Comparison of Macintosh Laryngoscopy in Bed-up-Head–Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial

Abstract

BACKGROUND: Approximately half of all difficult tracheal intubations (DTIs) are unanticipated; hence, proper positioning during intubation is critical to increase the likelihood of success. The bed-up-head–elevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications, and prolong safe apneic time during intubation. In this study, we sought to determine whether the BUHE intubation position is noninferior to Glidescope (GLSC)-assisted intubation with regard to laryngeal exposure. METHODS: A total of 138 American Society of Anesthesiologists (ASA) I to III patients were randomly assigned into 2 groups and underwent baseline laryngoscopy in the sniffing position. Group BUHE patients (n = 69) were then intubated in the BUHE position, while group GLSC patients (n = 69) were intubated using GLSC laryngoscopy. Laryngeal exposure was measured using Percentage of Glottic Opening (POGO) score and Cormack–Lehane (CL) grading, and noninferiority will be declared if the difference in mean POGO scores between both groups do not exceed −15% at the lower limit of a 98% confidence interval (CI). Secondary outcomes measured included time required for intubation (TRI), number of intubation attempts, use of airway adjuncts, effort during laryngoscopy, and complications during intubation. RESULTS: Mean POGO score in group BUHE was 80.14% ± 22.03%, while in group GLSC it was 86.45% ± 18.83%, with a mean difference of −6.3% (98% CI, −13.2% to 0.6%). In both groups, there was a significant improvement in mean POGO scores when compared to baseline laryngoscopy in the sniffing position (group BUHE, 25.8% ± 4.7%; group GLSC, 30.7% ± 6.8%) (P < .0001). The mean TRI was 36.23 ± 14.41 seconds in group BUHE, while group GLSC had a mean TRI of 44.33 ± 11.53 seconds (P < .0001). In patients with baseline CL 3 grading, there was no significant difference between mean POGO scores in both groups (group BUHE, 49.2% ± 19.6% versus group GLSC, 70.5% ± 29.7%; P = .054). CONCLUSIONS: In the general population, BUHE intubation position provides a noninferior laryngeal view to GLSC intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In view of the many advantages of the BUHE position for intubation, the lack of proven adverse effects, the simplicity, and the cost-effectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the general population.

Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations

“…37 Recommendations: Based on the clinical characteristics and expert experience and opinion, we recommend head-elevated positioning before intubation to optimise intubation conditions. 38,39 We recommend videolaryngoscopy over direct laryngoscopy. In case of difficulty, a second-generation supraglottic airway should be available.…”

Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis

“…The 10 included studies comprised 18 371 intubations across 4 countries (USA, South Korea, Wales, Malaysia). Settings varied across studies, with one prehospital,17 two ED,15 19 four operating room (OR),32–35 one intensive care unit (ICU)23 and one other (non-ED, non-ICU) in-hospital settings 14. Intubations were performed by anaesthesiology residents, anaesthesiology attendings or nurse anaesthetists in six studies,14 32–36 and by paramedics, EM residents, critical care fellows or EM attendings in the other studies.…”

“…Settings varied across studies, with one prehospital,17 two ED,15 19 four operating room (OR),32–35 one intensive care unit (ICU)23 and one other (non-ED, non-ICU) in-hospital settings 14. Intubations were performed by anaesthesiology residents, anaesthesiology attendings or nurse anaesthetists in six studies,14 32–36 and by paramedics, EM residents, critical care fellows or EM attendings in the other studies. Intubations in 78.4% of inclined patients and 49.3% of supine patients were performed with direct laryngoscopy (DL).…”

“…Patient populations included adults with the following indications for intubation: medical, trauma, elective surgery, sedation. Of the four OR studies, two included patients with obesity only,33 36 while the other two enrolled patients undergoing elective or ‘routine’ operations 34 35. Study designs included four RCTs,23 32–34 two prospective observational trials,19 36 one before and after observational study35 and three retrospective registry analyses 14 15 17…”

HELP-VDL: study protocol for a multicentre, open, randomised, controlled clinical trial comparing the use of the head-elevated laryngoscopy position and the use of a videolaryngoscope to facilitate orotracheal intubation in a patient population without predictable difficulty of intubation

“…8 This proposed position led to a position called bed-up-head-elevated, which has been proposed as the standard intubation position for all patients. 9 A similar position with the head and neck raised, the 'head-elevated laryngoscopy position' (HELP), is specified by an anatomical marker-an imaginary horizontal line should connect the patient's sternal notch with the external auditory meatus. 10 The HELP has been proven to be a better position for intubation in obese [11][12][13][14] and lean patients.…”