Bed Up Head Elevated Positioning for Airway Management

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  • Great post !

    I think this is a very interesting proposal, in fact I always tell my students that when the patient has difficulty in oxygenation, let the patient is sitting, to improve oxygenation and reduce anxiety.

    I think it’s a technique that should definitely be practiced before using it in real life, but I have a concern for people of short stature, this technique could be a problem when making laryngoscopy? Should they, prefer to perform intubation face to face?

    I say this because the size in Colombia regarding stretchers, and sometimes is a problem for people of short stature (<150 cm).

    Let me know!


    @juanpaesculapio / @UrgenciasCol

    Viva la #FOAMed !

    • Anand Swaminathan, MD says:

      Juan – great point regarding height. I’ve actually had some of my smaller stature residents use a stool to get up into position.

  • James DuCanto, M.D. says:

    Nicely done guys, placing the bed in a small amount of T-Burg is a good touch, and should the endoscopist find that they can’t get over the top of the airway adequately during endoscopy, further T-Burg can remedy the situation.

    • Anand Swaminathan, MD says:

      Jim – Thanks for your comments. Have been doing this exclusively recently with great results. Hopefully, this short video will empower others to do so.

  • sasha says:

    i accidentally used a similar technique about 3 months ago (more just a marked reverse trendelenberg rather than just the head elevated) it wasnt really til after the tube that i realized he was so angled (crashing, vomit everywhere, very hectic tube w not much time to get everything perfect beforehand) – – but once i realized that i had had a much more easy time intubating the guy than i had anticipated given all that chaos, it dawned on me maybe the angle was why, so i had been trying reverse trendelenberging people since, but everyone in the room looks at me like im crazy each time, so half the time i end up just laying them back flat and “normal” to appease everyone else. THANK YOU SO MUCH for this article ! now i have ammunition to incorporate what i really think is a superior method !!

  • Carolyn says:

    Great video! I’m adding your photo to our Airway Basics this year. I also noticed your monitor running Epic in the background…. do you have an airway procedure template that uses a safety pre-paralysis checklist? Having reviewed cases where some preparation elements were not optimized (like positioning) we are seeking such an electronic EMR decision support checklist. Any suggestions?

    Thanks for your great podcast as well.

  • Misbah says:

    Hey Anand,
    Could u please email or leave the link of the Anaesthesia Literature supporting this position?
    Would be interesting to go through that.

  • Wes Kyle says:

    Excellent post. A point in particular worth discussing is that the towels should be placed behind the occiput of the head, not the neck or the shoulder, in order to achieve ideal “sniffing” position. Placing your support only behind the base of the neck or shoulders instead worsens the laryngeal axis alignment (or “two-curve” straightening theory) by creating more of an acute angle between oral and laryngeal axis by loss of cervical flexion. Too often we see many providers attempting to achieve airway positioning by placing towels solely behind the shoulders or neck and letting the head fall against the bed which often results in cervical extension which may make laryngoscopy more difficult. This may stem from confusion with patient “ramping” and “sniffing position” as being seen as the same maneuver. Instead they’re two separate maneuvers, each optimizing aspects of airway management independently, that need to be done together to achieve optimal patient positioning. Part of the confusion (was for me at least initially) is that the pictures from the anesthesia literature show the use of 20+ towels to ramp patients into a semi-fowler position only because the OR tables aren’t designed to sit the patient up like ER stretchers. Simply pulling the head of the bed up as you show in the video provides the same benefits of ramping and is far easier. Towels then placed behind the occiput together with tilting the head into atlanto-occipital extension (face in plane with ceiling) will additionally provide the numerous airway advantages of “sniffing”. Thanks for all the great FOAM content.

    • Anand Swaminathan, MD says:

      Thanks for your thoughtful response. Positioning with towels etc will be patient specific as we attempt to achieve ear-to-sternal notch (not a big fan of “sniffing position” as I think it’s less descriptive). Agree, though, that occipital bolster is often required.

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