Gravity is your friend

Why are we still laying patients flat to intubate?

Intubating a patient in a low semi-fowlers position (head of bed 30-45 degrees)Semifowlers makes intubating much easier for several reasons.  Gravity pulls intestinal contents away from the thorax, making it easier to bag a patient and helps pull extra tissue away from the airway, since, let’s face it, some of our patients have a little extra tissue around the airway.   Stomach contents don’t join the party as easily, especially in those who made the mandatory stop at Taco Bell® on the way to the hospital though I still advise cricoid pressure.  The airway is in much better position and is easier to visualize.  Also, semi-fowler positioning relieves arm strain on the practitioner because the airway is attached to a bowling ball.  Much less force is required to just pull down the jaw than to lift the whole head.  As an added bonus, it is kinder to your back- no stooping required.

The next time you intubate, consider using semi-fowlers positioning, if you aren’t already.  Remember- gravity is your friend!


  1. #1 by Dr. J - September 19th, 2010 at 20:49

    I sometimes wonder if we subconsciously like the mystique of the difficulty of intubation. A hundred years ago Miller and Macintosh invented some airway tools and ever since then every single advance that has made the airway easier to manage has been referred to as a back up airway.
    The current best set of tools is probably the video laryngoscope (as a first look, not a rescue device), possibly used with a bougie, and the intubating LMA. Sure I can intubate most people most of the time with old tools, but then again I can put a blind central line in most of the time too and I didn’t hesitate to move on from that to US guided once it proved safer and easier.
    I am always puzzled by this topic, we intubate people in the worst position (I think you could also make a good argument for Trendellenburg but flat is definitely a bad position) with the worst technology we have. I admit I get teased about my use of rescue techniques for every airway but why not use the best tech I have for every patient?
    My 2 cents..
    Dr. J

  2. #2 by Scott - September 19th, 2010 at 22:12

    Here is a study in support of this:
    Lee BJ, Kang JM, Kim DO (2007)
    Laryngeal exposure during laryngoscopy
    is better in the 25 degrees back-up
    position than in the supine position.
    Br J Anaesth 99:581–586

(will not be published)

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