Positioning during RSI is a controversially discussed topic. There are arguments for and against head down or head up positioning on both sides, evidence however is very sparse. There are no recommendations neither in the German-speaking, nor in the big European, North American or Australian Societies for Anesthesia.


I found two recommendations in German-speaking countries:

Recommendation for prehospital RSI:

Reverse-Trendelenburg (but without explanation or citation)


Recommendation for RSI in pediatrics:

To ensure optimal intubation- and ventilation conditions, patients should be positioned supine and the head in neutral position.


Arguments for Reverse-Trendelenburg:

  • prevention of passive regurgitation
  • better Oxygenation (in my opinion though, there is nothing wrong with positioning the patient head up first for preoxygenation and then head down for RSI)


Arguments for Trendelenburg: 

  • Reduced risk of Aspiration


Arguments against Reverse-Trendelenburg: 

  • High risk of aspiration if there is active vomiting (immediate Trendelenburg positioning in that case!)


Technically more difficult conditions for intubations are described for both positions.


Positioning should of course be adopted to the clinical situations (abdominal distension, cardiorespiratory insufficiency, ICP etc.) According to a survey (amongst anesthesiologists), most patients are positioned in Reverse-Trendelenburg. Another interesting detail is that RSI for prevention of aspiration is only a grade E recommendation. Since aspiration is generally rare (1: 2000-3000 in general anesthesia, 1:600-900 in emergencies, 1:3000-4000 in elective cases) there will probably never be a trial that is large enough to obtain statistical significance.




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