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Lesson

Ramping the Obese Airway

11 min Airway & Breathing Skip to quiz

Objective: Build a ramp so the ear lines up with the sternal notch in a patient with a high body mass index. Do not lay them flat and fight the mattress.

Why this matters

The neck looks short because the chest wall is high and in the way. Crews lay the patient flat for intubation and then cannot see. Ramping, also called the head-elevated laryngoscopy position, raises the head and upper body so the ear lines up with the sternal notch. That line lets the bag move the chest and gives you a chance at the glottis. The mattress will not build it for you.

Verbalize
  • I keep them sitting, or I ramp until the ear canal is level with the sternal notch. I check that line from the side.
  • I do not lay a high body mass index airway flat. Flat drops the air left in the lungs and hides the glottis behind the chest wall.
  • If we bag, we use two people. I do not count a look until the ramp is built.

Clinical sequence

  1. Keep them sitting while you can. Give high-flow oxygen. If you must bag, use two people. Leaks are common. One person uses a jaw thrust and two hands on the mask. The other squeezes. A two-handed jaw-thrust seal beats a one-handed E-C clamp. Use an airway adjunct. Treat a leak as a position problem until you prove it is not.
  2. Build the ramp with blankets, a second mattress, or the head of the stretcher, until the ear canal is level with the sternal notch. If the ear is sunk into the mattress, you are not ramped. One thin pillow does not change that line.
  3. Then take the look, place a supraglottic airway, or move to the cannot-intubate, cannot-oxygenate plan. A seated or ramped supraglottic airway that raises the sat is better than a clear view you cannot pass a tube through on a flat stretcher. Attempt limits still apply. See the attempt-limits lesson.

Teaching points

  • Head-elevated laryngoscopy position is ear-to-sternal-notch for a patient with a high body mass index. It is the same goal, built with padding.
  • Do not take repeated direct-laryngoscopy looks with the chest wall still high and the head flat.

Common errors

  • Laying them flat so you can intubate, then watching the sat fall.
  • Using one thin pillow that does not change the line from the ear to the notch.
  • Taking three direct-laryngoscopy attempts before anyone builds a ramp.

Practice

One-minute check

Partner: high BMI, sat 90% while sitting, and the crew wants them flat for video laryngoscopy. Say what you do in the first 20 seconds. Then: they are already flat, and the ear is sunk in the mattress. 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

Questions drawn only from this lesson. 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 (head-elevated laryngoscopy position) / ramp 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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