
estimates. clinical routine practice globally. However, this resulted in a large
number of comparisons, with varying numbers of studies with
sufficient data. We therefore, can provide good quality evidence
for a selected set of tests. Moreover, we found a large number
of studies on test combinations which contained considerable
Informed decisions.

heterogeneity, and prevented pooling in some cases. We also found Standard airway examination tests do not appear to work well as
some heterogeneity in the definition of index tests and target screening tests. Although false negatives can result from bedside
conditions, which might potentially result in a loss in precision in examination tests, it is important to put the risk of an unanticipated
the estimates. In addition, we were not able to formally analyse difficult airway into context. Whereas failure to predict both difficult
the heterogeneity by demographics and the clinical setting such as face mask ventilation and difficult tracheal intubation could lead to
anaesthesia, critically ill patient, major trauma, or cardiac arrest, disastrous clinical situations ("cannot intubate - cannot ventilate"),
where clinicians face very different conditions, sometimes with unexpected isolated difficult laryngoscopy might be handled by
serious limitations to perform bedside tests. face mask ventilation. Among the investigated tests, the upper
lip bite test showed the most favourable diagnostic test accuracy
The risk of bias in the studies, one aspect of quality of the properties.
evidence, was generally low. However, as expected, we noted an
issue with blinding of the index test results when assessing the The 27 studies in ‘Studies awaiting classification’ may alter the
target condition in approximately half of the included studies, as conclusions of the review once we have assessed them.
in the clinical setting. Despite standardized outcome assessment
instruments, this could explain the relatively high specificity Implications for research
compared to sensitivity if outcome assessors tended to classify the
Current bedside tests have limited accuracy. Therefore, research
airway more frequently difficult when they knew that the bedside
to develop tests with high sensitivities are needed to make them
test predicted a difficult airway. However, this potential bias may
useful screening tests. Scarce information is available for difficult
also act in the opposite direction, i.e. better preparation due to
face mask ventilation and failed intubation, which are suitable
knowledge of a potential difficult airway, leading to less problems
target conditions to examine in future studies.
in actual airway management. We therefore do not expect that this
provides sufficient explanation for our results. ACKNOWLEDGEMENTS
Applicability of findings to the review question We would like to thank Jane Cracknell, Cochrane Anaesthesia
The included studies were generally performed in a broad Critical and Emergency Care Group (ACE) Managing Editor;
range of standard clinical settings and are expected to apply to Andrew Smith, ACE Content Editor; Peer Reviewers (Pierre
standard preoperative airway assessments done in apparently Diemunsch, Haldun Akoglu, Subrahmanyan Radhakrishna); Janet
normal hospital patients internationally. This review covers a Wale, Consumer Editor; Janne Vendt, Information Specialist who
broad range of standard and routinely applied bedside tests. re-ran the search in December 2016 and March 2018; the Diagnostic
The outcomes comply with routine target conditions, such as Test Accuracy (DTA) Editorial team and Peer Reviewers; and
difficult laryngoscopy and difficult tracheal intubation, which Marialena Trivella, ACE Statistical Editor. We would also like to
all healthcare professionals in the field are familiar with (ASA thank the Co-ordinating Editor Andrew Smith.
2003). For some relevant target conditions, such as difficult face
We would like to thank Alexander Hartmann who helped with data
mask ventilation and failed intubation, data were too scarce
extraction for several papers. We thank Pablo Emilio Verde, Senior
to draw robust conclusions, and therefore the applicability is
Researcher, University of Duesseldorf, Germany, for consultation
limited. As prespecified, this review includes only studies with
about Bayesian methods. We would also like to thank Yemisi
clinical reference standards, such as difficult tracheal intubation or
Takwoingi, School of Health and Population Sciences, University of
difficult face mask ventilation. We did not include studies deriving
Birmingham, for her help with the GLMM models in R. We would
prediction tools solely from radiological imaging and other non-
like to thank Zahid Hussain Khan, Professor of Anaesthesiology and
clinical reference standards.
Intensive Care at Tehran University of Medical Sciences, Iran, for
AUTHORS' CONCLUSIONS providing additional information on study patients.
We would also like to thank Mathew Zacharias, ACE Content

Implications for practice
Editor; Mariska Leeflang, DTA Contact Editor; Pierre Diemunsch and
Bedside airway examination tests for assessing the physical status Markus Weiss, ACE Peer Reviewers; and the DTA Peer Reviewers
of the airway in adult patients with no apparent anatomical airway for their help and editorial advice during the preparation of the
abnormality are designed as screening tests. Screening tests are protocol for the review (Lee 2010).
expected to have high sensitivities and depend less on specificity.
We found that all the investigated examination tests had relatively This review was selected for the third Cochrane Review Support
low sensitivities with high variability. In contrast, specificities were Programme.
consistently and markedly better than sensitivities across all tests.
Informed decisions.

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anesthetics. Anesthesiology 2009;110(4):891-7. [PUBMED:
Kamranmanesh 2013 {published data only} 19293691 ]
Kamranmanesh MR, Jafari AR, Gharaei B, Aghamohammadi H,
Poor Zamany NKM, Kashi AH. Comparison of Kim 2011 {published data only}
acromioaxillosuprasternal notch index (a new test) with Kim WH, Ahn HJ, Lee CJ, Shin BS, Ko JS, Choi SJ, et al. Neck
modified Mallampati test in predicting difficult visualization circumference to thyromental distance ratio: a new predictor
of larynx. Acta Anaesthesiologica Taiwanica 2013;51(4):141-4. of difficult intubation in obese patients. British Journal of
[PUBMED: 24529668 ] Anaesthesia 2011;106(5):743-8. [PUBMED: 21354999 ]
Informed decisions.

K Nasa 2014 {published data only} Liaskou 2014 {published data only}
K Nasa V, S Kamath S. Risk factors assessment of the difficult Liaskou C, Vouzounerakis E, Moirasgenti M, Trikoupi A,
intubation using intubation difficulty scale (IDS). Journal Staikou C. Anatomic features of the neck as predictive
of Clinical and Diagnostic Research: JCDR 2014;8(7):GC01-3. markers of difficult direct laryngoscopy in men and
[PUBMED: 25177576 ] women: A prospective study. Indian Journal of Anaesthesia
2014;58(2):176-82. [PUBMED: 24963183 ]
Knudsen 2014 {published data only}
Knudsen K, Högman M, Larsson A, Nilsson U. The best method Lundstrom 2009 {published data only}
to predict easy intubation: a quasi-experimental pilot study. * Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Gätke MR,
Journal of Perianesthesia Nursing 2014;29(4):292-7. [PUBMED: Wetterslev J, et al. A documented previous difficult tracheal
25062573 ] intubation as a prognostic test for a subsequent difficult
tracheal intubation in adults. Anaesthesia 2009;64(10):1081-8.
Koh 2002 {published data only} [PUBMED: 19735399 ]
Koh LK, Kong CE, Ip-Yam PC. The modified Cormack-Lehane
score for the grading of direct laryngoscopy: evaluation Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Gätke MR,
in the Asian population. Anaesthesia and Intensive Care Wetterslev J, et al. Avoidance of neuromuscular blocking agents
2002;30(1):48-51. [PUBMED: 11939440 ] may increase the risk of difficult tracheal intubation: a cohort
study of 103,812 consecutive adult patients recorded in the
Kolarkar 2015 {published data only} Danish Anaesthesia Database. British Journal of Anaesthesia
Kolarkar P, Badwaik G, Watve A, Abhishek K, Bhangale N, 2009;103(2):283-90. [PUBMED: 19457894]
Bhalerao A, et al. Upper lip bite test: A novel test of predicting
Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Wetterslev J.
difficulty in intubation. Journal of Evolution of Medical and
High body mass index is a weak predictor for difficult
Dental Sciences 2015;4(24):4149-56.
and failed tracheal intubation: a cohort study of 91,332
Komatsu 2007 {published data only} consecutive patients scheduled for direct laryngoscopy
registered in the Danish Anesthesia Database. Anesthesiology
Komatsu R, Sengupta P, Wadhwa A, Akça O, Sessler DI, Ezri T, et 2009;110(2):266-74. [PUBMED: 19194154]
al. Ultrasound quantification of anterior soft tissue thickness
fails to predict difficult laryngoscopy in obese patients. Mallat 2010 {published data only}
Anaesthesia and Intensive Care 2007;35(1):32-7. [PUBMED:
Mallat J, Robin E, Pironkov A, Lebuffe G, Tavernier B. Goitre and
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difficulty of tracheal intubation. Annales Françaises d'anesthèsie
Konwar 2015 {published data only} et de Rèanimation 2010;296(6):436-9. [PUBMED: 20547033]
Konwar C, Baruah ND, Saikia P, Chakrabartty A. A prospective Mashour 2008 {published data only}
study of the usefulness of upper lip bite test in combination
Mashour GA, Kheterpal S, Vanaharam V, Shanks A, Wang LY,
with sternomental distance, thyromental distance and inter-
Sandberg WS, et al. The extended Mallampati score and
incisor distance as predictor of ease of laryngoscopy. Journal of
a diagnosis of diabetes mellitus are predictors of difficult
Evolution of Medical and Dental Sciences 2015;4(97):16286-89.
laryngoscopy in the morbidly obese. Anesthesia and Analgesia
Krobbuaban 2005 {published data only} 2008;107(6):1919-23. [PUBMED: 19020139 ]
Krobbuaban B, Diregpoke S, Kumkeaw S. An assessment Mehta 2014 {published data only}
of the ratio of height to thyromental distance compared to
Mehta T, Jayaprakash J, Shah V. Diagnostic value of different
thyromental distance as a predictive test for prediction of
screening tests in isolation or combination for predicting
difficult tracheal intubation in Thai patients. Journal of the
difficult intubation: A prospective study. Indian Journal of
Medical Association of Thailand = Chotmaihet Thangphaet
Anaesthesia 2014;58(6):754-7. [PUBMED: 25624545 ]
2006;89(5):638-42. [PUBMED: 16756049]
Merah 2004 {published data only}
* Krobbuaban B, Diregpoke S, Kumkeaw S, Tanomsat M. The
predictive value of the height ratio and thyromental distance: * Merah NA, Foulkes-Crabbe DJ, Kushimo OT, Ajayi PA.
four predictive tests for difficult laryngoscopy. Anesthesia and Prediction of difficult laryngoscopy in a population of
Analgesia 2005;101(5):1542-5. [PUBMED: 16244029 ] Nigerian obstetric patients. West African Journal of Medicine
2004;23(1):38-41. [PUBMED: 15171524 ]
Langeron 2000 {published data only}
Merah NA, Wong DT, Ffoulkes-Crabbe DJ, Kushimo OT, Bode CO.
Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P,
Modified Mallampati test, thyromental distance and inter-
et al. Prediction of difficult mask ventilation. Anesthesiology
incisor gap are the best predictors of difficult laryngoscopy in
2000;92(5):1229-36. [PUBMED: 10781266 ]
West Africans. Canadian Journal of Anesthesia 2005;52(3):291-6.
Lee 2015 {published data only} [PUBMED: 15753502 ]
Lee SL, Hosford C, Lee QT, Parnes SM, Shapshay SM. Mallampati Mishra 2009 {published data only}
class, obesity, and a novel airway trajectory measurement to
Mishra SK, Bhat RR, Sudeep K, Nagappa M, Badhe AS.
predict difficult laryngoscopy. Laryngoscope 2015;125(1):161-6.
Comparison of upper lip bite test with modified Mallampati
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Informed decisions.

classification for prediction of difficult obstetric intubation. The Oates 1990 {published data only}
Internet Journal of Anesthesiology 2010;19(1):1-3. Oates JD, Oates PD, Pearsall FJ, McLeod AD, Howie JC.
Phonation affects Mallampati class. Anaesthesia
Montemayor-Cruz 2015 {published data only}
1990;45(11):984. [PUBMED: 2082969 ]
Montemayor-Cruz JM, Guerrero-Ledezma RM. Diagnostic
utility of the hyomental distance ratio as predictor of Oates 1991 {published data only}
difficult intubation at UMAE 25. Gaceta Médica de México Oates JD, Macleod AD, Oates PD, Pearsall FJ, Howie JC,
2015;151(5):599-607. [PUBMED: 26526473 ] Murray GD. Comparison of two methods for predicting difficult
intubation. British Journal of Anaesthesia 1991;66(3):305-9.
Myneni 2010 {published data only}
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Myneni N, O'Leary AM, Sandison M, Roberts K. Evaluation of the
upper lip bite test in predicting difficult laryngoscopy. Journal of Pottecher 1991 {published data only}
Clinical Anesthesia 2010;22(3):174-8. [PUBMED: 20400002] Pottecher T, Velten M, Galani M, Forrler M. Comparative value of
clinical signs of difficult tracheal intubation in women. Annales
Nadal 1998 {published data only}
Françaises d'anesthèsie et de Rèanimation 1991;10(5):430-5.
* Nadal JL, Fernandez BG, Escobar IC, Black M, Rosenblatt WH. [PUBMED: 1755552 ]
The palm print as a sensitive predictor of difficult
laryngoscopy in diabetics. Acta Anaesthesiologica Scandinavica Prakash 2013 {published data only}
1998;42(2):199-203. [PUBMED: 9509203 ] Prakash S, Kumar A, Bhandari S, Mullick P, Singh R, Gogia AR.
Difficult laryngoscopy and intubation in the Indian population:
Rae R, Kinsella J, Daniel M, Booth M. The palm print as predictor
An assessment of anatomical and clinical risk factors. Indian
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Journal of Anaesthesia 2013;57(6):569-75. [PUBMED: 24403616 ]
2001;45(8):1053. [PUBMED: 11576065 ]
Qudaisat 2011 {published data only}
Naguib 1999 {published data only}
Qudaisat IY, Al-Ghanem SM. Short thyromental distance is a
Naguib M, Malabarey T, AlSatli RA, Al Damegh S, Samarkandi AH.
surrogate for inadequate head extension, rather than small
Predictive models for difficult laryngoscopy and intubation. A
submandibular space, when indicating possible difficult
clinical, radiologic and three-dimensional computer imaging
direct laryngoscopy. European Journal of Anaesthesiology
study. Canadian Journal of Anaesthesia = Journal Canadien
2011;28(8):600-6. [PUBMED: 21610502]
d'anesthésie 1999;46(8):748-59. [PUBMED: 10451134 ]
Reghunathan 2016 {published data only}
Naguib 2006 {published data only}
Reghunathan U, Raghavan RK, Veetil BM. Airway assessment for
Naguib M, Scamman FL, O'Sullivan C, Aker J, Ross AF,
anticipation of difficult intubation: a double blind comparative
Kosmach S, et al. Predictive performance of three multivariate
study. Journal of Evolution Medical and Dental Sciences
difficult tracheal intubation models: a double-blind, case-
2016;5(40):2466-9.
controlled study. Anesthesia and Analgesia 2006;102(3):818-24.
[PUBMED: 16492835 ] Rocke 1992 {published data only}
Nasir 2011 {published data only} Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis
of factors associated with difficult intubation in obstetric
Nasir KK, Shahani AS, Maqbool MS. Correlative value of airway
anesthesia. Anesthesiology 1992;77(1):67-73. [PUBMED:
assessment by Mallampati classification and Cormack and
1610011 ]
Lehane grading. Rawal Medical Journal 2011;36:2-4.
Safavi 2014 {published data only}
Nasiri 2013 {published data only}
Safavi M, Honarmand A, Amoushahi M. Prediction of difficult
Nasiri E, Akbari H, Farrokhi H, Ebrahimi F, Nasiri R. A comparison
laryngoscopy: Extended mallampati score versus the MMT,
of the Upper Lip Bite Test with Inter Incisor Distance in
ULBT and RHTMD. Advances in Biomedical Engineering Research
predicting difficult laryngoscopy and tracheal intubation.
2014;3:133. [PUBMED: 24949304 ]
Journal of Mazandaran University of Medical Sciences
2013;23(105):71-9. Sahin 2011 {published data only}
Nath 1997 {published data only} Sahin SH, Yilmaz A, Gunday I, Kargi M, Sut N, Taskinalp O, et
al. Using temporomandibular joint mobility to predict difficult
Nath G, Sekar M. Predicting difficult intubation - a
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comprehensive scoring system. Anaesthesia and Intensive Care
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1997;25(5):482-6. [PUBMED: 9352759 ]
Salimi 2008 {published data only}
Noorizad 2006 {published data only}
Salimi A, Farzanegan B, Rastegarpour A, Kolahi AA. Comparison
Noorizad S, Mahdian M. Mallampati and thyromental distance
of the upper lip bite test with measurement of thyromental
to predict difficult intubation. Journal of Medical Sciences
distance for prediction of difficult intubations. Acta
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Anaesthesiologica Taiwanica 2008;46(2):61-5. [PUBMED:
18593650 ]
Informed decisions.

Samra 1995 {published data only} failed intubation using the Mallampati test. International
Samra SK, Schork MA, Guinto FC Jr. A study of radiologic Journal of Obstetric Anesthesia 2009;18:S1-63. [DOI: https://
imaging techniques and airway grading to predict a difficult doi.org/10.1016/j.ijoa.2009.03.006]
endotracheal intubation. Journal of Clinical Anesthesia
Tse 1995 {published data only}
1995;7(5):373-9. [PUBMED: 7576671]
Tse JC, Rimm EB, Hussain A. Predicting difficult endotracheal
Savva 1994 {published data only} intubation in surgical patients scheduled for general
Savva D. Prediction of difficult tracheal intubation. British anesthesia: a prospective blind study. Anesthesia and Analgesia
Journal of Anaesthesia 1994;73(2):149-53. [PUBMED: 7917726 ] 1995;81(2):254-8. [PUBMED: 7618711 ]
Schmitt 2000 {published data only} Tuzuner-Oncul 2008 {published data only}
Schmitt H, Buchfelder M, Radespiel-Tröger M, Fahlbusch R. Tuzuner-Oncul AM, Kucukyavuz Z. Prevalence and prediction
Difficult intubation in acromegalic patients: incidence and of difficult intubation in maxillofacial surgery patients. Journal
predictability. Anesthesiology 2000;93(1):110-4. [PUBMED: of Oral and Maxillofacial Surgery 2008;66(8):1652-8. [PUBMED:
10861153 ] 18634954 ]
Seo 2012 {published data only} Ul Haq 2013 {published data only}
Seo SH, Lee JG, Yu SB, Kim DS, Ryu SJ, Kim KH. Predictors Ul Haq MI, Ullah H. Comparison of Mallampati test with
of difficult intubation defined by the intubation difficulty lower jaw protrusion maneuver in predicting difficult
scale (IDS): predictive value of 7 airway assessment factors. laryngoscopy and intubation. Journal of Anaesthesiology,
Korean Journal of Anesthesiology 2012;63(6):491-7. [PUBMED: Clinical Pharmacology 2013;29(3):313-7. [PUBMED: 24106353 ]
23277808 ]
Uribe 2015 {published data only}
Shah 2013 {published data only} Uribe AA, Zvara DA, Puente EG, Otey AJ, Zhang J, Bergese SD.
Shah PJ, Dubey KP, Yadav JP. Predictive value of upper lip bite BMI as a predictor for potential difficult tracheal intubation in
test and ratio of height to thyromental distance compared males. Frontiers in Medicine (Lausanne) 2015;2(38):e. [PUBMED:
to other multivariate airway assessment tests for difficult 26137460 ]
laryngoscopy in apparently normal patients. Journal of
Vallem 2015 {published data only}
Anaesthesiology, Clinical Pharmacology 2013;29(2):191-5.
[PUBMED: 23878440 ] Vallem B, Thalisetty J, Challapalli SR, Israel N, Gudise S,
Murthigari S. Comparison of upper lip bite test with other four
Shah 2014 {published data only} predictors for predicting difficulty in intubation. Journal of
Shah AA, Rafique K, Islam M. Can difficult intubation be Evolution of Medical and Dental Sciences 2015;4(39):6811-7.
accurately predicted using upper lip bite test?. Journal of [DOI: 10.14260/jemds/2015/988]
Postgraduate Medical Institute 2014;28(3):282-7.
Vani 2000 {published data only}
Sharma 2010 {published data only} Vani V, Kamath SK, Naik LD. The palm print as a sensitive
Sharma D, Prabhakar H, Bithal PK, Ali Z, Singh GP, Rath GP, et al. predictor of difficult laryngoscopy in diabetics: a comparison
Predicting difficult laryngoscopy in acromegaly: a comparison with other airway evaluation indices. Journal of Postgraduate
of upper lip bite test with modified Mallampati classification. Medicine 2000;46(2):75-9. [PUBMED: 11013469 ]
Journal of Neurosurgical Anesthesiology 2010;22(2):138-43.
Wajekar 2015 {published data only}
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Wajekar AS, Chellam S, Toal PV. Prediction of ease of
Singh 2009 {published data only} laryngoscopy and intubation-role of upper lip bite test,
Singh R, Jain A, Swatantra M, Kohli P. Clinical evaluation of modified mallampati classification, and thyromental distance
predicting difficult laryngoscopy in obstetric patients. Journal of in various combination. Journal of Family Medicine and Primary
Anaesthesiology, Clinical Pharmacology 2009;25(1):38-42. Care 2015;4(1):101-5. [PUBMED: 25810998 ]
Soyuncu 2009 {published data only} Wilson 1988 {published data only}
Soyuncu S, Eken C, Cete Y, Bektas F, Akcimen M. Determination Wilson ME, Spiegelhalter D, Robertson JA, Lesser P.
of difficult intubation in the ED. The American Journal of Predicting difficult intubation. British Journal of Anaesthesia
Emergency Medicine 2009;27(8):905-10. [PUBMED: 19857405 ] 1988;61(2):211-6. [PUBMED: 3415893 ]
Tantri 2016 {published data only} Wong 1999 {published data only}
Tantri AR, Firdaus R, Salomo ST. Predictors of difficult Wong SH, Hung CT. Prevalence and prediction of difficult
intubation among Malay patients in Indonesia. Anesthesiology intubation in Chinese women. Anaesthesia and Intensive Care
and Pain Medicine 2016;6(2):e34848. [PUBMED: 27252905 ] 1999;27(1):49-52. [PUBMED: 10050224 ]
Thompson 2009 {published data only}

Thompson J, O'Neill SS, Hutchings L, Jones R. Retrospective
study of 1602 obstetric intubations: predicting difficult and
Informed decisions.

Wong 2009 {published data only} space length to predict difficult laryngoscopy?. Anaesthesiology
Wong P, Parrington S. Difficult intubation in ENT and 1994;81:69-75.
maxillofacial surgical patients: a prospective survey. The
Meininger 2010 {published data only}
Internet Journal of Anesthesiology 2009;21(1):1-3.
Meininger D, Strouhal U, Weber CF, Fogl D, Holzer L,
Yamamoto 1997 {published data only} Zacharowski K, et al. Direct laryngoscopy or C-MAC video
Yamamoto K, Tsubokawa T, Shibata K, Ohmura S, Nitta S, laryngoscopy? Routine tracheal intubation in patients
Kobayashi T. Predicting difficult intubation with indirect undergoing ENT surgery [Direkte laryngoskopie oder C-MAC-
laryngoscopy. Anesthesiology 1997;86(2):316-21. [PUBMED: Vvdeolaryngoskopie? Routineintubation von patienten in der
9054250 ] HNO-heilkunde]. Anaesthesist 2010;59:806-11.
Yildiz 2005 {published data only} Moon 2013 {published data only}
Yildiz TS, Solak M, Toker K. The incidence and risk factors of Moon HY, Baek CW, Kim JS, Koo GH, Kim JY, Woo YC, et al.
difficult mask ventilation. Journal of Anesthesia 2005;19(1):7-11. The causes of difficult tracheal intubation and preoperative
[PUBMED: 15674508 ] assessments in different age groups. Korean Journal of
Anesthesiology 2013;64(4):308-14. [PUBMED: 23646239 ]
Yildiz 2007 {published data only}
Oriol-Lopez
́ 2009 {published data only}
Yildiz TS, Korkmaz F, Solak M, Toker K, Erciyes N, Bayrak F, et al.
Prediction of difficult tracheal intubation in Turkish patients: Oriol-Lopez SA, Hernandez-Bernal CE. Assessment, prediction
a multi-center methodological study. European Journal of and presence of difficult intubation [Valoración, predicción
Anaesthesiology 2007;24(12):1034-40. [PUBMED: 17555609 ] y presencia de intubación difícil]. Revista Mexicana de
Anestesiologica 2009;32(1):41-9.
Yu 2015 {published data only}
́ 2010 {published data only}
Orozco-Diaz
Yu T, Wang B, Jin XJ, Wu RR, Wu H, He JJ, et al. Predicting
difficult airways: 3-3-2 rule or 3-3 rule?. Irish Journal of Medical Orozco-Díaz E, Alvarez-Ríos JJ, Arceo-Díaz JL, Ornelas-
Science 2015;184(3):677-83. [PUBMED: 25740093 ] Aguirre JM. Predictive factors of difficult airway with known
assessment scales. Cirugia y Cirujanos 2010;78(5):393-9.
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References to studies excluded from this review
Reed 2005 {published data only}
Acer 2011 {published data only}
Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment
Acer N, Akkaya A, Tugay BU, Öztürk A. A comparison of score predict difficulty at intubation in the emergency
Cormack-Lehane and Mallampati tests with mandibular department?. Emergency Medicine Journal 2005;22(2):99-102.
and neck measurements for predicting difficult intubation [PUBMED: 15662057 ]
[Zor Entübasyonu Tahmin Etmek İçin Cormeck-Lehane ve
Mallampati Testleri İle Mandibula ve Boyun Ölçümlerinin Safavi 2011 {published data only}
Karşılaştırılması]. Balkan Medical Journal 2011;28:157-63. [DOI: Safavi M, Honarmand A, Zare N. A comparison of the ratio of
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Mallampati and the upper lip bite test in predicting difficult
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laryngoscopy. Saudi Journal of Anaesthesia 2011;5(3):258-63.
Acikgoz AO, Karagoz H, Yilbas AA, Akca B, Uzumcugil F, Pamuk G. [PUBMED: 21957403 ]
Difficult airway and risk factors in bariatric surgery patients.
Bariatric Surgical Practice and Patient Care 2015;10(4):145-9. Siyam 2002 {published data only}
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patients with sleep apnea syndrome. Anesthesia and Analgesia
Beyus 2010 {published data only}
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Beyus C, Mort T. Challenges of airway management in obesity.
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Medicine; 2010 Jan 9-13; Miami Beach (FL). Miami Beach, FL: Tripathi M, Pandey M. Short thyromental distance: a predictor
Society of Critical Care Medicine, 2010. of difficult intubation or an indicator for small blade selection?.
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Hiremath 1998 {published data only}
Hiremath AS, Hillman DR, James AL, Noffsinger WJ, Platt PR,
Singer SL. Relationship between difficult tracheal intubation References to studies awaiting assessment
and obstructive sleep apnoea. British Journal of Anaesthesia
Akhlaghi 2017 {published data only}
1998;80:606-11.
Akhlaghi M, Abedinzadeh M, Ahmadi A, Heidari Z. Predicting
Lewis 1994 {published data only} difficult laryngoscopy and intubation with laryngoscopic exam
Lewis M, Keramati S, Benumof JL, Berry CC. What is the best test: a new method. Acta Medica Iranica 2017;55:453-8.
way to determine oropharyngeal classification and mandibular
Informed decisions.

Andrade 2017 {published data only} intubation: a prospective observational cohort study.
Andrade R, Lima BL, Lopes DK, Couceiro Filho RO, Lima LC, Anesthesia and Analgesia 2018;126:161-9.
Couceiro TC. Difficult laryngoscopy and tracheal intubation:
Jain 2017 {published data only}
observational study. Revista Brasileira de Anestesiologia
2017;20:20. Jain N, Das S, Kanchi M. Thyromental height test for prediction
of difficult laryngoscopy in patients undergoing coronary artery
Awan 2017 {published data only} bypass graft surgical procedure. Annals of Cardiac Anaesthesia
Awan A, Rehman A. Comparison of neck circumference to 2017;20:207-11.
thyromental distance ratio with modified Mallampati score
Khatiwada 2017 {published data only}
for prediction of difficult intubation in obese patients. Acta
Anaesthesiologica Scandinavica 2017;61:997. Khatiwada S, Bhattarai B, Pokharel K, Acharya R. Prediction
of difficult airway among patients requiring endotracheal
Banik 2017 {published data only} intubation in a tertiary care hospital in eastern Nepal. JNMA;
Banik D, Ray L, Akhtaruzzaman AK, Bhowmick DK, Hossain MS, Journal of the Nepal Medical Association 2017;56(207):314-8.
Islam MS, et al. Assessment of difficulties associated with
Lee 2017 {published data only}
endotracheal intubation using modified mallampati and upper
lip bite test. Mymensingh Medical Journal: MMJ 2017;26:395-405. Lee SY, Chien DK, Huang MY, Huang CH, Shih SC, Wu KM, et
al. Patient-specific factors associated with difficult mask
Belda 2017 {published data only} ventilation in the emergency department. International Journal
Belda I, Ayuso MA, Sala-Blanch X, Luis M, Berge R. A predictive of Gerontology 2017;11:263-6.
test for difficult intubation in laryngeal microsurgery. Validation
Mahmoodpoor 2017 {published data only}
study. Revista Espanola de Anestesiologia y Reanimacion
2017;64:71-8. Mahmoodpoor A, Soleimanpour H, Golzari SE, Nejabatian A,
Pourlak T, Amani M, et al. Determination of the diagnostic
Card 2017 {published data only} value of the modified mallampati score, upper lip bite test and
Card ME, Rucci J, Honiden S, Heavner J. Identifying factors facial angle in predicting difficult intubation: a prospective
associated with difficult airway during endotracheal intubation descriptive study. Journal of Clinical Anesthesia 2017;37:99-102.
in the medical ICU. Chest 2017;152(4 Suppl 1):A218.
Norskov 2017 {published data only}
Carlson 2017 {published data only} Norskov AK, Wetterslev J, Rosenstock CV, Afshari A, Astrup G,
Carlson JN, Hostler D, Guyette FX, Pinchalk M, Martin-Gill C. Jakobsen JC, et al. Prediction of difficult mask ventilation using
Derivation and validation of the prehospital difficult airway a systematic assessment of risk factors vs. existing practice - a
identification tool (PreDAIT): a predictive model for difficult cluster randomised clinical trial in 94,006 patients. Anaesthesia
intubation. The Western Journal of Emergency Medicine 2017; Vol. 72, issue 3:296-308.
2017;18:662-72.
Prakash 2017 {published data only}
Dar 2017 {published data only} Prakash S, Mullick P, Bhandari S, Kumar A, Gogia AR, Singh R.
Dar S, Khan MS, Iqbal F, Nazeer T, Hussain R. Comparison Sternomental distance and sternomental displacement as
of upper lip bite test (ULBT) with mallampati classification, predictors of difficult laryngoscopy and intubation in adult
regarding assessment of difficult intubation. Pakistan Journal of patients. Saudi Journal of Anaesthesia 2017;11:273-8.
Medical and Health Sciences 2017;11:767-9.
Rao 2017 {published data only}
Eiamcharoenwit 2017 {published data only} Rao CS, Ranganath T, Rao SP, Sujani K. Comparison of upper
Eiamcharoenwit J, Itthisompaiboon N, Limpawattana P, lip bite test with modified mallampati test and thyromental
Suwanpratheep A, Siriussawakul A. The performance of distance for predicting difficulty in endotracheal intubation -
neck circumference and other airway assessment tests for a prospective study. Journal of Evolution of Medical and Dental
the prediction of difficult intubation in obese parturients Sciences 2017;6:1413-6.
undergoing cesarean delivery. International Journal of Obstetric
Riad 2018 {published data only}
Anesthesia 2017;31:45-50.
Riad W, Ansari T, Shetty N. Does neck circumference help
Han 2017 {published data only} to predict difficult intubation in obstetric patients? A
Han YZ, Tian Y, Xu M, Ni C, Li M, Wang J, et al. Neck prospective observational study. Saudi Journal of Anaesthesia
circumference to inter-incisor gap ratio: A new predictor of 2018;12:77-81.
difficult laryngoscopy in cervical spondylosis patients. BMC
Selvi 2017 {published data only}
Anesthesiology 2017;17(1):1-3.
Selvi O, Kahraman T, Senturk O, Tulgar S, Serifsoy E, Ozer Z.
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Shankar 2017 {published data only} ASA 2013

Shankar D, Suresh YV. Comparison of various airway Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT,
assessment factors with ratio of height to thyromental distance Nickinovich DG, et al. American Society of Anesthesiologists
(rhtmd) in predicting difficult airway in apparently normal Task Force on Management of the Difficult Airway. Practice
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2017;61(8):1036-7. require study by study examination: first for heterogeneity,
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Workeneh SA, Gebregzi AH, Denu ZA. Magnitude and Combes X, Jabre P, Jbeili C, Leroux B, Bastuji-Garin S,
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Lee H. Inter-observer reliability of ten tests used for predicting
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1996;43(6):554-9. [PUBMED: 8773859] Nordic Cochrane Centre, The Cochrane Collaboration. Review
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Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD. A systematic
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Liberati 2009
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Samsoon 1987
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Luba 2010
Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult
Luba K, Cutter TW. Supraglottic airway devices in the intubation in apparently normal patients: a meta-analysis
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Lundstrøm LH, Vester-Andersen M, Møller AM, StataCorp. Stata. Version 14. College Station, TX, USA:
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prognostic value of the modified Mallampati score: a meta-
analysis involving 177 088 patients. British Journal of Whiting 2003
Anaesthesia 2011;107(5):659-67. [PUBMED: 21948956] Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The
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Yentis 1998
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Pott 2008 References to other published versions of this review
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Lee 2010
fiberoptic laryngoscopy. Current Opinion in Anaesthesiology
2008;21(6):750-8. [PUBMED: 18997526] Lee A, Herkner H, Hovhannisyan K, Pace NL. Airway physical
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Austria: R Foundation for Statistical Computing, 2017.
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Ramadhani 1996 Arrich J, et al. Bedside tests for predicting difficult airways: an
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* Indicates the major publication for the study
Informed decisions.


CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Adamus 2010
Patient sampling All adult patients selected for endotracheal

intubation for non-emergency surgical proce-
dures
Patient characteristics and setting Sample size: 1518
763 females
Index tests Modified Mallampati
Target condition and reference standard(s) Difficult laryngoscopy: following induction

of general anaesthesia and muscle relax-
ation, direct laryngoscopy was performed.
The laryngoscopic view under optimal condi-
tions (“morning air sniffing position”) was de-
scribed
Flow and timing Index test: on arrival at operating theatre

Reference standard: following induction of
general anaesthesia
Comparative
Notes
Methodological quality
Item Authors' Risk of bias Applicabili-

judgement ty concerns
DOMAIN 1: Patient Selection
Was a consecutive or random sample of patients enrolled?
Was a case-control design avoided?
Did the study avoid inappropriate exclusions?

DOMAIN 2: Index Test All Tests
Were the index test results interpreted without knowledge of the results of the refer-
ence standard?
If a threshold was used, was it pre-specified?
Did the assessors of the index test have appropriate training?
Was interobserver variability reported for some or all patients?
Informed decisions.

Adamus 2010 (Continued)
Was interobserver agreement acceptable?

DOMAIN 3: Reference Standard
Is the reference standards likely to correctly classify the target condition?
Were the reference standard results interpreted without knowledge of the results of
the index tests?

DOMAIN 4: Flow and Timing
Was there an appropriate interval between index test and reference standard?
Did all patients receive the same reference standard?
Were all patients included in the analysis?

Adnet 2001
Patient sampling All consecutive surgical patients scheduled

for anaesthesia requiring tracheal intubation
were studied
Patient characteristics and setting University hospital, surgical patients (ab-

dominal, cardiac, thoracic, orthopaedic, ENT
surgery)
Sample size: 1171
505 females
Mean age: 49 years
Index tests MMT, ULBT
Target condition and reference standard(s) Difficult laryngoscopy, IDS > 5
Flow and timing Preoperative visit to surgery
Comparative
Notes

Informed decisions.

Adnet 2001 (Continued)

ence standard?

the index tests?


Aktas 2015
Patient sampling "Selected at random" excluding emergency

operations, patients needing awake intuba-
tion and patients with congenital anomalies
67 females
Informed decisions.

Aktas 2015 (Continued)
Mean age: 47.5 years
Index tests MMT
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane
Flow and timing Not stated
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Aktas 2015 (Continued)

Al Ramadhani 1996
Patient sampling Patients planned for caesarian section were

evaluated. If patients were selected for gener-
al anaesthesia, they were included
523 females
Index tests SMD (13.5 cm)
Flow and timing Index test during pre-anaesthesia assesment

Target condition after RSI
Comparative
Notes


ence standard?
Informed decisions.

Al Ramadhani 1996 (Continued)

the index tests?


Ali 2009
Patient sampling Over 5 years, 66 consecutive patients with

acromegaly who presented for pituitary
surgery
Patient characteristics and setting Consecutive patients with acromegaly who

presented for pituitary surgery
Sample size: 66
32 females
Index tests MMT
Flow and timing The time interval was not described. Modified
Mallampati grade was assessed preoperative-
ly
Comparative
Notes
Informed decisions.

Ali 2009 (Continued)

ence standard?

the index tests?


Ali 2012
Patient sampling Adult patients (> 18 years of age) undergoing elective

surgeries requiring general anaesthesia with endotra-
cheal intubations were enrolled
Informed decisions.

Patient characteristics and setting Edentulous patients, those unable to open the mouth
or with limited cervical movement or requiring rapid se-
quence induction were excluded
Sample size: 324
199 females
Mean age: 43 years
Target condition and reference standard(s) Difficult laryngoscopy: laryngoscopy was done with Mac-
intosh laryngoscope blade size 3 or 4, and laryngoscop-
ic view of the first attempt at intubation was graded and
recorded according to Cormack and Lehane classifica-
tion with the patient in the sniffing position but without
applying external laryngeal pressure
Flow and timing Preoperatively; no further information
Comparative
Notes
Item Authors' judge- Risk of bias Applicability

ment concerns

Were the index test results interpreted without knowledge of the results
of the reference standard?

Informed decisions.

Were the reference standard results interpreted without knowledge of
the results of the index tests?

Was there an appropriate interval between index test and reference stan-
dard?

Allahyary 2008
Patient sampling Consecutive women were prospectively included

Exclusion criteria were gross anatomical abnor-
mality or recent surgery of the head and neck,
preeclampsia, severe cardiorespiratory disorders,
inability to sit and edentulous patients
Patient characteristics and setting Consecutive obstetric parturients with ASA I/II un-
dergoing general anaesthesia for caesarean deliv-
ery
Sample size: 203
203 females
Index tests MMT, TMD, SMD (13.5cm), mouth opening, ULBT,

combination of tests
Flow and timing No time interval defined, but the tests were per-
formed preoperatively
Comparative
Notes
Item Authors' Risk of bias Applicability

judgement concerns
Informed decisions.

Allahyary 2008 (Continued)

Were the index test results interpreted without knowledge of the results of the
reference standard?

Were the reference standard results interpreted without knowledge of the re-
sults of the index tests?


Ambesh 2013
Patient sampling Consecutive adult patients ASA I and II under-

going scheduled general anaesthesia
Patient characteristics and setting Obvious difficult airway excluded
Sample size: 500
208 females
Mean age: 46 years
Informed decisions.

Ambesh 2013 (Continued)
Index tests MMT, combination of tests
Target condition and reference standard(s) Difficult larnygoscopy: Cormack and Lehane,
Macintosh blade after general anesthesia and
muscle relaxation
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Ambesh 2013 (Continued)

Applegate 2013
Patient sampling Adult patients scheduled for head and neck

surgery with the ability to read, write, and
speak English were considered for inclusion
70 females
Mean age: 55 years
Index tests Combination of tests
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane,
Macintosh blade after general anesthesia and
muscle relaxation
Comparative
Notes


ence standard?
Informed decisions.

Applegate 2013 (Continued)

the index tests?


Arne 1998
Patient sampling During an 18-month period, any patient older

than 15 years of age undergoing ENT or gen-
eral surgery with tracheal intubation was con-
sidered as potentially eligible
Mean age: 47 years
Index tests MMT, TMD, mouth opening (< 5 cm)
Target condition and reference standard(s) DIfficult tracheal intubation: patient placed in
optimal (sniffing) position on OR table
Anaesthesia induced followed by neuromus-
cular blockade
Macintosh blade at first attempt
Flow and timing Index tests during preoperative consultation
Comparative
Notes

Informed decisions.

Arne 1998 (Continued)

ence standard?

the index tests?


Ayhan 2016
Patient sampling Adult patients surgically treated for endome-

trial cancer from January 2011 to December
2014
Patient characteristics and setting Patients operated for endometrial cancer

were reviewed and only those patients with
BMI ≥ 25 (N = 427) were included in the study
Informed decisions.

Ayhan 2016 (Continued)
Sample size: 427
427 females
Mean age: 58 years
Index tests MMT, mouth opening
Target condition and reference standard(s) DIfficult laryngoscopy: Cormack and Lehane;
difficult face mask ventilation
Flow and timing During preoperative visit and during induc-

tion of anaesthesia
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Ayhan 2016 (Continued)

Ayuso 2009
Patient sampling Consecutive adult patients with laryngeal dis-

ease to undergo laryngeal microsurgry under
general anaesthesia
Patient characteristics and setting No prior testing
Sample size: 181
47 females
Index tests MMT, TMD, mouth opening (< 4 cm)
Comparative
Notes


ence standard?
Informed decisions.

Ayuso 2009 (Continued)

the index tests?


Badheka 2016
Patient sampling Patients of both gender between 20 and 70 years of age with
ASA I–III scheduled to undergo elective surgery under gener-
al anaesthesia with endotracheal intubation
Patient characteristics and setting Patients with airway malformation, oral surgery, neck burns
contracture, midline neck swelling, emergency surgery, cae-
sarean section, edentulous patients, limitation of temporo-
mandibular/atlantoaxial joint mobility, and history of neck
surgery were excluded from the study
Sample size: 170
73 females
Index tests MMT, TMD (< 6 cm), SMD, mouth opening, ULBT
Target condition and reference standard(s) Difficult laryngoscopy: laryngoscopy was done by a qualified
and experienced anaesthesiologist, who was blinded to the
results of preoperative airway assessment and glottic visual-
ization were assessed and noted according to modified Cor-
mack and Lehane grade
Informed decisions.

Badheka 2016 (Continued)
Flow and timing Preoperatively
Comparative
Notes
Item Authors' judge- Risk of bias Applicability con-

ment cerns

Were the index test results interpreted without knowledge of the re-
sults of the reference standard?

Is the reference standards likely to correctly classify the target condi-

tion?
Were the reference standard results interpreted without knowledge

of the results of the index tests?

Was there an appropriate interval between index test and reference

standard?

Informed decisions.


Baig 2014
Patient sampling Patients having ASA II status, age above 18

years and known cases of diabetes mellitus
planned for elective surgeries requiring gen-
eral anaesthesia
Patient characteristics and setting Those who already had airway deformity due
to surgical or medical problem or those un-
dergoing rapid sequence induction were ex-
cluded
Sample size: 357
145 females
Comparative
Notes


ence standard?
Informed decisions.

Baig 2014 (Continued)

the index tests?


Basaranoglu 2010
Patient sampling Consecutive patients for emergency caesare-

an delivery
Patient characteristics and setting No prior testing, routine evaluation
Sample size: 239
239 females
Mean age: 28 years
Index tests MMT, TMD (< 6 cm), SMD, mouth opening (< 3
cm), combination of tests
Flow and timing Within Minutes
Comparative
Notes

Informed decisions.

Basaranoglu 2010 (Continued)

ence standard?

the index tests?


Basunia 2013
Patient sampling Patients (16 to 60 years), ASA I and II, sched-

uled for elective surgical procedures requiring
ETI were included
Patient characteristics and setting Patients with inoral growth, unable to open
mouth, chin on chest challenged person,
pregnancy, previous history of difficult intu-
bation, acquired disorders of head and neck
were excluded
Sample size: 300
Informed decisions.

Basunia 2013 (Continued)
Index tests MMT, SMD, combination of tests
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Basunia 2013 (Continued)

Bergler 1997
Patient sampling Patients with planned laser surgery (ENT)

Patients with reduced mobility were exclud-
ed
22 females
Mean age: 54 years
Index tests MMT
Flow and timing No details given
Comparative
Notes


ence standard?

Informed decisions.

Bergler 1997 (Continued)
the index tests?


Bhat 2007
Patient sampling ASA 1/2 patients, admitted for elective surgi-

cal procedure were prospectively included
Patient characteristics and setting Excluded: edentulous patients, restricted

mouth opening, restricted cervical movement
Presence of oropharyngeal, laryngeal pathol-
ogy
Sample size: 500
286 females
Index tests MMT, ULBT, combination of tests
Flow and timing Not described
Comparative
Notes

Informed decisions.

Bhat 2007 (Continued)

ence standard?

the index tests?


Bilgin 1998
Patient sampling ASA I-II for GA requiring endotracheal intuba-

tion. Excluded known abnormalities of upper
airway or head and neck trauma
253 females
Index tests MT, TMD (< 6 cm)
Informed decisions.

Bilgin 1998 (Continued)
Target condition and reference standard(s) Difficult laryngoscopy: using Macintosh blade
size 3, with head in "sniffing" position on a
pillow. Cormack and Lehane III/IV defined as
difficult. Difficult tracheal intubation
Flow and timing Exact timing not specified
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Bilgin 1998 (Continued)

Bindra 2010
Patient sampling Not stated
Patient characteristics and setting No prior test; standard assessment; routine

preoperative care
Sample size: 123
52 females
Mean age: 38 years
Index tests MMT
Flow and timing Not stated, but apparently just prior to being
taken to operating theatre
Comparative
Notes


ence standard?
Informed decisions.

Bindra 2010 (Continued)

the index tests?


Bouaggad 2004
Patient sampling All patients aged 18 years and older scheduled to

undergo thyroid surgery under general anaesthesia
were prospectively included in the study. Patients
with obvious malformations of the airway were ex-
cluded from the study
Patient characteristics and setting Patients undergoing elective thyroid surgery
Sample size: 320
281 females
Index tests MMT, TMD (< 6 cm), mouth opening
Target condition and reference standard(s) Difficult laryngoscopy: the laryngeal view was as-
sessed with rigid laryngoscopy by a certified anaes-
thesiologist or certified nurse anaesthetist using a
Macintosh laryngoscope, Blade 3 or 4. Difficult tra-
cheal intubation: evaluated by IDS
Flow and timing Unclear
Comparative
Notes
Informed decisions.

Bouaggad 2004 (Continued)
judgement concerns

reference standard?



Breckwoldt 2011
Patient sampling All ETIs performed by the emergency physi-

cians of the mobile intensive care unit and the
Informed decisions.

Breckwoldt 2011 (Continued)
helicopter emergency medical system were
included.
105 females
Mean age: 65 years
Index tests Mouth opening
Flow and timing Directly before intubation
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Breckwoldt 2011 (Continued)

Brodsky 2002
Patient sampling Consecutive
Patient characteristics and setting Morbidly obese patients (BMI > 40) undergo-
ing elective surgery
Sample size: 100
78 females
Mean age: 44 years
Index tests MMT
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane;
difficult tracheal intubation
Comparative
Notes


ence standard?
Informed decisions.

Brodsky 2002 (Continued)

the index tests?


Butler 1992
Patient sampling Mixed surgical patients
Patient characteristics and setting Patients with known abnormalities of the air-
way or with head or neck trauma were ex-
cluded
Sample size: 250
153 females
Index tests MMT, TMD (< 6 cm)
Flow and timing No information
Comparative
Notes
Informed decisions.

Butler 1992 (Continued)

ence standard?

the index tests?


Cattano 2004
Patient characteristics and setting Adult patients scheduled to receive general

anaesthesia requiring endotracheal intuba-
Informed decisions.

Cattano 2004 (Continued)
tion for elective abdominal, vascular, urolog-
ic, and endocrinologic surgery
Sample size: 1956
Index tests MMT, TMD, SMD (< 1.2 cm), mouth opening,
difficult face mask ventilation
Comparative
Notes


ence standard?

the index tests?

Informed decisions.


Cattano 2014
Patient sampling A retrospective investigation was performed.

1399 anaesthetics were identified where both
mask ventilation was attempted and a pre-
procedure airway evaluation was document-
ed. Of these, 557 obese patients were identi-
fied and included for analysis
Patient characteristics and setting Obese patients
Sample size: 557
307 females
Index tests MMT
Target condition and reference standard(s) Difficult face mask ventilation
Flow and timing Unknown
Comparative
Notes


ence standard?
Informed decisions.


the index tests?


Chaves 2009
Patient sampling Chart review
Patient characteristics and setting Patients having elective thyroid surgery be-
tween January 2005 and June 2007; routine
anaesthesia care
About 10% of patients had clinical signs of tra-
cheal compression or radiographic signs of in-
trathoracic goiter or tracheal compression in
cervical radiogram
Sample size: 512
448 females
Mean age: 55 years
Index tests MMT, TMD (< 6 cm), mouth opening (< 5 cm),
Target condition and reference standard(s) Difficult tracheal intubation: more than three
attempts necessary or a change in materials
used
Informed decisions.

Chaves 2009 (Continued)
Flow and timing Not given
Comparative
Notes

judgement concerns

Were the index test results interpreted without knowledge of the results of the ref-
erence standard?

Were the reference standard results interpreted without knowledge of the results
of the index tests?


Informed decisions.


Choi 2013
Patient sampling Consecutive patients of ASA I or II, aged 18 to

70 years old, and who were scheduled to un-
dergo elective surgery under general anaes-
thesia were considered for enrolment
Patient characteristics and setting Patients with loose upper incisors, airway
pathology, gross anatomical abnormalities,
BMI more than 35 kg/m2, or any history of dif-
ficult intubation were excluded
Sample size: 269
132 females
Index tests MMT
Comparative
Notes


ence standard?

Informed decisions.

Choi 2013 (Continued)
the index tests?


Connor 2011
Patient sampling "Patients meeting our entry criteria were

identified by examination of their anesthesia
records in the postanesthesia care unit"
Patient characteristics and setting Only one sex, one ethnicity
Sample size: 80
0 female
Index tests MMT, TMD
Flow and timing Standard preoperative examination
Comparative
Notes

Informed decisions.

Connor 2011 (Continued)

ence standard?

the index tests?


Cortellazzi 2007
Patient sampling "Data of consecutive patients intubated

in two 5-month periods in 2004 and 2006
were anonymously entered in a computer-
ized database for the purpose of the present
study"
885 females
Informed decisions.

Cortellazzi 2007 (Continued)
Flow and timing Index test was performed 1 day before
surgery
Comparative
Notes


ence standard?

the index tests?


Informed decisions.


De Jong 2015
Patient sampling All consecutive intubation procedures in obese

(BMI >= 30) patients using two multicentre data-
bases, one containing data from 60 French med-
ical, surgical ICUs, and the other containing data
from four anaesthesia departments
Patient characteristics and setting Obese (BMI >= 30) patients

Exclusion criteria were pregnancy or being un-
der 18 years of age
setting both ICU and OR
Sample size: 2385
1238 females
Mean age: 55 years
Index tests MMT, TMD (< 5 cm), mouth opening
Target condition and reference standard(s) Difficult tracheal intubation: three or more
laryngoscopic attempts or > 10 minutes
Comparative
Notes

judgement concerns

reference standard?
Informed decisions.

De Jong 2015 (Continued)

of the index tests?


Descoins 1994
Patient sampling ENT patients
Index tests MMT, TMD, mouth opening (< 5 cm), combina-

tion of tests
Comparative
Notes

Informed decisions.

Descoins 1994 (Continued)

ence standard?

the index tests?


Dohrn 2015
Patient sampling Consecutive patients scheduled for laparo-

scopic gastric bypass surgery
437 females
Target condition and reference standard(s) Difficult tracheal intubation: more than two
attempts
Flow and timing No further information
Informed decisions.

Dohrn 2015 (Continued)
Comparative
Notes


ence standard?

the index tests?


Informed decisions.

Domi 2009
Patient sampling "The patients were selected and evaluated by

a senior anesthesiologist"
Patient characteristics and setting "All the patients with previous anesthesia
records sugesting difficult intubation as well
as patients with congenital and acquired ill-
nesses of neck and head were excluded from
the study"
Sample size: 426
Index tests MMT, Wilson risk score, TMD, SMD, mouth

opening (< 4 cm), combination of tests
Comparative
Notes


ence standard?

Informed decisions.

Domi 2009 (Continued)
the index tests?


Domi 2010
Patient sampling Convenience sample
Patient characteristics and setting Exclusion: < 14 years; history of difficult to in-
tubate
Sample size: 426
209 females
Index tests MMT, TMD, SMD
Comparative
Notes


Informed decisions.

Domi 2010 (Continued)
ence standard?

the index tests?


Eberhart 2005
449 females
Mean age: 61 years
Comparative
Notes
Informed decisions.

Eberhart 2005 (Continued)

ence standard?

the index tests?


El-Ganzouri 1996
Patient sampling All patients who underwent general surgery
Patient characteristics and setting Sample size: 10,507
Informed decisions.

El-Ganzouri 1996 (Continued)
Index tests MMT, TMD (< 6 cm), mouth opening, combina-
tion of tests
Flow and timing Not specified
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

El-Ganzouri 1996 (Continued)

Ezri 2001
Patient sampling All patients > 18 years in preoperative holding

area between 08:00 h to 16:00 h enrolled
Patient characteristics and setting Excluded patients given regional anaesthe-

sia and patients receiving GA without endotra-
cheal intubation. Excluded also patients with
upper airway pathology, cervical spine frac-
tures and increased risk for aspiration of gas-
tric contents
Sample size: 764
367 females
Index tests MMT
Flow and timing Exact time interval between airway bedside

test and laryngoscopy not described
Comparative
Notes

judgement concerns

erence standard?
Informed decisions.

Ezri 2001 (Continued)

of the index tests?


Ezri 2003a
Patient sampling All consecutive patients older than 18 years of

age, who arrived in the preoperative holding
area for elective surgery
Patient characteristics and setting Patients with upper airway pathology, history
of difficult laryngoscopy/intubation and full
stomach were excluded
Sample size: 50
29 females
Mean age: 35 years
Index tests MMT, TMD (< 6 cm), mouth opening, combina-

tion of tests
Comparative
Informed decisions.

Ezri 2003a (Continued)
Notes


ence standard?

the index tests?


Ezri 2003b
Informed decisions.

Ezri 2003b (Continued)
Patient sampling Consecutive patients undergoing coronary
artery bypass surgery and general surgery (la-
paroscopies and open laparotomies)
Patient characteristics and setting All aged > 40 years, patients with BMI > 35, up-
per airway pathology, history of difficult aryn-
goscopy/intubation and full stomach were ex-
cluded
Sample size: 1472
735 females
Index tests MMT, TMD (< 6 cm), mouth opening (< 4 cm),
Comparative
Notes


ence standard?

Informed decisions.

Ezri 2003b (Continued)
the index tests?


Ezri 2003c
Patient sampling Morbidly obese (BMI > 35) scheduled for

weight reduction surgery
Patient characteristics and setting See above
Index tests MMT
Target condition and reference standard(s) Difficult tracheal intubation
Flow and timing Night before surgery
Comparative
Notes


Informed decisions.

Ezri 2003c (Continued)
ence standard?

the index tests?


Frerk 1991
Patient sampling Adults requiring tracheal intubation as part of

anaesthesia assessed before operation
101 females
Index tests MMT, TMD (< 7 cm), combination of tests
Macintosh blade for laryngoscopy
Flow and timing Tests done at preoperative visit
Comparative
Notes
Informed decisions.

Frerk 1991 (Continued)


ence standard?

the index tests?


Frerk 1996
Patient sampling Case-control
Informed decisions.

Patient characteristics and setting Ten patients with a history of difficult tracheal
intubation (Cormack and Lehane grade III
or IV) and 10 control patients in whom the
trachea was easy to intubate (Cormack and
Lehane grade I or II) were examined
Sample size: 20
Index tests MMT
Comparative
Notes


ence standard?

the index tests?

Informed decisions.


Freund 2012
Patient sampling Unknown
Patient characteristics and setting Patients intubated in physician-staffed EMS;

patients with alternative airway management
at first or second attempt excluded
Sample size: 694
264 females
Index tests TMD, combination of tests
Comparative
Notes


ence standard?
Informed decisions.

Freund 2012 (Continued)

the index tests?


Fritscherova 2011
Patient sampling Patients over 18 years of age undergoing surgery

under general anaesthesia with
their airway secured by tracheal intubation
Patient characteristics and setting Patients in whom difficult intubation could be

anticipated were excluded from the study
Sample size: 158
78 females
Index tests MMT, TMD, ULBT, combination of tests
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane; dif-
ficult tracheal intubation: failed or > 10 mins
Flow and timing Reference standard in the operation

Index test the following day for difficult intuba-
tion group, no details for easy intubation group
Informed decisions.

Fritscherova 2011 (Continued)
Comparative
Notes

judgement concerns

reference standard?

of the index tests?


Informed decisions.

Gonzalez 2008
Patient sampling All obese patients scheduled for surgery under

general anaesthesia with endotracheal intuba-
tion were enrolled in this prospective study at
University Hospital of Toulouse
Obesity was defined as a BMI > 30 kg/m2. Con-

comitantly, all the lean (BMI < 30 kg/m2) adult
patients who were scheduled for surgery dur-
ing the same period and who were intubated
by the same anaesthesiologists were included
in the control group
115 females
Index tests MMT
Target condition and reference standard(s) Difficult tracheal intubation: IDS
Comparative
Notes

judgement concerns

erence standard?

Informed decisions.

Gonzalez 2008 (Continued)
of the index tests?


Hagberg 2009
Patient sampling Retrospective analysis
Patient characteristics and setting Obese (BMI > 35) patients undergoing elective
surgery during a period of 9 years within one
hospital
Sample size: 283
216 females
Index tests MMT
Target condition and reference standard(s) Failed intubation
Comparative
Notes

Informed decisions.

Hagberg 2009 (Continued)

ence standard?

the index tests?


Hagiwara 2015
Patient sampling Patients requiring emergency intubation at

the ED
Those where alternative airway techniques at
first attempt were excluded
1236 females
Mean age: 71 years
Informed decisions.

Hagiwara 2015 (Continued)
attempts
Flow and timing Unclear; form filled out after intubation
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Hagiwara 2015 (Continued)

Hashim 2014
Patient sampling Patients who were diabetic for at least a year in the
age group between 30 and 80 years and underwent
elective surgery under general anaesthesia with endo-
tracheal intubation
Patient characteristics and setting Patients with obvious anatomical variation of their
face, neck, palate or hands and history of difficult in-
tubation in the past were excluded from the study. Pa-
tients with coexisting diseases such as rheumatoid
arthritis, oral malignancies and large neck masses
were also excluded
Sample size: 60
37 females
Mean age: 56 years
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane using
Macintosh blade
Comparative
Notes

judgement concerns

Were the index test results interpreted without knowledge of the results of
the reference standard?
Informed decisions.

Hashim 2014 (Continued)

Were the reference standard results interpreted without knowledge of the

results of the index tests?

dard?

Healy 2016
Patient sampling Patients undergoing general anaesthesia with a

documented preoperative airway examination
in combination with a documented glottic view
obtained at direct laryngoscopy
Patient characteristics and setting Excluded all patients without a documented in-
traoperative view or presence of an existing air-
way and patients in which intubation was per-
formed by alternative means
Sample size: 80,709
43,015 females
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane, us-
ing either Macintosh or Miller blade Difficult tra-
cheal intubation: IDS
Comparative
Informed decisions.

Healy 2016 (Continued)
Notes

judgement concerns

reference standard?

of the index tests?


Heinrich 2013
Informed decisions.

Heinrich 2013 (Continued)
Patient sampling Database
Patient characteristics and setting Patients undergoing anaesthesia

Patients with videolaryngoscopic assistance
without documentation of a direct laryngeal
view were excluded
Sample size: 102,305
50,608 females
Mean age: 57 years
Index tests MMT
standard cold light MacIntosh blade sized ap-
propriately
Flow and timing Preoperative maximum 12 hours
Comparative
Notes


ence standard?

Informed decisions.

Heinrich 2013 (Continued)
the index tests?


Hekiert 2007
Patient sampling Retrospetive analysis of consecutive obese

patients
Patient characteristics and setting Obese patients only (BMI > 30)
Sample size: 14
9 females
Index tests MMT
Flow and timing Reference standard: otolaryngology office

index test: OP
Comparative
Notes

Informed decisions.

Hekiert 2007 (Continued)

ence standard?

the index tests?


Hirmanpour 2014
Patient sampling Unclear
Patient characteristics and setting Patients with a history of trauma to the air-
way or cranial, cervical and facial regions, or
were edentulous or requiring awake intuba-
tion, patients with restricted motility of the
neck and mandible (e.g. cervical disc disor-
ders or rheumatoid arthritis) and inability to
sit were not included in the study
Sample size: 657
657 females
Mean age: 27 years
Informed decisions.

Hirmanpour 2014 (Continued)
size three Macintosh laryngoscope blade
Flow and timing Preoperative
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Hirmanpour 2014 (Continued)

Honarmand 2008
Patient sampling Consecutive patients selected for elective caesarean de-

livery
Patient characteristics and setting Exclusion: < 18, obvious malformations of the airway, in-
ability to sit, head/neck surgery
Sample size: 400
400 females
Mean age: 24 years
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane. A anesthe-
siologist with 7 years experience in anaesthesia, who
was not informed of the results of the index tests, car-
ried out laryngoscopy and assessed difficulty of laryn-
goscopy at intubation, which was performed
with the patient adequately anaesthetized and fully re-
laxed on the operating room table. Laryngoscopy was
performed using a Macintosh #4
Flow and timing Test was carried out prior to transfer to operating room
Comparative
Notes

ment concerns

Informed decisions.

Honarmand 2008 (Continued)



dard?

Honarmand 2014
Patient sampling ASA I-III adult patients programmed to be given general

anaesthesia necessitate endotracheal intubation for elec-
tive surgery
Patient characteristics and setting Patients with a history of previous surgery, burns or trau-
ma to the airways or to the cranial, cervical and facial re-
gions, patients with tumours or a mass in the above-men-
tioned regions, patients with restricted motility of the
neck and mandible (e.g. rheumatoid arthritis or cervical
disk disorders), inability to sit, edentulous or need awake
intubation were excluded from the study
Sample size: 525
184 females
Mean age: 46 years
Informed decisions.

Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane, laryn-
goscopy was done with using a Macintosh #4 blade to vi-
sualize the larynx
Comparative
Notes

ment concerns



tion?



standard?
Informed decisions.


Honarmand 2015
Patient sampling Adult patients, who were scheduled to under-

go elective operations under general anaes-
thesia with endotracheal intubation
319 females
Mean age: 44 years
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane.
Laryngoscopy was done by a Macintosh num-
ber 4 laryngoscope blade
Comparative
Notes


ence standard?
Informed decisions.


the index tests?


Huh 2009
Patient sampling Consecutive adult patients scheduled to un-

dergo general anesthesia requiring tracheal in-
tubation for elective surgery
Patient characteristics and setting Exclusion criteria included a gross anatomical

abnormality, recent surgery of the
head and neck, upper airway disease (e.g.
maxillofacial fracture or tumours), loose teeth,
or those requiring a rapid sequence or awake
intubation
Sample size: 213
104 females
Index tests MMT, TMD (< 6.2 cm)
Flow and timing Reference standard immediately after index

tests
Comparative
Notes
Informed decisions.

Huh 2009 (Continued)
judgement concerns

erence standard?

of the index tests?


Hui 2009
Patient sampling Patients presenting for elective, non-cardiac

surgery requiring intubation
Informed decisions.

Hui 2009 (Continued)
Index tests MT
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Hui 2009 (Continued)

Istvan 2010
Patient sampling Retrospective chart review of patients undergo-

ing appendectomy within 1 year
Patient characteristics and setting Inclusion criteria were patients from all ages and
sexes who were admitted to hospital from
the emergency department and whose preop-
erative and postoperative diagnosis was acute
appendicitis. Exclusion criteria were patients al-
ready in hospital whose postoperative
diagnosis was not acute appendicitis or who un-
derwent other surgical procedures in the same
setting
Sample size: 254
100 females
Index tests MMT
Target condition and reference standard(s) Failed intubation
Comparative
Notes

judgement concerns

reference standard?
Informed decisions.

Istvan 2010 (Continued)

of the index tests?


Ittichaikulthol 2010
Patient sampling Consecutive ASA I-IV adult patients
Patient characteristics and setting Patients scheduled to receive general anaes-

thesia requiring endotracheal intubation for
all surgery
Sample size: 1888
1239 females
Index tests MMT (I versus II-IV), TMD (< 6 cm), combina-

tion of tests
Comparative
Notes
Informed decisions.

Ittichaikulthol 2010 (Continued)

ence standard?

the index tests?


Juvin 2003
Patient sampling All obese (BMI > 35), adult (> 18 years) pa-
tients scheduled for laparoscopic gastroplas-
ty and all lean (BMI < 30) adult patients who
were scheduled for inguinal hernia repair or
Informed decisions.

Juvin 2003 (Continued)
laparoscopic cholecystectomy during the
same period and who were intubated
by the same anaesthesiologists were includ-
ed
Patient characteristics and setting Excluded: ASA III or IV, BMI 30 to 35
Sample size: 263
189 females
Mean age: 41 years
Index tests MMT, mouth opening, combination of tests
Comparative
Notes


ence standard?

Informed decisions.

Juvin 2003 (Continued)
the index tests?


K Nasa 2014
Patient sampling Patients above the age of 12 years who were

fit for general endotracheal anaesthesia irre-
spective of their ASA physical status were in-
cluded in the study
Patient characteristics and setting Patients with obvious airway malformations,

patient with inter incisor distance < 3 cm, pa-
tients allergic to drugs used in study were ex-
Sample size: 400
190 females
Comparative
Notes

Informed decisions.

K Nasa 2014 (Continued)

ence standard?

the index tests?


Kalezic 2016
Patient sampling Consecutive adult patients scheduled for thy-

roid surgery
1705 females
Informed decisions.

Kalezic 2016 (Continued)
Comparative
Notes


ence standard?

the index tests?


Informed decisions.

Kamalipour 2005
Patient sampling Adult patients who were scheduled for elective

surgery under general anaesthesia were ran-
domly selected (using the branched block ran-
domization method) and considered for enrol-
ment
Patient characteristics and setting Patients with obvious malformations of the

airway, edentulous patients, patients who re-
quired cricoid pressure for rapid sequence in-
tubation and pregnant women were excluded
from the study. Edentulous patients were also
excluded.
Sample size: 100
36 females
Index tests MMT
Comparative
Notes

judgement concerns

erence standard?
Informed decisions.

Kamalipour 2005 (Continued)

of the index tests?


Kamranmanesh 2013
Patient sampling Consecutive adult asian patients aged 20 to 65

years with ASA I and II, scheduled to undergo
elective surgery requiring endotracheal intuba-
tion, were enrolled in this prospective observa-
tional study
Patient characteristics and setting Exclusion criteria were as follows: obvious

anatomical abnormality, upper airway abnormali-
ty (e.g. tong tumour, maxillofacial tumour, or frac-
ture), recent head and neck
surgery, ASA class III and IV, and disability to open
the mouth
Sample size: 603
173 females
Comparative
Notes
Informed decisions.

Kamranmanesh 2013 (Continued)
judgement concerns

reference standard?



Khan 2003
Patient sampling Consecutive male and female patients, aged

>= 16 years, scheduled to undergo surgery
under general anaesthesia between January
Informed decisions.

Khan 2003 (Continued)
2001 and November 2001, were considered
for enrolment
Patient characteristics and setting Edentulous patients, those unable to open

the mouth, with laryngeal masses, or with
limitation of cervical movements were ex-
Sample size: 300
Comparative
Notes


ence standard?

the index tests?
Informed decisions.



Khan 2009a
Patient sampling ASA I patients older than 16 years scheduled

for elective surgical procedures requiring en-
dotracheal intubation were enrolled
Patient characteristics and setting Patients with any airway abnormality or obvi-
ous neck pathology were excluded
Sample size: 380
171 females
Mean age: 34 years
Index tests TMD (< 13.5 cm), SMD, mouth opening, ULBT,
Comparative
Notes


Informed decisions.

Khan 2009a (Continued)
ence standard?

the index tests?


Khan 2009b
Patient sampling Patients undergoing surgery and requiring endotra-

cheal intubation were enrolled in this study
Patient characteristics and setting Exclusion criteria included compromised critical air-
way, emergent cases, noncompliable patients and
those with anatomical anomalies in the airway, preg-
nant, edentulous, those having beard and patients less
than 14 years and those in whom a good mask fit was
not possible
Sample size: 200
118 females
Target condition and reference standard(s) Difficult face mask ventilation: mask ventilation was
performed by means of an appropriate sized face mask
Informed decisions.

Khan 2009b (Continued)
applied to the face and a reservoir bag receiving a con-
tinuous flow of oxygen from the anaesthesia machine
Flow and timing Shortly one after another
Comparative
Notes

judgement concerns




dard?
Informed decisions.

Khan 2009b (Continued)

Khan 2011
Patient sampling Consecutive patients of ASA physical status I and

II, aged 20-60 scheduled for elective surgical pro-
cedures requiring tracheal intubation between
July 2008 and June 2009
Patient characteristics and setting Edentulous patients, those unable to open the
mouth, patients with pharyngolaryngeal pathol-
ogy, with a history of thyroid neck surgery, preg-
nancy, or with limitation of temporomandibular
and atlanto-axial joints were excluded from the
study
Sample size: 300
175 females
Index tests ULBT, combination of tests
Comparative
Notes

judgement concerns

reference standard?
Informed decisions.




Khan 2013
Patient sampling Consecutive patients, ASA I to III who required

general anaesthesia and endotracheal in-
tubation were studied prospectively over a
3‑year period from January 2007 until De-
cember 2010
Patient characteristics and setting Exclusion criteria included inability to sit,

gross anatomical abnormality or recent
surgery of the head and neck and patients
with pregnancy or severe cardiorespiratory
disorders
Sample size: 4500
1505 females
Index tests TMD, SMD, ULBT
Informed decisions.

Comparative
Notes


ence standard?

the index tests?


Informed decisions.

Khan 2014
Patient sampling Consecutive male or female edentulous patients ≥

60 years old scheduled to undergo elective surgery
under GA between March 2008 and June 2011 were
considered for enrolment
Patient characteristics and setting Uncooperative patients, those unable to open the
mouth or with pharyngolaryngeal pathology were
excluded from the study. Patients with fixed pros-
thetic dentures were also excluded and mobile
dentures, if present, were removed to adhere to the
true definition of an edentulous case
Sample size: 588
253 females
Mean age: 64 years
Comparative
Notes

judgement concerns

reference standard?
Informed decisions.




Khan 2015
Patient sampling "In this cross-sectional study, 661 patients

aged 16-60 years were recruited during the
years 2011 to 2012"
Patient characteristics and setting Exclusion criteria included ASA class high-
er than II, urgency of the situation, facial,
mouth, throat and airway anomalies, preg-
nancy and awake intubation
Sample size: 661
366 females
Index tests MMT
Comparative
Notes

Informed decisions.


ence standard?

the index tests?


Kheterpal 2009
Patient sampling All adult patients (age 18 years or older) undergo-

ing a general anaesthetic at a tertiary care universi-
ty hospital were included over a 4-year period from
2004 to 2008
Patient characteristics and setting All cases without an attempt at mask ventilation
were excluded from the data collection and analy-
sis, including planned awake fiberoptic intubations
Informed decisions.

Kheterpal 2009 (Continued)
Sample size: 53,041
28,657 females
Mean age: 51 years
Index tests MMT, TMD (< 6 cm), mouth opening (< 3 cm)
Target condition and reference standard(s) Difficult face mask ventilation: inability to establish
face mask ventilation despite multiple airway adju-
vants and two-hand mask ventilation
Comparative
Notes

judgement concerns

reference standard?


Informed decisions.

Kheterpal 2009 (Continued)

Kim 2011
Patient sampling Patients undergoing surgery under general

anaesthesia with tracheal intubation
Patient characteristics and setting Patients were divided into obese (BMI >= 27.5)
and non-obese groups. Sufficient measures of
DTA presented for obese patients only. Same
number of obese and non-obese patients
(130 each), so consecutive sample is unlikely
Sample size: 123
77 females
Index tests MMT, Wilson risk score, combination of tests
Comparative
Notes


Informed decisions.

Kim 2011 (Continued)
ence standard?

the index tests?


Knudsen 2014
Patient sampling Patients scheduled for elective day surgery,

inclusion criteria were patients with ASA
scores of I or II who were older than 17 years
and were scheduled for general anaesthesia
requiring endotracheal intubation
Patient characteristics and setting Exclusion criteria were anaesthesia with rapid
sequence induction, pregnancy, and BMI
higher than 35 kg/ma
Sample size: 87
68 females
Mean age: 42 years
Informed decisions.

Knudsen 2014 (Continued)
Target condition and reference standard(s) Difficult tracheal intubation: "according to
ASA recommendations"
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Knudsen 2014 (Continued)

Koh 2002
Patient sampling Succesive adult (> 16 years) patients sched-

uled for elective surgery under general anaes-
thesia
Exclusion: RSI
339 females
Macintosh size 3, best view, BURP if needed;
Comparative
Notes


ence standard?
Informed decisions.

Koh 2002 (Continued)

the index tests?


Kolarkar 2015
Patient sampling 300 patients of either sex, undergoing elective

surgery under general anaesthesia with endotra-
cheal intubation. Inclusion criteria being patients
of ASA grade I/II, age: 21-60 years of either sex, elec-
tive surgery under GA
Patient characteristics and setting Exclusion criteria were edentulous patient, unable
to open the mouth, with pharyngolaryngeal pathol-
ogy, history of thyroid/neck surgery, limitations of
temporomandibular or atlanto-axial joint. Congen-
ital facial deformity
Sample size: 300
160 females
Index tests ULBT, combination of tests
Comparative
Notes
Informed decisions.

Kolarkar 2015 (Continued)

judgement concerns

reference standard?



Komatsu 2007
Patient sampling Morbidly obese patients (BMI > 35) scheduled

for elective surgery under GA with tracheal in-
Informed decisions.

Komatsu 2007 (Continued)
tubation. Patients with removable upper den-
tures, upper airway pathology, cervical spine
fractures, full stomach, significant gastro-oe-
sophageal reflux or a history of difficult laryn-
goscopy were excluded. Pregnant women
were also excluded
64 females
Index tests MMT (I versus II-IV)
Comparative
Notes


ence standard?

the index tests?
Informed decisions.

Komatsu 2007 (Continued)


Konwar 2015
Patient sampling 200 patients were randomly selected and en-

rolled in this study. The study population con-
sisted of patients of ASA class I and II, belonging
to either sex of age group 18-40 years admitted
for operation under GA with endotracheal intu-
bation
Patient characteristics and setting Patients with concurrent pregnancy; intraoral,

laryngeal or pharyngeal mass; altered head and
neck anatomy; and restricted movement of the
neck were excluded
Sample size: 200
83 females
Mean age: 28 years
Index tests TMD, mouth opening, ULBT
Comparative
Notes

judgement concerns
Informed decisions.

Konwar 2015 (Continued)

reference standard?

of the index tests?


Krobbuaban 2005
Patient sampling Consecutive ASA I–II adult patients scheduled

to receive GA requiring endotracheal intuba-
tion for elective orthopaedic, urologic, ab-
dominal, and gynaecologic surgery
Patient characteristics and setting Patients younger than 18 years of age, with
obvious malformations of the airway, eden-
tulous, or requiring a RSI or awake intubation
were excluded from the study
Sample size: 550
289 females
Informed decisions.

Krobbuaban 2005 (Continued)
Mean age: 45 years
Index tests MMT, TMD, mouth opening
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Krobbuaban 2005 (Continued)

Langeron 2000
Patient sampling All adult patients scheduled for orthopaedic, urolog-

ic, abdominal, gynaecologic and neurosurgery with
GA were prospectively included in the study over a 6-
month period
Patient characteristics and setting Those with contraindication of mask ventilation (i.e.
emergency cases requiring a RSI, planned awake intu-
bation) were excluded
Sample size: 1502
831 females
Target condition and reference standard(s) Difficult face mask ventilation: the inability of an unas-
sisted anaesthesiologist to maintain the measured oxy-
gen saturation as measured by pulse oximetry > 92%
or to prevent or reverse signs of inadequate ventilation
during positive-pressure mask ventilation under GA
Flow and timing No information given
Comparative
Notes

judgement concerns

Informed decisions.

Langeron 2000 (Continued)



dard?

Lee 2015
Patient sampling The 2011 year operating schedule was reviewed

to identify study patients
Patient characteristics and setting Exclusion criteria were: children, nasotracheal in-
tubation, emergency intubation, fiberoptic-assist-
ed intubation, existing tracheostomies or laryn-
gectomies, laryngeal mask airway
cases, regional anaesthesia without intubation,
and incomplete charts. Inclusion criteria were
adult (18 years) male and female patients under-
going direct laryngoscopy for the purpose of gen-
eral endotracheal anaesthesia
Sample size: 344
Index tests MMT
Flow and timing Not stated in study
Informed decisions.

Lee 2015 (Continued)
Comparative
Notes

judgement concerns

reference standard?



Informed decisions.

Liaskou 2014
Patient sampling 387 consecutive adult patients (age > 18

years) ASA I–II, without known airway pathol-
ogy, scheduled for surgical procedures under
GA with tracheal intubation were assessed for
eligibility
Patient characteristics and setting Teaching hospital, patients scheduled for

surgery
Sample size: 341
178 females
Mean age: 50 years
Index tests SMD (< 15 cm)
Comparative
Notes


ence standard?

Informed decisions.

Liaskou 2014 (Continued)
the index tests?


Lundstrom 2009
Patient sampling Nationwide prospective registry
Patient characteristics and setting For this retrospective analysis patients with
regional anaesthesia, sedation alone, no
planned endotracheal intubation, intubation
previous to OP, fibre optic intubation were ex-
cluded
Sample size: 103,728
59,287 females
Index tests MMT
attempts or more than one anaesthesist
Comparative
Notes

Informed decisions.

Lundstrom 2009 (Continued)

ence standard?

the index tests?


Mallat 2010
Patient sampling Patients were selected when at least one of

the following criteria was found at preopera-
tive evaluation: inability to palpate the cricoid
cartilage, endothoracic goitre (every goitre
that extends below the manubrium on the
chest x-ray), tracheal deviation of more than 1
cm or tracheal stenosis on the chest x-ray
Patient characteristics and setting Patients with goitre only (see above)
Sample size: 80
Informed decisions.

Mallat 2010 (Continued)
Mean age: 56 years
Index tests MMT
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Mallat 2010 (Continued)

Mashour 2008
Patient sampling All patients receiving anaesthesia with BMI >=

40
Patient characteristics and setting Only patients with BMI >= 40
Sample size: 346
231 females
Mean age: 50 years
Comparative
Notes


ence standard?
Informed decisions.

Mashour 2008 (Continued)

the index tests?


Mehta 2014
Patient sampling Patients posted for elective surgery under GA
Patients with obvious head and neck pathol-

ogy, edentulous patients, mass in the mouth,
BMI > 40, protruding upper incisors (total of
34) were excluded from the study
130 females
Mean age: 44 years
Index tests MMT, TMD (< 6 cm), SMD (< 1.5 cm), mouth
opening, ULBT
Comparative
Notes

Informed decisions.

Mehta 2014 (Continued)

ence standard?

the index tests?


Merah 2004
Patient sampling ASA I-III patients selected for GA for caesarean

section
Patient characteristics and setting Exclusion: inability to sit, gross anatomical

abnormity of head and neck, recent surgery
of this areas, severe cardiorespiratory disor-
ders
Informed decisions.

Merah 2004 (Continued)
Sample size: 80
80 females
Index tests MMT, TMD, SMD (< 13.5 cm), mouth opening (<
2.5 cm), combination of tests
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Merah 2004 (Continued)

Mishra 2009
Patient sampling No details given
Patient characteristics and setting 100 pregnant patients posted for caesarean sec-
tion under GA (both emergency and elective)
Patients with a history of burns, trauma, tumours

or a mass and previous surgery involving the
craniofaciocervical region or the airway, patients
with restricted mobility of the neck andmandible
(e.g. rheumatoid arthritis or cervical disk disor-
ders), and severe pregnancy induced hyperten-
sion were excluded from the study
Sample size: 100
100 females
Mean age: 25 years
Comparative
Notes

judgement concerns

Informed decisions.

Mishra 2009 (Continued)
reference standard?



Montemayor-Cruz 2015
Patient sampling A non-probabilistic sample was performed by selecting consecu-

tive cases over the month of January 2014
Patient characteristics and setting Inclusion criteria: male and female patients of 15 to 75 years of
age;elective surgical procedure; GA requiring orotracheal intuba-
tion
Exclusion criteria: patients who refused to participate in the study

(in the case of minors, patients whose legal guardians refused
their participation in the study); patients who, due to their clini-
cal status, were unable to co-operate with airway assessment (low
Glasgow Coma Scale score, mental retardation, dementia, etc.);
anatomical abnormalities altering the airway (deformity, tumours,
etc.) and that precluded airway exploration regardless of the diag-
nosis the surgical procedure was to be performed for; patients al-
ready intubated.
Sample size: 70
Informed decisions.

Montemayor-Cruz 2015 (Continued)
35 females
Mean age: 48 years
Comparative
Notes

ment cerns

Were the index test results interpreted without knowledge of

the results of the reference standard?

Is the reference standards likely to correctly classify the target

condition?
Were the reference standard results interpreted without knowl-

edge of the results of the index tests?

Informed decisions.

Montemayor-Cruz 2015 (Continued)
Was there an appropriate interval between index test and refer-
ence standard?

Myneni 2010
Patient sampling "All adult patients 18 years of age and older,

presenting in all surgical specialties, were in-
cluded in the study except for obstetric anes-
thesia or plastic surgery for burns"
Index tests ULBT
Comparative
Notes


ence standard?
Informed decisions.

Myneni 2010 (Continued)

the index tests?


Nadal 1998
Patient sampling All diabetic patients for elective surgery under

GA included from May 1994 to May 1995
Patient characteristics and setting Excluded: obvious anatomical variations of

face, neck, palate or hands, or had a history of
Sample size: 83
53 females
Mean age: 53 years
Index tests MT, TMD (< 6 cm)
Flow and timing Index test done one day before surgery
Comparative
Notes
Informed decisions.

Nadal 1998 (Continued)

ence standard?

the index tests?


Naguib 1999
Patient characteristics and setting Patients in whom an unanticipated difficult in-

tubation was identified and were scheduled to
Informed decisions.

Naguib 1999 (Continued)
undergo endotracheal anaesthesia for any type
of non-emergency surgical procedures except
traumatic facial abnormalities or obstetric and
cardiac surgery. Also
random control group whom laryngoscopy
and intubation was found to be easy and
anaesthetized by the same anaesthesiologists
Sample size: 57
15 females
Index tests MMT
Comparative
Notes

judgement concerns

erence standard?

Informed decisions.

of the index tests?


Naguib 2006
Patient characteristics and setting Adult patients presenting for GA for any type
of non-emergency surgical procedures ex-
cept traumatic facial abnormalities, obstetric
surgery, or cardiac surgery with unanticipated
difficult intubation. Also second patient from
same day as control
Sample size: 194
84 females
Index tests MMT
Target condition and reference standard(s) Difficult tracheal intubation: two or more at-
tempts at placing the endotracheal tube or
the use of an alternative device
Comparative
Notes

Informed decisions.


ence standard?

the index tests?


Nasir 2011
Patient sampling 122 patients were selected from the operative

schedule by convenient non-probability sampling
Patient characteristics and setting Adult patients belonging to ASA-I , II and III ranging
from 18-65 years of either gender undergoing elec-
tive procedures from all surgical specialties requir-
ing endotracheal intubation were included in the
study. Emergency surgical procedures, patients with
age < 18 years, pregnant patients, patients with un-
stable cervical spine and patients with tumour of the
larynx were excluded
Informed decisions.

Nasir 2011 (Continued)
Sample size: 122
79 females
Index tests MMT
Comparative
Notes

judgement concerns



Informed decisions.

Nasir 2011 (Continued)
dard?

Nasiri 2013
Patient sampling "Our study population included all patients

who were referred for elective surgery, adult
patients aged 18 to 75 years. Patients with
burns, neck, tumors, head and neck injury
were excluded"
204 females
Index tests Mouth opening, ULBT
Flow and timing Not reported
Comparative
Notes


ence standard?
Informed decisions.

Nasiri 2013 (Continued)

the index tests?


Nath 1997
Patient characteristics and setting Adults requiring GA and intubation (includ-

ing easy and difficult intubations). Also 16 pa-
tients reported to be difficult to intubate
Sample size: 300
127 females
Index tests MMT
Flow and timing Index test postoperative. Reference standard

was re-checked according to documentation
for those who were included retrospectively
Comparative
Notes
Informed decisions.

Nath 1997 (Continued)


ence standard?

the index tests?


Noorizad 2006
Patient sampling No details given
Informed decisions.

Noorizad 2006 (Continued)
200 females
Flow and timing Index test at preoperative visit. Reference

standard at OP
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Noorizad 2006 (Continued)

Oates 1990
Patient sampling Subgroup of patients scheduled for elective

surgery from an unpublished prospective
study
Index tests MT
Comparative
Notes


ence standard?
Informed decisions.

Oates 1990 (Continued)

the index tests?


Oates 1991
Patient sampling Patients requiring tracheal intubation for op-

eration. No further details
448 females
Index tests MT, Wilson risk score
Comparative
Notes

Informed decisions.

Oates 1991 (Continued)

ence standard?

the index tests?


Pottecher 1991
Patient sampling Gynaecologic-obstetric patients requiring in-

tubation for OP
663 females
Index tests MMT (I versus II-IV), TMD (< 8 cm), SMD, mouth
opening (< 4.1 cm)
Informed decisions.

Pottecher 1991 (Continued)
Comparative
Notes


ence standard?

the index tests?


Informed decisions.


Prakash 2013
Patient sampling "Patients under general anaesthesia requiring

tracheal intubation were included in this prospec-
tive study"
Patient characteristics and setting Adult ASA I and II adult patients scheduled for
elective surgery. Patients with obvious abnor-
mality of the airway where intubation under GA
would be contraindicated, those at increased risk
of aspiration, inter-incisor distance < 2.5 cm and
unstable cervical spine were excluded from the
study
Sample size: 330
222 females
Flow and timing Not provided
Comparative
Notes

judgement concerns

reference standard?
Informed decisions.

Prakash 2013 (Continued)



Qudaisat 2011
Patient sampling Unclear. "variety of elective procedures under

general anaesthesia"
Exclusion: facial asymmetry, upper incisor
protrusion, edentulousness, limited mouth
opening
98 females
Index tests TMD
Comparative
Notes

Informed decisions.

Qudaisat 2011 (Continued)

ence standard?

the index tests?


Reghunathan 2016
Patient sampling Patients of both sexes, between 15 and 55 years,

and belonging to ASA grade I or II were selected.
Patients with obesity, malposition of teeth, mi-
crostomia, macroglossia, edentulous or with arti-
ficial dentures, cervical spondylosis, short neck,
contractures of neck, neck swellings, postradi-
ation fibrosis, developmental anomalies which
may affect airway assessment, and in whom diffi-
cult intubation was expected were excluded from
the study
Informed decisions.

Reghunathan 2016 (Continued)
Mean age: 35 years
Comparative
Notes

judgement concerns

reference standard?


Informed decisions.

Reghunathan 2016 (Continued)

Rocke 1992
Patient sampling All patients undergoing elective or emergency

caesarean section under GA; no further infor-
mation
1500 females
Index tests MMT
Comparative
Notes


ence standard?
Informed decisions.

Rocke 1992 (Continued)

the index tests?


Safavi 2014
Patient sampling Consecutive ASA I-III adult patients
Patient characteristics and setting "These patients were scheduled for elective
surgery under general anesthesia requiring
endotracheal intubation"
Sample size: 476
150 females
Comparative
Notes

Informed decisions.

Safavi 2014 (Continued)

ence standard?

the index tests?


Sahin 2011
Patient sampling ASA I–III patients scheduled for elective surgery and re-
quiring endotracheal intubation were enrolled in the
study prospectively over a 1-year period
Patient characteristics and setting The exclusion criteria included patients aged less than 18
years, obstetric patients, patients with anatomic abnor-
mality or recent surgery of the head/neck, burns or trau-
ma to the airways or to the cranial, cervical, and facial re-
gions, patients with tumours or a mass in the aforemen-
Informed decisions.

Sahin 2011 (Continued)
tioned regions, patients with restricted mobility of the
neck and mandible, and patients who do not have incisor
teeth.
Sample size: 762
367 females
Flow and timing Index tests: during the preoperative visit

Reference standard: after induction of GA
Comparative
Notes

ment concerns



tion?


Informed decisions.

Sahin 2011 (Continued)

standard?

Salimi 2008
Patient sampling All patients aged above 16 who required GA with en-
dotracheal intubation for elective surgery within 1
year were included
Patient characteristics and setting Patients with a history of previous surgery, burns or
trauma to the airways or to the cranial, cervical and
facial regions, patients with tumours or a mass in
the above-mentioned regions, patients with restrict-
ed motility of the neck and mandible (e.g. rheuma-
toid arthritis or cervical disk disorders), patients with-
out teeth, and patients with incomplete information
forms were excluded from the study
Sample size: 350
114 females
Mean age: 32 years
Index tests TMD (< 4 cm), ULBT
Comparative
Notes

judgement concerns
Informed decisions.

Salimi 2008 (Continued)




dard?

Samra 1995
Patient sampling Random selection, no further details given
Patient characteristics and setting Patients with clinically obvious mandibular

abnormalities (i.e. receding mandible, poor
mobility of temporomandibular joint either
due to arthritis, pain, trauma, or trismus) and
those patients with history of arthritis and/or
limitation of movement of cervical spine were
excluded
Sample size: 564
Index tests MMT
Informed decisions.

Samra 1995 (Continued)
Comparative
Notes


ence standard?

the index tests?


Informed decisions.


Savva 1994
Patient sampling Consecutive patients (322 of them obstetric)

requiring tracheal intubation as part of their
anaesthesia
185 females
Mean age: 39 years
Index tests MMT, TMD, SMD, combination of tests
Comparative
Notes


ence standard?

Informed decisions.

Savva 1994 (Continued)
the index tests?


Schmitt 2000
Patient sampling "Between March 1994 and December 1998, all acromegalic patients
(American Society of Anesthesiologists class I-III,68 women, 60 men)
scheduled for elective transsphenoidal resection of a growth hor-
mone secreting pituitary adenoma were investigated. The diagnosis
of acromegaly was contirmed by clinical and endocrine reassessment
(failure to suppress growth hormone to < 2 pg/l after an oral glucose
load) as well as by magnetic resonance imaging showing the size and
the extent of a pituitary adenoma just before surgery"
Patient characteristics and setting "All patients showed typical acromegalic features such as macro-glos-
sia, prognathism, or soft tissue swelling in various degrees. Preopera-
tively, Mallampati classification, thyromental distance, and head and
neck movement were determined in each patient. After induction of
anesthesia and muscle paralysis, laryngoscopic grade was assessed
during direct laryngoscopy"
Sample size: 128
68 females
Mean age: 46 years
Comparative
Notes
Item Authors' judgement Risk of bias Applicability con-

cerns
Informed decisions.

Schmitt 2000 (Continued)

Were the index test results interpreted without knowledge

of the results of the reference standard?
Did the assessors of the index test have appropriate train-

ing?
Was interobserver variability reported for some or all pa-

tients?

Is the reference standards likely to correctly classify the tar-

get condition?
Were the reference standard results interpreted without

knowledge of the results of the index tests?

Was there an appropriate interval between index test and

reference standard?

Seo 2012
Informed decisions.

Seo 2012 (Continued)
Patient sampling The study was performed at the hospital on 305
ASA I and II patients between ages 19 and 70
years, who were scheduled for surgery under GA
Patient characteristics and setting Patients were excluded from the study if their
teeth were incomplete, if the patient had limit-
ed head and neck movement, had impairment
of the temporomandibular joint, or had oral or
laryngeal tumour
Sample size: 305
157 females
Index tests MMT, TMD (< 6 cm), mouth opening, ULBT, com-
bination of tests
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane; dif-
ficult tracheal intubation: IDS
Comparative
Notes

judgement concerns

reference standard?

Informed decisions.

Seo 2012 (Continued)
of the index tests?


Shah 2013
Patient sampling Adult patients of more than 18 years age, of

either sex, of ASA grade I and II, undergoing
elective surgeries under GA
Patient characteristics and setting Patients unable to sit or stand erect, pregnant
females, those having obvious malformation
of the airway or those requiring awake intu-
bation were excluded from the study
Sample size: 480
241 females
Index tests MMT, TMD, mouth opening (< 4 cm), ULBT,

Flow and timing Not provided
Comparative
Notes

Informed decisions.

Shah 2013 (Continued)

ence standard?

the index tests?


Shah 2014
Patient sampling Patients aged ≥16 years, scheduled to un-

dergo surgery under GA were included in the
study using nonprobability consecutive sam-
pling
Patient characteristics and setting Edentulous patients, those unable to open

the mouth, those with laryngeal masses,
those having large goiters or with limitation
of cervical movements were excluded from
the study
Sample size: 450
254 females
Informed decisions.

Mean ag: 38.8 years
Index tests ULBT
Comparative
Notes


ence standard?

the index tests?

Informed decisions.


Sharma 2010
Patient characteristics and setting Over a period of 5 years, 64 consecutive

acromegalic patients presenting for surgery
for excision of pituitary tumor were enrolled.
For each acromegaly patient enrolled, the
subsequent nonacromegalic patient sched-
uled for excision of pituitary tumour during
the same 5-year period was also enrolled to
serve as a control
Sample size: 125
Comparative
Notes


ence standard?
Informed decisions.

Sharma 2010 (Continued)

the index tests?


Singh 2009
Patient sampling No information of selection process
Patient characteristics and setting ASA I and II patients undergoing elective

lower segment caesarean section under GA.
Women with full stomach and apparent ab-
normalities of the neck and face were exclud-
ed
Sample size: 300
Index tests MMT (I versus II-IV), Wilson risk score, TMD (<
5 cm), combination of tests
Comparative
Notes

Informed decisions.

Singh 2009 (Continued)

ence standard?

the index tests?


Soyuncu 2009
Patient sampling All patients who required intubation in the ED

were included in the study
Patient characteristics and setting ED patients
Sample size: 366
Informed decisions.

Soyuncu 2009 (Continued)
115 females
Index tests Mouth opening (< 3 cm), combination of tests
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Soyuncu 2009 (Continued)

Tantri 2016
Patient sampling "Patients who underwent elective surgery with general anes-
thesia were included in this study"
Patient characteristics and setting The inclusion criteria were patients aged 18 to 65 years old;
an ASA score of 1 or 2; Indonesians of Malay race; and willing-
ness to participate in this study, as indicated by signing the
informed consent form. Patients with oral opening restrict-
ed to less than 3 cm, acute burns on the face and neck, tu-
mours on the airway, limitations on neck movement, airway
trauma, protruding upper teeth, a high risk of bleeding, acute
respiratory infection (croup, epiglottitis, Ludwig’s angina), or
anatomical disturbances (macroglossia, short neck, microg-
nathia, prognathism) were excluded from this study
Sample size: 277
160 females
Index tests MMT, TMD, combination of tests
Comparative
Notes

ment cerns

Informed decisions.

Tantri 2016 (Continued)
Were the index test results interpreted without knowledge of the re-
sults of the reference standard?

Is the reference standards likely to correctly classify the target con-

dition?
Were the reference standard results interpreted without knowledge

of the results of the index tests?


standard?

Thompson 2009
Patient sampling Database of obstetric patients who under-

went tracheal intubation and who had MMT
and Cormack and Lehane grade recorded
Index tests MMT
Comparative
Notes
Informed decisions.

Thompson 2009 (Continued)


ence standard?

the index tests?


Tse 1995
Informed decisions.

Tse 1995 (Continued)
Patient sampling Consecutive male and female patients aged
18 years and older undergoing elective
surgery
Patient characteristics and setting Excluded patients with obvious malforma-

tions of airway, edentulous patiens, and pa-
tients who required cricoid pressure for RSI
Sample size: 471
251 females
Index tests MT, TMD (< 7 cm), combination of tests
Flow and timing Preoperative measurements recorded on a

form not seen by attending anaesthetist. Ex-
act time interval not specified
Comparative
Notes


ence standard?

Informed decisions.

Tse 1995 (Continued)
the index tests?


Tuzuner-Oncul 2008
Patient sampling No details on selection
Patient characteristics and setting Adult maxillofacial surgery patients
Sample size: 208
108 females
Mean age: 29 years
Index tests MMT, TMD (< 6 cm), SMD, mouth opening test
(< 2.5 cm), combination of tests
Comparative
Notes


Informed decisions.

Tuzuner-Oncul 2008 (Continued)
ence standard?

the index tests?


Ul Haq 2013
Patient sampling Patients from the preoperative clinic, preop-

erative waiting area, and operating rooms
were enrolled. ASA I-III patients aged above
18 years of either sex who were scheduled for
elective surgeries under GA requiring tracheal
intubation were included in the study
422 females
Informed decisions.

Ul Haq 2013 (Continued)
Flow and timing Preoperative, operative, no time interval re-
ported
Comparative
Notes


ence standard?

the index tests?


Informed decisions.


Uribe 2015
Patient sampling "A computerized search was initiated through the elec-
tronic medical records, which revealed 20,985 patients
who underwent abdominal surgery requiring general
anesthesia at The Ohio State University Wexner Med-
ical Center during a period of 12 months, from Janu-
ary 1, 2007 to December 31, 2007. Using Microsoft Ex-
cel, every third patient from an alphabetized list was se-
lected to generate a random sample of 6964 patients for
this study. We performed a retrospective chart review of
patients who underwent abdominal surgeries with ASA
stratification I–V under general anesthesia requiring en-
dotracheal intubation"
2333 females
Index tests MMT
Flow and timing Not reported
Comparative
Notes

ment concerns

Informed decisions.

Uribe 2015 (Continued)



dard?

Vallem 2015
Patient sampling 200 ASA grade I and II (18 to 60 years of age)

adult patients scheduled to receive GA with en-
dotracheal intubation
Patient characteristics and setting Patients with airway malformations, edentulous

patients, pregnancy and lactating mothers and
patients with craniofacial anamolies were ex-
cluded from the study. Preoperative airway ex-
amination was performed using multiple screen-
ing tests to predict difficult airway
Sample size: 200
35 females
Index tests MMT, TMD (< 6 cm), SMD (< 11 cm), mouth open-
ing, ULBT
Comparative
Notes
Informed decisions.

Vallem 2015 (Continued)

judgement concerns

reference standard?

of the index tests?


Vani 2000
Informed decisions.

Vani 2000 (Continued)
Patient sampling Patients with diabetes undergoing elective
surgery
Patient characteristics and setting Excluded: diabetes < 1 year, obvious anatom-
ical malformation, history of difficult intuba-
tion
Sample size: 50
28 females
Comparative
Notes


ence standard?

Informed decisions.

Vani 2000 (Continued)
the index tests?


Wajekar 2015
Patient sampling ASA I and II patients above 18 years undergoing elec-

tive surgical procedures requiring
endotracheal intubation were included in the study
Patient characteristics and setting Patients with a history of previous surgery, burns
or trauma, tumours/mass in the airways or the cra-
nial, cervical and facial regions, patients with restrict-
ed mobility of the neck and mandible (rheumatoid
arthritis, cervical disc disorders, or temporomandibu-
lar joint disorders), edentulous patients, pregnant pa-
tients, and BMI > 26 kg/m2 were excluded from the
study
Sample size: 402
294 females
Index tests MMT, TMD, ULBT
Comparative
Notes

judgement concerns
Informed decisions.

Wajekar 2015 (Continued)




dard?

Wilson 1988
Patient sampling Patients > 16 years undergoing non-emergent

surgery who underwent anaesthesia by four
doctors
Index tests Wilson risk score
Informed decisions.

Wilson 1988 (Continued)
Flow and timing Index test was calculated retrospectively
Comparative
Notes


ence standard?

the index tests?


Informed decisions.


Wong 1999
Patient sampling All women scheduled for elective caesarean

section under GA. Also all women scheduled
for elective gynaecological OPs under GA
411 females
Index tests MMT, TMD, combination of tests
Flow and timing Index test by primary invastigator. Reference

standard by attending anaesthesiologist
Comparative
Notes


ence standard?

Informed decisions.

Wong 1999 (Continued)
the index tests?


Wong 2009
Patient sampling A prospective survey on consecutive adult pa-

tients scheduled for elective and emergency
head and neck surgery requiring GA was per-
formed. Data were collected over a 12-month
period
241 females
Mean age: 52 years
Index tests MMT, TMD, mouth opening (< 2.5 cm), combi-
nation of tests
Flow and timing Index tests during preoperative visit. Refer-

ence standard in the OR
Comparative
Notes

Informed decisions.

Wong 2009 (Continued)

ence standard?

the index tests?


Yamamoto 1997
Patient sampling Consecutive patients
Patient characteristics and setting Routine patient care
Sample size: 7270
3635 females
Mean age: 52 years
Index tests MMT, Wilson risk score
Informed decisions.

Yamamoto 1997 (Continued)
Flow and timing Index tests performed 2 days before general
surgery
Comparative
Notes


ence standard?

the index tests?


Informed decisions.


Yildiz 2005
Patient sampling Unknown
Patient characteristics and setting Patients presenting to a Turkish hospital. No

other details
Sample size: 576
346 females
Mean age: 45 years
Target condition and reference standard(s) Difficult face mask ventilation
Comparative
Notes


ence standard?

Informed decisions.

Yildiz 2005 (Continued)
the index tests?


Yildiz 2007
Patient sampling ASA I–III patients scheduled for elective surgery and re-
quiring endotracheal intubation from seven sites. Pa-
tients aged > 18 years, those requiring RSI or an awake
intubation, obstetrical patients, surgical procedures in-
volving the upper airway, or patients with a history of
difficult intubation or tracheotomy were excluded from
the study. No informaiton on selection
994 females
Index tests MMT, TMD (< 4.8 cm), SMD (< 10.5 cm), mouth opening
(< 4 cm), combination of tests
Target condition and reference standard(s) Difficult laryngoscopy: Cormack and Lehane; difficult
face mask ventilation
Flow and timing Index tests: preoperative visit

Reference standard: after induction of GA
Comparative
Notes

judgement concerns
Informed decisions.

Yildiz 2007 (Continued)




dard?

Yu 2015
Patient sampling "This prospective, observational study was

conducted among patients who had been ad-
mitted to our 20-bed operation center in a
university hospital During the observation,
1200 patients scheduled to undergo general
anesthesia with endotracheal intubation for
elective surgery were screened."
Informed decisions.

Yu 2015 (Continued)
Patient characteristics and setting All Chinese patients
Sample Size: 732
358 females
Mean age 50.8 years
Target condition and reference standard(s) Difficult laryngoscopy: Cormack & Lehane;
Difficult tracheal intubation
Flow and timing
Comparative
Notes


ence standard?

the index tests?

Informed decisions.

Yu 2015 (Continued)

ASA: American Society of Anesthesiologists Physical Status; BMI: body mass index; BURP: backward, upward and rightward pressure; DTA:
diagnostic test accuracy; ED: emergency department; EMS: emergency medical services; ENT: ear, nose and throat; ETI: endotracheal
intubation; GA: general anaesthesia; ICU: intensive care unit; IDS: intubation difficulty scale; MT: Mallampati test; MMT: modified Mallampati
test; OP: operation; OR: operating room; RSI: rapid sequence induction; SMD: sternomental distance; TMD: thyromental distance; ULBT:
upper lip bite test

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion
Acer 2011 Insufficient data to calculate measures of diagnostic test accuracy
Acikgoz 2015 Insufficient data to calculate measures of diagnostic test accuracy
Beyus 2010 Insufficient data to calculate measures of diagnostic test accuracy
Hiremath 1998 Insufficient data to calculate measures of diagnostic test accuracy
Lewis 1994 Insufficient data to calculate measures of diagnostic test accuracy
Meininger 2010 Insufficient data to calculate measures of diagnostic test accuracy
Moon 2013 Insufficient data to calculate measures of diagnostic test accuracy
Oriol-Lopez
́ 2009 Insufficient data to calculate measures of diagnostic test accuracy
́ 2010
Orozco-Diaz Insufficient data to calculate measures of diagnostic test accuracy
Reed 2005 Insufficient data to calculate measures of diagnostic test accuracy
Safavi 2011 Insufficient data to calculate measures of diagnostic test accuracy
Siyam 2002 Insufficient data to calculate measures of diagnostic test accuracy
Tripathi 2006 Insufficient data to calculate measures of diagnostic test accuracy

Characteristics of studies awaiting classification [ordered by study ID]

Akhlaghi 2017
Patient sampling
Informed decisions.

Akhlaghi 2017 (Continued)
Patient characteristics and setting
Index tests
Target condition and reference standard(s)
Flow and timing
Comparative
Notes Result from top-up search; will be incorporated

into the review at the next update

Andrade 2017
Patient sampling
Index tests
Flow and timing
Comparative


Awan 2017
Patient sampling
Index tests
Flow and timing
Comparative


Informed decisions.


Banik 2017
Patient sampling
Index tests
Flow and timing
Comparative


Belda 2017
Patient sampling
Index tests
Flow and timing
Comparative


Card 2017
Patient sampling
Index tests
Flow and timing
Comparative
Informed decisions.

Card 2017 (Continued)

Carlson 2017
Patient sampling
Index tests
Flow and timing
Comparative


Dar 2017
Patient sampling
Index tests
Flow and timing
Comparative


Eiamcharoenwit 2017
Patient sampling
Index tests
Informed decisions.

Eiamcharoenwit 2017 (Continued)
Flow and timing
Comparative


Han 2017
Patient sampling
Index tests
Flow and timing
Comparative


Hanouz 2018
Patient sampling
Index tests
Flow and timing
Comparative


Jain 2017
Informed decisions.

Jain 2017 (Continued)
Patient sampling
Index tests
Flow and timing
Comparative


Khatiwada 2017
Patient sampling
Index tests
Flow and timing
Comparative


Lee 2017
Patient sampling
Index tests
Flow and timing
Comparative

Informed decisions.


Mahmoodpoor 2017
Patient sampling
Index tests
Flow and timing
Comparative


Norskov 2017
Patient sampling
Index tests
Flow and timing
Comparative


Prakash 2017
Patient sampling
Index tests
Flow and timing
Informed decisions.

Prakash 2017 (Continued)
Comparative


Rao 2017
Patient sampling
Index tests
Flow and timing
Comparative


Riad 2018
Patient sampling
Index tests
Flow and timing
Comparative


Selvi 2017
Patient sampling
Informed decisions.

Selvi 2017 (Continued)
Index tests
Flow and timing
Comparative


Shankar 2017
Patient sampling
Index tests
Flow and timing
Comparative


Siljeblad 2017
Patient sampling
Index tests
Flow and timing
Comparative

into the review at the next update.

Informed decisions.

Srivilaithon 2018
Patient sampling
Index tests
Flow and timing
Comparative


Torres 2017
Patient sampling
Index tests
Flow and timing
Comparative


Wang 2017
Patient sampling
Index tests
Flow and timing
Comparative
Informed decisions.

Wang 2017 (Continued)

Workeneh 2017
Patient sampling
Index tests
Flow and timing
Comparative


Yildirim 2017
Patient sampling
Index tests
Flow and timing
Comparative


DATA
Presented below are all the data for all of the tests entered into the review.
Informed decisions.

Table Tests. Data tables by test
Test No. of studies No. of partici-

pants
1 Mallampati test: difficult laryngoscopy 6 2165
2 Mallampati test: difficult tracheal intubation 1 500
3 Modified Mallampati test: difficult laryngoscopy 80 232939
4 Modified Mallampati test: difficult face mask ventilation 6 56323
5 Modified Mallampati test: difficult tracheal intubation 24 191849
6 Modified Mallampati test: failed intubation 2 485
7 Wilson risk score: difficult laryngoscopy 5 5862
8 Wilson risk score: difficult tracheal intubation 1 123
9 Thyromental distance: difficult laryngoscopy 42 33189
10 Thyromental distance: difficult face mask ventilation 1 53041
11 Thyromental distance: difficult tracheal intubation 10 5089
12 Sternomental distance: difficult laryngoscopy 16 12211
13 Sternomental distance: difficult tracheal intubation 2 864
14 Mouth opening: difficult laryngoscopy 24 22179
15 Mouth opening: difficult face mask ventilation 2 53469
16 Mouth opening: difficult tracheal intubation 9 6091
17 Upper lip bite test: difficult laryngoscopy 27 19609
18 Upper lip bite test: difficult face mask ventilation 1 200
19 Upper lip bite test: difficult tracheal intubation 2 598
20 Combination of tests: difficult laryngoscopy 42 230680
21 Combination of tests: difficult face mask ventilation 4 10819
22 Combination of tests: difficult tracheal intubation 15 11089

Test 1. Mallampati test: difficult laryngoscopy.

Informed decisions.

Test 2. Mallampati test: difficult tracheal intubation.

Test 3. Modified Mallampati test: difficult laryngoscopy.

Test 4. Modified Mallampati test: difficult face mask ventilation.

Test 5. Modified Mallampati test: difficult tracheal intubation.

Test 6. Modified Mallampati test: failed intubation.

Test 7. Wilson risk score: difficult laryngoscopy.

Test 8. Wilson risk score: difficult tracheal intubation.

Test 9. Thyromental distance: difficult laryngoscopy.

Test 10. Thyromental distance: difficult face mask ventilation.

Test 11. Thyromental distance: difficult tracheal intubation.

Test 12. Sternomental distance: difficult laryngoscopy.

Test 13. Sternomental distance: difficult tracheal intubation.

Test 14. Mouth opening: difficult laryngoscopy.

Informed decisions.

Test 15. Mouth opening: difficult face mask ventilation.

Test 16. Mouth opening: difficult tracheal intubation.

Test 17. Upper lip bite test: difficult laryngoscopy.

Test 18. Upper lip bite test: difficult face mask ventilation.

Test 19. Upper lip bite test: difficult tracheal intubation.

Test 20. Combination of tests: difficult laryngoscopy.

Test 21. Combination of tests: difficult face mask ventilation.

Test 22. Combination of tests: difficult tracheal intubation.

ADDITIONAL TABLES

Table 1. Index screening tests for the difficult airway
Test Refer- Technique Definition of positive response Standard
ence cut-off in
this re-
view
Mallam- Mallam- Quote: "Visibility of pharyngeal Class 1. Faucial pillars, soft palate, and uvula could be Class 1
pati test pati 1985 structures (faucial pillars, soft visualized and 2 ver-
palate, and base of uvula) is noted sus Class
by instructing the patient to open Class 2. Faucial pillars and soft palate could be visual- 3
his/her mouth and protrude the ized, but uvula was masked by the base of the tongue
tongue maximally while in the sit-
Class 3. Only soft palate could be visualized
ting position."
This ordinal scale is dichotomized with assignment to
Class 3 being the predictor of a DA.
Modified Ezri Quote: "All the airway assessments Class 0. Ability to see any part of the epiglottis on Class 0 to
Mallam- 2001;Sam- were done by the same anaesthe- mouth opening and tongue protrusion 2 versus
pati test soon 1987 siologist, in the sitting position, Class 3
with the patient’s head in neu- Class 1. Soft palate, fauces, uvula, pillars seen and 4
Informed decisions.

Table 1. Index screening tests for the difficult airway (Continued)

tral position, mouth fully open, Class 2. Soft palate, fauces, uvula seen
tongue fully extended, and with-
out phonation." Class 3. Soft palate, base of uvula seen
Class 4. Soft palate not seen at all

Class 3 and 4 being the predictor of a DA.
Wilson Wilson Risk factor criteria score The maximum possible score is 10. Higher scores are >2
risk score 1988 considered to be predictive of a DA. The chosen cut-
Weight: < 90 kg (score 0), 90kg to off points have been > 2 or > 4.
110 kg (score 1), > 110 kg (score 2)
Head and neck movement: > 90

º (score 0), about 90 º (i.e. ± 10 º)
(score 1), < 90 º (score 2)
Jaw movement: I G ≥ 5 cm or SLux

> 0 (score 0), IG < 5 cm and SLux =
0 (score 1), I G < 5 cm and SLux < 0
(score 2)
Receding mandible: normal (score

0), moderate (score 1), severe
(score 2)
Buck teeth: normal (score 0), mod-

erate (score 1), severe (score 2)
Thyro- Lewis The distance between the mentum Shorter distances are considered to be predictive of a 6.5 cm
mental 1994 and the hyoid bone (alternatively DA. The chosen cut-off points have been < 4 cm, 6 cm,
distance thyroid cartilage) is measured in 6.5 cm, 7 cm or < 3 finger widths.
cm or finger widths. There is con-
siderable variation in performance
of this examination. Patient posi-
tion (sitting versus supine), neck
position (extension versus neu-
tral), and proximal endpoint (in-
side mentum versus outside men-
tum) are not standardized.
Ster- Ramad- Quote: "...sternomental distance Shorter distances are considered to be predictive of a 12.5 cm
nomental hani 1996 was measured as the straight dis- DA. The chosen cut-off points have been < 12.5 cm or
distance tance between the upper border 13.5 cm.
of the manubrium sterni and the
bony point of the mentum with
the head in full extension and the
mouth closed. A ruler was used
and the distance measured was
approximated to the nearest 0.5
cm."
Mouth Calder The interdental distance between Shorter distances are considered to be predictive of a 3.5 cm
opening 2003 the upper and lower incisors is DA. The chosen cut-off points have been < 3.5 cm or <
measured in mm. Neck position is 2 finger widths.
a factor affecting maximum mouth
opening. Neck position is not stan-
dardized.
Informed decisions.

Table 1. Index screening tests for the difficult airway (Continued)

Upper lip Khan 2003 The patient is instructed to pro- Class I. Lower incisors bite the upper lip above the Class I
bite test trude their mandible forward and vermilion border, mucosa not being visible and II ver-
bite their upper lip. sus III
Class II. Lower incisors bite the upper lip below the
vermilion border, mucosa partially visible
Class III. Lower incisors fail to bite the upper lip

Class III being a predictor of a DA.
DA difficult airway; IG interincisor gap; SLux subluxation (maximal forward protrusion of the lower incisors beyond the upper incisors.

Table 2. Four domains for quality assessment
1 Patient selection
A. Risk of Bias
Patient sampling description
Signalling question 1: was a consecutive or random sample of patients enrolled?
Signalling question 2: was a case-control design avoided?
Signalling question 3: did the study avoid inappropriate exclusions? (Criteria met if the study did not
exclude patients due to methods unusual in clinical practice, i.e. performed examination tests before
study inclusion)
Signaling questions reported as yes, no, unclear
Could the selection of patients have introduced bias?
Risk of bias judged as low, high, or unclear
B. Concerns regarding applicability
Are there concerns that the included patients and setting do not match the review question? (Crite-
ria met if the study sample did not correspond to the patient population encountered in daily clini-
cal practice of airway management in apparently normal patients)
Concerns about applicability reported as high, low, or unclear
2 Index test
A. Risk of bias
Description of index test and how it was conducted and interpreted
Signalling question 1: were the index test results interpreted without knowledge of the results of the
reference standard? (Criteria met if index test and reference standard were conducted by different
persons)
Signalling question 2: if a threshold was used, was it prespecified?
Signalling questions reported as yes, no, unclear
Could the conduct or interpretation of the index test have introduced bias?
Informed decisions.

Table 2. Four domains for quality assessment (Continued)

Are there concerns that the index test, its conduct, or interpretation differed from the review ques-
tion? (Applied to "non-bedside" tests, i.e. tests which require imaging techniques, etc.)
3 Reference standard
A. Risk of bias
Describe condition and reference standard(s)
Signalling question 1: are the reference standards likely to correctly classify the target condition? (Cri-
teria met if the study used reference standards as defined in the review)
Signalling question 2: were the reference standards interpreted without knowledge of the results of
the index test? (Criteria met if index test and reference standard were conducted by different persons)
Could the reference standard, its conduct, or its interpretation have introduced bias?
Are there concerns that the target condition as defined by the reference standard does not match
the review question?
4 Flow and timing
A. Risk of bias
Describe any patients who did not receive index tests or reference standard or was excluded
from 2 x 2 table
Describe the interval and interventions between the index test and the reference standard
Signalling question 1: was there an appropriate interval between index tests and reference standard?
(Usually not a problem in this review. Considered appropriate if index tests and reference standards
were conducted within a usual time-span in clinical practice, e.g. during pre-anaesthesia visit or with-
in same hospital stay)
Signalling question 2: did all patients receive the same reference standard?
Signalling question 3: were all patients included in the analysis?
Could the patient flow have introduced bias?

Table 3. Non-prespecified tests and combinations of screening tests for the difficult airway
Test References Main characteristics
Combination of ULBT and Allahyary 2008 ULBT and MMT, if any single test positive combination considered positive
MMT
Informed decisions.

Table 3. Non-prespecified tests and combinations of screening tests for the difficult airway (Continued)
Combination of MMT, TM dis- Ambesh 2013 MMT, TM distance, anatomical abnormalities, head movement
tance, anatomical abnormali-
ties, head movement MMT 1 to 4 points, all others 0 or 1 point
> 3 points: considered positive
Telemedicine ASA checklist Applegate 2013 ASA 11-point checklist;

2 or more points: considered positive
ASA checklist Applegate 2013 ASA 11-point checklist;

2 or more points: considered positive
Prayer's sign Baig 2014 Patients not able to do praying gesture considered positive
Combination of mouth open- Basaranoglu 2010 Mouth opening, TM distance, SM distance, atlanto-occipital extension, MMT
ing test, TM distance, SM dis- combination cut-off not defined
tance, MMT, atlanto-occipital
extension
Calder test Basunia 2013 Protrusion of lower jaw not possible: considered positive
Delilkan test Basunia 2013 "While performing Delilkan's test the patient was asked to look straight
ahead. The head was held in the neutral position. The index finger of the left
hand of the observer was placed under the tip of the jaw, whereas the index
finger of the right hand was placed on the patient's occipital tuberosity. The
patient was now asked to look at the ceiling. If the left index finger became
higher than the right, extension of the atlanto-occipital joint was considered
normal."
Combination of MMT and Bhat 2007 MMT and ULBT, if any single test positive combination considered positive
ULBT
Neck mobility Cattano 2004 Grading I to IV, III and IV: considered positive
Cervical mobility Chaves 2009 < 90°: considered positive
El-Ganzouri index test Cortellazzi 2007 Index assigning points to mouth opening, TM distance, MMT, neck move-
ment, ability to prognatha, body weight, history of difficult tracheal intuba-
tion
> 2: considered positive
Head mobility Descoins 1994 < 90°: considered positive
Cormack-Lehane Dohrn 2015 III and IV: considered positive
Lower jaw protrusion Domi 2009 Not possible: considered positive
Irregular teeth Domi 2009 Presence of irregular teeth: considered positive
BMI Domi 2009 > 30: considered positive
Lower jaw length Domi 2009 < 9 cm: considered positive
Delilkan test Domi 2009 Same definition used as Basunia 2013
Body weight El-Ganzouri 1996 > 110 kg: considered positive
Informed decisions.

Neck movement El-Ganzouri 1996 < 80°: considered positive
Neck movement Ezri 2003a < 90°: considered positive
Abnormal upper teeth Ezri 2003b Presence of irregular teeth: considered positive
Neck movement Ezri 2003b < 90°: considered positive
Combination of MMT and TM Frerk 1991 MMT and TM distance, any positive considered positiveif any single test posi-
distance tive combination considered positive
Cormack-Lehane Freund 2012 III and IV: considered positive
Receding mandible Fritscherova 2011 Presence: considered positive
LEMON Hagiwara 2015 At least one positive: considered positiveif any single item positive test con-
sidered positive
Head movement Hashim 2014 < 35°: considered positive
Palm print sign Hashim 2014 "Deficiency in the inter-phalangeal areas of second to fifth digit"
Prayer sign Hashim 2014 A gap observed between the palms
Combination of ULBT and Healy 2016 ULBT and MMT, if any single test positive combination considered positive
MMT
Combination of MMT and TM Healy 2016 MMT and TM distance, if any single test positive combination considered pos-
distance itive
Combination of ULBT and Honarmand 2008 ULBT and MMT, if any single test positive combination considered positive
MMT
Combination of MMT and TM Ittichaikulthol MMT and TM distance, if any single test positive combination considered pos-
distance 2010 itive
Neck movement Juvin 2003 < 80°: considered positive
Mandibular recession Juvin 2003 Presence: considered positive
Abnormal teeth Juvin 2003 Buck/missing tooth: considered positive
Hyomental distance Kalezic 2016 < 5.3 cm: considered positive
Own score Kalezic 2016 Including gender, age, BMI, MMT, hyomental distance
Acromioaxillosuprasternal Kamranmanesh < 0.5 considered positive

notch index 2013
Combination of mouth open- Khan 2009a Mouth opening and ULBT, if any single test positive combination considered
ing and ULBT positive
Combination of SM distance Khan 2009a SM distance and ULBT, if any single test positive combination considered
and ULBT positive
Combination of mouth open- Khan 2009a Mouth opening and SM distance, if any single test positive combination con-
ing and SM distance sidered positive
Informed decisions.

Mandible length Khan 2011 < 9 cm: considered positive
TM distance Khan 2011 < 6.5 cm: considered positive
Combination of mandible Khan 2011 Mandible length and TM distance, if any single test positive combination con-
length and TM distance sidered positive
Combination of mouth open- Khan 2014 Mouth opening and ULBT, if any single test positive combination considered
ing and ULBT positive
Cormack-Lehane Kim 2011 III and IV: considered positive
Combination of Corma- Kim 2011 Cormack-Lehane and history of difficult tracheal intubation, if any single test
ck-Lehane and history positive combination considered positive
Cormack-Lehane Knudsen 2014 III and IV: considered positive
Modified Cormack-Lehane Koh 2002 IIb, III, IV: considered positive
Mandible length Kolarkar 2015 < 9 cm: considered positive
Combination of mandible Kolarkar 2015 Mandible length and hyomental distance, if any single test positive combina-
length and hyomental dis- tion considered positive
tance
Combination of mandible Kolarkar 2015 Mandible length and TM distance, if any single test positive combination con-
length and TM distance sidered positive
Subjective anticipation Langeron 2000 Subjective anticipation of difficult tracheal intubation by anaesthesiologist
Beard Langeron 2000 Presence: considered positive
Lack of teeth Langeron 2000 Lack of teeth: considered positive
Receding mandible Langeron 2000 Presence: considered positive
Macroglossia Langeron 2000 Presence: considered positive
Cormack-Lehane Langeron 2000 III and IV: considered positive
Combination of ULBT and Mashour 2008 ULBT and MMT, if any single test positive combination considered positive
MMT
Mandible length Merah 2004 < 9 cm: considered positive
Bellhouse Montemayor-Cruz III, IV: considered positive

2015
Patil Aldreti Montemayor-Cruz III: considered positive

2015
Short neck Prakash 2013 Not defined
Mandibular protrusion Prakash 2013 Limited protrusion: considered positive
Neck movement Prakash 2013 < 80°: considered positive
Informed decisions.

Snoring Prakash 2013 History of snoring: considered positive
Beard Prakash 2013 Presence: considered positive
Receding mandible Prakash 2013 Presence: considered positive
Own score Reghunathan > 1.4: considered positive

2016
Ratio of height to TM distance Safavi 2014 > 29: considered positive
Jaw excursion Sahin 2011 < 5°: considered positive
Mandibular protrusion Savva 1994 Lack: considered positive
Neck extension Schmitt 2000 < 80°: considered positive
Head and neck movement Seo 2012 < 90°: considered positive
Buck teeth Seo 2012 Presence: considered positive
Head movement Shah 2013 < 80°: considered positive
Mandibular length Singh 2009 < 9 cm: considered positive
Cormack-Lehane Soyuncu 2009 III, IV: considered positive
Combination of hyomental Tantri 2016 Hyomental distance and MMT, if any single test positive combination consid-
distance and MMT ered positive
Combination of MMT and ret- Tuzuner-Oncul MMT and retrognathia, if any single test positive combination considered
rognathia 2008 positive
Combination of MMT and Tuzuner-Oncul MMT and mouth opening, if any single test positive combination considered
mouth opening 2008 positive
Combination of MMT, TM dis- Tuzuner-Oncul MMT and TM distance and SM distance and mouth opening, if any single test
tance, SM distance, and mouth 2008 positive combination considered positive
opening
Combination of MMT and his- Tuzuner-Oncul MMT and history of snoring, if any single test positive combination consid-
tory 2008 ered positive
Cormack-Lehane Tuzuner-Oncul III, IV: considered positive

2008
Combination of MMT and TM Tse 1995 MMT and TM distance, if any single test positive combination considered pos-
distance itive
Lower jaw protrusion Ul Haq 2013 Grades A, B, C

B and C: considered positive
Neck extension K Nasa 2014 < 80°: considered positive
Combination of MMT and TM Wong 1999 MMT and TM distance, if any single test positive combination considered pos-
distance itive
Informed decisions.

Mandibular luxation score Wong 2009 Grades A, B, C
Beard Yildiz 2005 Presence: considered positive
Mandibular protrusion Yildiz 2007 Grades A, B, C

Combination of MMT and Yildiz 2007 MMT and mandibular protrusion, if any single test positive combination con-
mandibular protrusion sidered positive
Combination of TM distance Yildiz 2007 TM distance and mandibular protrusion, if any single test positive combina-
and mandibular protrusion tion considered positive
Combination of MMT and SM Yildiz 2007 MMT and SM distance, if any single test positive combination considered pos-
distance itive
Combination of MMT and TM Yildiz 2007 MMT and TM distance, if any single test positive combination considered pos-
distance itive
Combination of MMT and Yildiz 2007 MMT and mouth opening, if any single test positive combination considered
mouth opening positive
Combination of SM distance Yildiz 2007 SM distance and mandibular protrusion, if any single test positive combina-
and mandibular protrusion tion considered positive
Combination of mouth open- Yildiz 2007 Mouth opening and hyomental distance, if any single test positive combina-
ing and hyomental distance tion considered positive
ASA: American Society of Anesthesiologists; BMI: body mass index; MMT: modified Mallampati test; SM: sternomental; TM: thyromental;
ULBT: upper lip bite test;
aPrognath: the ability to bring the jaw in a forward position so that the mandibular incisors are before the upper incisors.

APPENDICES
Appendix 1. Search strategy for CENTRAL, the Cochrane Library

#1 ((airway* near (test* or physical status or assess* or examinat*)) or ((distance or gap* or test* or length) near (interdental or sternomental
or thyromental or interincisor* or incisor*)) or Wilson risk score or upper lip bite test or physical examin* test* or (length near upper incisor*)
or (relat* and (maxillary or mandibular) and incisor*) or (visibility near uvula) or (shape near palate) or ((submandibular or mandibular)
near space) or (neck near (length or thickness or diameter)) or (range and (motion or movement or flexion or extension) and (head or
neck))) or mouth opening
#2 MeSH descriptor Laryngoscopy explode all trees
#3 MeSH descriptor Intubation, Intratracheal explode all trees
#4 MeSH descriptor Bronchoscopy explode all trees
#5 MeSH descriptor Laryngeal Masks explode all trees
#6 MeSH descriptor Anesthesia, this term only
#7 MeSH descriptor Laryngoscopes explode all trees
#8 (difficult* near (airway or face mask or ventilation or laryngoscopy or intubation or tracheal)) or (intubat* near (fiberoptic or stylet*
or retrograde or failed)) or (laryngeal mask* or airway access):ti,ab or ((styletted or unstyletted) near tube*):ti,ab or ((laryngoscope* or
Macintosh) near blade*):ti,ab or airway management:ti,ab
#9 (#2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8)
#10 (#9 AND #1)
#11 mallampati* or (difficult near intubation):ti,ab
#12 (#10 OR #11)
Informed decisions.

Appendix 2. Search strategy for MEDLINE (Ovid SP)

1. ((airway* adj3 (test* or physical status or assess* or examinat*)) or ((distance or gap* or test* or length) adj5 (interdental or sternomental
or thyromental or interincisor* or incisor*)) or Wilson risk score or upper lip bite test or physical examin* test* or (length adj3 upper incisor*)
or (relat* and (maxillary or mandibular) and incisor*) or (visibility adj3 uvula) or (shape adj3 palate) or ((submandibular or mandibular)
adj3 space) or (neck adj3 (length or thickness or diameter)) or (range and (motion or movement or flexion or extension) and (head or
neck))).mp. or mouth opening.af.
2. exp Laryngoscopy/ or exp Intubation, Intratracheal/ or exp Bronchoscopy/ or exp Laryngeal Masks/ or Anesthesia/ or Laryngoscopes/
or (difficult* adj5 (airway or face mask or ventilation or laryngoscopy or intubation or tracheal)).mp. or (intubat* adj5 (fiberoptic or stylet*
or retrograde or failed)).mp. or (laryngeal mask* or airway access).ti,ab. or ((styletted or unstyletted) adj3 tube*).ti,ab. or ((laryngoscope*
or Macintosh) adj3 blade*).ti,ab. or airway management.ti,ab.
3. 1 and 2
4. mallampati*.af. or (difficult adj3 intubation).ti.
5. 3 or 4
Appendix 3. Search strategy for Embase (Ovid SP)

1. ((airway* adj3 (test* or physical status or assess* or examinat*)) or ((distance or gap* or test* or length) adj5 (interdental or sternomental
or thyromental or interincisor* or incisor*)) or Wilson risk score or upper lip bite test or physical examin* test* or (length adj3 upper incisor*)
or (relat* and (maxillary or mandibular) and incisor*) or (visibility adj3 uvula) or (shape adj3 palate) or ((submandibular or mandibular)
adj3 space) or (neck adj3 (length or thickness or diameter)) or (range and (motion or movement or flexion or extension) and (head or neck))
or mouth opening).mp.
2. exp laryngoscopy/ or exp endotracheal intubation/ or exp bronchoscopy/ or exp laryngeal mask/ or anesthesia/ or laryngoscope/ or
(difficult* adj5 (airway or face mask or ventilation or laryngoscopy or intubation or tracheal)).mp. or (intubat* adj5 (fiberoptic or stylet* or
retrograde or failed)).mp. or (laryngeal mask* or airway access).ti,ab. or ((styletted or unstyletted) adj3 tube*).ti,ab. or ((laryngoscope* or
Macintosh) adj3 blade*).ti,ab. or airway management.ti,ab.
3. 1 and 2
4. mallampati*.af. or (difficult adj3 intubation).ti.
5. 3 or 4
Appendix 4. Search strategy for ISI Web of Science

#1 TS=( mallampati* or Wilson risk score or Upper Lip Bite test or Mouth Opening or physical examin* test*) or TS=(airway* SAME
(test* or physical status or assess* or examinat*)) or TS=((distance or gap* or test* or length) SAME (sternomental or thyromental or
interincisor* or incisor*)) or TS=(relat* and (maxillary or mandibular) and incisor*) or TS=(Visibility SAME uvula) or TS=(Shape SAME palate)
or TS=((submandibular or mandibular) SAME space) or TS=(neck SAME (length or thickness or diameter)) or TS=(range and (motion or
movement or flexion or extension) and (head or neck))
#2 TS=(endotracheal intubation or bronchoscopy or laryngeal mask) or TS=(difficult* SAME (airway or face mask or ventilation or
laryngoscopy or intubation or tracheal)) or TS=(Intubat* SAME (fiberoptic or stylet* or retrograde or failed)) or TS=(laryngeal mask* or
airway access) or TS=((styletted or unstyletted) SAME tube*) or TS=((laryngoscope* or Macintosh) SAME blade*) or TI=anesthesia
#3 #2 AND #1
Appendix 5. Search strategy for CINAHL (EBSCO host)

S1 (MM "Physical Examination")
S2 TX mallampati* or TX Wilson risk score or TX Upper Lip Bite test or TX Mouth Opening or TX physical examin* test*
S3 airway* N3 (test* or physical status or assess* or examinat*)
S4 ((distance or gap* or test* or length) N4 (sternomental or thyromental or interincisor* or incisor*))
S5 Length N3 upper incisor*
S6 relat* and (maxillary or mandibular) and incisor*
S7 Visibility N3 uvula
S8 Shape N3 palate
S9 ((submandibular or mandibular) N3 space)
S10 (neck N3 (length or thickness or diameter))
S11 (range and (motion or movement or flexion or extension) and (head or neck))
S12 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11
S13 (MM "Laryngoscopy") OR (MM "Intubation, Intratracheal") OR (MM "Bronchoscopy") OR (MM "Laryngeal Masks") OR (MH "Anesthesia
+")
S14 difficult* N4 (airway or face mask or ventilation or laryngoscopy or intubation or tracheal)
S15 Intubat* N4 (fiberoptic or stylet* or retrograde or failed)
S16 AB laryngeal mask* or AB airway access
S17 ((styletted or unstyletted) N3 tube*)
S18 ((laryngoscope* or Macintosh) N3 blade*)
Informed decisions.

S19 S13 or S14 or S15 or S16 or S17 or S18

S20 S19 and S12
Appendix 6. Risk of bias and applicability concerns summary figures

Mallampati test Figure 16

Figure 16. Risk of bias and applicability concerns summary for Mallampati test: review authors' judgements about
each domain for each included study.

Modified Mallampati test (part 1) Figure 17
Informed decisions.

Figure 17. Risk of bias and applicability concerns summary for modified Mallampati test (part 1): review authors'
judgements about each domain for each included study.
Informed decisions.



Modified Mallampati test (part 2) Figure 18
Informed decisions.

Figure 18. Risk of bias and applicability concerns summary for modified Mallampati test (part 2): review authors'
Informed decisions.

Mouth opening test Figure 19

Figure 19. Risk of bias and applicability concerns summary for mouth opening: review authors' judgements about

Sternomental distance Figure 20

Informed decisions.

Figure 20. Risk of bias and applicability concerns summary for sternomental distance: review authors' judgements
about each domain for each included study.

Thyromental distance Figure 21
Informed decisions.

Figure 21. Risk of bias and applicability concerns summary for thyromental distance: review authors' judgements
Informed decisions.



Upper lip bite test Figure 22
Informed decisions.

Figure 22. Risk of bias and applicability concerns summary for upper lip bite test: review authors' judgements
Informed decisions.

Wilson risk score Figure 23

Figure 23. Risk of bias and applicability concerns summary for Wilson risk score: review authors' judgements about

Combinations of tests (part 1) Figure 24
Informed decisions.

Figure 24. Risk of bias and applicability concerns summary for combination of tests (part 1): review authors'
Informed decisions.



Combinations of tests (part 2) Figure 25
Informed decisions.

Figure 25. Risk of bias and applicability concerns summary for combination of tests (part 2): review authors'
Informed decisions.



WHAT'S NEW

Date Event Description
7 March 2019 Amended Co-publication Roth 2019

HISTORY
Protocol first published: Issue 12, 2010
Review first published: Issue 5, 2018

Date Event Description
4 October 2018 Amended Acknowledgement section amended to include Co-ordinating

Editor

Informed decisions.

CONTRIBUTIONS OF AUTHORS
Conceiving the review: Nathan L Pace (NLP)
Designing the review: Anna Lee (AL), NLP, Harald Herkner (HH), Karen Hovhannisyan (KH)
Co-ordinating the review: HH, NLP
Undertaking manual searches: KH, HH, Dominik Roth (DR)
Screening search results: DR, NLP, HH, AL
Organizing retrieval of papers: AL, KH, DR, HH
Screening retrieved papers against inclusion criteria: NLP, HH, DR, AL
Appraising quality of papers: NLP, HH, Alexandra Warenits (AW), Jasmin Arrich (JA), DR, AL
Abstracting data from papers: NLP, HH, AW, JA, DR, AL
Writing to authors of papers for additional information: DR, KH, JA
Providing additional data about papers: AL, KH, JA
Obtaining and screening data on unpublished studies: DR, KH
Data management for the review: NLP, HH, DR
Entering data into Review Manager (Review Manager 2014): NLP, HH, DR
Checking data entry in Review Manager (Review Manager 2014): AL, DR
Review Manager statistical data (Review Manager 2014): AL, NLP, HH, DR
Other statistical analysis, not using Review Manager (Review Manager 2014): NLP
Interpretation of data: AL, NLP, HH, DR
Statistical inferences: AL, NLP, HH, DR
Writing the review: AL, NLP, HH , KH, DR, AW, JA
Providing guidance on the review: AL, NLP, HH, KH, DR
Securing funding for the review: not applicable
Performing previous work that was the foundation of the present study: AL
Guarantor for the review (one author): HH
Person responsible for reading and checking review before submission: AL, NLP, HH, KH, AW, JA, DR
DECLARATIONS OF INTEREST
Dominik Roth: none known
Nathan L Pace: none known
Anna Lee: is the first author of a previously published diagnostic test accuracy review of the Mallampati score (Lee 2006).
Karen Hovhannisyan: none known
Alexandra-Maria Warenits: none known
Jasmin Arrich: none known
Harald Herkner: none known
This review was selected for the third Cochrane Review Support Programme.
Informed decisions.

SOURCES OF SUPPORT
Internal sources
• The Chinese University of Hong Kong, Shatin, NT, Hong Kong.
• Medical University of Vienna, Vienna, Austria.
• The Cochrane Anaesthesia Review Group, Rigshospitalet, Copenhagen, Denmark.
• University of Utah, Salt Lake City, UT, USA.
• Third Cochrane Review Support Programme, Other.
External sources
• No sources of support supplied
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
We removed the secondary objective of this review: to determine which test or combination of tests has the highest accuracy in studies
with direct comparisons for assessing the physical status of the airway in patients with no apparent anatomical airway abnormalities.
INDEX TERMS
Medical Subject Headings (MeSH)

*Intubation, Intratracheal [statistics & numerical data]; *Laryngoscopy [statistics & numerical data]; Airway Management [statistics
& numerical data]; Physical Examination [*methods]; Point-of-Care Systems [statistics & numerical data]; Sensitivity and Specificity;
Treatment Failure
MeSH check words

Adult; Humans

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Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H

Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H.

ADDITIONAL TABLES.................................................................................................................................................................................... 233

[Diagnostic Test Accuracy Review]

Airway physical examination tests for detection of difficult airway

Editorial group: Cochrane Anaesthesia Group.

Data collection and analysis

Test under investigation

The index tests (diagnostic tests of interest) included:

- mouth opening test;

- upper lip bite test;

- or any combination of these tests.

Quality of the evidence

Settings: operating theatres, intensive care units and emergency departments

Cochrane Database of Systematic Reviews

Difficult tracheal intubation

Cochrane Database of Systematic Reviews

Difficult face mask ventilation

IQR: interquartile range.

Cochrane Database of Systematic Reviews

BACKGROUND • Failed intubation: placement of the tracheal tube fails after

Figure 1. Study flow diagram.

0.16 to 0.41) and a summary specificity of 0.93 (95% CI 0.87 to 0.96).

We would also like to thank Mathew Zacharias, ACE Content

Mallampati-Score]. Anaesthesist 1997;46(5):437-40. [PUBMED: Chaves 2009 {published data only}

Thompson 2009 {published data only}

Shankar 2017 {published data only} ASA 2013

Wang 2017 {published data only} Chu 2006

Workeneh 2017 {published data only} Combes 2006

Characteristics of included studies [ordered by study ID]

Patient sampling All adult patients selected for endotracheal

Patient characteristics and setting Sample size: 1518

Index tests Modified Mallampati

Target condition and reference standard(s) Difficult laryngoscopy: following induction

Flow and timing Index test: on arrival at operating theatre

Item Authors' Risk of bias Applicabili-

DOMAIN 1: Patient Selection

Was a consecutive or random sample of patients enrolled?

Was a case-control design avoided?

Did the study avoid inappropriate exclusions?

DOMAIN 2: Index Test All Tests

If a threshold was used, was it pre-specified?

Did the assessors of the index test have appropriate training?

Was interobserver variability reported for some or all patients?

DOMAIN 3: Reference Standard

Is the reference standards likely to correctly classify the target condition?

DOMAIN 4: Flow and Timing

Did all patients receive the same reference standard?

Were all patients included in the analysis?

Patient sampling All consecutive surgical patients scheduled

Patient characteristics and setting University hospital, surgical patients (ab-

Sample size: 1171

Mean age: 49 years

Index tests MMT, ULBT

Target condition and reference standard(s) Difficult laryngoscopy, IDS > 5

Flow and timing Preoperative visit to surgery

Item Authors' Risk of bias Applicabili-

Was a consecutive or random sample of patients enrolled?

Was a case-control design avoided?

Did the study avoid inappropriate exclusions?