When first learning intubation, a beginner often concentrates on memorizing the key laryngeal anatomy. This is important of course. If you can’t recognize the vocal cords, you will not be able to successfully intubate. However, even more important to learning intubation is understanding how the larynx relates to the other structures in the head and neck. In order to intubate you must manipulate those other structures to bring the larynx into view.
A prior post, When Learning Intubation Is Hard, described in detail some of the most common barriers to learning to intubate. Here I will concentrate on helping you see how head position effects your ability to see the larynx.
Larynx Location In The Neck
To feel your own larynx, place your hand on the front of your neck, with thumb and forefinger on either side of the firm, roughly cylindrical shape in the midline.
The adult larynx lies opposite the 5th, 6th cervical vertebrae, as opposed to the infant larynx that lies opposite the 2nd, 3rd and 4th. The fact that the infant larynx is higher in the neck leads to greater risk of airway obstruction and a need to slightly alter technique during pediatric intubation. A link to how to intubate the pediatric patient is located at the end of this article. Here we will concentrate on the adult.
The larynx is located in front of the esophagus in the neck. The opening to the larynx, called the glottis, and the opening to the esophagus are immediately adjacent to each other. Misidentification of the esophagus as the glottic can lead to esophageal intubation.
How The Larynx Relates To Other Structures
Look at this lateral Xray of a head in neutral position. The outline of the epiglottis, the hyoid bone, the thyroid cartilage and the cricoid cartilage are easily identified. Notice the relationship of the larynx to the esophagus. The larynx lies in front of the esophagus but the opening to the larynx (the glottis) and the esophagus are right next to each other. Accidental esophageal intubation is a risk with every intubation.
Now imagine yourself intubating this patient. what would you have to do to bring the larynx into view? How deep would you have to insert a Macintosh blade to place the tip in the vallecula? How deep would you need to insert a Miller blade to lift the epiglottis?
Here is a CT scan of another adult patient. Notice that in this second patient the larynx is located higher in the neck.
Whereas the epiglottis in the first patient is low behind the tongue, this patient’s epiglottis is higher. The depth of insertion and the strategy to lift the epiglottis will change from patient to patient. Straight blades often work better in patients with a larynx higher in he neck and this may be one of those patients.
How Does Neck Position Affect The Larynx During Intubation
Let’s look at a lateral Xray of our first patient, but now with his head tilted all the way back in full extension. Patients with respiratory distress, will often tilt their heads back. You can see that this position more fully opens the airway and decreases resistance to breathing.
During intubation, we need to tilt the head back to bring the axis of the oral and pharyngeal axes into alignment. But if the patient is not in a good sniffing position, with the head moved slightly forward in addition to being tilted, the larynx may remain hidden behind the tongue during laryngoscopy.
Let me rotate this image to show you what I mean.
You can now see how anterior that larynx would look during laryngoscopy. Pushing down on the cricoid cartilage might help rescue a difficult intubation in a situation like this, but optimal head and neck positioning from the beginning would work better.
When getting ready to intubate, always glance at the side of your patient and assess whether the head and neck are in an optimal position before you start. If it’s not optimal, try to fix it. That several seconds can save you, and your patient, potential trauma.
Head Position Also Affects Laryngeal Opening
As long as we are looking at X-rays, let’s look at our first patient with his head flexed fully forward. When the head is flexed forward, the structures in the posterior pharynx and the tongue tend to obstruct the airway. You can test this by flexing your head forward as far onto your chest as you can. It becomes much harder to take a breath.
While no one would position a patient’s head this way for intubation, it’s common for novices to place too many pillows under the head trying to obtain a good sniffing position. If the head is too high, the patient, and the intubator, will not be able to tilt the head back. In other words, our novice intubator, trying to maximize sniffing position, sabotages himself. Again, prior to intubation take a look to the side of your patient. Try to tilt the head back (or have the patient tilt their head back).
When learning to intubate, learn the anatomical relationships, not just laryngeal anatomy. A good intubator understands that knowledge of how those structures move in relationship to each other gives you the power to manipulate that anatomy to give you the best possible view during intubation.
Please share with your fellow students. I’ve included a list with links below to previous posts on learning intubation to help you perfect your skills. Feel free to ask questions. Let me know if there are any topics that you would find helpful.
May The Force Be with You
Christine Whitten MD, author
Anyone Can Intubate, A Step By Step Guide
Pediatric Airway Management, A Step By Step guide
LINKS TO PRIOR DISCUSSIONS WITH MORE DETAILS OF HOW TO INTUBATE:
- WHEN LEARNING INTUBATION IS HARD
- INTUBATION: STEP BY STEP
- POSITIONING THE HEAD FOR INTUBATION
- INTUBATION WITH A CURVED BLADE
- USING STRAIGHT LARYNGOSCOPY BLADES
- AVOIDING DIFFICULT INTUBATION OF THE EASY AIRWAY
- TIPS TO TEACHING INTUBATION
Please click on the covers to preview my books at amazon.com
2 thoughts on “Learning Intubation: Head Position Effects Laryngeal View”
I just found your site (after reading one of your Anesthesia News articles): great resource! On this particular page, though, I’m with you right up until the end — too much head lift? Is there such a thing, I say only half jokingly? In my experience, at least, residents’ most common error is removing pillows from the head, not putting too many there. Sure, if the head is flexed as in your last x-ray image, intubation would be pretty challenging! But with the neck flexed like there, but with added head extension (just found this, which kind of describes what I mean: https://www.sciencedirect.com/science/article/pii/S0952818014003365) I would expect to have a good view!
Thanks for the feedback. I have indeed seen students have the head tilted so far forward on pillows that it did prevent them from then tilting the patient’s head back into the sniffing position. I have also sabotages myself at one of the surgicenters where I work. We place the patient for shoulder surgery in the Captain’s chair, with the back down, for intubation. Unless the headrest places the head in a neutral position or unless a pillow under the back/neck is used to improve positioning, the head is locked in a forward tilt. I wanted to remind providers that unless they look from the side, one can be fooled into thinking position is optimal when it’s not.