Optimal combination of head, mandible and body positions for pharyngeal airway maintenance during perioperative period: lesson from pharyngeal closing pressures

Maintenance of the pharyngeal airway is an essential task assigned to anesthesiologists for patients’ oxygenation and ventilation during the perioperative period. Based on preoperative identification of risk factors of pharyngeal obstruction such as obstructive sleep apnea (OSA), optimal positioning of the head, neck, mandible, and body is the key for accomplishment of this task. In this context, accumulated knowledge on changes of pharyngeal closing pressures in response to various positional interventions is helpful for determining airway management strategy. Combination of the triple airway maneuver (mandible advancement, head extension, and mouth opening) with sniffing position in the Fowler’s (semi-sitting) position is optimal for anesthesia induction in morbidly obese patients with severe OSA. Disturbance of any one of the elements of the triple airway maneuver indicates tracheal intubation during wakefulness in these patients. Sitting or lateral position is advantageous over supine position for pharyngeal airway maintenance, whereas nasal CPAP should be applied in severe OSA patients.