JOURNAL ARTICLE
MULTICENTER STUDY
RANDOMIZED CONTROLLED TRIAL

A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults

Matthew W Semler, David R Janz, Derek W Russell, Jonathan D Casey, Robert J Lentz, Aline N Zouk, Bennett P deBoisblanc, Jairo I Santanilla, Yasin A Khan, Aaron M Joffe, William S Stigler, Todd W Rice
Chest 2017, 152 (4): 712-722
28487139

BACKGROUND: Hypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room.

METHODS: Multicenter, randomized trial comparing the ramped position (head of the bed elevated to 25°) with the sniffing position (torso supine, neck flexed, and head extended) among 260 adults undergoing endotracheal intubation by pulmonary and critical care medicine fellows in four ICUs between July 22, 2015, and July 19, 2016. The primary outcome was lowest arterial oxygen saturation between induction and 2 minutes after intubation. Secondary outcomes included Cormack-Lehane grade of glottic view, difficulty of intubation, and number of laryngoscopy attempts.

RESULTS: The median lowest arterial oxygen saturation was 93% (interquartile range [IQR], 84%-99%) with the ramped position vs 92% (IQR, 79%-98%) with the sniffing position (P = .27). The ramped position appeared to increase the incidence of grade III or IV view (25.4% vs 11.5%, P = .01), increase the incidence of difficult intubation (12.3% vs 4.6%, P = .04), and decrease the rate of intubation on the first attempt (76.2% vs 85.4%, P = .02), respectively.

CONCLUSIONS: In this multicenter trial, the ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared with the sniffing position. The ramped position may worsen glottic view and increase the number of laryngoscopy attempts required for successful intubation.

TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02497729; URL: www.clinicaltrials.gov.

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Terren Trott

Interesting article that is pretty contradictory to current views. This is the most relevant article published to EM or CC in that it was outside of the OR with emergent intubations. Part of the study that wasn't focused on as much was the post-hoc analysis of obese patients which did not redemonstrate levitans defining "ramp" article of better views in bariatric surgery patients.

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david avellatall

Probably and generate little bit compresion in airway... Worsen in mallampaty III or IV

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Tyler Christifulli

Did this 25 degree angle always result in an ear to sternal notch?

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