Letter to the Editor
Not too much hyperextension: Airway positioning using magnetic resonance imaging
No demasiada hiperextensión: posicionamiento de la vía aérea por medio de resonancia magnética nuclear
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Fernández Simón, S. Alcántara Carmona, R. Fernández Muñoz, L. Martínez Álvarez, C.J. Rodríguez, I. Lipperheide Vallhonrat" "autores" => array:6 [ 0 => array:2 [ "nombre" => "I." "apellidos" => "Fernández Simón" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Alcántara Carmona" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Fernández Muñoz" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Martínez Álvarez" ] 4 => array:2 [ "nombre" => "C.J." "apellidos" => "Rodríguez" ] 5 => array:2 [ "nombre" => "I." "apellidos" => "Lipperheide Vallhonrat" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113001034?idApp=WMIE" "url" => "/02105691/0000003800000005/v1_201405230944/S0210569113001034/v1_201405230944/es/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Not too much hyperextension: Airway positioning using magnetic resonance imaging" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "330" "paginaFinal" => "332" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.J. Arevalo, L.A. Muñoz, A.M. Cardona, B.R. Rosero, L.E. Reyes" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J.J." "apellidos" => "Arevalo" "email" => array:1 [ 0 => "jarevalo@fucsalud.edu.co" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L.A." "apellidos" => "Muñoz" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A.M." "apellidos" => "Cardona" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "B.R." "apellidos" => "Rosero" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "L.E." "apellidos" => "Reyes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Faculty of Medicine, Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Anesthesiology, Hospital de San Jose, Bogota, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Research Division, Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "No demasiada hiperextensión: posicionamiento de la vía aérea por medio de resonancia magnética nuclear" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 797 "Ancho" => 1754 "Tamanyo" => 188614 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging scans of a single volunteer. Panel A shows the interscapular support with hyperextension position and Panel B shows the sniffing position. The closed polygons depict the area between the oro-pharyngeal airway and the line of site (A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>43.60<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>, B<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>37.90<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>). The intersection between a horizontal line and a line drawn at the point where the two curves intersect, define the angle <span class="elsevierStyleItalic">α</span> (A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>33.03°, B<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.97°).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Airway management is of utmost importance to every anesthesiologist. The technique of choice is orotracheal intubation with direct laryngoscopy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Determinants of orotracheal intubation include airway anatomical configuration and the type of devices and techniques used.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In 1897 Kirstein performed the first comparison between two positions for airway management. This comparison was followed by Chevalier Jackson's description of the neck extension and full hyperextension positions performed by his assistant during surgery in 1913. Magill (1932) described that a patient during tracheal intubation adopts a position as if he/she were to sniff and Bannister and McBeth (1944) described the three-axes theory which postulates that an alignment of the oral, pharyngeal and laryngeal axes was necessary to achieve an adequate glotic opening.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, a recent magnetic resonance imaging study on airway configuration suggests that such theory cannot be proven and proposes another method to assess objective measures for airway evaluation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Some studies have suggested that the use of an interscapular support with hyperextension improves airway configuration for laryngoscopy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> However, this position has never been compared to the generally accepted sniffing position described by Magill.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to compare airway configurations of healthy volunteers measured as <span class="elsevierStyleItalic">α</span> angle and area under the line of site between the use of an interscapular support with hyperextension and sniffing positions. We wished to measure the differences of these two values between both positions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">After institutional and local ethics committee approval we performed six magnetic resonance imaging (MRI) studies on three healthy (no difficult airway risk factors) volunteers. Each volunteer was evaluated with both interscapular support with hyperextension and sniffing positions. T1-weighted images in the sagittal plane were obtained with a 1.5<span class="elsevierStyleHsp" style=""></span>T Magnetom Vision MRI scanner (Siemens Medical Solutions, Erlangen, Germany). The interscapular support with hyperextension position was achieved by placing a 10<span class="elsevierStyleHsp" style=""></span>cm height and 8<span class="elsevierStyleHsp" style=""></span>cm width non-collapsible rubber device covered with silicone. The sniffing position was achieved by elevating the occiput 10<span class="elsevierStyleHsp" style=""></span>cm and extending the head at the atlanto-occipital joint. The images were analyzed with OsiriX 5.0.2 DICOM viewer for MacOS.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two Bézier splines were measured as described by Greenland.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We used the slide that corresponded to the medial line as confirmed by both a radiologist and an otorhinolaryngologist. The splines were drawn starting at the tip of the top front incisors, through the middle of the airway passage, at the junction of the hard and soft palates, at the lever of the tip of the epiglottis, at the glottis, and the trachea at the level of the seventh vertical vertebra (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This created 2 curves, one that represents the oro-pharyngeal airway (curving toward the right) and one that represents the pharyngo-glotto-tracheal airway (curving toward the left). A line was drawn at the point where the two curves met and the angle formed by this line and the horizontal one was calculated (<span class="elsevierStyleItalic">α</span> angle). In addition, we measured the area between the first curve and a straight line that was drawn from the tip of the top front incisors to the middle of the glottis (representing the line of sight). The data from the two position groups were compared descriptively.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The results of the measurements of <span class="elsevierStyleItalic">α</span> angle and area under the line of sight are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. These suggest that smaller angles and areas are obtained with the sniffing position as compared to the interscapular support with hyperextension position.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">To our knowledge, the comparison between the sniffing and interscapular support with hyperextension positions had not been previously reported in the literature. In recent years, different studies have compared the sniffing position with other positions of the head and neck with apparently conflicting results.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7,8</span></a> The sniffing position has not been found to be superior to the simple extension of the neck during direct laryngoscopy in patients requiring elective surgery.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> However, differences have been found when approaching obese patients and those with limited neck movement. In one study of obese patients requiring bariatric surgery the ramped position had a better performance than the sniffing position.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, the use of an interscapular support with hyperextension position increases objective measures related to airway configuration. While these increases are not desirable for subjects without risk factors for difficult airway, it could provide an alternative approach for the management of the airway of obese patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding disclosure</span><p id="par0045" class="elsevierStylePara elsevierViewall">This study was carried out with funds of <span class="elsevierStyleGrantSponsor" id="gs0005">the Departments of Anesthesiology and Magnetic Resonance Imaging, Hospital de San Jose, Bogota</span>.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding disclosure" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:2 [ "identificador" => "xack83339" "titulo" => "Acknowledgments" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 797 "Ancho" => 1754 "Tamanyo" => 188614 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging scans of a single volunteer. Panel A shows the interscapular support with hyperextension position and Panel B shows the sniffing position. The closed polygons depict the area between the oro-pharyngeal airway and the line of site (A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>43.60<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>, B<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>37.90<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>). The intersection between a horizontal line and a line drawn at the point where the two curves intersect, define the angle <span class="elsevierStyleItalic">α</span> (A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>33.03°, B<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>5.97°).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volunteer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">α</span> angle (°)</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Area (cm<span class="elsevierStyleSup">2</span>)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sniffing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Hyperextension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Sniffing \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Hyperextension \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.79 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43.60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.64 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab505258.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Measurement results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aids to tracheal intubation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S. 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Dobson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/EJA.0b013e32833944a6" "Revista" => array:5 [ "tituloSerie" => "Eur J Anaesthesiol" "fecha" => "2010" "volumen" => "27" "paginaInicial" => "921" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20498607" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Endotracheal anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "I. Magill" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Surg" "fecha" => "1936" "volumen" => "34" "paginaInicial" => "450" "paginaFinal" => "455" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Head and neck position for direct laryngoscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. El-Orbany" 1 => "H. Woehlck" 2 => "M.R. Salem" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0b013e31821c7e9c" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2011" "volumen" => "113" "paginaInicial" => "103" "paginaFinal" => "109" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21596871" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laryngoscopy force in the sniffing position compared to the extension–extension position" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Lee" 1 => "W.M. Weightman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.2008.05492.x" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2008" "volumen" => "63" "paginaInicial" => "375" "paginaFinal" => "378" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18336487" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Randomized study comparing the sniffing position with simple head extension for laryngoscopic view in elective surgery patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Adnet" 1 => "C. Baillard" 2 => "S.W. Borron" 3 => "C. Denantes" 4 => "L. Lefebvre" 5 => "M. Galinski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2001" "volumen" => "95" "paginaInicial" => "836" "paginaFinal" => "841" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11605921" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "sniff or not to sniff: that is the question" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Khorasani" 1 => "K.D. Candido" 2 => "S. Saatee" 3 => "Ghaleb A.H. To" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2002" "volumen" => "97" "paginaInicial" => "752" "paginaFinal" => "753" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12218552" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Laryngoscopy and morbid obesity: a comparison of the sniff and ramped positions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.S. Collins" 1 => "H.J. Lemmens" 2 => "J.B. Brodsky" 3 => "J.G. Brock-Utne" 4 => "R.M. Levitan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1381/0960892042386869" "Revista" => array:6 [ "tituloSerie" => "Obes Surg" "fecha" => "2004" "volumen" => "14" "paginaInicial" => "1171" "paginaFinal" => "1175" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15527629" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack83339" "titulo" => "Acknowledgments" "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">We would like to honor the work of Astrid A Amezquita, MD, Faculty of Medicine, Fundacion Universitaria de Ciencias de la Salud, Bogota, Colombia, who was part of the research team and who died during the course of this study. She participated in the design and analysis of this study, therefore she is considered as a coauthor.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000003800000005/v1_201405230944/S0210569113001307/v1_201405230944/en/main.assets" "Apartado" => array:4 [ "identificador" => "24372" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas Científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000003800000005/v1_201405230944/S0210569113001307/v1_201405230944/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569113001307?idApp=WMIE" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 10 | 22 |
| 2024 Octubre | 94 | 62 | 156 |
| 2024 Septiembre | 84 | 40 | 124 |
| 2024 Agosto | 108 | 43 | 151 |
| 2024 Julio | 84 | 30 | 114 |
| 2024 Junio | 94 | 45 | 139 |
| 2024 Mayo | 84 | 56 | 140 |
| 2024 Abril | 105 | 43 | 148 |
| 2024 Marzo | 94 | 38 | 132 |
| 2024 Febrero | 93 | 63 | 156 |
| 2024 Enero | 113 | 36 | 149 |
| 2023 Diciembre | 87 | 35 | 122 |
| 2023 Noviembre | 89 | 51 | 140 |
| 2023 Octubre | 89 | 66 | 155 |
| 2023 Septiembre | 89 | 46 | 135 |
| 2023 Agosto | 61 | 31 | 92 |
| 2023 Julio | 97 | 36 | 133 |
| 2023 Junio | 97 | 18 | 115 |
| 2023 Mayo | 89 | 42 | 131 |
| 2023 Abril | 70 | 28 | 98 |
| 2023 Marzo | 122 | 43 | 165 |
| 2023 Febrero | 125 | 32 | 157 |
| 2023 Enero | 116 | 29 | 145 |
| 2022 Diciembre | 115 | 44 | 159 |
| 2022 Noviembre | 119 | 55 | 174 |
| 2022 Octubre | 115 | 34 | 149 |
| 2022 Septiembre | 90 | 51 | 141 |
| 2022 Agosto | 133 | 42 | 175 |
| 2022 Julio | 143 | 35 | 178 |
| 2022 Junio | 75 | 31 | 106 |
| 2022 Mayo | 91 | 54 | 145 |
| 2022 Abril | 95 | 57 | 152 |
| 2022 Marzo | 121 | 77 | 198 |
| 2022 Febrero | 126 | 38 | 164 |
| 2022 Enero | 140 | 41 | 181 |
| 2021 Diciembre | 132 | 62 | 194 |
| 2021 Noviembre | 113 | 43 | 156 |
| 2021 Octubre | 162 | 79 | 241 |
| 2021 Septiembre | 119 | 55 | 174 |
| 2021 Agosto | 92 | 52 | 144 |
| 2021 Julio | 54 | 33 | 87 |
| 2021 Junio | 86 | 34 | 120 |
| 2021 Mayo | 98 | 63 | 161 |
| 2021 Abril | 192 | 122 | 314 |
| 2021 Marzo | 151 | 44 | 195 |
| 2021 Febrero | 107 | 41 | 148 |
| 2021 Enero | 107 | 23 | 130 |
| 2020 Diciembre | 86 | 27 | 113 |
| 2020 Noviembre | 80 | 36 | 116 |
| 2020 Octubre | 80 | 24 | 104 |
| 2020 Septiembre | 69 | 20 | 89 |
| 2020 Agosto | 67 | 20 | 87 |
| 2020 Julio | 75 | 25 | 100 |
| 2020 Junio | 62 | 9 | 71 |
| 2020 Mayo | 67 | 18 | 85 |
| 2020 Abril | 45 | 27 | 72 |
| 2020 Marzo | 39 | 12 | 51 |
| 2020 Febrero | 158 | 36 | 194 |
| 2020 Enero | 84 | 28 | 112 |
| 2019 Diciembre | 113 | 29 | 142 |
| 2019 Noviembre | 93 | 29 | 122 |
| 2019 Octubre | 86 | 33 | 119 |
| 2019 Septiembre | 83 | 38 | 121 |
| 2019 Agosto | 72 | 13 | 85 |
| 2019 Julio | 80 | 29 | 109 |
| 2019 Junio | 97 | 18 | 115 |
| 2019 Mayo | 110 | 37 | 147 |
| 2019 Abril | 82 | 22 | 104 |
| 2019 Marzo | 96 | 38 | 134 |
| 2019 Febrero | 67 | 37 | 104 |
| 2019 Enero | 57 | 33 | 90 |
| 2018 Diciembre | 101 | 63 | 164 |
| 2018 Noviembre | 213 | 50 | 263 |
| 2018 Octubre | 163 | 25 | 188 |
| 2018 Septiembre | 78 | 13 | 91 |
| 2018 Agosto | 56 | 17 | 73 |
| 2018 Julio | 100 | 15 | 115 |
| 2018 Junio | 97 | 14 | 111 |
| 2018 Mayo | 54 | 8 | 62 |
| 2018 Abril | 113 | 12 | 125 |
| 2018 Marzo | 69 | 9 | 78 |
| 2018 Febrero | 73 | 8 | 81 |
| 2018 Enero | 92 | 18 | 110 |
| 2017 Diciembre | 92 | 9 | 101 |
| 2017 Noviembre | 61 | 13 | 74 |
| 2017 Octubre | 71 | 7 | 78 |
| 2017 Septiembre | 54 | 7 | 61 |
| 2017 Agosto | 65 | 10 | 75 |
| 2017 Julio | 53 | 16 | 69 |
| 2017 Junio | 69 | 15 | 84 |
| 2017 Mayo | 111 | 12 | 123 |
| 2017 Abril | 72 | 22 | 94 |
| 2017 Marzo | 94 | 9 | 103 |
| 2017 Febrero | 126 | 17 | 143 |
| 2017 Enero | 43 | 12 | 55 |
| 2016 Diciembre | 49 | 8 | 57 |
| 2016 Noviembre | 93 | 16 | 109 |
| 2016 Octubre | 113 | 20 | 133 |
| 2016 Septiembre | 165 | 9 | 174 |
| 2016 Agosto | 34 | 3 | 37 |
| 2016 Julio | 28 | 13 | 41 |
| 2016 Febrero | 1 | 0 | 1 |
| 2015 Diciembre | 2 | 0 | 2 |
| 2015 Septiembre | 0 | 14 | 14 |
| 2014 Diciembre | 1 | 0 | 1 |
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