How are patients positioned for rapid sequence intubation (RSI)?

Updated: Apr 07, 2020
  • Author: Keith A Lafferty, MD; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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In cases of trauma in which cervical spine injury is suspected and not yet ruled out, intubation must be performed without movement of the head. Immobilization is best provided by an experienced assistant. In cases in which cervical injury is not a concern, proper head positioning greatly improves visualization.

In the neutral position, the oral, pharyngeal, and laryngeal axes are not aligned to permit adequate visualization of the glottic opening (see images below).

Proper alignment of the axes for tracheal intubati Proper alignment of the axes for tracheal intubation.
Three-axis theory. OA is oral axis, PA is pharynge Three-axis theory. OA is oral axis, PA is pharyngeal axis, and LA is laryngeal axis. Used with permission from Springer Publishing Company.

Place the patient in the sniffing position for adequate visualization; flex the neck and extend the head. This position helps to align the axes and facilitates visualization of the glottic opening.

Studies have shown that simple head extension alone (without neck flexion) was as effective as the sniffing position in facilitating endotracheal intubation. [46]

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