Positioning the head and neck for intubation in the sniffing position can make intubation easy, or extremely hard. Many years ago our operating room administration decided that the bath towels we were using to position the head for intubation were a potential danger for shedding lint. So one night, in their infinite wisdom, the towels were all summarily confiscated and when we arrived the next morning there wasn’t a single towel to be found, ever again. It may be an exaggeration to say that chaos ensued, but it felt like that.
The reason this event is so memorable is that for the next several days our anesthesia providers had trouble intubating. We likened it to an expert golfer who, when suddenly faced with a new set of golf clubs of slightly different weight and length, suddenly has to relearn the game. It made us realize that how we position the head in the sniffing position often sets us up for either an easy or for a more difficult intubation if you don’t realize what’s happening during the positioning.
Optimizing Head Position for Intubation
Let’s start by reviewing the goals of positioning. To orally intubate you need to bring the path from the incisor teeth to the larynx into a straight line. This path has three axes:
-
The 3 axes of the airway with the head in a neutral position
axis of the cavity of the mouth (oral axis)
- axis of the cavity of the pharynx (pharyngeal axis)
- axis of the larynx and trachea (laryngeal axis)
The angle of the axis of the mouth to the larynx is 90°. That of the pharynx to the trachea is obtuse. Aligning them is merely a matter of applied mechanics. You make this alignment by moving the patient’s head and neck into optimal position and then using the laryngoscope blade to make the final adjustment. (Note: Here I am talking about patients without risk of cervical spinal cord injury. Other techniques can be used if you shouldn’t move the patient’s head and neck.) You can intubate in any position, however, placing the patient’s head at the level of the lower tip of your breastbone, or xyphoid process, gives the best mechanical advantage.
The 3 axes of the airway with the head in the sniffing position.
To get the average, non-obese adult patient’s head into this position, we raise the head about 10 cm (4 inches) off the bed by placing a folded sheet or other object under the head. Leave the shoulders on the bed.
This positioning aligns the pharyngeal and laryngeal axes into what we call the sniffing position. The cervical spine is now straight and the patient is in the so-called “sniffing position.” Picture how someone out of breath holds her head: forward and tilted slightly back. We automatically straighten the airway to minimize resistance when we want to move a lot of air easily. Another analogy is picturing the sword swallower. In order to pass the sword without injury down the esophagus, which is parallel to the trachea, everything has to be in as straight a line as possible.
The 3 axes of the airway in the sniffing position with the head extended.
The sniffing position typically places the ear canal level with the anterior shoulder. Once you head is optimally positioned, tilt the head into extension with your right hand to bring all the axes into alignment.
Different Ways to Position The Head In The Sniffing Position for Intubation
You can always use personal strength to lift the head into the air and into the optimal position, and many times in the emergency situation, such as in the field, you may not have much choice. However, it can be very tiring, especially if the intubation attempt is prolonged and your upper body strength is not well developed. It’s easy to loose focus, pivot your wrist and damage teeth. To avoid the need to lift so high, we typically position the head in the sniffing position to bring the axes into alignment without having to lift the head off the bed.
The most common things used to position the head are folded towels, folded sheets, rolled blankets, foam “donuts”, foam headrests, and a helper’s hand. Does it matter what you use? As my anesthesia department discovered that morning so long ago, the density and texture of what you use actually can affect technique.
Folded Towel:
Pros: 1-2 folded towels usually optimal. Soft and easily malleable, allowing quick alteration in shape (mounding or flattening) as needed. Easy to tilt the patient head backward even if the stack of towels is too high because they slide and mold to the shape you need quickly, without having to pull a towel out of the stack.
Cons: Allegedly may shed some minimal lint (potential Operating Room issue).
Folded Sheets:
Pros: Easily available in most settings. Soft and somewhat malleable but not quite as much as towels. Can usually tilt head backward even if too high by shoving the top sheet inward toward the patients shoulders. No lint.
Cons: Not quite as malleable as towels but pretty good. You need a lot more of them because they are thinner which may create a linen supply issue.
Folded Blankets
Pros: Don’t need as many to lift the head because they are thicker.
Cons: Very dense. Hard to change shape if the head position is not optimal. If too high may prevent tilting the head back and impede opening mouth. They also tend to be quite firm and if the patient is going to lie on them for hours, such as in an OR, you should periodically move the head to prevent pressure spots.
Foam Donut and Foam Headrest (e.g. Shea type headrest)
When using a foam “donut” or a Shea foam headrest, the head often sits low in the central hole. It can deceive you into thinking that the head is in the sniffing position when it isn’t. (From Anyone Can Intubate, 5th Ed.)
Pros: Designed to hold the head steady for procedures so head won’t “roll”. Soft cushion which can then be used during the anesthetic to protect the head from pressure points.
Cons: Makes it harder to tilt the head back. It’s also easy to be fooled into thinking head is optimally positioned when it isn’t. The back of head is in the donut hole, often flat on the surface — however from the side the head looks like it is lifted into the sniffing position. . If you are going to use a foam headrest/donut check to see if the patient’s ear canal is level with the sternal notch. If it’s not you may need to add something underneath to lift it higher. Then make sure the patient can still tilt their head back. If they can’t, you won’t be able to see the larynx easily.
Assistant’s Hand
When having an assistant lift the head, the assistant must keep the head steady or the intubator can break teeth. (from Anyone Can Intubate)
Pros: You usually have one immediately available.
Cons: It’s easy for your assistant to accidentally move the head during intubation, which is dangerous for teeth. The most secure way is to have your assistant place his/her closed fist under the head and rest it on the surface (Fig 5-3). If your assistant is providing physical then lift make sure you’re both communicating well. Teeth can be broken if the assistant suddenly shifts the head at the wrong moment.
The Linen Ramp
Using a linen ramp to optimally position a morbidly obese patient into the sniffing position for intubation. Make sure that the patient can still tilt the head back. (/from Anyone Can Intubate 5th Ed.)
If the patient is obese, the anterior-posterior width of his/her chest wall and breast tissue can interfere with laryngoscopy and visualization. Building a shallow ramp by placing folded linen under the shoulders, with the goal of aligning the ear canal with the sternal chest, often improves your ability to open the mouth and see the larynx.
Ramping With The OR Table
Using the OR table to ramp the patient. Raise the back up about 20-30 degrees and then tilt the head section back to extend the neck.
You can, in fact, use the standard OR table to ramp the patient as long as the head rest is on and the patient is positioned on the bed with his back on the back section (as opposed to being rotated on the bed with his back on the leg section).Raise the back section about 20-30 degrees and then tilt the head section back, checking to make sure that the ear canal and the sternal notch are aligned.
If the patient is rotated on the bed you can accomplish the same effect by placing the bed in reverse trendelburg and tilting the head back. The disadvantage of this maneuver is that there is a greater risk of hypotension with the legs down.
The nice thing about using the bed to create the ramp for the OR is:
- You can adjust the degree of ramp easily during the intubation if it’s not optimal
- You don’t have to remove the linen that you used to build the ramp after the patient is intubated if it interferes with surgical positoning. Removing a sizable linen ramp from underneath an anesthetized morbidly obese patient can be difficult.
- You can put the patient back into the ramped position at the end of the case for extubation, thereby being better prepared to reintubate should the patient fail the extubation attempt
- You don’t need a lot of linen to build the ramp
There are many different ways to attain the “sniffing position” for an intubation. Each one has advantages and disadvantages. However, if you don’t take those differences into account, your intubation can be a lot more difficult than it needs to be.
For additional information on positioning for intubation see also:
May The Force Be With You
Christine Whitten MD, Author: Anyone Can Intubate, 5th Edition
Please click the cover to see inside my books at Amazon.com
Hello!
I would like to use your image of the Ramp position in a lecture and possibly in a book chapter. Please let me know how I may get proper permission to do so. Please reply by email neipe@toh.ca
Thanks,
Naveen Eipe,MD
Ottawa, ON
Canada
Please use the illustration.
Thank you!
Just published online here-
https://link.springer.com/article/10.1007%2Fs42399-019-00136-8
May I use this webpage for an in-service for OR staff?
Please do. . Thank you for the compliment
May I use this webpage for a lecture/discussion for residents and at ED department meetings?
Yes, absolutely. sorry for the late reply.
Very nicely done. May I use this page in educating paramedics? I would like to use one or two images in a slide to display during the talk. No other reproduction. Again, very nice educational info.
Sorry I am late responding. You have my permission to use any of my pages and photos for education. Thank you for the compliment.
Great article well written.
Solved my question why I had a diff intub today.
So glad you found it helpful. I find that the majority of time I myself have difficulty, it’s because I didn’t take the time to position properly. Position really is essential.
Thank you. So glad I was able to help.
Dr. Whitten, OPENPediatrics at Boston Children’s Hospital would like to include your ramping illustration in our educational medical video. Videos will be distributed online, worldwide. Can we use the illustration? Thanks so much.
Yes, please feel free to use. Attribution would be nice.
Wonderful! Thanks so much Dr. Whitten. We will be happy to provide attribution.
Hello,do you have. a video ,about intubation in prono posicion?
I don’t, but that that would be an interesting discussion of a rare emergency technique. I will work on that. Thanks for the suggestion.
Hi Dr. Whitten. This is a great overview. Would it be possible to use some of the images for a blog about intubating in the ICU? Happy to credit you.
Please feel free to use with credit.
So sorry to be so late in responding, there was a family emergency. Please feel free to use the images for your blog with attribution.
Hello Dr. Whitten. Thank you for the excellent visual presentation. May I use your material/images in a lecture and potentially an article? Thank you! (of course citing you) 🙂
Absolutely. Thank you for the compliment.
Hello,
I would like to use some of your images in one of my presentation which will be presented to critical care nurses in Quebec. Can I?
Thank you!
Yes, please do. Please use attribution.
Hi can I use your article for school research? If so I ask for a reference
Hello Dr. Whitten!
I am an assistant nurse specializing in operation and anesthesia department. May I use your material/images for my thesis regarding optimal position for intubation?
Thank you in advance.
Yes, please use it with attribution,. Good luck on your thesis.
Dear Dr Whitten,
I work for a small Viennese publisher (https://www.braumueller.at/home) specializing in non-fiction books. Currently, we are preparing the standard manual for paramedics in Austria. We would like to reproduce the images of the ramp positions in our book and ask for your permission to do so. Could you let us have the images in its original size and resolution? Of course exact quotation and attribution is granted.
Details on the project:
title: Das Handbuch für Notfall- und Rettungssanitäter (The Manual for Emergency and Rescue Paramedics)
author: Christoph Redelsteiner
publisher: Braumüller Verlag, Vienna
publication date: January 2020
print run: ca. 3000
publication format: 21,00×29,70 cm
pages: 1000
retail selling price: ca. EUR 54,90
Previous edition: https://www.braumueller.at/t?isbn=9783994000201
Best regards from Vienna, Austria,
Angelika Höritzauer, M.A., B.A.
Öffentlichkeitsarbeit und Vertrieb
————————————————————
Braumüller GmbH
Tel. (+43 1) 319 11 59-14 | Fax (+43 1) 310 28 05
E-Mail: a.hoeritzauer@braumueller.at
Servitengasse 5, 1090 Wien | http://www.braumueller.at
Dear Dr Whitten,
I work for a small Viennese publisher specializing in non-fiction books (https://www.braumueller.at/home). Currently, we are preparing the standard manual for paramedics in Austria.
We would like to reproduce the images of the ramp positioning in our book and ask for your permission to do so. Could you let us have the image in its original size and resolution? Of course exact quotation and attribution is granted.
Details on the project:
title: Das Handbuch für Notfall- und Rettungssanitäter (The Manual for Emergency and Rescue Paramedics)
author: Christoph Redelsteiner
publisher: Braumüller Verlag, Vienna
publication date: January 2020
print run: ca. 3000
publication format: 21,00×29,70 cm
pages: 1000
retail selling price: ca. EUR 54,90
Previous edition: https://www.braumueller.at/t?isbn=9783994000201
Thank you very much in advance.
Best regards from Vienna, Austria,
Angelika Höritzauer
Öffentlichkeitsarbeit und Vertrieb
————————————————————
Braumüller GmbH
Tel. (+43 1) 319 11 59-14 | Fax (+43 1) 310 28 05
E-Mail: a.hoeritzauer@braumueller.at
Servitengasse 5, 1090 Wien | http://www.braumueller.at
Firmenbuch: 321586x | Gerichtsstand: Wien
Dear Dr. Whitten,
I would like to use these images for the standard manual for paramedics in Austria (Das Handbuch für Notfall- und Rettungssanitäter by Christoph Redelsteiner (The Manual for Emergency and Rescue Paramedics). I work for a Viennese publisher specializing in non-fiction books and we are looking for suitable images for the new edition of the book. Could you grant us permission to use them? Of course exact quotation and attribution is granted.
Best regards from Vienna, Austria,
Angelika Höritzauer (Email: praktikant@braumueller.at)
yes indeed. Thank you for the compliment
Dear Sir or Madam,
We are a small Viennese publisher (Braumüller Verlag, Vienna) specializing in non-fiction books. Currently, we are preparing the standard manual for paramedics in Austria (Das Handbuch für Notfall- und Rettungssanitäterin by Christoph Redelsteiner).
For the manual we are looking for images similiar to the ones found on this website, the images we are looking to use are of the person being positioned on the linen ramp and OR table.
We would like to reproduce this image in our book and ask for your permission to do so. Of course exact quotation and attribution is granted.
Thank you very much in advance. We are looking forward to hearing from you,
Best regards from Vienna, Austria,
Angelika Höritzauer
Dear Dr. Whitten,
I am so sorry to disturb you again during the holiday saison. For you too, it must be a very busy time. The issue is that we are looking to collect all the data for our paramedics manual until the end of the year. If you could find the time to consider our inquiry, we would be very grateful.
Thank you for your time and with kind regards from Vienna,
Angelika Höritzauer
I think I already responded to this but just to make sure, you may use the material with attribution. Just making sure I responded to you.
Dr. Whitten,
Thank you for the work you’ve done in developing educational materials! I host a podcast called Depth of Anesthesia in which we investigate evidence behind common practices in anesthesia. I was wondering your thoughts about some of the recent debate and controversy about the three-axis alignment theory and whether the sniffing position is truly the optimal position for viewing the glottic opening.
Thanks!
David
Dear Dr Whitten,
Thank you kindly for this very informative article.
I am the senior editor of a new online perioperative medicine education journal with University College London Press, UK. It is a growing and free access online education journal that utilises multimedia to enhance reader engagement.
I am impressed with a number of your illustrations, particularly the “Ramping with the OR table” drawing. With your permission, may I use it for an article we intend to publish on the website? I will make sure that attribution to the illustration will be made to you. Thank you.
Kind regards,
Anas
Please feel free to use the article and any illustrations with attribution. Thank you for the compliment. Education and patient safety are my primary goals. In case it assists your students, I listed my two books for sale at cost on amazon.com when the pandemic started. My on-line videos are also available for free.
Dr. Whitten, I really enjoyed your site. I am assembling a lecture to teach paramedics and wondering if I might be able to use some of the illustrations showing positioning? I would most certainly provide attribution.
Thank you!
Kyle
Please use the material for your classes. Your students may also like to know my books are available on Amazon at cost (and without profit to me) during the pandemic.
I would really like to use some of your images. I am a paramedic program coordinator at the University of Iowa. I am presenting about airway positioning. Your images are great.
So sorry for the late reply. Please use the images with attribution.
I would love to use your images in a workshop teaching intubation to medical students. Would appreciate your permission.
You may use my images and Videos with attribution in your instruction. Good luck with your lectures.
Thank you for the compliment. You have my permission to use the images and videos with attribution. Good luck with your lectures.
Hi, always come back to this site! Could I possibly use your images of the head and neck positions in my thesis? With accreditation of course. I would be grateful!
Kind regards,
Laura
Yes, of course. Sorry for the late reply. Please use the illustrations
Hi, I would love to use you images of the head and neck positions for my thesis with attribution, would this be ok? Thanks for you content 😊
Kind regards
Laura
Yes, of course. Sorry for the late reply. Please use the illustrations for your thesis with attribution. Good luck
may i use your illustration in the MEMC conference in MALTA 2022 fro my lecture
J gorchynski
Yes, you may use the illustration with attribution.
Yes, of course. Sorry for the late reply. Please use the illustrations for your lecture with attribution