Between Issues

Patient positioning is 90% of the airway management battle. “How goes your battle?”

September 12, 2022

James M. Gayes, MD

The 2022 ASA Difficult Airway Algorithm reviews expert opinions and new intubating devices. However, as in the 2012 Guidelines, little is mentioned of the value of patient head/neck positioning in difficult airway management. Elevation of the head/neck/upper torso improves spontaneous and controlled ventilation and laryngoscopy views leading to improved airway maintenance. Pre-planned patient positioning in conjunction with an intubating device can improve airway management and intubation success.

Anesthesia Patient PositioningTen years ago, in a Letter addressed to the Editor of the American Society of Anesthesiologists Newsletter, I queried why head position was not mentioned as a preplanned strategy in the 2012 ASA Difficult Airway Guidelines?1,2 I further noted that pre-cognition of head position is essential and should not be considered mundane or overlooked in the shadow of new intubating devices. In response, the ASA Committee on Standards and Practice Parameters for Difficult Airway Management replied that they regarded my comments as valuable and important and would be recorded by their analysts, and carefully reviewed and considered during the next update process.1 Fast forward to the 2022 Guidelines and my original question regarding the lack of emphasis and value placed on patient head/neck positioning remains relevant.3

Placing the obese surgical patient in the head elevated laryngoscopy position (HELP) improves spontaneous and controlled ventilation. It also promotes airway axis alignment resulting in better laryngoscopy views that contribute to first-pass intubation.4-6 Upper-body elevation increases the dimensions of the upper airway by changing direction of gravity on the upper airway soft tissues and decreases the upward diaphragmatic push by abdominal adiposity when lying supine.5-7 Head elevation during emergency tracheal intubation also reduces the incidence of airway-related complications.4

A recent 2022 Anesthesia Patient Safety Foundation Update placed an emphasis on the time sensitive nature for hypoxemia.8 The head-elevated position achieves substantially higher oxygen tensions, allowing for a clinically significant increase in the desaturation safety duration. This increased time of higher oxygen tension avoids the deleterious effects of hypoxia and provides a margin of safety during intubation. The potential for difficult airway management is not always obvious and cannot always be predicted in advance.9 To be optimally prepared for airway management, airway devices should be within the immediate vicinity of the clinician given that airway difficulties must be managed within seconds before adverse outcomes occur. A pre-thought-out plan for patient positioning prior to laryngoscopy, thus becomes an immediately available “tool” for the clinician.

Newer intubating devices do not alter patient position. Any head, neck, and upper torso position the clinician judges as beneficial in airway management should be viewed as synergistic with intubating devices, improving their effectiveness. Some anesthesia providers feel having a video-laryngoscope diminishes the usefulness of pre-positioning the obese patient. This is a misconception since favorable positioning will facilitate all methods of airway management (mask ventilation, direct laryngoscopy, video-laryngoscopy, laryngeal mask airway, etc.).10-12 Forethought given to head and neck position and the use of an intubating device should not be considered an either/or scenario. Airway “tools” and patient positioning work in conjunction to promote successful first-pass intubation.

The 2022 Guidelines briefly mention positioning optimization in a footnote.3 The value of head and neck position should be a recognized Standard in the management of difficult airways and have equal emphasis as intubating devices. Even with the best equipment and technology, simple strategies, such as optimizing head/neck positioning can lead to high-yield results. This means using all the “tools” in our “toolbox” to maximize quality and patient safety. In my clinical experience, patient positioning is 90% of the battle in providing a pre-planned approach to airway management.


James M. Gayes, MD
Department of Anesthesiology
Abbott Northwestern Hospital
Minneapolis, Minnesota

James M. Gayes, MD is the founder of OPAD Airway Inc., a start-up medical device company. Dr. Gayes is co-inventor on patents covering an inflatable patient adjustment device and has equity in the company but does not receive any personal or professional financial renumeration. The company has no commercial product.


  1. Gayes, JM: Proper Head Position: Let’s not forget who brought us to the dance. American Society of Anesthesiologists Newsletter. 77:11, 60-61, November 2013.
  2. Updated by the Committee on Standards and Practice Parameters, Jeffrey L. Apfelbaum, Carin A. Hagberg, Robert A. Caplan, Casey D. Blitt, Richard T. Connis, David G. Nickinovich, Carin A. Hagberg, The previous update was developed by the American Society of Anesthesiologists Task Force on Difficult Airway Management, Robert A. Caplan, Jonathan L. Benumof, Frederic A. Berry, Casey D. Blitt, Robert H. Bode, Frederick W. Cheney, Richard T. Connis, Orin F. Guidry, David G. Nickinovich, Andranik Ovassapian; Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118:251–270.
  3. Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O’Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung; 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022.
  4. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-elevated patient positioning decreases complications of emergent tracheal intubation in the ward and intensive care unit. Anesth Analg. 2016;122(4):1101-7. PMID: 26866753.
  5. Levitan RM, Mechem CC, Ochroch EA, Hollander, JE. Head elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003; 41:322-30.
  6. Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94(3):732-6. PMID: 11867407.
  7. Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, Laurie CP. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology 2005; 102:1110-5. PMID: 15915022.
  8. Fiadjoe JE, Mercier D. Anesthesia Patient Safety Foundation update: 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. APSF Newsletter. 2022; 37:47–53. 2022.
  9. Nørskov AK. Preoperative airway assessment – experience gained from a multicenter cluster randomized trial and the Danish Anesthesia Database. Dan Med J. 2016 May;63(5): B5241. PMID: 27127020.
  10. Kim EH, Lee JH, Song Effect of head position on laryngeal visualization with the McGrath MAC video laryngoscope in pediatric patients: A randomized controlled trial. Eur J Anaesthesiol 2016 Jul;33(7):528-34. PMID: 26986776.
  11. Pournajafian A, Pokhtabnk MA, Ghodrathy M. Success rate of airway devices insertion: laryngeal mask airway versus supraglottic gel device. Anesthesiology and Pain Medicine, 29 Mar 2015, 5(2): Corpus ID: 9999503.
  12. Ramachandran KS, Mathis MR, Tremper KK, Shanks AM, Kheterpal S. Predictors and Clinical Outcomes from Failed Laryngeal Mask Airway Unique: A Study of 15,795 PatientsPerioperative Medicine. June 2012 Volume 116, Issue 6, June 2012. Anesthesiology 2012; 116:1217–1226.