Effects of head-elevated position on tracheal intubation using a McGrath MAC videolaryngoscope in patients with a simulated difficult airway: a prospective randomized crossover study

Abstract

Background The head-elevated laryngoscopy position has been described to be optimal for intubation, particularly in obese patients and those with anticipated difficult airways. Horizontal alignment of the external auditory meatus and sternal notch (AM-S) can be used as endpoints for optimal positioning. Thus, we aligned the head-elevated position with the AM-S in the horizontal plane and evaluated its effect on laryngeal visualization and ease of intubation using a McGrath MAC videolaryngoscope in patients with a simulated difficult airway. Methods Sixty-four patients were included in this prospective, crossover, randomized controlled trial. A cervical collar was used to restrict neck movement and mouth opening. The head-elevated position was achieved by raising the back section of the operation room table and ensuring that the end point was horizontally aligned with the AM-S (table-ramp method). The laryngeal view was randomly assessed in both head-flat and head-elevated positions based on the percentage of glottic opening (POGO) score and modified Cormack–Lehane (MCL) grade. External laryngeal manipulation was not permitted when laryngeal visualization was scored. The trachea was intubated only once (in the second position). The ease of intubation was assessed based on the need for optimization maneuvers, intubation difficulty scale (IDS) scores and time to intubation. Results The mean table-ramp angle required to achieve the horizontal alignment of AM-S was 17.5 ± 4.1°. The mean POGO score improved significantly in the head-elevated position (59.4 ± 23.8%) when compared with the head-flat position (37.5 ± 24%) (P < 0.0001). MCL grade 1 or 2a was achieved in 56 (85.9%) and 28 (43.7%) of patients in the head-elevated and head-flat positions, respectively (P < 0.0001). Optimization maneuvers for intubation were required in 7 (21.9%) and 17 (53.1%) patients in the head-elevated and head-flat positions, respectively (P < 0.0001). The IDS scores and time to intubation did not differ significantly between the two positions. Conclusion In the head-elevated position, aligning the AM-S in the horizontal plane consistently improved laryngeal visualization without worsening the view when the McGrath MAC videolaryngoscope was used in patients with simulated difficult airways. It also improved the ease of intubation, which reduced the need for optimization maneuvers. Trial registration This trial was registered with www.clinicaltrials.gov, NCT04716218, on 20/01/2021.

Comparing the posture and comfort of anaesthesiologists during laryngoscopy and tracheal intubation in the head-elevated laryngoscopy position in supine position and with a 25° backup: A randomised clinical crossover trial

“…The height of the operating theatre (OT) table in our study was set at the xiphisternum of the performer, which could have also contributed to the lower CL grade as described in a study by Lee et al . [ 11 ] This study reported how table height influenced laryngeal views and anaesthesiologist comfort. The authors found that the operating table level at the xiphisternum provided better laryngeal views and anaesthesiologist comfort; hence, we decided to adopt this height in our study.…”

“…Since our study recruited only patients with easy airways, that is, those with a normal BMI, mouth opening of more than 3 cm, Mallampati grades 1 and 2, normal neck movements and positive upper lip bite test, it is uncertain whether the findings can be applied to laryngoscopy and intubation in difficult airways. Even though research suggests that even in simulated difficult airways, the percentage of glottic opening and the CL grade are improved with backup HELP,[ 11 ] future prospective research can be designed to evaluate the posture and effectiveness between the two positions in anticipated difficult airways, like obese or restricted neck movements.…”

Standardising intubation position terminology

“…Among studies considered for our review but not meeting inclusion criteria, additional terms that were used include ‘sitting’,2 ‘semirecumbent’3 and ‘non-standard’ 4. Studies that have been published since we finished our literature search have continued to use variable terms 5–7…”