Defining Optimal Head-Tilt Position of Resuscitation in Neonates and Young Infants Using Magnetic Resonance Imaging Data

Abstract

Head-tilt maneuver assists with achieving airway patency during resuscitation. However, the relationship between angle of head-tilt and airway patency has not been defined. Our objective was to define an optimal head-tilt position for airway patency in neonates (age: 0–28 days) and young infants (age: 29 days–4 months). We performed a retrospective study of head and neck magnetic resonance imaging (MRI) of neonates and infants to define the angle of head-tilt for airway patency. We excluded those with an artificial airway or an airway malformation. We defined head-tilt angle a priori as the angle between occipito-ophisthion line and ophisthion-C7 spinous process line on the sagittal MR images. We evaluated medical records for Hypoxic Ischemic Encephalopathy (HIE) and exposure to sedation during MRI. We analyzed MRI of head and neck regions of 63 children (53 neonates and 10 young infants). Of these 63 children, 17 had evidence of airway obstruction and 46 had a patent airway on MRI. Also, 16/63 had underlying HIE and 47/63 newborn infants had exposure to sedative medications during MRI. In spontaneously breathing and neurologically depressed newborn infants, the head-tilt angle (median ± SD) associated with patent airway (125.3° ± 11.9°) was significantly different from that of blocked airway (108.2° ± 17.1°) (Mann Whitney U-test, p = 0.0045). The logistic regression analysis showed that the proportion of patent airways progressively increased with an increasing head-tilt angle, with > 95% probability of a patent airway at head-tilt angle 144–150°.

Effects of Head Extension on Peak Airway Pressure During Mask-Ventilation: A Prospective, Randomized, Clinical Single-Centre Trial

“…In pre-school (-1°or 13°) and school children (16°), it was beneficial to extend the head to a lesser extent than in adults to optimize mask-ventilation (16), which may be explained by the reduced cervical spine movement in children (17). An MRT study in spontaneously breathing neonates showed a high probability of a patent upper airway with a head tilt angle of 144 to 150°(angle between occipital-opisthion line and ophisthion-C7 spinous process line) (18). Studies in adults during midazolam sedation (19) or propofol anaesthesia (with muscle relaxation) (20) showed that head extension decreased upper airway collapsibility and closing pressures, respectively.…”

Versorgung und Reanimation des Neugeborenen nach der Geburt

“…Eine retrospektive Analyse von MRT-Bildern der Atemwege von 53 sedierten Säuglingen zwischen 0 und 4 Monaten, bei denen eine kraniale MRT-Untersuchung durchgeführt werden musste, zeigte, dass z. B. bei einer Überstreckung des Kopfs eine Obstruktion der oberen Atemwege auf Höhe der Zunge durch die Verschiebung der posterioren Atemwegsteile in Richtung anterior hervorgerufen werden kann [ 149 ]. Daher wird die Lagerung des Kopfs in Neutralposition bevorzugt, um eine optimale Durchgängigkeit der Atemwege zu gewährleisten.…”

An approach to define newborns´ sniffing position using an angle based on reproducible facial landmarks

“…Variations of the sniffing position have been used by clinicians for years and are mainly based on expert opinion 19 ; yet a detailed definition of the angle used to unify its application is missing and may be a first step in addressing this omission. 20 Up to now, there is only one study in spontaneously breathing yet sedated neonates receiving magnetic resonance imaging (MRI) that showed that the sniffing position was best to open up the airway, defined by an angle at the back of the head based on landmarks, in particular the head tilt angle, which is the angle between the occipitoophisthion line and the ophisthion-C7-spine process line only visible on sagittal MR scans 21 (Figure 1). MRI, however, is time-consuming and expensive; thus, a simple, easily obtainable and reproducible angle is needed.…”

“…The arrow points to the open airway. In the back of the head, a sketched an "obtuse angle" symbolizes the head tilt angle, which is the angle between the occipito-ophisthion line and the ophisthion-C7-spine process line only visible on sagittal MR images 21 [Colour figure can be viewed at wileyonlinelibrary.com] Two lateral 2D images were taken using a Nikon D7100 camera (Nikon, Chiyoda, Tokio, Japan). A plastic scale (sliding millimeter caliper, Maped®, Cedex, France) was placed on the side of the infant's head as a measurement reference.…”

“…The arrow points to the blocked airways at tongue level. In the back of the head, a sketched “sharp angle” symbolizes the head tilt angle, which is the angle between the occipito‐ophisthion line and the ophisthion‐C7‐spine process line only visible on sagittal MR images 21 . B sketch of an MRI image showing the head and neck region of a newborn infant in sniffing position.…”