Modified-ramped Position: A New Position for Intubation of Obese Females

by NRSKarenRN NRSKarenRN, BSN, RN (Guide) Guide Expert Nurse

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 45 years experience.

Having personally experienced an "Unable to Intubate" scenerio, thought this article might be helpful to CRNA's. Karen

BMC Anesthesiology 2020;20(151)

Modified-ramped Position: A New Position for Intubation of Obese Females


...Methods: Sixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position (n = 30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position (n = 30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view.

Results: Fourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position (p < 0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position....

The special pillow designed for achieving modified ramped position


Undercat, BSN, MSN, CRNA

Specializes in Retired. Has 41 years experience. 307 Posts

A lot of us have done this intuitively for years with a couple of IV bags under the shoulders. This pillow is surely more elegant but would also be just something else to go look for during a critical time.


Specializes in Anesthesia Care, Molecular Cancer Biology , Med AI. 16 Posts

On 01.08.2020 at 19:45, Undercat said:

Birçoğumuz bunu omuzlarının altında birkaç serum torbası ile yıllarca sezgisel olarak yaptık. Bu yastık kesinlikle daha zarif ama aynı zamanda kritik bir zamanda gidilecek başka bir şey de olacaktı.

ı agree. After applying the head-chin position to the patient, I applied this many default by putting roll covers under the neck. 



1,374 Posts

In 25 years I can count on one hand the number of times I've formally "ramped" a patient. 

wtbcrna, MSN, DNP, CRNA

Specializes in Anesthesia. 5,078 Posts

The better question is why were 60 obese OB patients scheduled for general anesthesia.