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5 tips for airway management in the bariatric patient

Pre-oxygenate, evaluate for LEMONS and position a patient of any size correctly to help secure an airway

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These tips may not only help you manage your bariatric patient’s airway, but will also be useful in managing an airway in a patient of any size.


Treating and transporting a bariatric patient can require coordination with outside agencies, as well as specialized lifting and monitoring equipment. Bariatric patients have the right to expect professional and timely emergency care, with consideration given to their unique assessment challenges, and providers have the obligation to deliver such care without risking their own health. Learn more in this EMS1 Special Coverage series, “Bridging the gap in bariatric patient care: Pathophysiology, assessment and transport solutions.”

The EMS1 Academy features “Respiratory Emergencies,” a 30-minute accredited course for EMTs. This course provides examples of the common signs and symptoms a patient with inadequate breathing may present with in an emergency situation. Visit the EMS1 Academy to learn more and schedule a demo.

The 911 call was for cardiac arrest, and I was in the enviable position of second-in medic; do all the procedures and none of the paperwork. I’ll admit I was pretty cocky as I arrived, ready to strut in, do all the easy stuff (ALS procedures being “easy” compared to chest compressions, though not nearly as important) and clear the scene in a blaze of glory, leaving bewildered cops and firefighters to exclaim, “Who was that masked man?”

And then I saw the patient.

He weighed well over 600 pounds and had collapsed in the hallway. His head and shoulders – with no neck visible – were in the hall, and his entire lower body was still in the bedroom. The first-in crew was in the bedroom – they’d had to climb over the patient – already doing CPR as best they could, and the medic looked up hopefully and asked, “Get the airway?”

Maybe this second-in medic stuff isn’t that sweet a deal, after all, I mused as I lay down at the patient’s head, assembling my equipment as my partner knelt in the bathroom doorway and attempted BVM ventilation as best she could. Thirty seconds later, I had a patent 8.0 tube, and was delivering effective ventilations with 100% oxygen.

The rest of the resuscitation went pretty smoothly as resuscitations go, despite the fact that we were essentially two code teams in two separate rooms. Securing the airway that easily in a patient that challenging gained me a reputation among my colleagues as an airway samurai, and did little to help my already bloated ego.

Pride, as they say, goeth before the fall.

It was barely six months later that we ran a bariatric patient in respiratory failure, who lived, predictably, in the back bedroom of a cramped frame house. He was struggling, but he wanted to move himself, and realistically, there was no way we could have moved him to our stretcher ourselves anyway.

Turns out, a stand and pivot onto a stretcher three feet away was more than he had in him, and he stopped breathing as we were securing the straps. This time I did not coat myself in glory. I managed to secure a tube … eventually, but not without a great deal of failed BVM ventilation, sweating, cursing and using every trick in my airway bag.

All this is to say that, like Forrest Gump’s bawx o’ chawklits, when it comes to airway management in the bariatric patient, you never know what you’re gonna get.

With that in mind, here are some ventilation tips that will work with a patient of any size, but may serve you well in managing the bariatric patient airway:

1. Size matters not. With apologies to Yoda, size actually does matter, but perhaps not in the way you think. Don’t approach airway management in the bariatric patient as an impossible feat, or that mental attitude will make the prospect of a failed airway a self-fulfilling prophecy. However, size does matter when it comes to tidal volumes. Remember that tidal volumes are calculated on ideal body weight, not actual. It doesn’t matter if your patient weighs 700 pounds, if he’s of average height, his calculated tidal volume is going to be the same as that of an average-sized male. If you need to improve oxygenation, do it with inspired FiO2 and PEEP, not bigger breaths.

2. Pre-oxygenate. The mantra you need to follow here is, resuscitate, then intubate. Your patient is dying from hypoxia, not lack of an ET tube. Utilize effective two-person BVM ventilation and start with a minimum of 5.0 cm H20 of PEEP. Use the NO-DESAT apneic oxygenation technique, and get your patient’s oxygen saturation above 95% (if you can) for at least three minutes before you attempt an advanced airway adjunct. Doing so will broaden your intubation window from seconds into many minutes before hypoxia sets in. This will give you time to formulate an airway plan, and speaking of plans …

3. Evaluate for LEMONS. Every intubation attempt requires a plan, and the first part of planning is knowing what you’re facing. Evaluate the LEMONS mnemonic, and formulate a treatment plan while you’re pre-oxygenating:

  • Look externally
  • Evaluate the 3-3-2 rule
  • Mallampati
  • Obstructions/obesity
  • Neck mobility
  • Saturation

Plan A is your preferred airway, Plan B is your backup airway and Plan C is cricothyrotomy. And remember, your supraglottic airway device might be the preferred one instead of the backup, depending upon your skill level at intubation and what you learn from LEMONS.

4. Position your patient appropriately. It doesn’t matter if your patient weighs five pounds or 500, the sniffing position is the same; face parallel with the ceiling, and external auditory canal horizontally aligned with the top of the shoulder or the sternum. The only thing that varies is where and how much you pad. Most people think of the sniffing position as neck extension, but in reality, it’s neck flexion of 15 degrees or so, with the head extended about 10 degrees on the neck. Think of someone extending a flower for you to sniff, and that’s the position you want your patient in.

In the five-pound neonate, that may mean a couple of inches of towels padded under the shoulders. In the bariatric patient, it means ramping, using whatever means you have at hand: towels, blankets, sofa cushions or your partner’s knees.

Ramping allows you to position your patient appropriately to align the oral and laryngeal axes, and keep the airway open to allow all that nasal oxygen to diffuse down to the alveoli and broaden that normoxic window to get the airway device secured.

Ramping allows you to position your patient appropriately to align the oral and laryngeal axes, and keep the airway open to allow all that nasal oxygen to diffuse down to the alveoli and broaden that normoxic window to get the airway device secured.

5. Remember that airway management is a team sport. Every winning team utilizes all its players effectively, and plays with the proper equipment. A video laryngoscope is an extremely useful adjunct and growing so affordable these days that there is little excuse not to have one. You should also be using a bougie. Have your suction unit ready and be prepared to utilize suction assisted laryngoscopic airway decontamination (SALAD). Use bimanual laryngeal manipulation using the backwards, upwards, rightward pressure on the larynx (BURP) method, and have your partner provide lip retraction to the right corner of the mouth.

These tips may not only help you manage your bariatric patient’s airway, but will also be useful in managing an airway in a patient of any size. columnist Kelly Grayson, is a paramedic ER tech in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. Kelly is the author of the book Life, Death and Everything In Between, and the popular blog A Day in the Life of An Ambulance Driver.