Emergent endotracheal intubation has risks of complications including hypoxia, pulmonary aspiration, and prolonged time to intubation. Previous studies from the anesthesiology literature suggests that bed-up head-elevated (BUHE) positioning is associated with improved glottic views and prolonged apnea time. Using this positioning method could lead to decreased complication rates with emergent intubation.

Clinical Question

Is a head-elevated patient position associated with decreased complication rates in emergent tracheal intubation in the ward and intensive care unit?


Patients >18 years old requiring emergent endotracheal intubation


BUHE patient positioning at 30 degrees incline (see image below)


Supine patient positioning


(Primary): Occurrence of a composite of any intubation-related complication (difficult intubation, hypoxemia, esophageal intubation, or pulmonary aspiration)


Multicenter, retrospective observational clinical trial. Participants and clinicians were unblinded.


Patients < 18 years old, patients in cardiopulmonary arrest, intubations in the ER, OR, or PACU, intubations performed with video laryngoscopy or fiberoptic endoscopy. If patients were reintubated during their hospital stay only initial intubations were included.

Primary Results

  • Bed-Up-Head-Elevated Positioning

    Bed-Up-Head-Elevated Positioning

    1665 intubations examined over 18 months in 2 hospitals

  • 1137 intubations excluded (51 involving patients younger than 18, 266 not direct laryngoscopy, 395 performed by EM, 84 performed during CPR, 10 using other airway procedure, 331 due to incomplete charting)
  • 528 intubations included in this analysis: 214 patients included in standard group & 214 in modified group
  • No significant differences in baseline characteristics (including gender, age, presenting vital signs, and cardiac/medical history)

Critical Findings:

  • Primary outcome (> 1 intubation related complication)
    • Supine position: 76/336 (22.6%)
    • BUHE position: 18/192 (9.3%)
  • BUHE position associated with significantly lower odds of reaching primary endpoint.
    • OR 0.42; 95% CI 0.23-0.77 p=0.005)
    • After adjusting for BMI & MACOCHA (predicted difficult intubation) score
  • BUHE position was more commonly performed by senior intubators (>1 year of anesthesiology experience) compared to supine position (93% vs 66%, p<0.0001)
  • BUHE position was performed on patients with MACOCHA score >3 in significantly lower number of patients than with supine position (8% vs 19%)


  • Large, multicenter study
  • Study asked a clear, clinically relevant question


  • Excluded ED intubations limiting applicability to ED patients
  • Retrospective, non-randomized nature yielded inequalities in baseline characteristics (training level of intubator, MACOCHA score)
  • Subjective to recall/collector bias
  • Uncertain degree of patient benefit (unclear how intubation complications translates to length of stay, mortality, etc.)

Author's Conclusions

“Placing patients in a back-up head-elevated position, compared with supine
position, during emergency tracheal intubation was associated with a reduced odds of airway related complications.”

Our Conclusions

There is evidence that BUHE patient positioning may be associated with significantly decreased rates of intubation-related complications during emergent endotracheal intubation in the ward or intensive care unit. A randomized control trial would be needed to suggest clear causal association, but it seems reasonable to use this positioning when not medically contraindicated.

Potential Impact To Current Practice

BUHE position shows promise in reducing adverse events during emergent intubation. If these results are echoed in prospective studies including ED patients, this could lead to a paradigm shift in positioning for RSI.

Bottom Line

This retrospective, observational study demonstrated a lower odds of intubation-related complications in patients placed in the BUHE position for emergent intubation.

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