Letters to the Editor: Let’s Not Forget Who Brought Us To The Dance

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November 1, 2013 Volume 77, Number 11
Letters to the Editor: Let’s Not Forget Who Brought Us To The Dance

The September 2013 issue of the ASA NEWSLETTER is a useful compendium on airway management. Nevertheless, while I read each article, I am surprised by the omission of a strategic aspect in the care of these patients: the emphasis on proper head position. Other articles reviewing airway management similarly concentrate on the description of intubation devices, yet overlook the advantages of proper head position in airway management.


Airway management is a major responsibility for the anesthesiologist and practice guidelines systematically develop recommendations that assist the practitioner in making health care decisions. Since the early “Practice Guidelines for Management of the Difficult Airway,” adopted by ASA in 1992 and 2003, the addition of the 2013 revision provides a wider range of management techniques.1-3 Emergency room and intensive care units also have difficult airway algorithms, but they emphasize the merit of calling for early assistance and underscore the value of proper head position prior to ventilation and intubation.4,5 However, the NEWSLETTER articles, like the ASA Difficult Airway Algorithm, do not rigorously address the benefit of optimal head position during airway management.


Obese patients are frequently the source of airway management challenges. Several articles in the anesthesia literature have promoted the use of the head-elevated laryngo-scopy position (HELP) to facilitate intubation in the obese patient.6-9 This position should be further defined to indicate that the patient should be placed in a ramped position so that the pinna of the ear and the sternum are in the same horizontal plane (P-S line). High rates of successful intubations are obtained when patients are placed in the HELP position. This “P-S” (pinna-sternum) alignment, or HELP position, also improves ventilation and maximizes the view of the larynx during laryngoscopy and intubation.


Bariatric surgery patients are morbidly obese, have a large circumferential neck mass and typically present with con-comitant obstructive sleep apnea. They are challenging to ventilate and problematic to intubate. It is my observation that fiberoptic intubation aids and airway devices, such as the laryngeal mask airway, are most useful when proper head position is obtainable. Accordingly, what has remained constant for us over the years is the attention to reliable head positioning prior to attempting ventilation, laryngeal visualization and intubation.


The current ASA algorithm states the anesthesiologist should have “a preplanned strategy for intubation of the difficult airway.” As a result, the query remains, why doesn’t a preplanned strategy include the planning for optimal head position? Why is an important entrance point into the difficult airway algorithm, such as head position, absent in the NEWSLETTER’s comprehensive review? Do the authors view proper head position as merely intuitive? Is head position in patients with potentially difficult airways a mundane issue in the shadow of new intubation devices?


New intubation devices come and go. The importance of head position to improve ventilation and increase the likelihood of a successful intubation is time tested. That is to say, proper head position should be viewed as a posteriori knowledge, that which derives from experience, rather than a priori knowledge, that which is independent of all particular experiences. In an emergency intubation cart filled with clever eponym-labeled intubation aids, let’s not forget who (what) brought us to the dance – proper head position.


James M. Gayes, M.D. Minneapolis, Minnesota


Reply to Dr. Gayes

On behalf of the ASA Task Force on Management of the Difficult Airway and the ASA Committee on Standards and Practice Parameters, we thank Dr. Gayes for his thoughtful letter to the editor. Dr. Gayes reminds us that the position of the patient’s head can be part of a preplanned strategy for management of a known or suspected difficult airway.


Dr. Gayes poses a specific question – why is head position not mentioned as a preplanned strategy in the ASA Difficult Airway Guidelines? The straightforward answer to this question is that the inclusion of head position was not identified as a priority during the development of the original difficult airway guidelines or the recent revision. Dr. Gayes suggests that proper head position may be viewed by some practitioners as an intuitive concept. In part, this may explain why task force members, consultants, open forum attendees and survey participants did not call for the inclusion of head position as a specifically described element of the difficult airway guidelines.


But make no mistake – we regard the comments of Dr. Gayes as valuable and important. Through the participation of our members and readers such as Dr. Gayes, we continue to improve our practice parameters. Dr. Gayes’ comments will be recorded by our analysts, and these comments will be carefully reviewed and considered during the next update process.


Once again, we thank Dr. Gayes for his insights. We look forward to additional commentary and suggestions from ASA members and NEWSLETTER readers.


Robert A. Caplan, M.D.

Chair, ASA Task Force on Guidelines for Management of the Difficult Airway


Jeffrey L. Apfelbaum, M.D.

Chair, ASA Committee on Standards and Practice Parameters


Richard T. Connis, Ph.D.

ASA Committee on Standards and Practice Parameters


David G. Nickinovich, Ph.D.

ASA Committee on Standards and Practice Parameters

The views and opinions expressed in the “Letters to the Editor” are those of the authors and do not necessarily reflect the views of ASA or the NEWSLETTER Editorial Board. Letters submitted for consideration should not exceed 300 words in length. The Editor has the authority to accept or reject any letter submitted for publication. Personal correspondence to the Editor by letter or e-mail must be clearly indicated as “Not for Publication” by the sender. Letters must be signed (although name may be withheld on request) and are subject to editing and abridgement. Send letters to newsletter_editor@asahq.org.


1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology.1993;78(3):597-602.

2. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology. 2003;98(5):1269-1277.

3. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway. Anesthesiology. 2013;118(2):251-270.

4. Sakles JC, Laurin FG, Rantapaa AA, Panacek EA. Airway management in the emergency department: one year study of 610 tracheal intubations. Ann Emerg Med. 1998;31(3):325-332.

5. Lim MS, Hunt-Smith JJ. Difficult airway management in the intensive care unit: practical guidelines. Crit Care Resusc. 2003;5(1):43-52.

6. Brodsky JB. Physiological and anesthetic considerations in morbidly obese patients. Curr Rev Clin Anesth. 2006;26(18):237-248.

7. Brodsky JB, Lemmens HJ, Brock-Utne JG, Saidman LJ, Levitan R. Anesthetic considerations for bariatric surgery: proper positioning is important for laryngoscopy [letter to editor]. Anesth Analg. 2003;96(6):1841-1842.

8. Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003;41(3):322-330.

9. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg. 2004;14(9):1171-1175.