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MAXIM: Most patients with airway/respiratory problems should be positioned for their comfort, not ours.


If mentating normally and physically able, a patient with airway difficulty will assume a position that optimizes their airway patency and gas exchange, usually sitting up and leaning forward. Such patients include those with incomplete airway obstruction, flash pulmonary edema, and massive airway bleeding from oropharyngeal trauma. Unfortunately, during preparation for intubation, such patients often are placed supine prematurely, increasing the patients’ respiratory distress and anxiety, increasing the likelihood of spontaneous emesis and aspiration, and decreasing their ability to handle oropharyngeal bleeding or secretions. In these clinical situations, rethink the desire to immediately place a patient supine for endotracheal intubation. Intubation is accomplished with the patient sitting up, by either:

  1. Altering the intubation technique (see Fig. 22.7); or

  2. Altering the intubator position relative to the patient (see Fig. 22.8).


Intubation Facing the Sitting Patient or “Tomahawk Technique.” Holding the laryngoscope in the right hand and displacing the mandible forward and passage of the tube with the left hand is an alternative position to supine intubation. (Photo contributor: Lawrence B. Stack, MD.)


Intubation Above the Sitting Patient. Standing above a patient and intubating in the conventional manner is an alternative airway management position in a patient who may be difficult to ventilate in the supine position. An assistant may be necessary to hold the patient upright if sedated and/or paralyzed. (Photo contributor: Lawrence B. Stack, MD.)


  1. Keep patients in optimal position for spontaneous ventilation until they are sedated just prior to intubation; then, place them supine.

  2. Consider intubating a patient sitting upright if you feel the supine position will compromise the patient’s ability to be ventilated.

  3. Titrating ketamine in small doses (10 mg every 1-2 minutes) can facilitate awake intubation in a patient sitting upright.

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