Do beards really bear bad tidings for anaesthetists?
Date First Published:
October 4, 2007
Last Updated:
July 13, 2009
Report by:
Craig Ferguson, SPR Emergency Medicine (Manchester Royal Infirmary)
Search checked by:
Rick Body, Manchester Royal Infirmary
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
Ovid Medline 1950 - June Week 4 2009
Search Details:
[beard.mp OR facial hair.mp OR facial topiary.mp] AND [intubation.mp OR exp intubation/ OR exp Intubation, intratracheal OR endotracheal tube.mp]
Outcome:
27 papers were found. None were relevant to the three part question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|
Author Commentary:
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)
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)
Bottom Line:
There is no evidence to say whether or not the presence of a beard on a patient signifies a difficult intubation.
References:
- Sachin Kheterpal, Lizabeth Martin, Amy M Shanks, Kevin K Tremper. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics
- Vincent C, Ames W. The Bearded Airway
- Thomas, D. Overcoming the beard
- Sinha P, Pandey J, Dubey P, Singh P, Singh S. Cloth Band: Another Unusual Cause of Difficult Endotracheal Intubation
- Fairley C, O'Riordan J. Beard restraint causing difficult intubation
- Bhogal H, Gan T. Awareness of Sikh Custom of Restraining a Beard with a Cord Leading to Possible Airway Problems