Increase Your Intubation Success With Proper Positioning.

Achieving first pass success with any procedure requires proper preparation, and intubation is most certainly no exception.  One of the most important things you can do to improve your intubation success rates is positioning your patient.  Here are a few tips to help you get it right the first time.

The ideal way to position your patient prior to an intubation attempt is with the lower cervical spine slightly flexed, and the upper cervical spine slightly extended.  This is commonly known as the “sniffing position”.  Here’s how to position your patient this way:

1. With your patient lying supine on level ground, place folded towels (or whatever you can find) beneath their head until the external auditory meatus (opening) of the ear is on the same horizontal plane as the manubrium (where the left and right clavicle meet).
2. Position the patients face so that it is parallel to the ground, and extend the neck slightly.  The neck should only be extended until the patient’s chin is the highest point on their body.

And that’s it!  You are now in the prime position to get the best view of the vocal cords.  Below are a few more tips, along with some pictures.

• DO NOT over-extend the patient’s neck–this can actually cause the tongue to obscure your view, and possibly occlude the airway.
• If the patient is obese, more towels or other padding may be required, and a positioning technique called “ramping” (which is pretty much just like it sounds) can be used.
• In small children, padding behind the shoulders only may be the most effective option due to their disproportionately larger heads.  The key is to get their face as close to parallel with the ceiling as possible, just like adults.
• By no means am I suggesting that you should carry a suitcase full of towels on scene with you.  Use your imagination when you need padding (in my most recent intubation, I used some balled up chux pads with great success).  Just remember to be adaptive to your environment.

So that about sums up basic positioning.  There are many excellent (and free) resources available online that cover in great detail, all aspects of airway management, and I highly encourage everyone to take a look at them.  Some of these resources can be found on my links page.

Thanks for reading!  At first, I really wasn’t sure what to make my first post of 2017 about, but I knew I wanted it to be something important.  Pre-intubation positioning is so simple, yet often overlooked, so the choice became quite clear.  Please take a moment to follow my blog via email if you haven’t done so already, to ensure you don’t miss an episode.  I’m working on some great content that I plan to release over the next week, so stay tuned! I hope everyone is having a great 2017 so far!

-Owen

P.S.  The top (featured) image is NOT an example of good airway positioning, I just thought the picture was eye catching.  Also, the photos I used are borrowed from the sites listed below in my references.

References

Holt, LE. The Diseases of Infancy and Childhood. New York, NY: D. Appleton; 1920.

Lawner, B. Avoiding common prehospital errors. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2013.

Sherief, M. Khan. 10 COMMON ‘PROCEDURAL BASICS’ ANAESTHESIOLOGISTS MAY OVERLOOK! ANAESTHESIA TODAY.  [accessed 2017 Jan 4]. http://anaesthesiatoday.blogspot.com/2013_03_01_archive.html