Ramped Position Not Superior to Sniffing Position for Intubating Critical Care Patients

Richard L. Byyny, MD, MSc, FACEP


In this study of intensive care unit patients, the ramped position did not reduce rates of desaturation, and it increased the difficulty of intubation.


These authors performed a multicenter randomized trial to compare the ramped versus the sniffing position for intubating intensive care unit (ICU) patients. A total of 260 adult patients at four U.S. tertiary care center ICUs were assigned to either have the head of the bed elevated to 25 degrees (ramped position) or folded blankets or towels placed under the patient’s head and neck to elevate and extend only the head (sniffing position; the most commonly used position).


Sepsis, altered mental status, and pneumonia were the most common indications for intubation. The median lowest pulse oxygen saturation was similar in the sniffing position and ramped position groups (92% and 93%). However, the ramped position group had significantly worse operator-reported laryngoscopic views, higher rate of second laryngoscopy attempts, and more need for use of a bougie or secondary laryngoscope blade.


In previous studies in the operating room environment, use of the ramped position decreased rates of desaturation and increased rates of successful intubation. However, it is clear that the patient population in acute care settings is much different, as are the indications for intubation. This study calls into question whether providers in acute care settings should adopt the ramped position. I would advocate for continuing to place the patient in the position you feel would optimize your success.


Semler MW et al. A multicenter, randomized trial of ramped position versus sniffing position during endotracheal intubation of critically ill adults. Chest 2017 May 6; [e-pub]. (http://dx.doi.org/10.1016/j.chest.2017.03.061)


Copyright © 2017. Massachusetts Medical Society. All rights reserved.