What is the best approach for intubating a patient with a short neck?

Management of Intubation in Patients with Short Necks

For patients with short necks, video laryngoscopy should be the first-line approach for intubation, with immediate availability of adjuncts such as a gum elastic bougie and preparation for possible awake intubation if significant difficulty is anticipated. 1

Initial Assessment and Preparation

• Recognize that a short neck is a risk factor for difficult airway management, particularly when combined with other factors such as obesity 1
• Evaluate for additional predictors of difficult intubation including:
  • Limited mouth opening
  • Reduced thyromental distance
  • Mallampati score III or IV
  • Obesity (particularly BMI >30 kg/m²) 1
• Identify the cricothyroid membrane before induction using ultrasound if it's impalpable (especially important in obese patients) 1
• Position the patient optimally in a ramped position with head extension and neck flexion ("sniffing position") 1

Intubation Approach Algorithm

First Attempt:

• Use video laryngoscopy as the primary approach for better visualization 1
• Apply optimal external laryngeal manipulation (OELM) or BURP (backward, upward, rightward pressure) on the thyroid cartilage to improve laryngeal view 1
• Have a gum elastic bougie immediately available as it significantly improves success rates in patients with difficult airways 2

If First Attempt Fails:

• Maintain oxygenation between attempts with mask ventilation 1
• Consider alternative laryngoscope (McCoy or straight blade) 1
• Use a gum elastic bougie - this has been specifically recommended for patients with short necks and suspected cervical spine injuries 2
• Limit total attempts to maximum of 3-4 to avoid trauma and worsening edema 1

If Multiple Attempts Fail:

• Insert a supraglottic airway device (LMA or ILMA) to maintain oxygenation 1, 3
• Consider intubation through the ILMA if appropriate 3
• Be prepared to awaken the patient if oxygenation can be maintained 1

Special Considerations for Short Neck Patients

• For patients with extremely short necks, consider awake intubation techniques if significant difficulty is anticipated 1

• When performing awake intubation:

  • Position the patient in a head-up position 1
  • Use minimal sedation with adequate topical anesthesia 1
  • Maintain active pre-oxygenation (e.g., HFNO) 1
  • Have a clear plan for failure 1

• For obese patients with short necks:

  • Ramped position is essential to improve intubation success rates 1
  • Pre-oxygenate thoroughly in head-up position with CPAP/NIV or HFNO 1
  • Be prepared for rapid desaturation if difficulties occur 1

Emergency Rescue Plan

• Have a "can't intubate, can't ventilate" (CICV) plan ready 1
• Mark the midline and cricothyroid membrane before induction 1
• Consider a "double set-up" approach with a second operator prepared for front of neck access if high risk 1
• If CICV occurs, proceed promptly to front of neck airway access rather than multiple failed attempts 1

Common Pitfalls and Caveats

• Avoid multiple intubation attempts as this can lead to airway trauma, edema and convert a "can ventilate" to a "can't ventilate" situation 1
• Don't delay moving to alternative techniques if initial approach fails 1
• Recognize that short neck combined with obesity significantly increases risk of rapid desaturation 1
• In patients with previous cervical radiotherapy and short necks, ILMA may not be successful 3
• Ensure adequate muscle relaxation before attempting intubation to optimize conditions 1

By following this structured approach with appropriate preparation and equipment, the majority of patients with short necks can be safely intubated with minimal complications.