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MORBIDLY OBESE PATIENT AIRWAY MANAGEMENT
Category: Emergency Medicine
Abstract : Airway Management in morbidly obese patient Obesity may be associated with
difficult intubation or bag-valve-mask ventilation, particularly if other
predictors of intubation difficulty are present. Obesity alone is not a
contraindication to rapid-sequence intubation and this may be the preferred
method in most patients. However, in this population it is particularly
important to asses
Airway Management in morbidly obese patient
Obesity may be associated with
difficult intubation or bag-valve-mask ventilation, particularly if other
predictors of intubation difficulty are present. Obesity alone is not a
contraindication to rapid-sequence intubation and this may be the preferred
method in most patients.
However, in this population it is particularly
important to assess and recognize other objective predictors of a difficult
intubation.
Preoxygenation is critical, since morbidly obese patients
will desaturate more quickly than normal-sized adults. Patients should be kept
sitting upright or semirecumbent as long as possible prior to intubation. If
bag-mask ventilation is required, the obese patient often has reduced pulmonary
compliance, which necessitates higher ventilatory pressures. The pop-off valve
on the ventilation bag may have to be occluded in order to provide adequate
ventilation.
Once the process of intubation is begun, access to the
airway is enhanced by elevating both the head and shoulders with towels or by
placing a rolled blanket between the scapulae and under the occiput. Elevation
of the shoulders allows displacement of the breasts away from the midline. The
greater elevation of the head places it in the sniffing position, and creates
more space, as the chest wall of the morbidly obese patient may actually
obstruct the handle of the laryngoscope. A shorter-than-average handle for the
laryngoscope or an adjustable-angle laryngoscope is useful in this
situation.
Alternative techniques of airway management such as awake oral
intubation or blind nasotracheal intubation may be utilized if difficulty is
predicted. Nasotracheal intubation is technically more difficult than
orotracheal intubation, but may be relatively advantageous if performed by an
experienced physician to intubate a spontaneously breathing patient with a short
thick neck.
Transtracheal jet ventilation requires higher ventilatory
pressures and therefore may be less useful and cause increased barotrauma in the
obese patient with decreased pulmonary compliance. The intubating laryngeal mask
airway and the esophageal-tracheal double-lumen tube are possible rescue
devices, and their utility in the morbidly obese patient has been described. A
fiberoptic bronchoscope can also be used to aid intubation, although
visualization may be impaired by circumpharyngeal fat.
Finally, a
cricothyrotomy may be indicated if other maneuvers fail. Landmarks may not be
appreciated by palpation and the cricothyroid membrane is located approximately
four fingerbreadths above the sternal notch. Needle cricothyrotomy is difficult
given the anatomy of a morbidly obese patient's neck.
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