**2. Anticipating difficulty is key**

As with any skill, preparation is fundamental and is the secret to avoiding harm to patients. Ideally, all patients needing airway manipulation outside the OR should be assessed for potential difficulty, and prepared just as they would be for an elective procedure in the OR. One of the reasons airway management is more difficult outside the OR than inside is due to the fact that there may not be enough time to learn about the patient's physical condition and to predict risk of difficult airway or aspiration. Whenever possible patients should be assessed for comorbidities, drug allergies and fasting status. An airway assessment should be completed. There are many aides-memoires to help with a quick but relatively thorough assessment of the airway to predict difficulty with mask ventilation and intubation. These should be available in all areas for the physician to refer to, ideally attached to the difficult airway trolley. Risk factors for difficult mask ventilation include an increased body mass index (BMI), history of obstructive sleep apnea (OSA), presence of a beard that may disrupt the seal of the face mask, being edentulous and having limited mandibular protrusion. A difficult laryngoscopy is anticipated when a patient has limited mouth opening, a Mallampati score of III or IV, limited head and neck movements, is obese and has an increased neck circumference.

Patient preparation is also important. A patient who is not fasting adequately is at a higher risk of aspiration of gastric contents during induction of anesthesia and intubation. Standard airway equipment and monitoring that conforms to international safety standards should be readily available. These are discussed below. For intubating patients, it is sometimes difficult to get optimal positioning of the patient outside the OR. The OR tables allow all kinds of position changes, but the trolleys and ward beds are not as versatile. In obese patients, one has to try to achieve the ramp position to aid intubation. Outside the OR, one may need to improvise to achieve this. The Oxford HELP® (Head Elevating Laryngoscopy

**39**

**Table 1.**

*Sedation continuum.*

*Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

lie, which in turn decides the airway support needed.

the alternative to having MR compatible machines.

Responsiveness Alert/awake Responds to

Ventilation Unaffected Adequate Maybe

Cardiovascular Unaffected Maintained Usually

Airway Unaffected No intervention Intervention

carefully used in these deeply sedated patients (**Figure 2**).

**3. Areas outside the OR**

of the other areas:

**3.1 The radiology suite**

Pillow) and the Troop Elevation Pillow® System (**Figure 1**) are examples of adjuncts used to achieve optimal laryngoscopy position in obese patients.

There are many areas in hospitals outside of operation theaters and ICUs where

Every hospital facility will have different areas where airway management will be required or needed to be on standby. Airway management in some areas such as the ICU and prehospital setting will be discussed in other chapters. These are some

Most hospitals have a very large radiology suite. It can consist of MRI scanners, CT scanners and interventional radiology suites. Patients requiring both diagnostic and therapeutic procedures in these areas may need some form of sedation or analgesia to tide over the procedure. They may even need a general anesthetic. These areas need to be equipped from the start with all the airway kit that is required in an operating room setting. It is important to have MRI compatible airway equipment, as airway difficulties can arise when the patient is in the scanner tunnel. Laryngoscopes need to be non-ferromagnetic and MR compatible anesthetic machines, ventilators and vaporizers are available. Having long breathing circuits is

Another problem faced in scanner suites is the inability to prop-up the head-end of the patient. This can sometimes lead to partial airway obstruction in the deeply sedated patient who is spontaneously breathing. Partial obstruction to breathing causes movement artifacts on the head and neck scans. Nasal or oral airways can be

The coils used in MR magnets need to be kept cold in order to maintain superconductivity. This is often achieved by immersing them in liquid helium. If the machine gets quenched (usually an emergency process involving the rapid boil-off

**Signs Minimal Moderate Deep General** 

verbal stimuli

**Depth**

Responds to painful stimuli

inadequate

maybe needed

maintained

**anesthesia**

Frequently inadequate

Intervention often required

Maybe impaired

Unresponsive

sedation or general anesthesia is given for various reasons. This could be to aid uncomfortable diagnostic or therapeutic procedures or for patients who do not have the capacity to understand the need for such essential procedures. The medication that a patient receives defines where on the continuum of sedation (**Table 1**) they

**Figure 1.** *Troop Elevation Pillow® System.*

Pillow) and the Troop Elevation Pillow® System (**Figure 1**) are examples of adjuncts used to achieve optimal laryngoscopy position in obese patients.
