BESTA Airway Algorithm -a modified EGRI- El Ganzouri Risk Index -New Evidence of relevance to Morbid Obesity

The Besta Airway Algorithm
an improved  El Ganzouri Risk Index

The Besta Modification of the El Ganzouri Risk Index has been incorporated in the "Systematic" approach to airway management reported by Dr. Caldiroli and Cortellazzi in Milan Italy as the development of a systematic approach to airway management. ( Minerva Anesth. 2011 oct ,77 (10) , 1011-1017.)

The approach involved getting 13 Anesthesiologists to agree to try to do optimal airway management by using the GlideScope VL for all airway management in a very structured way. The method in short included the following important steps never done before:

Develop a  modified Airway approach with mutually agreed steps.

• Application of a method of airway assessment that incorporated many of the known airway measures, each of which is known to be moderately effective in assessment, into the El Ganzouri Risk Index. This index was developed prior to the GlideScope era but with significant modification was adopted to the BESTA airway Algorithm-  the best available index for the " BESTA Culture and System".

• The scoring system was used as follows:                                                                                                               EGRI Score. plus a number of custom features that modify the BESTA index to make it appropriate to the GlideScope Age.

          BESTA modifications Add the score for each individual indicator to total all and prescribe actions based on the score.

            1-3  Low Risk of Difficult Airway for endotracheal intubation - proceed with GlideScope .

            4-6  significant risk of difficult airway management - proceed with consultation followed by

                   GlideScope intubation. The "Programmed Consultation" is fundamental because it gives
                   the patient the highest chance  of having airway management without injury or failed
                   attempts.

             7   (or higher)   consultation is obtained and alternate awake airway management will
                   be selected either with GlideScope or Flexible Video Endoscopy. Further examination of
                   the airway may be considered with Flexible pre-op endoscopy , CT or MR to be
                   absolutely clear what problems may be encountered.

• The Consultation Process- This is very much like the aviation model where weather or other flight conditions are reviewed Prior to takeoff. Team work is then established as a norm and individual skill or lack of skill is offset by design.

• The Airway management event itself is executed using Equipment that is known to be operational and appropriate.

• The Immediate recording of the airway encounter to provide a database for quality assurance and improvement of the process.

While Dr Caldiroli's initial work was monumental with 6,278 patients managed The BESTA  Neurological Hospital.  Patients with Obesity were excluded from the original study. The results were that 2 were excluded because of local malignancy , 6,270 with BESTA modified EGRI 1-6 were intubated with the Glidescope .  Flexible endoscopy was used on 6 patients with BESTA modified EGRI > 7. This left a gap in the understanding of how Morbidly Obese patients should be managed. This Gap was recently addressed by the  Group from Milan  in a study of 214 patients with Morbid obesity managed by the same method as  Caldiroli Et. Al.  using the BESTA modified EGRI assessment tool.