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In Response

Khandelwal, Nita MD, MS; Joffe, Aaron M. DO, FCCM

doi: 10.1213/ANE.0000000000001419
Letters to the Editor: Letter to the Editor

Department of Anesthesiology and Pain Medicine, University of Washington and Harborview Medical Center, Seattle, Washington,



We greatly appreciate Dr. El-Orbany’s interest in our article and agree that universal terminology related to airway positioning would be beneficial. Positioning of patients in our cohort would be most consistent with the description by Stept and Safar1 from their 1970 article, “Rapid Induction and Intubation for Prevention of Gastric-Content Aspiration.” Specifically, they were placed “in semisitting, V-position, with trunk elevated about 30 degrees, to counteract regurgitation by gravity, and feet elevated to prevent postural hypotension [with a]…pillow [or towel] under occiput to support the head in the ‘sniffing’ position.” As noted by Dr. El-Orbany, this is graphically represented in our Figure. An important additional point regarding optimal airway positioning is worth emphasizing. In addition to flexion of the cervical spine and head extension, the height to which the head should be elevated in relation to the neck and the rest of the body is not an arbitrary distance, but rather whatever is required to align the external auditory meatus with the sternal notch.2 Although the original figure itself was not explicitly marked to highlight this anatomic relationship, it is clearly stated in the figure legend. A corrected portion of the original figure is included herein to additionally highlight this point (Figure). Once again, we stress that positioning patients as we describe is easily performed, has no cost, requires no equipment other than the bed, and, most importantly, optimizes conditions for airway management.

Nita Khandelwal, MD, MS

Aaron M. Joffe, DO, FCCM

Department of Anesthesiology and Pain Medicine

University of Washington and Harborview Medical Center

Seattle, Washington

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1. Stept WJ, Safar P. Rapid induction-intubation for prevention of gastric-content aspiration. Anesth Analg. 1970;49:633–636.
2. Greenland KB, Edwards MJ, Hutton NJ, Challis VJ, Irwin MG, Sleigh JW. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications. Br J Anaesth. 2010;105:683–690.
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