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Use of an Elevation Pillow to Produce the Head-Elevated Laryngoscopy Position for Airway Management in Morbidly Obese and Large-Framed Patients

2004; Lippincott Williams & Wilkins; Linguagem: Inglês

10.1213/01.ane.0000077676.55641.a2

1526-7598

James M. Rich,

Obstructive Sleep Apnea Research

To the Editor: Drs. Brodsky, Lemmens, Brock-Utne, and Saidman are to be commended for their letter, "Anesthetic Considerations for Bariatric Surgery: Proper Positioning is Important for Laryngoscopy"(1). They have increased needed awareness of this well-documented dilemma requiring special positioning for morbidly obese patients prior to initiating airway management (2,3). The picture they included shows a large stack of hospital linen being used to position a morbidly obese patient (1). Our anesthesia department recently began using a premanufactured elevation pillow (C & R Enterprises, Frisco, TX) (Fig. 1) to position morbidly obese and large-framed patients. When used in conjunction with a standard intubation pillow, the elevation pillow provides better positioning than use of a standard intubation pillow alone (Fig. 2). Head elevation beyond the sniffing position by raising the back and shoulders is known as the "head-elevated laryngoscopy position" (HELP) (4,5). It facilitates alignment of the pharyngeal, laryngeal, and oral axis of the airway during difficult laryngoscopy, especially in the large patient (2,4–7). Concerning how much elevation is required, Brodsky et al. state, "An imaginary horizontal line should connect the patient's sternal notch with the external auditory meatus"(1) (Fig. 3). Figure 1.: The elevation pillow. (Used with permission, C&R Enterprises, Frisco, TX.)Figure 2.: Morbidly obese patient (118 kg, 62') in recumbent position with standard intubation pillow only. This position creates misalignment of the laryngeal, pharyngeal, and oral axis of the airway in the morbidly obese and large framed patients. (Used with permission, C&R Enterprises, Frisco, TX.)Figure 3.: Morbidly obese patient (188 kg, 62") properly positioned for laryngoscopy using standard intubation pillow in conjunction with elevation pillow. Elevation of the shoulders and upper back facilitates alignment of the laryngeal, pharyngeal and oral axis of the airway in morbidly obese and large framed patients. (Used with permission, C&R Enterprises, Frisco, TX.)Like the stacked ramp of hospital linen, the elevation pillow properly positions the obese and large framed patient for endotracheal intubation. It also eases the work of breathing for those patients who cannot lay flat secondary to obesity-induced orthopnea. Therefore, the patient is better able to tolerate the preinduction period or a longer period of time when required (i.e., monitored anesthesia care). The elevation pillow can be prepositioned, inserted, and removed much faster and with less difficulty than that required to build and dismantle a ramp made of hospital linen. James M. Rich, MA, CRNA