Mississippi Anesthesia Professionals

Preparing a Patient for Tracheal Intubation

Tracheal intubation is a common procedure used in anesthesiology and critical care to secure a patient’s airway, facilitate mechanical ventilation, and/or protect the airway from aspiration. Given the difficulties that can arise, the benefits of first-pass success, and the discomfort patients may experience from the procedure, it is important for anesthesia providers to adhere to best practices when preparing a patient for tracheal intubation.  

Whenever possible, the first step in preparing a patient for tracheal intubation should involve a thorough preoperative assessment. This assessment helps to identify any potential difficulties or complications that may arise during intubation. Factors such as the patient’s medical history, airway anatomy, and the presence of comorbid conditions (obesity, sleep apnea, etc.) can influence the approach and techniques used for intubation. A thorough evaluation includes a review of previous anesthesia records for any intubation difficulties, a physical examination of the airway, and, if necessary, imaging studies to assess airway anatomy. The Mallampati score, which classifies the visibility of the oropharyngeal structures, is commonly used to predict difficult airway management (1). In addition to the physical assessment, confirmation of the patient’s fasting status is recommended to minimize the risk of aspiration during the procedure. The American Society of Anesthesiologists (ASA) guidelines recommend a fasting period of at least 6 hours for solid foods and 2 hours for clear liquids prior to elective procedures requiring general anesthesia (2). This fasting guideline is recommended to reduce the volume and acidity of stomach contents, thereby reducing the risk of aspiration pneumonitis. 

Another critical aspect of preparing to perform tracheal intubation is ensuring the availability and functionality of all necessary equipment. The checklist for intubation equipment should ideally include a laryngoscope with appropriately sized blades, endotracheal tubes of various sizes, a stylet, a suction device, and alternative airway management devices, such as a supraglottic airway or a video laryngoscope, for difficult intubations (3). Additionally, emergency equipment, including drugs for rapid sequence induction, vasopressors, and resuscitation equipment should be readily available. 

Furthermore, patient positioning is a vital consideration in preparing for tracheal intubation. The “sniffing” position, which involves slight flexion of the neck and extension of the head at the atlanto-occipital joint, is widely regarded as the optimal position for intubation as it aligns the oral, pharyngeal, and laryngeal axes to facilitate visualization of the vocal cords and insertion of the endotracheal tube (4). For patients with suspected cervical spine injuries, manual in-line stabilization should be employed to prevent neck movement during intubation. In addition to the technical and clinical aspects of preparation, obtaining informed consent from the patient or their legal representative is a fundamental ethical and legal requirement. This involves explaining the procedure, its rationale, potential risks, and alternatives to ensure that the patient or their surrogate has a clear understanding and agreement before proceeding. 

Although tracheal intubation is a relatively common procedure, it necessitates a thorough preoperative assessment, adherence to fasting guidelines, equipment preparation, careful patient positioning, and obtaining informed consent. By following established best practices and clinical guidelines, anesthesia providers can minimize the risks associated with tracheal intubation and enhance patient safety and procedural success. 

References 

  1. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32(4):429-434. 
  1. American Society of Anesthesiologists. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology. 2017;126(3):376-393. 
  1. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251-270. 
  1. Levitan RM, Mechem CC, Ochroch EA, et al. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003;41(3):322-330.