Optimising patient positioning

Jan 16, 2025

Picture perfect - Optimising patient positioning for adults πŸ–ΌοΈπŸ‘©‍βš•οΈπŸ‘¨‍βš•οΈ

Not all intubations are equal! πŸ€” The key to increasing your chances of successful intubation lies in the prep work πŸ’ͺπŸ”§. Optimising the positioning of your patient’s head and neck prior to laryngoscopy helps to align structures of the airway and improve line of sight πŸ‘€, increasing the likelihood of airway success! 

Theories such as the three-axis alignment πŸ”„, two-curve ➰ and three-column theories πŸ“ are all based around alignment of airway structures to optimise laryngoscopy view and ease of intubation 🩺. The theories all endorse the “sniffing position” πŸ‘ƒ, which done correctly achieves ear to sternal notch alignment πŸ‘‚ to achieve optimal positioning for laryngoscopy.

The sniffing position: 🀧
🟒 Flexion of the neck by approximately 35 degrees πŸ”„
🟒 Face plane extension by approximately 15 degrees ↗️

Ear to sternal notch alignment: βž‘οΈπŸ”²
🦻 Patient’s ear is in line with their sternal notch
πŸ‘ΆπŸ‘΅ Dependent on the size of the patient
πŸ›οΈ Smaller patients may only need one slim pillow under their head to achieve this
πŸ§‘‍🦱 Larger or obese patients can have large fat pads on their upper back, and require excess pillows or folded-up sheets to achieve adequate ramping and alignment πŸ›οΈ

During preoxygenation πŸ’¨, a head-up tilt ⬆️ may be used to help increase functional residual capacity and increase safe apnoea time ⏱️, but be mindful of the impact this may have during laryngoscopy πŸ”¬. Your Anaesthetist may need a step πŸ‘£ to position themselves high enough during intubation πŸ› οΈ, or you may be required to flatten the table for them πŸ›οΈ, depending on your patient πŸ‘©‍🦱.

As always – be mindful of factors that can hinder or limit optimal positioning! ⚠️

πŸ§“ Elderly patients may have decreased range of movement in their neck πŸ‘΅


🦴 Patients with conditions affecting the neck such as arthritis, Ankylosing spondylitis, or previous fusion surgery πŸ’₯


🚨 Suspected or confirmed head and neck trauma is an immediate contraindication and requires a specialised airway plan⚠️

Beware of long hair! πŸ’‡‍♀️ Hair tied or clipped into a bun or ponytail will hinder neck flexion and make it difficult to perform a head lift 🚫.

Finally – before you commence Anaesthesia, be sure to step back and admire your handiwork! πŸ‘€πŸ‘ There is no point going to the effort of positioning your patient if you don’t then step back and confirm that you’ve done it properly! βœ”οΈ

βœ… Build Knowledge
βœ…Improve Safety 

 

References:

Bradley, P., Chapman, G., Crooke, B., Greenland, K. (2016). Airway Assessment. ANZCA. https://www.anzca.edu.au/getattachment/eff1ab5d-46cf-46db-95ef-5e65ecb88c26/PU-Airway-Assessment-20160916v1

Nickson, C. (2024) Three axis alignment, Two Curve Theory and the Three Column model. LITFL. https://litfl.com/three-axis-alignment-two-curve-theory-and-the-three-column-model/

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