An Evaluation of the Rapid Airway Management Positioner in Obese Patients Undergoing Gastric Bypass or Laparoscopic Gastric Banding Surgery

Abstract

A new positioning device, the Rapid Airway Management Positioner (RAMP, Airpal Inc., Center Valley, PA) was evaluated to determine if there was an improvement in either mask ventilation, direct laryngoscopy, or both with the use of the RAMP in this patient population. Fifty-one morbidly obese patients (BMI > 35 kg/m(2)) undergoing elective bariatric surgery were enrolled. Ventilation and laryngoscopy was performed in the neutral and head-elevated laryngoscopy position (HELP). Direct laryngoscopy was performed noting the glottic view according to the Cormack-Lehane classification (Samsoon and Young, Anesthesiology 42:487, 1987). Mask ventilation was then recommenced. The HELP, or "ramped," position was achieved by inflating the RAMP, which was placed underneath the patient prior to entering the OR. Once proper HELP position was achieved, a second laryngoscopy was performed followed by endotracheal intubation. Two main outcomes were noted in the neutral and HELP positions: (1) laryngoscopic view and (2) ease of ventilation. The inflated ramped position provided greater ease of ventilation as compared to the neutral position (p = 0.0003). There was also a significant improvement in the glottic view in the ramped position (p = 0.04). Ease of intubation was perceived to be severely difficult among two, and overall use of the positioning device was found to be difficult among seven of the residents. The RAMP effectively positions morbidly obese patients in the HELP position. Ease of ventilation and laryngoscopic view were both improved with its use in this patient population.

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position

“…Various methods and degrees of head elevation have been described for intubating OR patients [3][4][5], [7][8], difficult ED patients [6], patients undergoing awake intubation [10], and even simulated patients in an ambulance setting [11]. Nevertheless, traditional supine intubation remains widespread and upright intubation remains underrepresented in research and in medical education.…”

“…Live tissue in real patients is affected by gravity differently than mannequins. However, previous studies have suggested that head elevation may decrease the force of gravity on live tissues, indicating that the anatomic advantages of upright position would likely be important in live patients [4], [6], [7].…”

“…Head elevation may also have the advantage of decreasing the amount of force required for the intubator to lift the patient's tissues out of the way [4], [6], [7].…”

Airway management and morbid obesity

“…When using patients as their own controls and comparing laryngoscopy in both 'ramped' and 'sniffing' position, the former provides improved or unchanged views of the larynx in 88% of patients with BMI less than 25 kg m À2 , in 91% in patients with BMI higher than 30 kg m À2 and in 100% of patients with BMI higher than 45 kg m À2 . 12 The use of a premanufactured elevation pillow, 13 or an inflatable pillow, 14 instead of blankets can improve both view of the larynx and mask ventilation. During surgery, the inflatable pillow can be deflated, bringing the patient back to the supine position.…”

“…42 It should follow a planned strategy and logically should be performed in the same 'ramped' position used for intubation. This is not easy to do in an anaesthetised patient without the inflatable pillow, 14 or an operating table that can be suitably configured.…”