|Year : 2022 | Volume
| Issue : 2 | Page : 207-212
Comparing the sensitivity of palm print sign and prayer sign in prediction of difficult intubation in diabetic patients
Harjot Singh1, Deepak Dwivedi2, Urvashi Tandon1, Vidhu Bhatnagar1, Kavitha Jinjil1, Swayam Tara1
1 Department of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Command Hospital (EC), Kolkata, West Bengal, India
|Date of Submission||26-Jul-2022|
|Date of Acceptance||14-Oct-2022|
|Date of Web Publication||23-Dec-2022|
Prof. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (EC) Alipore, Kolkata - 700 027, West Bengal
Source of Support: None, Conflict of Interest: None
Background and Aim: Palm print and prayer signs are manifestations of “limited joint mobility” syndrome caused by long-standing Type I and Type II diabetes mellitus. This study aims at finding out, which of the two signs is more sensitive for the prediction of difficult intubation in type II diabetes mellitus patients. The secondary objective is to correlate the above two signs with the Cormack–Lehane View during direct laryngoscopy and also to determine whether the duration of Type II diabetes mellitus correlates with difficult intubation in isolation. Materials and Methods: A prospective observational study was carried out in a tertiary care hospital. One hundred and fifty patients suffering from Type II diabetes mellitus, undergoing elective general anesthesia with endotracheal intubation, were enrolled in the study. The correlation between Palm print and Prayer sign with Cormack and Lehane grades was studied using the Chi-square test, continuity correction, and Fisher's exact test. The diagnostic efficacy of intubation difficulty for both the signs was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratio. Results: The palm print sign was found to be a better indicator of difficult intubation in type II diabetes mellitus patients (P < 0.01). The duration of Type II diabetes mellitus was found to be associated well with difficult intubation (P = 0.007). Conclusion: Palm print sign is the single most important test for predicting difficult intubation in Type II diabetes mellitus patients. Duration of Type II diabetes mellitus itself correlates well with difficult intubation.
Keywords: Airway management, diabetes, glycosylation, laryngoscopy
|How to cite this article:|
Singh H, Dwivedi D, Tandon U, Bhatnagar V, Jinjil K, Tara S. Comparing the sensitivity of palm print sign and prayer sign in prediction of difficult intubation in diabetic patients. Arch Med Health Sci 2022;10:207-12
|How to cite this URL:|
Singh H, Dwivedi D, Tandon U, Bhatnagar V, Jinjil K, Tara S. Comparing the sensitivity of palm print sign and prayer sign in prediction of difficult intubation in diabetic patients. Arch Med Health Sci [serial online] 2022 [cited 2023 Feb 5];10:207-12. Available from: https://www.amhsjournal.org/text.asp?2022/10/2/207/364956
| Introduction|| |
Over the years, airway management has come a long way. Endotracheal intubation became a prevalent procedure in anesthetic practice in the latter half of the 20th century. The inability to manage difficult intubation adequately has led to, as high as 30% of deaths attributable to anesthesia. There are certain conditions that by virtue of their pathophysiology, lead to difficult intubation in patients. Some of them are diabetes mellitus, ankylosing spondylosis, trauma to the cervical spine, etc., Many clinical indices have been devised to anticipate difficult intubation preoperatively. However, these indices have low sensitivity and specificity. By examining features specific to a subpopulation of patients based on their diagnosis, improves the sensitivity of tests.
The reported incidence of difficult laryngoscopy in diabetic patients is 27%–31%. Long-standing diabetes leads to nonenzymatic glycosylation of collagen and its deposition in joints leads to “Limited joint mobility” syndrome., It is hypothesized that the syndrome is the result of tissue glycosylation associated with chronic hyperglycemia seen in diabetic patients. There is an abnormality of collagen metabolism, which leads to cross-link formation. As a result, collagen fibrils become stable and resistant to enzyme degradation. The involvement of atlantooccipital joint by this process limits head and neck extension leading to difficult intubation. Involvement of interphalangeal joints by this process leads to limited joint mobility syndrome in these joints, which becomes the basis of the palm print sign [Figure 1]a. The degree of interphalangeal involvement can be objectively assessed by scoring ink impressions made by palm of the dominant hand. Similarly, failure of approximation of the digits of both the hands while doing “NAMASTE” leads to positive prayer sign [Figure 1]b.
The two signs can become potential indices for prediction of difficult intubation in diabetic patients. This study aims at finding out which of the two signs (Palm print or Prayer sign) is more sensitive for prediction of difficult intubation in patients suffering from diabetes mellitus with the secondary objective is to correlate the above two signs with the Cormack–Lehane View during direct laryngoscopy and also to determine whether the duration of type II diabetes mellitus correlates with difficult intubation in isolation.
| Materials and Methods|| |
This prospective observational study was conducted in the Department of Anesthesiology at a tertiary care hospital for 1 year 6 months from January 2018 to June 2019. The permission of the institute's ethical committee was taken before the study after fulfilling all the criteria.
Using α error of 0.05, β error of 0.20 (power of 80%) and using a sensitivity of 62% for the Prayer sign in prediction of difficult laryngoscopy to that of 77% for the Palm print sign Hashim and Thomas, the sample size calculated comparing the sensitivity between the two tests for the present study was 147. It was planned to enroll 150 cases for the present study to cater for dropouts.
During the stipulated time, 150 patients, who were known cases of Type II diabetes mellitus, aged between 35 and 85 years, undergoing elective general anesthesia with endotracheal intubation, were enrolled in the study. Written informed consent was taken from all patients. Exclusion criteria included, Mallampati classification (MPCL) grade III and beyond, the thyromental distance of <6.5 cm, obesity, body mass index (BMI) >30 kg/m2, restricted neck movements due to co-existing cervical spondylosis in diabetes, deformities of the face, neck and palate, deformities of hands, rheumatoid arthritis, oral malignancies and neck masses such as thyroid swellings, history of trauma to neck and face, and emergency surgeries.
All the patients underwent pre anesthesia check-up and were assessed as per history, clinical examinations, and investigations. Patients with deranged blood sugar levels were optimized. On the day before surgery, patients were evaluated for Palm print signs and Prayer signs during preoperative assessment rounds. Patients were asked to bring both palms together as “NAMASTE.” Failure to approximate the interphalangeal joints of two palms was considered positive prayer sign [Figure 1]b. Palm and fingers of patient's dominant hand were firmly pressed against the blue ink pad. The patient would then press his/her hand on the white sheet of paper firmly without putting body weight [Figure 1]a. It was objectively scored as Grade 0: All the phalangeal areas visible, Grade 1: Deficiency in the interphalangeal areas of the 4th and 5th digits, Grade 2: Deficiency in the interphalangeal areas of the 2nd to 5th digits, and Grade 3: Only the tips of the digits seen. Grades 2 and 3 were considered indicator of difficult intubation.
All the patients were administered alprazolam 0.25 mg orally, ranitidine 150 mg orally, and metoclopramide 10 mg orally the night before and in the morning of surgery with a sip of water. Patients were advised to be nil per oral for eight hours for solids and 2 h for clear fluids, before surgery. No other premedication was administered on the morning of the surgery.
On the day of surgery, patients were made to lie down comfortably in the supine position on the operation table with a 10 cm pillow beneath the head. Mandatory minimum monitoring ensued. Patients were explained the anesthesia technique. An intravenous line was established under aseptic precautions. Intravenous midazolam 1 mg, fentanyl 2 μg/kg were administered. Induction of general anesthesia was done with 1% propofol 2 mg/kg. After checking for the ability to ventilate with bag and mask, vecuronium 0.1 mg/kg was administered. Patients were ventilated with oxygen and sevoflurane for 3 min. Laryngoscopy was performed by an anesthesiologist, who having more than 2 years' of experience in the field. It was performed with Macintosh size 3 blade. No external manipulation (ELM) was done, and different sizes and types of blades were not used in the first attempt. The best possible glottic view was obtained, and Cormack and Lehane (CL) grade was noted. Grade I-Full exposure of glottis (Anterior and posterior commissure), Grade II-Anterior commissure not visualized, Grade III-Epiglottis only, and Grade IV-No glottic structure visible. CL grades III and IV were considered difficult intubation. The rest of the intra and postoperative management was done as per the requirements of the case. The investigator was blinded and did not attempt the intubation. Specific equipment was always kept ready to assist difficult intubation in every case: stylet, Bougie, I gel, one size smaller tube, intubating LMA, larger Macintosh blade, and McCoy blade. Use of any ELM, airway adjuncts or CL Grades III and IV were labeled as difficult intubation.
Nominal type of qualitative data, which included sex of cases, intubation difficulty as assessed by Palm print sign and Prayer sign, as well as CL grade, was represented in form of frequency and percentage. Association between nominal types of qualitative variables was assessed by the Chi-Square test, with continuity correction for all 2 × 2 tables and by Fisher's exact test for all 2 × 2 tables where the Chi-square test was not valid. Diagnostic efficacy of intubation difficulty by Palm print sign as well as by Prayer sign when compared to CL grade (separately) was assessed by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio, and negative likelihood ratio. Correlation between the various variables and CL grade was done utilizing Spearman's rank correlation coefficient. Appropriate statistical software, SPSS software Version 22.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis.
| Results|| |
A total of 150 patients were enrolled in the study. The demographic data show that majority proportion (37.3%) of the patients were between the age group of 45–54 years, followed by 55–64 years (20%). Females (51.4%) were more than males (48.6%) and when the BMI was compared, 77.3% were in the normal BMI range, with 22.6% being overweight [Table 1]. The association of the demographic variables to the CL grade predicting difficult intubation is represented in [Table 2], which shows that the duration of diabetes in years closely relates to the difficult intubation with significant results (P < 0.007).
|Table 2: Comparison of demographic variables with the Cormack–Lehane grade|
Click here to view
[Table 3] shows the distribution of cases based on the ease and difficulty in intubation as assessed by palm print sign, prayer sign, and CL grade on laryngoscopy in isolation. CL grade predicted difficulty in intubation in 62.6% of cases, followed by the Palm print sign (40%) and Prayer sign (34%). ELM was used in 80% (n = 48) of the predicted difficult intubation in the Palm print sign category, with bougie being used in only 20% (n = 12) patients, when compared to the Prayer sign category where ELM was used in 69.3% (n = 36) patients and bougie was used in 16% (n = 30.7). Correlation between the various variables and the CL grade, a gold standard for assessing the difficult intubation, shows significant results with palm print grades and duration of the diabetes [Table 4]. Sensitivity, specificity of the palm print sign and the prayer sign in predicting difficult intubation in our study is compared with the results of other existing studies and presented in [Table 5]. Our study has 100% specificity and PPV for the Palm print sign when compared to the Prayer sign, with 76.92% specificity and 75% PPV.
|Table 3: Distribution of cases based on ease and difficulty in intubation by various methods|
Click here to view
|Table 4: Correlation between the various variables with the gold standard Cormack-Lehane grade|
Click here to view
|Table 5: Comparison of sensitivity and specificity of palm print and prayer sign in various studies in predicting difficult intubation|
Click here to view
| Discussion|| |
Diabetes mellitus is one of the leading lifestyle related disorders that is crippling the world., As a result, anesthesiologists have to deal with its sequelae on a daily basis, and sometimes, they are caught off guard due to the same. This study was carried out with the objective of evaluating the Palm print sign and Prayer sign as a screening tool in prediction of difficult intubation in diabetic patients by comparing it with CL grading. All the patients were evaluated in terms of Palm print sign and Prayer sign before induction of general anesthesia and CL grade at the time of intubation. The sequence of induction and the drugs were kept constant. CL grades were considered the gold standard, and respective grades of the Palm print sign and Prayer sign were compared with it by an investigator who was blinded and did not attempt intubation.
Diabetes mellitus affects almost every system in the human body, and wide spectrums of medical specialties have been involved in managing its complications and sequelae. It also poses multiple challenges to the anaesthesiologist at different levels of patient care. Management of diabetic ketoacidosis in the intensive care unit, glycemic control in the perioperative period, and dealing with electrolyte abnormalities are some of the challenges posed by the disease.
One serious and potentially life-threatening complication of diabetes Mellitus is the involvement of joints, leading to an unanticipated difficult laryngoscopy and intubation. Such patients present to preanesthesia check-up clinic with normal routine airway indices. The importance of this study lies in evaluating physical indices specific to diabetes mellitus that can help the anesthesiologist to identify cases, suspected of having difficult laryngoscopy and intubation as a result of it.
For the present study, 150 patients were enrolled. The mean (standard deviation) age of the study sample is 56.46 (10.41). The mean BMI of the study participants was 25.10 (3.4) kg/m2. This negates the influence of obesity on the difficulty of intubation. In this study, 60 cases (40%) were predicted to have difficult intubation as per palm print sign in contrast to 52 cases (34.6%) as per prayer sign [Table 3]. The actual incidence of difficult intubation in this study was observed in 94 cases (62.6%) as per the gold standard CL grading [Table 3].
The cheiroarthropathy of small joints of the hand and fingers closely follows the involvement of joints in the cervical spine. The same association was tested in the present study by evaluating palm print signs and prayer signs with CL grade. The sensitivity of the palm print sign during analysis was found to be 63.64%, whereas the prayer sign reflected a sensitivity of 40.91%. The specificity of the palm print sign was 100% and that of the prayer sign was 76.92%. The PPV of the palm print sign was found to be 100% in contrast to the prayer sign, which showed the PPV of 75% [Table 5]. The predictive value of the negative test for the palm print sign was found to be 61.90% in comparison to the prayer sign, where the predictive value of the negative test was 43.48%. The association between palm print signs with CL grade was found to be statistically significant [Table 4]. It implies that higher palm print grades are associated with higher CL grades, thus indicating difficult intubation. In contrast to this, the association between Prayer sign and CL grade was found not significant (P = 0.463).
Diabetic cheiroarthropathy is found in 8%–50% of patients with diabetes mellitus, more commonly with Type I but also with Type II in substantial amount. The prevalence of cheiroarthropathy/limited joint mobility syndrome leading to difficult intubation increases with the duration of diabetes. In our study, all the enrolled patients were suffering from Type II diabetes mellitus. Yet, a similar association was found between the duration of diabetes mellitus and the incidence of difficult intubation (P = 0.007) [Table 2].
Our results were similar to those achieved by Hashim and Thomas Palm print sign turned out to be a better preoperative test than the prayer sign in all parameters. However, we recorded higher specificity and PPV for palm print sign than Hashim et al. [Table 5]. We also noted a statistically significant correlation between the duration of diabetes mellitus and the incidence of difficult intubation [Table 4]. This could not be statistically illustrated by Hashim et al., even though they proposed it theoretically. This could be because the mean duration of diabetes mellitus in our study was 10.41 years, while in their study, it was 6.7 years.
Vani et al. reported higher sensitivity but poor specificity and PPV of palm print sign in comparison to nonspecific indices of difficult intubation [Table 5]. However, our study recorded higher specificity and predictive value of positive tests for palm print signs. This could be because Vani et al. considered palm print grades of more than 0 as a predictor of difficult laryngoscopy, leading to high numbers of false positives. Furthermore, 50% of patients with difficult intubation in their study were obese, while in our study, 63% of patients having difficult intubations were within normal BMI. They also could not obtain statistical significance between the duration of diabetes mellitus and the incidence of difficult intubation. Their overall incidence of difficult intubation and duration of diabetes mellitus was also lower than our study.
Similar to Vani et al., Nadal et al. also considered Palm print grade of more than 0 to be a predictor of difficult laryngoscopy. This again led to higher sensitivity but with a high false-positive rate, leading to low specificity and PPV. They enrolled patients with both types of diabetes mellitus but could not derive a correlation between the type of diabetes and the incidence of difficult intubation. However, the correlation between the duration of diabetes and the incidence of difficult intubation was positive in their study. Our study included patients suffering from type II diabetes mellitus and we also derived a similar positive correlation between the duration of diabetes and the incidence of difficult intubation, thereby proving the hypothesis that both types of diabetes lead to difficult intubation in the long run.
Studies by George and Jacob and Sachdeva et al. reported similar sensitivities, specificities, and PPVs for palm print signs. However, Sachdeva et al. also reported higher sensitivity for Prayer signs for both type of diabetes mellitus. The average age of type II diabetes in patients studied by Sachdeva et al. was comparable to our study and yet the incidence of difficult intubation was found to be low in that group. This variation could be because of the smaller sample size in both studies.
Mahmoodpoor et al. reported very low sensitivity for palm print signs. This could be because they conducted their study on the general population. Our study aimed at finding the relevance of this sign only in diabetic patients due to the pathophysiology explained above. We agree that palm print sign is not a good predictor of difficult intubation in the general population but only in patients with diabetes mellitus. Reissell et al. conducted a study where it was inferred that the higher scores of palm print were found to be associated with higher laryngoscopic view scores with the correlation coefficient r = 0.6, but they included only type I diabetes mellitus patients. In our study, all the patients were suffering from type II diabetes mellitus and our results show that palm print signs can act as a reliable indicator of difficult intubation preoperatively in these patients as well.
The studies conducted by Erden et al. and Baig and Khan showed prayer signs to be a poor predictor of difficult intubation preoperatively in diabetic patients. We also inferred that that prayer signs alone could not be used to assess airway difficulty in patients with diabetes mellitus.
The present study inferred that the Palm print sign is a better preoperative test in terms of sensitivity, specificity, PPV and NPV for the prediction of difficult laryngoscopy and intubation in diabetic patients.
The strength of this study lies in excluding obesity (BMI >35 Kg/m2), thereby limiting the confounders related to difficult airways. The limitation of the study is primarily due to the failure to compare and co-relate MPCL grades, range of neck movements, neck circumference, and thyromental distance with palm print and prayer sign in predicting the difficult laryngoscopy and intubation, respectively. A multicentric research will be required further in future to substantiate the results with other difficult airway predictors.
| Conclusion|| |
Palm print signs, in conjunction with the duration of diabetes, may be used as a routine preoperative airway assessment tool in patients suffering from type II diabetes mellitus slated for surgeries to predict anticipated difficult intubation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Goksu S, Sen E. History of intubation. J Acad Emerg Med 2015;14:35-6.
Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991;75:1087-110.
Hashim K, Thomas M. Sensitivity of palm print sign in prediction of difficult laryngoscopy in diabetes: A comparison with other airway indices. Indian J Anaesth 2014;58:298-302.
] [Full text]
Fitzcharles MA, Duby S, Waddell RW, Banks E, Karsh J. Limitation of joint mobility (cheiroarthropathy) in adult noninsulin-dependent diabetic patients. Ann Rheum Dis 1984;43:251-4.
Somai P, Vogelgesang S. Limited joint mobility in diabetes mellitus: The clinical implications: The onset is insidious and may predate the recognition of overt disease. J Musculoskelet Med 2011;28:118-24.
Goh SY, Cooper ME. Clinical review: The role of advanced glycation end products in progression and complications of diabetes. J Clin Endocrinol Metab 2008;93:1143-52.
Hall GM, Ruggier R. Diabetes mellitus and anaesthesia. Curr Opin Anaesthesiol 1999;12:343-7.
Nowcid L, Valentine E. Difficult air-way in diabetes. Transl Perioper Pain Med 2015;2:19-21.
Asfar SN, Salman JM. Management of crises during anesthesia and surgery. part VI: Difficult intubation. Basrah J Surg 2014;20:76-9.
Gupta S, Sharma R, Jain D. Airway assessment: Predictors of difficult airway. Indian J Anaesth. 2005;49:257-62.
Huizinga MM, Rothman RL. Addressing the diabetes pandemic: A comprehensive approach. Indian J Med Res 2006;124:481-4.
] [Full text]
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Kim RP, Edelman SV, Kim DD. Musculoskeletal complications of diabetes mellitus. Clin Diabetes 2001;19:132-5.
Vani V, Kamath SK, Naik LD. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics: A comparison with other airway evaluation indices. J Postgrad Med 2000;46:75-9.
] [Full text]
Nadal JL, Fernandez BG, Escobar IC, Black M, Rosenblatt WH. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics. Acta Anaesthesiol Scand 1998;42:199-203.
George SP, Jacob R. Predictability of airway evaluation indices in diabetic patients. Indian J Anaesth 2003;47:476-78. [Full text]
Sachdeva KP, Singh A, Kathuria S, Kaul TK, Rupinder M, Bajwa N, et al
. Prediction of difficult laryngoscopy in diabetics by palm print and interphalangeal gap. J Anaesth Clin Pharmacol 2005;21:261-4.
Mahmoodpoor A, Soleimanpour H, Nia KS, Panahi JR, Afhami M, Golzari SE, et al
. Sensitivity of palmprint, modified mallampati score and 3-3-2 rule in prediction of difficult intubation. Int J Prev Med 2013;4:1063-9.
Reissell E, Orko R, Maunuksela EL, Lindgren L. Predictability of difficult laryngoscopy in patients with long-term diabetes mellitus. Anaesthesia 1990;45:1024-7.
Erden V, Basaranoglu G, Delatioglu H, Hamzaoglu NS. Relationship of difficult laryngoscopy to long-term non-insulin-dependent diabetes and hand abnormality detected using the 'prayer sign'. Br J Anaesth 2003;91:159-60.
Baig MM, Khan FH. To compare the accuracy of prayer's sign and Mallampatti test in predicting difficult intubation in diabetic patients. J Pak Med Assoc 2014;64:879-83.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]