Abstract

It was with great interest that I read the description of various head positions and angles for face-mask ventilation of subjects by novice anaesthetists [1]. The notion that a particular angle is optimal must, of course, be considered in the context of the patient's condition and circumstances. For example, in the event of a known or presumed neck injury, caution must be used to balance the risk of neurological catastrophe with effective or adequate ventilation until expert care can assume responsibility. Although the angles described in the paper suggest reasonable differences, and perhaps limits of flexion and extension, I propose that the authors have omitted an important and likely very helpful positioning feature well known to experienced anaesthetists: the placement of a roll under the shoulders. This permits further extension of the head and neck and extends the mentum-hyoid-ariepiglottic line and permits greater opening of the hypopharyngeal structures as previously described [2], and more effective ventilation, particularly by the novice. In the field, this can be done with a piece of clothing (for example a jacket or sweater), or other item (notebook, towel) and will likely permit further extension and likely superior opening of the hypopharyngeal airway. As a demonstration of the effect of such a small manoeuvre, I include several images obtained using superimposition. The images were obtained in different subject positions: simple cushion under the head (commonly performed for mask ventilation), and with an additional cushion under the shoulders (usually reserved for the large or obese patient). Sagittal MRI images were acquired in the same positions. Overlaying the images demonstrates the effect of the base of neck/shoulder cushion on the opening of the airway (Fig. 2a, b). Sagittal representation of the airway with MRI image overlay with (a) a simple head cushion, and (b) shoulder roll. If, indeed, you believe that an electronic liquid level would be of use, establishing the true bounds of airway positioning would be in order.

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