A Best Practice Solution.

Experts agree that ear to sternal notch positioning is the optimum position for airway management. Ramping improves upper airway patency, decreases the work of breathing and prolongs the safe apnea period. The Rapid Airway Management Positioner™ provides these benefits and is superior to conventional positioning solutions.

Improved upper airway patency.

Decreased work of breathing.

Prolongs the safe apnea period.

Extubation icon

Improved Safety During Extubation.

Existing Solutions

A ramped position is essential but can be difficult to achieve with static foam products or stacking linen. Experts agree that this is a best practice positioning technique that improves the rate of successful endotracheal intubation, especially in obese patients.

Used with permission by Rich Levitan, MD

Ear to Sternal Notch Positioning

The ideal “ramped” position is one in which the upper body, neck and head are elevated to a point where an imaginary horizontal line can be drawn from the external auditory meatus to the sternal notch.

The historical basis for ramping can be traced back to Alfred Kirstein, MD in his seminal work from 1897, Autoscopy of the Larynx and Trachea.

Images used with permission from Rich Levitan, MD

Safe Apnea Period

The ‘safe apnea period’ refers to the time available until critical desaturation occurs in the absence of ventilation. A ramped position increases the safe apnea time for obese patients, which can be critical if multiple intubation attempts are required.

Used with permission by Rich Levitan, MD

Improved Laryngeal View

A ramped position is essential for successful airway management and can dramatically improve laryngeal view. The below videos show Rich Levitan, MD discussing how head elevated laryngoscopy improves landmark recognition for the laryngoscopist. The term “ear to sternal notch position” was coined by Dr. Levitan.

The importance of HELP “Head Elevated Laryngoscopy Position”

Head Positioning

Airwaycam views pre/post ramping with an early generation RAMP prototype

Photos and Videos used with permission from Rich Levitan, MD. Videos filmed at Practical Emergency Airway Management Course.

Physiological Challenges

Important Pathophysiologic Considerations in Obesity Emergency Management

1. Decreased respiratory reserve is secondary to diminished total lung capacity and functional residual capacity. The decreased reserve compromises an obese patient’s ability to tolerate respiratory insults such as pneumonia


2. Increased airway pressures are a result of increased airway resistance (heavier chest walls, increased abdominal girth, atelactatic lung bases). The increased pressures lead to:

  • Smaller oxygen reserves at baseline

  • Increased work of breathing

  • Shorter time to desaturation during induction and a shorter Safe Apnea Time

3. Higher incidence of hypoxemia and hypercapnia at baseline


4. Higher risk of aspiration pneumonitis


5. More difficult to ventilate with BMV

The Data

Ear to sternal notch positioning facilitated a 99% DL success rate in obese patients Anesth Analg 2002; 94: 732-6 99%
Ramped position is superior to standard “sniff position” Obesity Surgery 2004: 14 (9); 1171-1175 100%
Mean POGO score (87%) in cadaveric study looking at head elevated laryngoscopy Ann Emerg Med 2003; 41(3) 87%
Head elevation prolongs the time to desaturation safety period Anesthesiology 2005; 102(6); 1110-1115 100%
Pre-oxygenation is more efficacious with head elevation Anaesthesia 2005; 60: 1064-1067 100%

RAMP Studies

RAMP usage resulted in:

  • Faster intubation times using both direct laryngoscopy and video laryngoscopy
  • Improved POGO scores in both groups
  • Fewer esophageal intubations

RAMP usage:

  • Improved laryngoscopic view
  • Inflated ramped position provided greater ease of ventilation as compared to the neutral position

Professional Society Recommendations


Difficult Airway Society


Difficult Airway Society


Difficult Airway Society


International Society for the Perioperative Care of the Obese Patient


The Society for Obesity and Bariatric Anaesthesia

Supporting Medical Literature

Supporting Medical Literature

Improved Safety During Extubation

Extubation can be risky, especially in obese patients. Desaturation after premature extubation can cause a host of adverse postoperative events, including higher cost of care, prolonged hospital stay, and greater risks for adverse discharge, ICU admissions and respiratory complications.

The PPS RAMP can be easily reinflated at the end of a case so that the ideal ramped position may be reconstituted prior to extubation. This mitigates the sequel of premature extubation or an unexpected complication.

Clinical Evaluations were performed using an earlier version of the RAMP device.

The solution is: