Comparison of ease of intubation in sniffing position and further neck flexion

Gudivada, Kiran Kumar; Jonnavithula, Nirmala; Pasupuleti, Sai Lakshman; Apparasu, Chaitanya Prathyusha; Ayya, Syama Sundar; Ramachandran, Gopinath

doi:10.4103/joacp.joacp_100_16

Cited by 10 publications

(8 citation statements)

References 11 publications

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“…Published literature suggests optimal patient positioning for direct- and Mac-VL is the “sniffing” position. 91 - 94 This is typically obtained by aligning the patient’s tragus with their sternum in the horizontal plane, by flexing the lower neck and extending the head. 95 In the obese patient, similar alignment can be achieved in several ways, including commercial positioning devices, back-of-bed elevation, or by creating a ramp with folded sheets.…”

Section: Implementation Of the Planned Strategy When Difficult Tracheal Intubation Is Predictedmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

101

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

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Section: Implementation Of the Planned Strategy When Difficult Tracheal Intubation Is Predictedmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

101

View full text Add to dashboard Cite

show abstract

“…• Consider directly lifting the epiglottis (applies to both Macintosh and straight blades). • Exaggerate head lift and “sniff” positions, 126 – 129 if not contraindicated. • Release any applied cricoid pressure.…”

Section: Response To Difficulty With Airway Management In the Unconscious Patientmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. Findings and key recommendations Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider “exit strategy” options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a “cannot ventilate, cannot oxygenate” emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as “airway lead” to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

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“…have compared the glottic view as well as intubating conditions with SP and further head elevation. [ 11 ] Their results are encouraging as they have demonstrated further head elevation position to be better than standard SP with respect to both these parameters. The strengths of this study are assessment of intubating conditions in addition to laryngoscopic view and ensuring appropriate SP.…”

mentioning

confidence: 91%

Head elevation beyond sniffing position – An aid to airway management

Mohta

2018

J Anaesthesiol Clin Pharmacol

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Comparison of ease of intubation in sniffing position and further neck flexion

Cited by 10 publications

References 11 publications

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

Head elevation beyond sniffing position – An aid to airway management

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