A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults

Semler, Matthew W.; Janz, David R.; Russell, Derek W.; Casey, Jonathan D; Lentz, Robert J.; Zouk, Aline N.; deBoisblanc, Bennett P.; Santanilla, Jairo I.; Khan, Yasín A.; Joffe, Aaron M.; Stigler, William S.; Rice, Todd W.; Creek, Grady P.; Haddock, Jody L.; Vonderhaar, Derek J; Lapinel, N.; Samant, Sneha D.; Paccione, Rose; Dischert, Kevin M; Majid-Moosa, Abdulla; Crespo, Joaquin; Fashho, Michael B.; Matthews, Daniel T.; Berg, Jeannette Zinggeler; Assad, Tufik R.; McKown, Andrew C.; Huerta, Luis E.; Kocurek, Emily G.; Halliday, Stephen; Kerchberger, V.E.; Merrick, Christopher; Warren, Melissa; Brown, Ryan M; Self, Wesley H.; Sharif, Roozbeh; Garcia, Bryan; Gulati, Swati; He, Chao; LaFon, David C.

doi:10.1016/j.chest.2017.03.061

Cited by 98 publications

(110 citation statements)

References 38 publications

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“…One randomized controlled trial of ramped versus sniffing head position during urgent intubations in the ICU found that ramping worsened the Cormack-Lehane grade view of the airway, while a similar study in an operating room population showed significantly better laryngeal views when patients were ramped. 20,21 Despite these mixed data, more than one-quarter of all patients in our study were placed in a ramped position. This parallels the percentage of patients listed as being either obese or morbidly obese.…”

Section: Discussionmentioning

confidence: 83%

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Brown

Kaji

Fantegrossi

et al. 2020

Academic Emergency Medicine

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Objective The objective was to compare first‐attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (A‐DL) with unaided video laryngoscopy (VL) in adult emergency department (ED) intubations. Methods This study was a secondary analysis of a multicenter prospective observational database of ED intubations from the National Emergency Airway Registry (NEAR). We compared all VL procedures to seven exploratory permutations of A‐DL using multivariable regression models. We further stratified by blade shape into hyperangulated VL (HA‐VL) and standard‐geometry VL (SG‐VL). We report differences in first‐attempt intubation success and peri‐intubation adverse events with cluster‐adjusted odds ratios (ORs) with 95% confidence intervals (CIs). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and OR with 95% CI. Results We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either A‐DL or unaided VL on first attempt. A‐DL was used first in 3,936 (56.7%, 95% CI = 46.9 to 66.5) versus unaided VL in 3,002 (43.3%, 95% CI = 33.5 to 53.1). Of the A‐DL first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (ELM), and 365 (9.3%) used a bougie. Rapid sequence intubation (RSI) was the most common method used in 5,602 (80.8%, 95% CI = 77.0 to 84.5) cases. First‐attempt success was significantly higher with all VL (90.9%, 95% CI = 88.7 to 93.1) versus all A‐DL (81.1%, 95% CI = 78.7 to 83.5) despite the VL group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry‐recorded difficult airway predictors revealed first‐attempt success was higher with all unaided VL compared with any A‐DL (adjusted OR [AOR] = 2.8, 95% CI = 2.4 to 3.3), DL with bougie (AOR = 2.7, 95% CI = 2.1 to 3.5), DL with ELM (AOR = 1.8, 95% CI = 1.5 to 2.2), DL with ramped positioning (AOR = 2.8, 95% CI = 2.3 to 3.3), or DL with ELM plus bougie (AOR = 2.8, 95% CI = 2.3 to 3.3). Subgroup analyses of HA‐VL and SG‐VL compared with any A‐DL yielded similar results (AOR = 3.2, 95% CI = 2.6 to 3.0; and AOR = 2.4, 95% CI = 1.9 to 3.0, respectively). The propensity score–adjusted odds for first‐attempt success with VL was also 2.8 (95% CI = 2.4 to 3.3). Fewer esophageal intubations were observed in the VL cohort (0.4% vs. 1.3%, AOR = 0.2, 95% CI = 0.1 to 0.5). Conclusions Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first‐attempt success than does DL that is augmented by use of a bougie, ELM, ramping, or combinations thereof.

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Section: Discussionmentioning

confidence: 83%

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Brown

Kaji

Fantegrossi

et al. 2020

Academic Emergency Medicine

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“…We appreciate the interest demonstrated by Dr Abdulmahdi et al in our recent multicenter randomized trial comparing ramped position to sniffing position during endotracheal intubation of critically ill adults. 1 Our trial found no difference in lowest oxygen saturation but a worse glottic view and an increased number of laryngoscopy attempts with a ramped position. Abdulmahdi et al highlight two important considerations: (1) the BMI of the patients and (2) their precise position during intubation.…”

Section: Responsementioning

confidence: 46%

“…1 Our trial found no difference in lowest oxygen saturation but a worse glottic view and an increased number of laryngoscopy attempts with a ramped position. Abdulmahdi et al highlight two important considerations: (1) the BMI of the patients and (2) their precise position during intubation.…”

Section: Responsementioning

confidence: 46%

Pleurodesis

Acton

2017

Chest

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We appreciate the interest demonstrated by Dr Abdulmahdi et al in our recent multicenter randomized trial comparing ramped position to sniffing position during endotracheal intubation of critically ill adults. 1 Our trial found no difference in lowest oxygen saturation but a worse glottic view and an increased number of laryngoscopy attempts with a ramped position. Abdulmahdi et al highlight two important considerations: (1) the BMI of the patients and (2) their precise position during intubation.First, they point out that several prior studies of ramped position during endotracheal intubation in the operating room focused on obese patients 2-4 and that the benefit of a ramped position might be greatest in this subgroup. In our trial, 95 patients (37.1%) had a BMI $ 30 kg/m 2 . Thus, the number of obese patients in our trial was greater than in any of the prior studies specifically targeting obese patients (sample sizes ranging from 26-85 patients). 2-5 Moreover, our prespecified analysis by BMI did not suggest the ramped position to be beneficial for obese patients (Fig 4, e-Fig 3 in original manuscript). The best position in which to intubate critically ill adults at the extremes of BMI, however, remains unknown.Second, Abdulmahdi et al inquire about the positioning of patients in both study arms. They worry that our trial "did not permit torso elevation in the sniffing position cohort," impairing optimal airway alignment, which would bias the trial in favor of the ramped positon. They also worry that the approach to ramped positioning in our trial may have resulted in suboptimal head and neck positioning for optimal airway alignment, which would bias the trial in favor of the sniffing position. Each of the prior trials comparing ramped position to sniffing position in the operating room used differing definitions of ramped position and sniffing position. 2,3,5 We did not attempt to redefine the ramped or sniffing position for our trial and simply provided operators with figures and instructions about each position from prior studies and guidelines. We agree that patient positioning may exert independent effects on physiology (eg, functional residual capacity) and anatomy (eg, upper airway alignment). We also agree that a likely explanation for the difference in findings between our trial and prior trials in the operating room may be the challenge of achieving optimal head and neck alignment in the ramped position during endotracheal intubation of critically ill adults.

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“…Multiple studies on patients in the operating room have demonstrated that the head‐up position results in improved preoxygenation and increases the safe apnea time . Interestingly, a recent randomized controlled trial in critically ill patients in the ICU found that preoxygenation in the head‐up position resulted in no improvement in oxygenation compared to the supine position . The majority of the patients in this trial, however, had respiratory failure, many with shunt physiology, and this many have limited the benefits of upright preoxygenation.…”

mentioning

confidence: 82%

Maintenance of Oxygenation During Rapid Sequence Intubation in the Emergency Department

Sakles

2017

Academic Emergency Medicine

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A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults

Abstract: ClinicalTrials.gov; No.: NCT02497729; URL: www.clinicaltrials.gov.

Cited by 98 publications

References 38 publications

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Pleurodesis

Maintenance of Oxygenation During Rapid Sequence Intubation in the Emergency Department

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