Optimising patient positioning
Jan 16, 2025Picture perfect - Optimising patient positioning for adults πΌοΈπ©βοΈπ¨βοΈ
Not all intubations are equal! π€ The key to increasing your chances of successful intubation lies in the prep work πͺπ§. 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 π, increasing the likelihood of airway success!
Theories such as the three-axis alignment π, two-curve β° and three-column theories π are all based around alignment of airway structures to optimise laryngoscopy view and ease of intubation π©Ί. The theories all endorse the “sniffing position” π, which done correctly achieves ear to sternal notch alignment π to achieve optimal positioning for laryngoscopy.
The sniffing position: π€§
π’ Flexion of the neck by approximately 35 degrees π
π’ Face plane extension by approximately 15 degrees βοΈ
Ear to sternal notch alignment: β‘οΈπ²
𦻠Patient’s ear is in line with their sternal notch
πΆπ΅ Dependent on the size of the patient
ποΈ Smaller patients may only need one slim pillow under their head to achieve this
π§π¦± 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 ποΈ
During preoxygenation π¨, a head-up tilt β¬οΈ may be used to help increase functional residual capacity and increase safe apnoea time β±οΈ, but be mindful of the impact this may have during laryngoscopy π¬. Your Anaesthetist may need a step π£ to position themselves high enough during intubation π οΈ, or you may be required to flatten the table for them ποΈ, depending on your patient π©π¦±.
As always – be mindful of factors that can hinder or limit optimal positioning! β οΈ
π§ Elderly patients may have decreased range of movement in their neck π΅
𦴠Patients with conditions affecting the neck such as arthritis, Ankylosing spondylitis, or previous fusion surgery π₯
π¨ Suspected or confirmed head and neck trauma is an immediate contraindication and requires a specialised airway planβ οΈ
Beware of long hair! πβοΈ Hair tied or clipped into a bun or ponytail will hinder neck flexion and make it difficult to perform a head lift π«.
Finally – before you commence Anaesthesia, be sure to step back and admire your handiwork! ππ 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! βοΈ
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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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