E Editorial

Airway Evaluation: Thin Sliced and Packaged

Randolph H. Hastings, MD, PhD

n occasion I have noticed a face at a distance across

a room and had the thought, That person would
be difficult to intubate. This happens from time to
time to other anesthesiologists I know. In the book Blink,
Malcolm Gladwell uses the term thin slicing to describe
unintended snap judgments that occur in a rapid, spontaneous manner.1 He explains that the subconscious mind
can recognize patterns in a brief flash of visual information
and will derive conclusions from the patterns as a matter of
course. Someone with finely honed instincts could be successful in making accurate rapid judgments after a momentary glance. However, first impressions formed in the blink
of an eye lack objective reflection and can be swayed by an
individuals recent experience and by multiple biases.2
Considering the potential pitfalls, it is unclear what
weight should be given to an impression regarding potential airway difficulty made in a thin slice of time. The question is not purely academic. Thin slicing is part of human
nature, and it can occur in professional settings and informal environments. Anesthesiologists may be influenced by
thin slicing when they perform preoperative airway examinations. The issue is the extent to which rapid, subjective
impressions based on patient appearance affect the decision
about potential airway difficulty and whether the result is
beneficial. Thin slicing could make a positive contribution
to airway evaluation if it were founded on subconscious but
insightful pattern recognition, but jumping to an unfounded
conclusion could interfere with accurate airway assessment.
In a study reported in this months issue, Connor and
Segal3 hypothesized that the availability of facial photographs would augment the ability of anesthesiologists
to predict intubation difficulty over that achieved with
Mallampati score (MP) and thyromental distance (TMD).
Anesthesiologist subjects assessed airways based on TMD
and MP scores for 80 patients who were known to be either
easy (40 patients) or difficult to intubate (40 patients). The
160 anesthesiologists were then given frontal and lateral

From the Department of Anesthesiology, VA San Diego Healthcare System,

San Diego, California.
Accepted for publication October 18, 2013.
Funding: Salary from VA San Diego Healthcare System and from UC San
Diego Department of Anesthesiology.
The author declares no conflicts of interest.
Reprints will not be available from the author.
Address correspondence to Randolph H. Hastings, MD, PhD, Department
of Anesthesiology, VA San Diego Healthcare System, 3350 La Jolla Village
Dr.,125 San Diego, CA 92161. Address e-mail to rhhastings@ucsd.edu.
Copyright 2014 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000056

February 2014 Volume 118 Number 2

photographs of the patients along with TMD and MP and

asked to repeat the predictions.
The group changed their assessment for some of the
patients because of the photographs, most commonly
deciding that an individual with a favorable MP score (< 3)
or TMD ( 3 cm) would present greater difficulty than initially imagined. Occasionally, they downgraded a difficult
rating for patients with TMD <3 cm to easy. The bedside airway evaluation tests have notoriously low sensitivity,4 but
sensitivity increased when facial photographs were added.
It is important to note that the positive predictive value for
intubation difficulty improved significantly from 57% (95%
confidence interval, 56% to 58%, with TMD and MP alone
to 62% [confidence interval, 61%62.4%]). Thus, seeing
patients facial characteristics helped the anesthesiologists
predict intubation difficulty in this study.
Determining how feature recognition improves prognostic accuracy would be useful in understanding how
anesthesiologists make airway predictions and might lead
to insights about airway evaluation. The subjects were not
asked, so we do not have explicit information about why
viewing images changed decisions. Connor and Segal suggest that anesthesiologists develop a subjective opinion
about difficulty based on facial patterns. The impression
may be subconscious and difficult to put in words. However,
the investigators surmised some facial characteristics that
anesthesiologists might link with difficulty by analyzing
the images that affected airway assessment. Photographs of
patients with a thick jaw relative to the height of the face
(a high chin-to-nose/nose-to-chin ratio), those with a large
chin-neck slope, or those with a large body mass index
were likely to trigger a change in airway assessment.3 Thus,
these facial features and/or a hefty appearance may have
been part of the pattern the subjects perceived as related to
intubation difficulty. In a previous study, the authors had
used facial analysis software and logistic regression to show
that the same facial features, brow-nose-chin ratio and the
jaw-neck slope, indeed discriminated between patients who
were easy and difficult to intubate.5 (See Fig. 3 and Fig. 5
in that article for illustrations). To my knowledge, neither
measurement had been previously recognized to predict
difficult intubation. Posterior mandibular depth has been
tested as a marker of difficulty (with inconclusive results)
but not as a ratio normalized to face height.68
Connor and Segal have entered a novel, previously
untapped field by studying the role of facial analysis in airway assessment. Additional work will be needed to establish the validity of their findings and to address unanswered
questions. The prevalence of intubation difficulty in the
www.anesthesia-analgesia.org

247

E Editorial
current study population was 50%, much higher than the
usual rate of around 5% in most surgical populations.4,9
It would be worthwhile to test whether facial images add
appreciably to airway prognostication when the prevalence
of difficulty is lower. On another topic, various bedside tests,
such as sternomental distance, interincisor gap, head extension, mandible length, and upper lip bite test are in use for
predicting difficult intubation.9 Future investigators could
conduct a more stringent test of whether examining facial
images carries an advantage by augmenting the list of airway parameters beyond MP score and TMD. One might
expect that the images would still be beneficial because the
combination of MP score and TMD perform as well or better
than other sets of airway parameters.4 A final suggestion for
future research would be exploration of whether anesthesiologists consciously recognize specific facial features as markers for prognostication or whether they modify their opinion
based on an overall pattern that is difficult to explain.
Rapid judgments can be influenced by irrelevant factors, so anesthesiologists who develop a thin slice impression of airway difficulty would do well to look for objective
criteria supporting their assessment before proceeding.
Thin slice conclusions are derived from ones memory of
how circumstances and events have been associated with
outcomes in the past. If the thin slicing is based on only a
coincidental association rather than a causal relationship,
the conclusion is likely to be faulty. For example, suppose
an anesthesiologist encounters in a short space of time 2
bald patients with large noses who are difficult to intubate. The next bald patient with a bulbous nose may make
the anesthesiologist think of intubation difficulty, even
though that combination of features is not a sure predictor of airway outcome. Daniel Kahnemans book, Thinking
Fast and Slow, reviews in-depth various biases that can
impair the accuracy of thin slice judgments.2 Biases are
not necessarily bad. Connor and Segal3 estimated that
anesthesiologists were inclined to overcall intubation difficulty, preparing unnecessarily for difficult intubations
6.5 times for every unexpected instance of difficulty. In
this situation, the benefit of avoiding airway surprises
seems to be valued highly compared with the cost of
unnecessary preparation.
Connor and Segals study has practical implications for
anesthesiology. Based on the evidence to date, anesthesiologists should not be averse to using impressions based on
patient facial appearance in planning airway management
in conjunction with standard measurements. On average,
thin slice airway assessments appear to improve the diagnostic accuracy for airway evaluation. Some clinicians had
better results than others with thin slicing. If it were possible to measure individual talent in facial evaluation, anesthesiologists could calibrate personal skill and know how
much weight to put on their subjective impressions of airway difficulty. Predictive ability had a tendency to improve
with experience in this study, although more work is necessary on this point. If talent for thin slice airway evaluation
increases with experience, it might be possible to design
a
Connor CW, Tammineedi VS, Sparling J, Djang R, Oh E, Huh S, Segal S.
Bedside recruiting, recording, and processing of data on ease or difficulty of
intubation with a handheld app. Anesth Analg 2013;116:S388

248
www.anesthesia-analgesia.org

teaching exercises for facial evaluation that would improve

performance.
The 2 Connor and Segal studies3,5 demonstrate that
facial analysis can be used to identify new markers for airway difficulty. If facial analysis were used in much larger
studies, it might be possible to identify additional, novel
predictive measurements that would strengthen airway
examination. Furthermore, computerized facial analysis
could hold hope for establishing sensitive and specific
computer-based algorithms for predicting airway difficulty. The interobserver reliability of airway assessment
tests is only moderately good under optimal conditions,
and frequent discrepancies are possible when conditions are worse.10,11 A computerized procedure might also
improve the reproducibility of airway evaluation. Connor
and colleagues have developed a phone application to
process facial appearance and physical data for airway
evaluation, and they reported preliminary work with the
app at the 2013 International Anesthesia Research Society
meeting.a Such endeavors could eventually support telemedicine practice of anesthesiology in which airway evaluation tests could be performed at a glance, not just across
the room but across the world. E
DISCLOSURES

Name: Randolph H. Hastings, MD, PhD.

Contribution: This author helped write the manuscript.
Attestation: Randolph H. Hastings approved the final
manuscript.
This manuscript was handled by: Franklin Dexter, MD, PhD.
REFERENCES
1. Gladwell M. Blink. New York: Back Bay Books, Little, Brown
and Company, 2005, Chapter 1: pp. 3847
2. Kahneman D. Thinking Fast and Slow. New York: Farrar,
Strauss and Giroux, 2011, Chapter 7 and Chapter 22: pp. 7988,
23444
3. Connor CW, Segal S. The importance of subjective facial
appearance on the ability of anesthesiologists to predict difficult intubation. Anesth Analg 2014;118:41927
4. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult
intubation in apparently normal patients: a m
eta-analysis
of bedside screening test performance. Anesthesiology
2005;103:42937
5. Connor CW, Segal S. Accurate classification of difficult
intubation by computerized facial analysis. Anesth Analg
2011;112:8493
6. Naguib M, Malabarey T, AlSatli RA, Al Damegh S, Samarkandi
AH. Predictive models for difficult laryngoscopy and intubation. A clinical, radiologic and three-dimensional computer
imaging study. CanJ Anaesth 1999;46:74859
7. White A, Kander PL. Anatomical factors in difficult direct
laryngoscopy. BrJ Anaesth 1975;47:46874
8. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting
difficult intubation. BrJ Anaesth 1988;61:2116
9. Khan ZH, Mohammadi M, Rasouli MR, Farrokhnia F, Khan
RH. The diagnostic value of the upper lip bite test combined
with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study. Anesth Analg 2009;109:8224
10. Karkouti K, Rose DK, Ferris LE, Wigglesworth DF, Meisami-Fard
T, Lee H. Inter-observer reliability of ten tests used for predicting difficult tracheal intubation. CanJ Anaesth 1996;43:5549
11. Rosenstock C, Gillesberg I, Gtke MR, Levin D, Kristensen
MS, Rasmussen LS. Inter-observer agreement of tests used for
prediction of difficult laryngoscopy/tracheal intubation. Acta
Anaesthesiol Scand 2005;49:105762

anesthesia & analgesia