How can you increase your ear “Sternal Notch” size?

By: LoydMartin

Sternal Notch Spoon Feed

We are all taught to use “sniffing posture” when intubating patients. When there is ramped positioning for sternal notch pre-oxygenation and intubation, the “sniffing position” is not a good option. Two Australian anesthesiologists sent a letter clarifying the proper technique.

What’s the point?

Recently, ramped positioning during intubation has been the subject of controversy in the EM and critical care literatures. Ramped positioning Boom Racing can increase the time taken for anesthesia patients become saturated with a sternal notch (20-25°). Recent RCTs by Check-UP researchers in the ICU found no improvement in safe anesthetic times and worsened glossic views. We found grave concern regarding cervical hyperextension based on the study’s appendix photos and description (see the link above). Clay and Chip Lange created a podcast on TOTALEM about the paper if you prefer audio.

The anesthesiologists respond with gloves off…Blue or Curtain Down

Figure A illustrates the most common position to sniff in a supine patient. This optimal positioning is achieved through flexion of the lower cervical spine and extension of the occipito-atlanto-axial complex. Novice intubators learn how to achieve this position by placing their sternal notch, and ear parallel to the ground. When the “parallel” mantra breaks, the ramping position (Figure A–as demonstrated in the Check-UP research), causes lower cervical extension and worsens vision. Figure C shows the proper ramped position. This position allows for excellent glottic views, with coordinated flexion/extension, and improved pre-oxygenation via higher functional residual ability. These anesthesiologists feel that the Check-UP study needs to be re-examined.

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