In the Field
Sniffing position is the simplest airway intervention you can perform and the one most often skipped. A casualty whose respiratory rate drops after fentanyl or ketamine may not need a definitive airway. They may just need their head positioned correctly. Tilt the chin away from the chest, slightly extend the head, and the airway often opens. If that does not work, then move to BVM ventilation. TCCC 2026 explicitly lists sniffing position as the first step before ventilatory support in casualties with reduced respirations after analgesia.
Common Mistake
Skipping straight to advanced airway when positioning would have worked. Or overdoing the extension and creating excessive cervical strain in trauma patients. The sniffing position is subtle: the goal is alignment of axes, not maximum extension. In an obese or short-necked patient, the sniffing position may require head-of-bed elevation or padding under the shoulders. In a pediatric patient, the relatively large occiput already provides flexion, so a shoulder roll is often needed to achieve a neutral or slight extension instead.
Technical Detail
The sniffing position aligns three axes: the oral axis (from mouth to oropharynx), the pharyngeal axis (oropharynx to laryngeal inlet), and the laryngeal axis (laryngeal inlet to trachea). In a normal supine adult, these axes are not aligned and a direct line of sight from mouth to vocal cords does not exist. Flexion of the neck (by elevating the head 8 to 10 cm with a pillow or folded blanket) plus extension of the head at the atlanto-occipital joint aligns these axes. The position is named for the appearance of a person sniffing the morning air. Validated for direct laryngoscopy and BVM ventilation. TCCC 2026 specifies sniffing position as the first intervention for reduced respirations following opioid or ketamine, before progressing to ventilatory support.
