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Lesson

Ramping the Obese Airway

11 min Airway & Breathing Skip to quiz

Objective: Build a head-elevated laryngoscopy position so the ear, sternal notch, and glottis line up in a high-BMI patient instead of fighting a flat mattress.

Why This Is Hard

The neck looks short because the chest is in the way. Crews flatten them “for intubation” and then cannot see. DAS difficult-airway teaching and HELP (head-elevated laryngoscopy position) evidence: ramping improves view and ventilation mechanics. Ear-to-sternal-notch still applies — you just have to build the geometry instead of hoping the mattress does it.

On this truck
  • Blankets, a second mattress, the head of the cot, or the patient sitting up if they can still breathe.
  • Preoxygenate sitting or ramped. Laying a high-BMI patient flat is an apnea plan.
  • If you must look: ramp first, then the blade. Do not collect looks on a flat hill.

Street Sequence

  1. Keep them sitting while you can. High-flow oxygen. Two-person BVM if needed — leak is common; jaw thrust and a second set of hands.
  2. Build the ramp: stacked blankets or raise the cot so the external auditory canal is at the sternal notch (HELP / ramp).
  3. Ear-to-sternal-notch check from the side. If the ear is buried in the mattress, you are not ramped.
  4. Then the look, SGA, or the CICO plan. Attempt limits still apply. See the attempt-limits lesson.

Field Rules (Education)

  • HELP / ramp: head and upper torso elevated so the ear aligns with the sternal notch. This is the obese-airway version of ear-to-sternal-notch, not a different religion.
  • Do not flatten first: supine on a thin mattress drops FRC and hides the glottis behind the chest.
  • BVM is harder too: two hands on the mask, one person squeezing, airway adjuncts. A leak is a position problem until proven otherwise.
  • SGA may be the win: a seated or ramped SGA that oxygenates beats a pretty view you cannot pass on a flat cot.
Say out loud
  • Ramping — ear to sternal notch
  • Not flattening a high-BMI airway
  • Two-person bag if we bag
  • Look number __ after the ramp is built

Field Pitfalls

  • Laying them flat “so I can intubate” and then losing the sat.
  • One thin pillow that does not change the ear-to-notch line.
  • Three DL attempts before anyone built a ramp.

Practice

60-second drill

Partner: BMI high, sat 90% sitting, crew wants them flat for VL. First 20 seconds. Then: they are already flat, ear buried. What do you build before the next look?

Related: Ear-to-Sternal-Notch Positioning, Airway Attempt Limits.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.

1. For a high-BMI patient who still has a pulse, the first positioning move is:
2. HELP / ramp position means:
3. Flattening a high-BMI patient on a thin mattress typically:
4. If the ear is still buried in the mattress:
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