Cephalometry and risk prediction in airway management: limitations

I read with interest the editorial commentary by Gonçalves et al. (1). The issue of poor predictive power of standard bedside airway assessments in identifying patients at risk of challenging airway management is well recognised (2) and their suggestion to incorporate cephalometric indices to enhance accuracy of risk prediction (with the aim of improving patient safety) is made with the best of intentions. However, there are a number of potential limitations to their proposal that might affect its clinical applicability.

First, their commentary exclusively considers laryngoscopy/tracheal intubation. When evaluating a patient’s airway, this is not the only consideration and ease of facemask seal and ventilation, supraglottic airway insertion, seal and ventilation, and front of neck airway insertion should all be assessed routinely in every patient. This is crucial, since the findings inform selection of the most appropriate airway management strategy (primary and rescue plans) for each individual patient, prioritising successful oxygenation (not tracheal intubation). Where there are concerns about more than one facet of airway management and the ability to deliver oxygen safely and effectively, an awake airway management technique should be considered.

Second, predicting difficulty in airway management based solely on bony anatomy and soft tissue dimensions/dynamics is a rather outdated approach, and does not recognise that airway management difficulty may arise from a number of other factors (e.g., pathological, physiological, situational, organisational, educational, human factors, etc.) and it is the complex interplay of all of these aspects that influence airway management difficulty (3). In this context, ‘physiological’ difficulty refers to patients’ relative clinical instability and/or impaired homeostatic reserve due to acute or chronic conditions and disease processes that might complicate airway management and/or lead to adverse events (e.g., sepsis which might predispose to hypoxaemia or haemodynamic compromise; e.g., obesity, where oxygen desaturation may be more likely, etc.)—not to be confused with the rather more predictable/intended effect of general anaesthetic agents on airway tone (which the authors termed “anesthetic physiology”).

Third, the studies to which the authors refer concern direct laryngoscopy, such that the findings may be less relevant to airway managers in an era when videolaryngoscopy accessibility and utilisation are far more prevalent [with first-line videolaryngoscopy being recommended by recently published guidelines (4)] and where techniques such as combined videolaryngoscopy/flexible bronchoscopy [also called “hybrid” or “VAFI” (video assisted fibreoptic intubation)] can be employed in patients with known/anticipated difficulty (5). Specifically, the studies report impaired laryngeal views with direct laryngoscopy in the presence of disadvantageous anatomical proportions—an issue that is less frequently encountered with videolaryngoscopy (6) [the glottic view is often superior with videolaryngoscopy, though tracheal tube delivery can sometimes be more challenging—with adjunct selection/proficiency ascribed greater importance (7)]. Similarly, the authors highlight the contribution of retrognathia/micrognathia—this may still be a predictor of difficulty when severe (and/or in combination with other complexity factors), but with the advent of hyperangulated videolaryngoscope blades, may have significantly less impact on tracheal intubation success when compared with direct laryngoscopy.

Fourth, the proposed use of static cephalometric imaging fails to recognise the dynamic changes that occur to airway dimensions (and any intra- or extra-luminal pathology) during the respiratory cycle, following induction of general anaesthesia (loss of muscle tone) and with changes in patient positioning (supine versus semi-recumbent versus upright). Computed tomography and magnetic resonance imaging also suffer from similar limitations; whereas, awake nasendoscopy or awake videolaryngoscopy offer real-time, dynamic evaluation of the airway (8). Where there is concern about at least one facet of airway management (primary or rescue plans), these tests should be considered since they can be performed in the operating theatre immediately prior to any intervention, utilising the same equipment that will be employed during subsequent tracheal intubation—arguably providing more useful information to guide airway management planning decisions than static imaging performed in a geographically separate radiology department, often undertaken in a different patient position to that which will be used during airway management and likely performed well in advance of surgery (where any pathology, if present, may have also progressed).

Lastly, it is concerning to see reference to blind nasotracheal intubation. This technique may be appropriate in low resources settings where there is no access to a flexible bronchoscope for emergency awake tracheal intubation; however, blind techniques are not generally recommended where there is access to bronchoscopes and videolaryngoscopes [availability in >50% lower-income countries (9)] since blind instrumentation is associated with reduced success rates and iatrogenic trauma, which may compromise patient safety. At institutions where cephalometric imaging is being undertaken, these airway management devices are also likely to be routinely available.

To improve relevance to airway managers practising modern airway management techniques, the authors might consider exploring whether cephalometric imaging can assist in videolaryngoscope decision-making, e.g., whether certain measurements can assist in selection of the optimum videolaryngoscope blade shape, size and/or airway adjunct that might improve first pass success and minimise complications.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-2026-0017/coif). P.A.W. serves as an unpaid editorial board member of Journal of Oral and Maxillofacial Anesthesia from June 2022 to December 2027. P.A.W. had honoraria for Invited expert speaker on videolaryngoscopy educational podcast from Medtronic, he is the advisory board of Medtronic, and he is the unpaid Chair of Scottish Airway Group and the unpaid appointed committee member of Difficult Airway Society. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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