A randomized study comparing the sniffing position with simple head extension for glottis visualization and difficulty in intubation during direct laryngoscopy

Abstract

Background:Proper positioning of the head and neck is important for an optimal laryngeal visualization. Traditionally, sniffing position (SP) is recommended to provide a superior glottic visualization, during direct laryngoscopy, enhancing the ease of intubation. Various studies in the last decade of this belief have challenged the need for sniffing position during intubation. We conducted a prospective study comparing the sniffing head position with simple head extension to study the laryngoscopic view and intubation difficulty during direct laryngoscopy.Materials and Methods:Five-hundred patients were included in this study and randomly distributed to SP or simple head extension. In the sniffing group, an incompressible head ring was placed under the head to raise its height by 7 cm from the neutral plane followed by maximal extension of the head. In the simple extension group, no headrest was placed under the head; however, maximal head extension was given at the time of laryngoscopy. Various factors as ability to mask ventilate, laryngoscopic visualization, intubation difficulty, and posture of the anesthesiologist during laryngoscopy and tracheal intubation were noted. In the incidence of difficult laryngoscopy (Cormack Grade III and IV), Intubation Difficulty Scale (IDS score) was compared between the two groups.Results:There was no significant difference between two groups in Cormack grades. The IDS score differed significantly between sniffing group and simple extension group (P = 0.000) with an increased difficulty during intubation in the simple head extension. Patients with simple head extension needed more lifting force, increased use of external laryngeal manipulation, and an increased use of alternate techniques during intubation when compared to SP.Conclusion:We conclude that compared to the simple head extension position, the SP should be used as a standard head position for intubation attempts under general anesthesia.

Influence of videolaryngoscopy using McGrath Mac on the need for a helper to perform intubation during general anaesthesia: a multicentre randomised video-no-video trial

“…Alternative techniques were used at a similar incidence in both groups, mainly the BURP in around 40% of the patients and the use of a gum elastic bougie (railroading technique) in around 10% of the patients. Such incidence of use of BURP is not surprising in that incidences of 23% 20 and 36% 24 have been reported previously. High incidence of their use is probably explained by the fear of dental breakage, with an incidence up to 0.2% of all general anaesthesia procedures, is responsible for 40% of the complaints against anaesthesiologists in France.…”

Optimal position for laryngoscopy – Time for individualization?

“…In addition to the glottic view, SP has been shown to structurally improve the pharygeal airway patency and provide wider mouth opening and the use of lesser force during laryngoscopy when compared with simple head extension. [91011] However, Adnet et al showed that SP provided no advantage over simple head extension during laryngoscopy under anesthesia. In this study, laryngoscopy was performed without the use of neuromuscular blockade, which may have lead to inadequate intubating conditions.…”

Airway management in hospital. Methodological recommendations of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists” (third edition)

“…ÿ Применение дополнительных маневров для улучшения визуализации гортани во время прямой ларингоскопии -внешние манипуляции на гортани (BURP-маневр) [274][275][276], придание пациенту «принюхивающегося положения» [277][278][279], придание пациенту с ожирением HELP-позиции (head-elevated laryngoscopy position) [280][281][282][283] или ramped-позиции [284][285][286][287].…”

“…ň Рекомендация 12. В случае неудачи первой попытки прямой ларингоскопии рекомендуется придание пациенту улучшенного Джексоновского положения (HELP-позиции и иных рекомендованных), применение BURP-маневра [274][275][276][277][278][279][280][281][282][283][284][285][286][287] (УДД -3, УУР -В).…”