Defining the 'Sniffing Position" in Infants and Toddlers - A Pilot Study
Condition: Airway Management; Infant ALL; Children, Only; Endotracheal Intubation
Study type: Interventional

Summary: 
      The "sniffing position" is widely accepted as a favorable position for direct laryngoscopy
      (DL) in both pediatric and adult patients. External anatomical markers are well documented to
      confirm proper 'sniffing position' in adults, but data on their use in the pediatric
      population is sparse. The investigators propose to define these markers in young children and
      investigate whether patients positioned using this standardized approach have better
      intubating conditions than those positioned randomly per the preference of the
      anesthesiologist.
    

Detailed description: 
      The procedure of endotracheal intubation in adults and children is a continuum, and begins
      with proper head positioning prior to direct laryngoscopy (DL). It is an accepted paradigm
      that proper positioning optimizes intubating conditions, and decreases subsequent airway
      maneuvers and manipulation.

      The sniffing position is an accepted airway positioning concept in pediatric airway
      management, and continues to be recommended by experts and textbooks in the field. Anatomical
      peculiarities such as the large head relative to the torso in infants and toddlers is assumed
      to put the head in proper position when gently extended. However, reproducible parameters to
      confirm optimal head positioning remain vague and unclear. In the absence of objective and
      measurable markers, practitioners position infants and toddlers according to their individual
      preferences, and as such the procedure lacks definition and objective clarity.

      The investigators plan to recruit 40 healthy patients between the ages of 1 month - 48 months
      and randomize them to be positioned either according to a predetermined algorithm or
      positioned freely according to the provider's preference. Patients randomized to the
      intervention group will be positioned with the aim to horizontally align the external
      auditory meatus (EAM) with the sternal notch (SN).

      In summary, the study aims to define the sniffing position for infants and toddlers using
      reproducible objective secondary markers, and investigate whether a systematic approach to
      positioning using such markers improves direct laryngoscopic outcomes in the young pediatric
      patient population.
    

Intervention name(s): Airway positioning per specified protocol followed by Direct Laryngoscopy and Endotracheal Intubation; Airway positioning per provider preference followed by Direct Laryngoscopy and Endotracheal Intubation
Intervention type(s): Procedure; Procedure
Intervention description(s): Positioning of the patient's head and neck for the purpose of direct laryngoscopy and endotracheal intubation; Positioning of the patient's head and neck for the purpose of direct laryngoscopy and endotracheal intubation
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Other
Keywords: pediatric intubation; direct laryngoscopy; sniffing position; external auditory meatus; pediatric anesthesia; pediatric airway management