Journal of Anesthesia

, Volume 24, Issue 4, pp 526–530 | Cite as

A comparison of direct laryngoscopic views depending on pillow height

  • Sang-Heon Park
  • Hee-Pyoung Park
  • Young-Tae Jeon
  • Jung-Won Hwang
  • Jin-Hee Kim
  • Jae-Hyon Bahk
Original Article



This study was conducted to determine the optimal pillow height for the best laryngoscopic view.


Fifty patients were enrolled and preanesthetic airway evaluations were recorded. After induction of anesthesia, the Macintosh 3 blade was used for direct laryngoscopy without a pillow or with a pillow 3, 6, or 9 cm high in randomized order while the laryngeal view was imaged continuously on a monitor of the integrated video system. The best direct laryngoscopic view was sought for in each condition and graded by one anesthesiologist. The correlations between the preanesthetic airway assessments and the pillow height providing the best laryngoscopic view were analyzed.


The laryngoscopic view with the 9-cm pillow was significantly superior to that with other pillows and without a pillow (P < 0.001). The incidence of difficult laryngoscopy (Cormack and Lehane grade 3) was 16% without a pillow. In these cases, laryngoscopic views were improved with a 9-cm pillow. In five patients with a short neck (<15 cm), better laryngoscopic view was observed with a 3- or 6-cm pillow compared with the 9-cm pillow. Neck length had a significant correlation (ρ = 0.326, P = 0.027) with the pillow height providing the best laryngoscopic views.


We recommend the use of a 9-cm pillow during direct laryngoscopy in the sniffing position. In contrast, pillows <9 cm appear to be advantageous in short-necked patients.


Pillow height Laryngoscopic view Sniffing position 


  1. 1.
    Miller R. Endotracheal intubation, 5th edn. Philadelphia: Elsevier Churchill Livingstone; 2000. p. 1426–36.Google Scholar
  2. 2.
    Benumof JL. Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen tube). In: Benumof JL, editors. Airway management: principle and practice. St. Louis: Mosby; 1996. p. 267.Google Scholar
  3. 3.
    Adnet F, Borron SW, Dumas JL, Lapostolle F, Cupa M, Lapandry C. Study of the “sniffing position” by magnetic resonance imaging. Anesthesiology. 2001;94:83–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Adnet F, Baillard C, Borron SW, Denantes C, Lefebvre L, Galinski M, Martinez C, Cupa M, Lapostolle F. Randomized study comparing the “sniffing position” with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology. 2001;95:836–41.CrossRefPubMedGoogle Scholar
  5. 5.
    Lee BJ, Kang JM, Kim DO. Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Br J Anaesth. 2007;99:581–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg. 2004;14:1171–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Savva D. Prediction of difficult tracheal intubation. Br J Anaesth. 1994;73:149–53.CrossRefPubMedGoogle Scholar
  8. 8.
    Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth. 1988;61:211–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Axelsson S, Kjaer I, Bjornland T, Storhaug K. Longitudinal cephalometric standards for the neurocranium in Norwegians from 6 to 21 years of age. Eur J Orthod. 2003;25:185–98.CrossRefPubMedGoogle Scholar
  10. 10.
    Axelsson S, Kjaer I, Heiberg A, Bjornland T, Storhaug K. Neurocranial morphology and growth in Williams syndrome. Eur J Orthod. 2005;27:32–47.CrossRefPubMedGoogle Scholar
  11. 11.
    Levitan RM, Ochroch EA, Kush S, Shofer FS, Hollander JE. Assessment of airway visualization: validation of the percentage of glottic opening (POGO) scale. Acad Emerg Med. 1998;5:919–23.CrossRefPubMedGoogle Scholar
  12. 12.
    Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39:1105–11.CrossRefPubMedGoogle Scholar
  13. 13.
    Page EB. Ordered hypotheses for multiple treatments: a significance test for linear ranks. J Am Stat Assoc. 1963;58:216–30.CrossRefGoogle Scholar
  14. 14.
    Horton WA, Fahy L, Charters P. Defining a standard intubating position using “angle finder”. Br J Anaesth. 1989;62:6–12.CrossRefPubMedGoogle Scholar
  15. 15.
    Kitamura Y, Isono S, Suzuki N, Sato Y, Nishino T. Dynamic interaction of craniofacial structures during head positioning and direct laryngoscopy in anesthetized patients with and without difficult laryngoscopy. Anesthesiology. 2007;107:875–83.CrossRefPubMedGoogle Scholar
  16. 16.
    Takenaka I, Aoyama K, Iwagaki T, Ishimura H, Kadoya T. The sniffing position provides greater occipito-atlanto-axial angulation than simple head extension: a radiological study. Can J Anaesth. 2007;54:129–33.CrossRefPubMedGoogle Scholar
  17. 17.
    Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003;41:322–30.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2010

Authors and Affiliations

  • Sang-Heon Park
    • 1
  • Hee-Pyoung Park
    • 2
  • Young-Tae Jeon
    • 1
  • Jung-Won Hwang
    • 1
  • Jin-Hee Kim
    • 1
  • Jae-Hyon Bahk
    • 2
  1. 1.Department of Anesthesiology and Pain MedicineSeoul National University Bundang HospitalGyeonggi-doKorea
  2. 2.Department of Anesthesiology and Pain MedicineSeoul National University HospitalSeoulKorea

Personalised recommendations