‘Flextension’: a new term to describe optimal head and neck positioning for airway management

Abstract

The optimal position, for much of non-infant airway management is often described colloquially as ‘the sniffing position’ or ‘sniffing the morning air’ [1]. The literature also includes the terms ‘drinking a (full) pint (of beer)’; ‘last orders’; ‘sniff for smoke’; ‘win with the chin’ [2-4]; and we find many use the term ‘first pint position’. These terms are either arcane or arguably trivialising the positioning they intend to describe. It is reported that they may be of limited benefit to those without previous knowledge of correct airway positioning [4, 5] and even to those with such knowledge [6]. It is also plausible that the descriptions may either translate poorly to other languages or be culturally unhelpful.

The airway position each of these terms intends to describe is that of elevating the head from the recumbent position in a supine patient. It has potential benefits in airway management during face mask ventilation, supraglottic airway placement, laryngoscopy and tracheal intubation. As such, it is important the concept is understood and well communicated.

As the anatomical positioning involves flexion of the lower cervical spine and extension of the upper cervical spine, we introduce the term ‘flextension’ (TC) and have developed an infographic (NC) to support its dissemination (Fig. 1). Flextension can be combined with torso elevation to better describe the ‘ramped’ position for airway management in patients who are obese. We have been using the term for several years now with good anecdotal feedback and local adoption, but it has yet to be described in the academic literature.

Figure 1

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Flextension and flextension with torso elevation to describe airway positioning in patients with and without obesity, respectively.

It is common to see inexperienced airway managers, who are familiar with the terms ‘sniffing position’ etc., when asked to position the patient before anaesthesia, place a pillow under the shoulders and extend the head on the neck. This leaves the lower cervical spine in the neutral or even extended position, rather than the desired flexed position. We believe widespread adoption of the term flextension will promote better understanding of head and neck positioning for airway management and, more importantly, provide a practical reminder.