IS NON-SUPINE POSITIONING PREFERABLE IN PATIENTS REQUIRING INTUBATION IN THE EMERGENCY DEPARTMENT?
Date First Published:
April 22, 2026
Last Updated:
April 22, 2026
Report by:
Gregory Yates, Doctor (Manchester Royal Infirmary)
Search checked by:
Megan Kerr, Doctor
Three-Part Question:
In [adult patients requiring intubation in the ED] is [non-supine positioning] associated with [a higher rate of first-pass intubation?]
Clinical Scenario:
An obese 37-year-old patient is brought to the emergency department (ED) by ambulance after having been found unconscious outside a local nightclub. They are unresponsive on arrival and not protecting their airway. As your team prepares for intubation, you wonder whether the likelihood of first-pass success would be increased with non-supine positioning?
Search Strategy:
1 intubat*.mp.
2 exp rapid sequence intubation/
3 exp endotracheal intubation/
4 1 or 2 or 3
5 position*.mp.
6 pillow*.mp.
7 5 or 6
8 emergency department*.mp.
9 4 and 7 and 8
10 remove duplicates from 9
2 exp rapid sequence intubation/
3 exp endotracheal intubation/
4 1 or 2 or 3
5 position*.mp.
6 pillow*.mp.
7 5 or 6
8 emergency department*.mp.
9 4 and 7 and 8
10 remove duplicates from 9
Search Details:
EMBASE and MEDLINE databases (1946-2026) were searched utilising the Ovid interface and the strategy above utilising keywords and Medical Subject Headings.
Case reports, conference abstracts, review articles, and non-English language papers were removed.
The Google Scholar ‘cited by’ function was then used to find studies that had referenced the papers we identified as relevant in our database searches. Finally, the reference lists of relevant papers were screened for studies missed by our search process.
Case reports, conference abstracts, review articles, and non-English language papers were removed.
The Google Scholar ‘cited by’ function was then used to find studies that had referenced the papers we identified as relevant in our database searches. Finally, the reference lists of relevant papers were screened for studies missed by our search process.
Outcome:
190 papers were identified using our search strategy. 178 were excluded on abstract review as they were not relevant to the three-part question outlined above.
Thirteen studies underwent full text review. Four studies were excluded for use of a duplicate data source. In three studies [1-3] relevant outcomes were not reported in the published manuscript. Corresponding authors were contacted to provide additional data: two did not respond [1-2] and one felt that their study numbers were too low for first-pass success rates to be meaningful [3].
Six papers [4-9] were retained for final analysis: four prospective observational studies and two randomised trials.
Thirteen studies underwent full text review. Four studies were excluded for use of a duplicate data source. In three studies [1-3] relevant outcomes were not reported in the published manuscript. Corresponding authors were contacted to provide additional data: two did not respond [1-2] and one felt that their study numbers were too low for first-pass success rates to be meaningful [3].
Six papers [4-9] were retained for final analysis: four prospective observational studies and two randomised trials.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Feasibility of upright patient positioning and intubation success rates at two academic EDs. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD 2017 USA | N intubations = 231 Male = 48% Mean age = 56 years Mean BMI = 29 Indication for intubation = AMS (52%), respiratory failure (30%), shock (9%) Intubator grade = resident (100%) DL / VL = 79% / 20% Positioning = supine; 0-10o bed head elevation (16%), inclined; 20-40 o bed head elevation (29%), upright; >45 o bed head elevation (54%) | Multi-centre (n=2) prospective observational study | Exclusion of obstetric and trauma patients may limit generalisability of findings to higher-risk intubation scenarios. Preferential use of DL may limit generalisability of findings to centres with protocolised use of VL. Non-consecutive recruitment used, with high amount of attrition (>50%) and incomplete data (28%) Absence of randomisation risks selection bias: patients with anticipated airway difficulty may have been allocated to non-supine intubation |
||
| Multicenter comparison of nonsupine versus supine positioning during intubation in the emergency department: a National Emergency Airway Registry (NEAR) study Stoecklein HH, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown III CA, NEAR Investigators 2019 USA | N intubations = 11,480 Male = 70% Median age = 56 years Obesity = 33% Indication for intubation = trauma (24%) medical (76%) Intubator grade = resident (93%), attending (3.8%), DL / VL = 34% / 66% Positioning = supine (94%), fully upright (1.6%), ramped (3.6%), ramped with C-spine extension (0.4%), ramped with neutral C-spine (0.2%) | Multi-centre (n=25) prospective observational study | High participation in registry data entry (>90%) but no definitions provided to intubators for terms such as “ramped.” Registry outcomes were reported post-intubation by intubators – which may have introduced recall bias. Absence of randomisation risks selection bias: patients with anticipated airway difficulty may have been allocated to non-supine intubation |
||
| First-Pass Success Rates of Endotracheal Intubation Using Ramped versus Supine Positioning in the Emergency Department Chanthawatthanarak S, Tangpaisarn T, Kotruchin P, Phungoen P, Ienghong K, Apiratwarakul K 2020 Thailand | N intubations = 267 Male = 62.5% Mean age = 67 years BMI > 30 = 4.5% Indication for intubation = respiratory failure (52%), cardiac failure (13%), sepsis (11%) Intubator grade = resident (100%) DL / VL = 87% / 13% Positioning = ramped (51%), supine (49%) | Single-centre prospective observational study | Single-centre study conducted in a tertiary care setting – may lack generalisability to a wider body of EM clinicians. Preferential use of DL may limit generalisability of findings to centres with protocolised use of VL. Absence of randomisation risks selection bias: patients with anticipated airway difficulty may have been allocated to non-supine intubation |
||
| Bed tilt and ramp positions are associated with increased first‐pass success of adult endotracheal intubation in the emergency department: A registry study Bennett S, Alkhouri H, Badge H, Long E, Chan T, Vassiliadis J, Fogg T 2023 Australia & NZ | N intubations = 3,708 Obesity = 18.4% Indication for intubation = AMS (28.7%), trauma (18.9%), airway compromise (13%) Intubator grade = resident (83.7%), consultant (15.9%) Positioning = pillow / occipital pad (43.3%), flat (32.8%), ramped/head-up (15.9%), bed tilt (5.3%) | Multi-centre (n=43) prospective observational study | Laryngoscopy modality (DL/VL) not reported. Registry outcomes were reported post-intubation by intubators – which may have introduced recall bias. Absence of randomisation risks selection bias: patients with anticipated airway difficulty may have been allocated to non-supine intubation |
||
| Bed-up-head-elevated Position versus Supine Sniffing Position in Patients Undergoing Rapid Sequence Intubation Using Direct Laryngoscopy in the Emergency Department–A Randomized Controlled Trial Reddy AA, Ayyan SM, Anandhi D, Ganessane E, Amrithanand VT 2024 Apr 1;17(2):58-65 India | N intubations = 136 Male = 50% Median age = 50 years Median weight = 68kg Indication for intubation = AMS (58%), acidosis (17%), respiratory failure (10%), seizure (10%) Intubator grade = resident (100%) DL / VL = 100% / 0% Positioning = bed up head elevated (50%), supine sniffing (50%) | Single-centre randomised trial | Single-centre study conducted in a tertiary care setting – may lack generalisability to a wider body of EM clinicians. Exclusive use of DL may limit generalisability of findings to centres with protocolised use of VL. Exclusion of prior difficult airways, pregnant women, trauma (including burns) and “crash intubations” may limit generalisability of findings to higher-risk intubation scenarios. |
||
| Evaluation of the success rate of the semi-sitting position compared with the supine position in the emergency intubation of traumatic patients Nasr-Esfahani M, Hooshmand AR 2025 Iran | N intubations = 162 Male = 52% Median age = 56 years Median weight = 69kg Positioning = supine (33%), semi-sitting at 25o (33%), semi-sitting at 35o (33%) | Single-centre randomised trial | Restriction of sample to trauma patients may limit generalisability of findings to medical intubation scenarios. Laryngoscopy modality (DL/VL) and intubator experience not reported. Single-centre study may lack generalisability to a wider body of EM clinicians. |
Author Commentary:
Our key results are summarised in Table 1. In a pooled sample of 15,984 ED intubations, non-supine positioning was found to be either non-inferior [5,6,8] or superior [4,7,9] to supine positioning. These findings were present when direct or video laryngoscopy was used. In three studies [4,7,9] a linear relationship was observed between patient angulation and first-pass intubation.
The 2025 Difficult Airway Society (DAS) guidelines describe 30o head-up positioning as optimal for tracheal intubation [10]. However, the studies cited by DAS were conducted in theatre and critical care settings [10]. The findings of our BET review confirm that this recommendation is applicable to ED patients. It is worth adding that inclined positioning provides additional benefits for pre-oxygenation [11].
Ideally, inclined positioning would be adopted for every ED intubation in order to build experience for difficult cases. A comparison can be drawn here to the ‘bougie-first’ approach to intubation [12]. There may be challenges in achieving the desired positioning, given the unavailability of elevating pads (or even pillows) in many EDs. Re-usable devices such as the Oxford HELP® Pillow [13] may be of use here, provided they are readily accessible with other difficult airway equipment.
REFERENCES:
[1] Umana E, Foley J, Grossi I, Deasy C, O’Keeffe F. National Emergency Resuscitation Airway Audit (NERAA): a pilot multicentre analysis of emergency intubations in Irish emergency departments. BMC Emergency Medicine. 2022 May 28;22(1):91.
[2] Sulistio S, Habib H, Mulyana RM, Albar IA. Emergency intubation practices in a tertiary teaching hospital in Jakarta, Indonesia: A prospective observational study. Emergency Medicine Australasia. 2022 Jun;34(3):347-54.
[3] Nikolla DA, Asar I, Dalglish P, Carlson JN. Pilot Study Examining Bed Angles and Heights During Ramped Position Intubation in the Emergency Department. Cureus. 2023 Apr 4;15(4):e37104.
[4] Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Feasibility of upright patient positioning and intubation success rates at two academic EDs. The American journal of emergency medicine. 2017 Jul 1;35(7):986-92.
[5] Stoecklein HH, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown III CA, NEAR Investigators. Multicenter comparison of nonsupine versus supine positioning during intubation in the emergency department: a National Emergency Airway Registry (NEAR) study. Academic Emergency Medicine. 2019 Oct;26(10):1144-51.
[6] Chanthawatthanarak S, Tangpaisarn T, Kotruchin P, Phungoen P, Ienghong K, Apiratwarakul K. First-Pass Success Rates of Endotracheal Intubation Using Ramped versus Supine Positioning in the Emergency Department. Journal of the Medical Association of Thailand. 2020 Jun 2;103.
[7] Bennett S, Alkhouri H, Badge H, Long E, Chan T, Vassiliadis J, Fogg T. Bed tilt and ramp positions are associated with increased first‐pass success of adult endotracheal intubation in the emergency department: A registry study. Emergency Medicine Australasia. 2023 Dec;35(6):983-90.
[8] Reddy AA, Ayyan SM, Anandhi D, Ganessane E, Amrithanand VT. Bed-up-head-elevated Position versus Supine Sniffing Position in Patients Undergoing Rapid Sequence Intubation Using Direct Laryngoscopy in the Emergency Department–A Randomized Controlled Trial. Journal of Emergencies, Trauma, and Shock. 2024 Apr 1;17(2):58-65.
[9] Nasr-Esfahani M, Hooshmand AR. Evaluation of the success rate of the semi-sitting position compared with the supine position in the emergency intubation of traumatic patients. International Journal of Burns and Trauma. 2025 Jun 15;15(3):143.
[10] Ahmad I, El-Boghdadly K, Iliff H, Dua G, Higgs A, Huntington M, Mir F, Nouraei SR, O'Sullivan EP, Patel A, Rivett K. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. British Journal of Anaesthesia. 2025 Nov 7.
[11] Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Annals of emergency medicine. 2012 Mar 1;59(3):165-75.
[12] Barnicle RN, Bracey A, Weingart SD. Managing emergency endotracheal intubation utilizing a bougie. Annals of Emergency Medicine. 2025 Jan 1;85(1):14-20.
[13] Oxenham O, Pairaudeau C, Moody T, Mendonca C. Standard and flexible tip bougie for tracheal intubation using a non‐channelled hyperangulated videolaryngoscope: a randomised comparison. Anaesthesia. 2022 Dec;77(12):1368-75
The 2025 Difficult Airway Society (DAS) guidelines describe 30o head-up positioning as optimal for tracheal intubation [10]. However, the studies cited by DAS were conducted in theatre and critical care settings [10]. The findings of our BET review confirm that this recommendation is applicable to ED patients. It is worth adding that inclined positioning provides additional benefits for pre-oxygenation [11].
Ideally, inclined positioning would be adopted for every ED intubation in order to build experience for difficult cases. A comparison can be drawn here to the ‘bougie-first’ approach to intubation [12]. There may be challenges in achieving the desired positioning, given the unavailability of elevating pads (or even pillows) in many EDs. Re-usable devices such as the Oxford HELP® Pillow [13] may be of use here, provided they are readily accessible with other difficult airway equipment.
REFERENCES:
[1] Umana E, Foley J, Grossi I, Deasy C, O’Keeffe F. National Emergency Resuscitation Airway Audit (NERAA): a pilot multicentre analysis of emergency intubations in Irish emergency departments. BMC Emergency Medicine. 2022 May 28;22(1):91.
[2] Sulistio S, Habib H, Mulyana RM, Albar IA. Emergency intubation practices in a tertiary teaching hospital in Jakarta, Indonesia: A prospective observational study. Emergency Medicine Australasia. 2022 Jun;34(3):347-54.
[3] Nikolla DA, Asar I, Dalglish P, Carlson JN. Pilot Study Examining Bed Angles and Heights During Ramped Position Intubation in the Emergency Department. Cureus. 2023 Apr 4;15(4):e37104.
[4] Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Feasibility of upright patient positioning and intubation success rates at two academic EDs. The American journal of emergency medicine. 2017 Jul 1;35(7):986-92.
[5] Stoecklein HH, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown III CA, NEAR Investigators. Multicenter comparison of nonsupine versus supine positioning during intubation in the emergency department: a National Emergency Airway Registry (NEAR) study. Academic Emergency Medicine. 2019 Oct;26(10):1144-51.
[6] Chanthawatthanarak S, Tangpaisarn T, Kotruchin P, Phungoen P, Ienghong K, Apiratwarakul K. First-Pass Success Rates of Endotracheal Intubation Using Ramped versus Supine Positioning in the Emergency Department. Journal of the Medical Association of Thailand. 2020 Jun 2;103.
[7] Bennett S, Alkhouri H, Badge H, Long E, Chan T, Vassiliadis J, Fogg T. Bed tilt and ramp positions are associated with increased first‐pass success of adult endotracheal intubation in the emergency department: A registry study. Emergency Medicine Australasia. 2023 Dec;35(6):983-90.
[8] Reddy AA, Ayyan SM, Anandhi D, Ganessane E, Amrithanand VT. Bed-up-head-elevated Position versus Supine Sniffing Position in Patients Undergoing Rapid Sequence Intubation Using Direct Laryngoscopy in the Emergency Department–A Randomized Controlled Trial. Journal of Emergencies, Trauma, and Shock. 2024 Apr 1;17(2):58-65.
[9] Nasr-Esfahani M, Hooshmand AR. Evaluation of the success rate of the semi-sitting position compared with the supine position in the emergency intubation of traumatic patients. International Journal of Burns and Trauma. 2025 Jun 15;15(3):143.
[10] Ahmad I, El-Boghdadly K, Iliff H, Dua G, Higgs A, Huntington M, Mir F, Nouraei SR, O'Sullivan EP, Patel A, Rivett K. Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults. British Journal of Anaesthesia. 2025 Nov 7.
[11] Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Annals of emergency medicine. 2012 Mar 1;59(3):165-75.
[12] Barnicle RN, Bracey A, Weingart SD. Managing emergency endotracheal intubation utilizing a bougie. Annals of Emergency Medicine. 2025 Jan 1;85(1):14-20.
[13] Oxenham O, Pairaudeau C, Moody T, Mendonca C. Standard and flexible tip bougie for tracheal intubation using a non‐channelled hyperangulated videolaryngoscope: a randomised comparison. Anaesthesia. 2022 Dec;77(12):1368-75
Bottom Line:
In patients requiring intubation in ED, inclined positioning should be used if the patient does not require C-spine immobilization.
Level of Evidence:
Level 1: Recent well-done systematic review was considered or a study of high quality is available
References:
- Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Feasibility of upright patient positioning and intubation success rates at two academic EDs.
- Stoecklein HH, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown III CA, NEAR Investigators. Multicenter comparison of nonsupine versus supine positioning during intubation in the emergency department: a National Emergency Airway Registry (NEAR) study
- Chanthawatthanarak S, Tangpaisarn T, Kotruchin P, Phungoen P, Ienghong K, Apiratwarakul K. First-Pass Success Rates of Endotracheal Intubation Using Ramped versus Supine Positioning in the Emergency Department
- Bennett S, Alkhouri H, Badge H, Long E, Chan T, Vassiliadis J, Fogg T. Bed tilt and ramp positions are associated with increased first‐pass success of adult endotracheal intubation in the emergency department: A registry study
- Reddy AA, Ayyan SM, Anandhi D, Ganessane E, Amrithanand VT. Bed-up-head-elevated Position versus Supine Sniffing Position in Patients Undergoing Rapid Sequence Intubation Using Direct Laryngoscopy in the Emergency Department–A Randomized Controlled Trial
- Nasr-Esfahani M, Hooshmand AR. Evaluation of the success rate of the semi-sitting position compared with the supine position in the emergency intubation of traumatic patients