EMS calls ahead for a patient in respiratory extremis.  They are just a few minutes out and your team is calmly putting the resuscitation space together and preparing for intubation.  A question catches you off guard - do you want this patient in a ramped or sniffing position?

Intubation safety (measured by adverse events like hypoxia, hypotension, aspiration, etc.) and intubation efficiency (measured by first pass success and time until successful intubation) are two paramount factors in determining whether an endotracheal intubation practice should be adopted.  Among best practices recommended for safe airway management, having the patient in a “ramped” position (the patient is recumbent with the back of the bed angled at 20-25 degrees and the head extended with the external auditory meatus level with the sternal notch) versus in a “sniffing” position (bed is flat, but the lower C-spine is flexed while the upper C-spine is extended - think of inhaling a delicious aroma over the stove but laying on your back) has been discussed.  A recent meta-analysis showed no difference in first pass success, intubation after two or fewer attempts, glottic view (though VL/DL not specified), and time to secure the airway. Safety outcomes were not reported in the trials the authors evaluated so measures like hypoxia, aspiration, etc. are not commented on.

What does this mean?  First, there is no advocacy for a flat bed without any augmentation of patient positioning.  Second, as with many other airway topics, comfort and skill of the operator are likely more paramount than deciding if the patient is in a ramped or sniffing position.  Third, what is your team comfortable with, used to, and expecting? Respecting team dynamics in airway management is vital to ensure everyone in the room has a shared mental model of the procedure.  Finally, patient factors may be the leading determinant in what position to use in terms of habitus and underlying pathology.

Reference: Okada Y, Nakayama Y, Hashimoto K, Koike K, Watanabe N. Ramped versus sniffing position for tracheal intubation: A systematic review and meta-analysis. Am J Emerg Med. April 2020. doi:10.1016/j.ajem.2020.03.058.