(Last Updated On: February 6, 2017)

We continue on with the series with Knowledge Bomb #9. The purpose and motivation for this series is outlined in the first entry. This entry we discuss a different technique for intubation of patients.


Intubation is a popular topic in emergency medicine and everyone has an opinion on the best technique. Video laryngoscopy only? First attempt with a bougie? Use of apneic oxygenation? Succinylcholine or Rocuronium?

These topics have been discussed ad nauseam, but what about patient positioning? Should the patient be supine or instead should we be intubating with the head of the bed elevated? This is a topic that receives little attention, and the majority of intubations in the emergency department are performed with the patient supine. However, I almost exclusively intubate with the head up. This receives quizzical looks from attendings and nursing staff alike, and I have even had a respiratory therapist drop the bed supine right as I was going to insert the laryngoscope. Since head of bed elevated for intubation is not common in the ED, I wondered if my practice actually results in benefit to the patient?


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 Apr;122(4):1101-7. doi: 10.1213. PMID 26866753

Study Design

Retrospective study of 528 patients at the University of Washington that were intubated by either an anesthesia resident or attending, or CRNA. They compared head of bed elevation (defined as ≥ 30 degrees) to supine positioning. They included all adults intubated outside of the OR/PACU and excluded those intubated in the emergency department, patients in cardiac arrest, intubations that the first attempt was with video. The primary endpoint was any intubation related complication.


Patients had a significantly different rate of intubation related complications between those intubated in the supine position compared with head of bed elevated position with at least one complication in 22.6% and 9.3%, respectively, with hypoxia (SpO2 < 90%) being most common. When controlled for various factors; head of bed elevated was associated with significant lower odds of reaching primary endpoint  (odds ratio = 0.42; 95% CI, 0.23–0.77; P = 0.005).


This paper further validates that intubation with the head of bed elevated (>30 degrees) is safe and may even lead to improved patient outcomes. It adds additional data to numerous other studies that demonstrate other benefits to head of bed elevated intubation, such as increased non-hypoxic apneic time and improved glottic views.1-6 After reading this article I plan to continue intubating in this position without relative contraindications (trauma, cardiac arrest) and will encourage others to try this technique.


  • Position your patient with the top of their head flush with the top of the bed, and place ear to sternal notch as per usual practice.
  • Raise head of bed to 30 degrees, enjoy an improved view and decreased complications



Dr. Evan Robinson is a current PGY2 at UIC’s EM Program with a strong interest in ICU. Follow him on twitter @EM_EvanRobinson.


Click to Read Attending Response - Dr. Eric Krueger


A big thanks to Dr. Robinson for highlighting an interesting variation on intubation positioning that is not commonly seen in the Emergency Department; I’ve never once seen it used in medical school, residency, nor as an attending. As with any procedure, be it central access, procedural sedation, joint reduction, or intubation, it is important to become comfortable with many different techniques to fit each individual patient and situation. The authors shed additional light on another method of positioning to have in our arsenals.
However, this article can hardly be considered practice changing to emergency physicians. While it seems that heads-up intubation is likely safe, it falls short of providing evidence beyond that. To say nothing of the exclusion of ED patients, this study was a retrospective look at outcomes of a procedure in which the operator used whichever technique he or she felt most appropriate for the patient. This variability makes it nearly impossible to draw and hard conclusions. The study design is a flaw that is hard to overcome.

Dr. Eric Krueger is an Attending physician at Advocate Lutheran General Hospital – one of the hospital sites where UIC residents rotate. He is an active contributor to browncoatnation.com as producer and writer of the Inconceivable series.



  1. Lane S, Saunders D, Scho eld A, Padmanabhan R, Hildreth A, Laws D. A prospective, randomised controlled trial comparing the efficacy of pre-oxygenation in the 20 degrees head-up vs supine position. Anaesthesia 2005;60:1064–7
  2. Ramkumar V, Umesh G, Philip FA. Preoxygenation with 20° head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth 2011;25:189–94
  3. Altermatt FR, Muñoz HR, Del no AE, Cortínez LI. Pre- oxygenation in the obese patient: effects of position on tolerance to apnoea. Br J Anaesth 2005;95:706–9
  4. Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, Laurie CP, O’Brien PE. Preoxygenation is more effective in the 25 degrees head-up position than in the supine posi- tion in severely obese patients: a randomized controlled study. Anesthesiology 2005;102:1110–5
  5. Boyce JR, Ness T, Castroman P, Gleysteen JJ. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient. Obes Surg 2003;13:4–9
  6. Lee BJ, Kang JM, Kim DO. Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Br J Anaesth 2007;99:581–6