What are the best practices for intubating a patient with a short neck?

Best Practices for Intubating a Patient with a Short Neck

Videolaryngoscopy should be used as the first-line approach for intubating patients with a short neck, as it provides better laryngeal visualization while allowing the operator to maintain distance from the airway. 1

Pre-Intubation Assessment and Preparation

• Thoroughly evaluate the airway for additional predictors of difficulty, including mouth opening, Mallampati score, and neck mobility, as short necks often present with multiple difficult airway features 1
• Ensure full preparation of equipment before induction, including:
  • Videolaryngoscope with appropriate blade (most familiar to the operator) 1
  • Bougie or stylet for use with the videolaryngoscope 1
  • Backup airway devices including supraglottic airways 1
  • Emergency cricothyroidotomy kit 1
• Position the patient optimally with ramped positioning to improve the laryngeal view in patients with short necks 1
• Pre-oxygenate thoroughly and consider apneic oxygenation techniques to extend safe apnea time 1

Intubation Technique

• Use a videolaryngoscope with a separate screen to maintain optimal distance from the airway while providing the best view 1
• For videolaryngoscopy:
  • With a Macintosh-type blade, have a bougie immediately available 1
  • With a hyperangulated blade, use a stylet to direct the tube 1
• Ensure full neuromuscular blockade before attempting intubation to optimize conditions 1
• Limit the number of attempts at laryngoscopy (maximum of 2-3) to prevent airway trauma and edema 1
• Stay as distant from the airway as practical while maintaining optimal technique 1

Alternative Approaches

• If initial videolaryngoscopy fails, consider a second-generation supraglottic airway device as a rescue technique 1
• For anticipated extremely difficult airways, consider awake fiberoptic or video laryngoscopy intubation with adequate topical anesthesia 1
• In cases where neck mobility is severely limited, a flexible fiberoptic approach may be superior to direct laryngoscopy 2

Special Considerations

• For patients with unstable necks or cervical spine concerns (which may accompany short neck anatomy):
  • Remove the anterior portion of any cervical collar to improve mouth opening while maintaining spine stabilization 1
  • Use manual in-line stabilization rather than head tilt/chin lift for airway maintenance 1
  • Videolaryngoscopy has been shown to reduce cervical spine movement compared to direct laryngoscopy 1, 3
• Be prepared for rapid desaturation, as patients with short necks often have reduced functional residual capacity and may be obese 1

Common Pitfalls and How to Avoid Them

• Attempting multiple direct laryngoscopy attempts when initial attempt fails—instead, switch to an alternative technique after 1-2 attempts 1
• Inadequate positioning—ensure proper head elevation and alignment of oral, pharyngeal, and laryngeal axes 1
• Failure to recognize when to abort intubation attempts—have clear criteria for when to stop attempts and implement alternative plans 1
• Using unfamiliar equipment in a crisis—train regularly with videolaryngoscopes and other advanced airway devices 1
• Forgetting to confirm tube placement—always verify with capnography after intubation 1

By following these evidence-based recommendations, the challenges presented by a short neck during intubation can be effectively managed, reducing the risk of complications and improving patient outcomes.