Jackson Position – Airway Positioning for Intubation

What is the Jackson Position?

The Jackson position is a standardized patient positioning technique primarily used during direct laryngoscopy and endotracheal intubation. It was named after the American laryngologist Chevalier Jackson, who established it as a standard for upper airway endoscopic procedures in the early 20th century.

The goal of this positioning is to align the three anatomical axes of the airway as closely as possible – the oral axis, the pharyngeal axis, and the laryngeal axis – to provide an unobstructed line of sight to the larynx and vocal cords.

Anatomical Background

Understanding the Jackson position requires a basic knowledge of airway anatomy. In a supine patient, the three relevant axes naturally diverge:

• Oral axis: Runs from the mouth opening posteriorly and inferiorly.
• Pharyngeal axis: Passes through the pharynx (throat) downward.
• Laryngeal axis: Passes through the larynx (voicebox) into the trachea.

In a relaxed supine position, these axes form unfavorable angles with one another. The Jackson position aims to bring them into alignment, creating a direct visual pathway from the mouth to the vocal cords.

How the Position is Performed

The classic Jackson position is achieved as follows:

• The patient lies flat on their back in the supine position.
• The head is slightly elevated, for example by placing a flat pillow or head support beneath the occiput (back of the head). This step aligns the pharyngeal and laryngeal axes.
• The head is then extended at the atlanto-occipital joint (the joint between the base of the skull and the first cervical vertebra) – a movement called head extension or neck extension. This aligns the oral axis with the other two axes.

This combined motion – elevating the head and extending the neck – is also referred to as the improved Jackson position or the sniffing position, and is today the preferred standard in anesthesia and emergency medicine.

Clinical Applications

The Jackson position is used across various medical specialties:

• Anesthesia: Standard positioning before endotracheal intubation for general anesthesia induction.
• Emergency medicine: Airway management in unconscious or ventilator-dependent patients.
• Otolaryngology (ENT): Direct laryngoscopy for examination and treatment of laryngeal disorders.
• Gastroenterology / Endoscopy: Preparation for upper gastrointestinal procedures.

Clinical Relevance and Limitations

Correct application of the Jackson position significantly improves intubation conditions and reduces the risk of complications such as dental trauma, vocal cord injury, or failed intubation. However, there are situations where this position is limited or contraindicated:

• Cervical spine injuries: Suspected cervical spine trauma is a contraindication for neck extension, as it may worsen spinal cord injuries.
• Reduced neck mobility: Patients with degenerative cervical spine disease or rheumatic conditions may not be able to achieve full positioning.
• Obesity: Significantly overweight patients may require additional elevation of the upper body, known as the ramped position.

Classic vs. Improved Jackson Position

Modern medicine often distinguishes between the classic Jackson position (head extension only, without head elevation) and the improved Jackson position (elevation of the occiput combined with head extension). Evidence suggests that the improved position generally provides a better view of the glottis (the opening between the vocal cords) and is therefore preferred in current clinical practice.

References

1. Lumb, A.B. & Biercamp, C. - Nunn's Applied Respiratory Physiology, 9th Edition. Elsevier, 2021.
2. Apfelbaum, J.L. et al. - Practice Guidelines for Management of the Difficult Airway. Anesthesiology, 2022. Available at: https://pubs.asahq.org
3. World Health Organization (WHO) - Safe Surgery Saves Lives. WHO Press, Geneva, 2009. Available at: https://www.who.int