Does Ramped Position Impact Intubation Success?

Written by Clay Smith

Spoon Feed
There was no difference in first pass success with a non-supine (ramped) vs supine intubating position in this retrospective study, and composite adverse events were more common when ramped.  But patients most likely to be ramped were also obese or had predicted difficult airway.

Why does this matter?
Head-up or ramped position may be helpful for some patients when intubating in the ED and is certainly helpful for preoxygnation, especially in obese patients.  Check-UP found it did not help in ICU patients, though there were some issues with their ramping technique.  Whether or not this applies to all-comers is unknown.

NEAR to our hearts
This was a retrospective look at the prospectively collected NEAR study data, an airway registry including 25 EDs.  Of 11,480 intubations, the overwhelming majority were supine, with just 5.8% non-supine.  There was a strong association with obesity and suspected difficult airway and use of non-supine position.  Multivariable logistic regression for factors known to be associated with first-pass success, such as age, initial SpO2, level of experience of the intubator, VL vs DL, etc was used to statistically adjust the odds ratio.  With these adjustments, there was no difference in first pass success between those intubated supine or non-supine, (adjusted OR 1.1, 95% CI 0.9-1.4).  There was also no difference in grade I glottic view.  Adverse events (hypoxia, bradycardia, arrest, etc) were more common in the non-supine group (aOR 1.4, 95% CI 1.1-1.7).  Hypoxia was far and away the most common adverse event.  Interestingly, emesis/aspiration was the only adverse event that was lower in the non-supine group.  This suggests, but does not prove, that non-supine may be a good option for UGI bleeds, massive hemoptysis, or bowel obstruction.  The issue of confounding cannot be overstated in this study.  It shows, at least, there is clinical equipoise, paving the way for more randomized trials.  For now, I think it is reasonable to ramp obese patients, especially during preoxygenation, and to consider it when there is greater aspiration risk.

Source
Multicenter Comparison of Non-supine versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study.  Acad Emerg Med. 2019 May 22. doi: 10.1111/acem.13805. [Epub ahead of print]

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Reviewed by Thomas Davis

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