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Three Part Question

In [patients who require intubation] does [the presence of a beard] signifiy a [difficult intubation]?

Clinical Scenario

An elderly gentleman is brought in with a reduced GCS following an unfortunate high speed accident involving several reindeer and a sleigh. You decide that he requires intubation in order to protect his airway. A colleague suggests that the presence of his full, white beard suggests that he will be difficult to intubate. You wonder if there is any truth in this statement.

Search Strategy

Embase 1980- 2009 Week 27
Ovid Medline 1950 - June Week 4 2009
[beard.mp OR facial hair.mp OR facial topiary.mp] AND [intubation.mp OR exp intubation/ OR exp Intubation, intratracheal OR endotracheal tube.mp]

Search Outcome

27 papers were found. None were relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

It is a commonly held belief that patients with beards may be difficult to intubate as the patient may have a small jaw under their facial hair. There was no evidence in the medical literature to support this theory. There was some literature that dealt with other difficulties associated with airway management in patients with beards. Ventilation using bag and mask may be more difficult as it is harder to obtain a good seal in an unshaven patient. Kheterpal et al reviewed 50,000 patients who had undergone bag and mask ventilation during an anaeasthetic procedure and found the presence of facial whiskers a significant factor in predicting which patients would be impossible to ventilate by this method.(6) Various solutions to this hairy situation have been proposed including wrapping the patient's head repeatedly with cling-film and piercing a hole for the airway (2) or cutting a hole in a debrillator contact pad and sticking this to the face(3). Some have also suggested shaving the patient. Another problem encountered is the difficulty in securing an endotracheal tube in place once the patient has been intubated as tape will not adhere to the beard. This can obviously be overcome by tying the ET tube in place. A third potential airway problem is due to the fact that some Sikh men use a beard tie or 'tha-tha' that is tied around the head and under the chin. The beard is combed under this tie to keep it in place. The presence of the tie may not be obvious and there are case reports where difficult intubations have been encountered due to the unrealised presence of the cord.(1,4) One report describes a patient who underwent an emergency tracheostomy due to failure to intubate because of the presence of the tie.(5)

Clinical Bottom Line

There is no evidence to say whether or not the presence of a beard on a patient signifies a difficult intubation.

References

1. Sachin Kheterpal, Lizabeth Martin, Amy M Shanks, Kevin K Tremper Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics Anesthesiology 2009; 110 (4): 891-7
2. Vincent C, Ames W The Bearded Airway Anaesthesia 1998; 53: 1028-37
3. Thomas, D Overcoming the beard Anaesthesia 1999; 54: 86-101
4. Sinha P, Pandey J, Dubey P, Singh P, Singh S Cloth Band: Another Unusual Cause of Difficult Endotracheal Intubation Anesth. Analg 1999; 88: 227-34
5. Fairley C, O'Riordan J Beard restraint causing difficult intubation Anaesthesia 1994; 49 (8): 740-1
6. Bhogal H, Gan T Awareness of Sikh Custom of Restraining a Beard with a Cord Leading to Possible Airway Problems Anesth. Analg 1999; 89: 1585-92