Why Not Ramp All Intubations? New RCT Suggests We Should

September 5, 2019

Written by Clay Smith

Spoon Feed
Bed-up-head-elevated (BUHE, aka ramped) position improved glottic view with Mac direct laryngoscopy (DL) over sniffing position and was noninferior to the GlideScope (GS) laryngeal view.

Why does this matter?
The Check-UP RCT found no difference in lowest SpO2 using the ramped position. But there is concern they were ramping incorrectly, with excessive cervical hyperextension and worsened glottic view. A retrospective look at NEAR data also did not show improvement in first pass success when ramped, but the patients most likely to have a difficult airway were also most likely to be ramped. Ramping is most often used in obese patients or when a difficult airway is anticipated. What would prove best in a RCT of all-comers?

Heads up…
This was a single center RCT of 138 low risk OR patients that compared percent of glottic opening (POGO) score with BUHE position using DL with a Mac vs GS view and compared both to baseline sniffing position. Groups were well randomized and otherwise equal. BUHE/DL was noninferior to GS. POGO score with BUHE was 80.14%; GS was 86.45%; difference -6.3% (98% CI, -13.2% to 0.6%). Noninferiority was considered a difference of > -15% on the lower 98% confidence interval. Both were significantly better than sniffing position: BUHE had a 26% improvement in POGO score; GS had a 31% improvement. Since half of difficult intubations are unanticipated, why not position every patient to optimize the view every time? Check-UP ramped wrong. See image. Image A is the sniffing position. Image B was what Check-UP did per their supplemental material (photos). Image C is the correct way to do BUHE, aka ramped position.

Source
Comparison of Macintosh Laryngoscopy in Bed-up-Head-Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial. Anesth Analg. 2019 Jul 23. doi: 10.1213/ANE.0000000000004349. [Epub ahead of print]

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Reviewed by Thomas Davis