Ramped position provides comparable first-pass success to sniffing position for intubating obese patientsRamped position may reduce intubation attempts for obese patients

Critical care science Published August 13, 2026 Study authors: Basavanna Gopal Krishna, Garcia Berta Grases, Azevedo Rebecca Fonseca de, Lesinszki Lukács Sándor, H… PubMed ↗ DOI ↗ Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

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Key Takeaway

Note that ramped position offers comparable first-pass success to sniffing position but may reduce attempts in specific subgroups.

This meta-analysis evaluated the efficacy of the ramped position compared to the sniffing position for endotracheal intubation in patients with obesity. The study included a total of 938 participants and focused on primary outcomes including first-pass success and Cormack-Lehane grading, alongside secondary outcomes such as tube insertion time and number of attempts.

The analysis found no significant difference in first-pass success (RR 1.07; 95%CI 0.98 - 1.16; p = 0.14) or Cormack-Lehane grades 1-2 (RR 0.99; 95%CI 0.97 - 1.02; p = 0.61) between the two positions. For Cormack-Lehane grades 3-4, no significant difference was found (RR 1.94; 95%CI 0.86 - 4.37; p = 0.11). While a decrease in tube insertion and intubation time was observed in the ramping group, this finding did not persist in sensitivity analysis.

Notably, the ramped position showed a significant reduction in the number of intubation attempts in both the operating room subgroup (RR 0.33; 95%CI 0.19 - 0.58; p < 0.001) and the video-laryngoscopy subgroup (RR 0.33; 95%CI 0.15 - 0.70; p = 0.02). The authors noted a lack of standardized definitions in primary studies as a limitation. Clinically, while both positions offer comparable first-pass success and laryngeal views, the ramped position may reduce attempts in specific settings.

How this fits prior evidence

This meta-analysis addresses a gap in clinical management for obese patients by comparing intubation techniques. While prior coverage has focused on metabolic interventions such as GLP-1RAs, Citrus bergamia nutraceuticals, and surgical procedures like RYGB or SG for obesity, this finding specifically addresses the procedural challenges of airway management in the obese population.

When doctors need to place a breathing tube (intubation) in a patient with obesity, the process can be physically challenging. Doctors often choose between two positions: the "sniffing" position or a "ramped" position where the head is elevated. This study looked at 938 patients to see which method worked best.

The results showed that both the ramped and sniffing positions were equally effective at getting the tube in on the first try and providing a clear view of the throat. However, there was a notable difference in how many attempts it took to succeed. In specific settings, like those using an operating room or video-laryngoscopy (a camera used to see the airway), the ramped position led to significantly fewer attempts.

While some data suggested faster insertion times with the ramped position, this finding was not consistent across all types of analysis. Because different studies in this review lacked standard definitions, the results should be viewed with caution. For now, both positions offer similar success rates for first-pass placement.

What this means for you:

The ramped position offers similar success rates to sniffing but may require fewer attempts in specific settings.

Common questions

Is the ramped position safer or more effective than the sniffing position?

Both the ramped and sniffing positions showed no significant difference in first-pass success or the quality of the view of the throat. While some data suggested faster tube insertion with the ramped position, this did not remain consistent across all types of analysis.

Does the ramped position help reduce the number of attempts?

Yes, in specific settings like those using an operating room or video-laryngoscopy, the ramped position led to a significant decrease in the number of intubation attempts compared to other methods.

Who is this finding most relevant for?

This information is specifically relevant for medical teams managing patients with obesity who require intubation. It suggests that while both positions are effective for first-pass success, the ramped position may reduce the number of attempts in certain clinical settings.

Study Details

Study typeMeta analysis

Sample sizen = 938

EvidenceLevel 1

PublishedJan 2026

PMID42585384

View Original Abstract ↓

OBJECTIVE: To evaluate the effectiveness of the ramp position over the sniffing position for endotracheal intubation in obese patients. METHODS: We performed a systematic review and meta-analysis comparing ramping with sniffing position for endotracheal intubation in obese patients. We systematically searched PubMed®, Embase, and the Cochrane Library. Primary outcomes included Cormack-Lehane grading and first-pass success. We applied a random-effects model to pool relative risks and mean differences with 95% confidence intervals. Statistical analyses were performed using R 4.4.2. RESULTS: We included four randomized controlled trials and two cohort studies. Of the 938 participants, 54.16% (508) were intubated in the ramp position. Ramping did not improve first pass success (RR 1.07; 95%CI 0.98 - 1.16; p = 0.14; I2 = 61.6%), Cormack-Lehane grades 1 - 2 (RR 0.99; 95%CI 0.97 - 1.02; p = 0.61; I2 = 0%), or Cormack-Lehane grades 3 - 4 (RR 1.94; 95%CI 0.86 - 4.37; p = 0.11; I2 = 0%). Although ramping decreased mean tube insertion and intubation time, these results did not persist in the sensitivity analyses. However, ramping decreased the number of intubation attempts in the operating room subgroup (RR 0.33; 95%CI 0.19 - 0.58; p < 0.001; I2 = 0%) and video-laryngoscopy subgroup (RR 0.33; 95%CI 0.15 - 0.70; p = 0.02; I2 = 0%). CONCLUSION: Our results suggest that ramping offers first-pass success and laryngeal view rates comparable to those of the sniffing position. In terms of secondary outcomes, patients in the operating room or those intubated with a video-laryngoscopy may benefit from decreased intubation attempts. Future studies with standardized definitions are required to evaluate these findings in different settings.PROSPERO register: CRD42025638839.

Ramped position provides comparable first-pass success to sniffing position for intubating obese patientsRamped position may reduce intubation attempts for obese patients

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Common questions

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