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Bennett S, Alkhouri H, Badge H, Long E, Chan T, Vassiliadis J, Fogg T. Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study. Emerg Med Australas 2023; 35:983-990. [PMID: 37429648 DOI: 10.1111/1742-6723.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE Successful endotracheal intubation in the ED requires optimum body positioning. In patients with obesity, the ramp position was suggested to achieve better intubating conditions. However, limited data are available on the airway management practices for patients with obesity in Australasian EDs. The aim of this study was to identify current patient positioning practices during endotracheal intubation and its association with first-pass success (FPS) at intubation and adverse event (AE) rates in obese and non-obese populations. METHODS Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between 2012 and 2019 were analysed. Patients were categorised into two groups according to their weight: <100 kg (non-obese) or ≥100 kg (obese). Four position categories were investigated; supine, pillow or occipital pad, bed tilt and ramp or head-up with relation to FPS and complication rate using logistic regression modelling. RESULTS A total of 3708 intubations from 43 EDs were included. Overall, the non-obese cohort had a greater FPS rate (85.9%) compared to the obese group (77.0%). The bed tilt position had the highest FPS rate (87.2%), whereas the supine position had the lowest (83.0%). AE rates were highest in the ramp position (31.2%) compared to all other positions (23.8%). Regression analysis showed ramp, or bed tilt positions and a consultant-level intubator were associated with higher FPS. Obesity, in addition to other factors, was independently associated with lower FPS. CONCLUSION Obesity was associated with lower FPS, which could be improved through performing a bed tilt or ramp positioning.
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Affiliation(s)
- Samantha Bennett
- Faculty of Medicine, The University of Notre Dame Australia, Sydney, New South Wales, Australia
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Helen Badge
- School of Allied Health, Faculty of Health Science, Australian Catholic University, Sydney, New South Wales, Australia
| | - Elliot Long
- The Royal Children's Hospital, Murdoch Children's Research Institute, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trevor Chan
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
- Emergency Department, St George Hospital, Sydney, New South Wales, Australia
| | - John Vassiliadis
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Discipline of Emergency Medicine, Northern Clinical School, The University of Sydney Medical School, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- CareFlight, Sydney, New South Wales, Australia
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Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med 2023; 51:1411-1430. [PMID: 37707379 DOI: 10.1097/ccm.0000000000006000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
RATIONALE Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division or Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
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Genc A, Karaman T, Karaman S, Gurler Balta M, Tapar H, Dogru S, Suren M. The effect of head position on glottic visualization with video laryngoscope and intubation success in obese patients who are not expected to have a difficult airway: a prospective randomized clinical study. J Clin Monit Comput 2022; 36:1785-1793. [PMID: 35141803 DOI: 10.1007/s10877-022-00827-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 02/01/2022] [Indexed: 11/29/2022]
Abstract
Intubation is required to maintain anesthesia in patients who are planned to undergo surgery under general anesthesia. One of the most important steps for successful intubation is to position head and neck appropriately. Sniffing position, head extension position, and neutral head position are the most known and used head and neck positions. The aim of this study is to examine the effect of head position on glottic visualization with McGrath MAC® video laryngoscope (VL) and intubation success in obese patients who are scheduled for surgery. A total of 150 patients, 50 patients in each group, with a body mass index of 30 and above were included in the study. The patients included in the study were divided into three groups: neutral head position, head extension position and sniffing position. During the intubation with McGrath MAC® VL, the groups were compared in terms of percent of glottic opening (POGO) score, intubation duration and Intubation Difficulty Scale (IDS) score. While the POGO score was found to be statistically significantly higher in the sniffing position than in the neutral head position (p < 0.001), it was similar in the extension position. The intubation duration was found to be statistically significantly shorter in the sniffing position than in the neutral head position (p = 0.001). However, there was no statistically significant difference between sniffing and extension positions. IDS score was found to be statistically significantly higher in the neutral head position compared to the other positions (p < 0.001, p < 0.001, respectively). In addition, the IDS score was statistically significantly higher in head extension position than in sniffing position (p = 0.016). This study is a randomized controlled trial of 150 patients investigating the impact of head position on glottic visualization and intubation success in obese patients when using Macintosh-like VL. The results show that sniffing position may be favored.
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Affiliation(s)
- Ali Genc
- Anesthesiology and Reanimation Department, Tokat Turhal State Hospital, Tokat, Turkey.
| | - Tugba Karaman
- Anesthesiology and Reanimation Department, Tokat Gaziosmanpasa University Hospital, Tokat, Turkey
| | - Serkan Karaman
- Anesthesiology and Reanimation Department, Tokat Gaziosmanpasa University Hospital, Tokat, Turkey
| | - Mehtap Gurler Balta
- Anesthesiology and Reanimation Department, Tokat Gaziosmanpasa University Hospital, Tokat, Turkey
| | - Hakan Tapar
- Anesthesiology and Reanimation Department, Tokat Gaziosmanpasa University Hospital, Tokat, Turkey
| | - Serkan Dogru
- Anesthesiology and Reanimation Department, Mersin Training and Research Hospital, Mersin, Turkey
| | - Mustafa Suren
- Anesthesiology and Reanimation Department, Samsun Training and Research Hospital, Samsun, Turkey
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Hung CCL, Wong A. Endotracheal intubation in a ramped versus supine position in the emergency department: A randomised crossover manikin study. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920941638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Performing endotracheal intubation by placing patients in a ramped position has been shown to improve the ease of intubation and to reduce complications. The above findings, however, were only established in the operation theatre and intensive care settings. Objective: In order to establish the findings in the setting of the emergency department, we attempt to compare the ramped versus supine positions in normal and difficult airway scenarios. Methods: Medical doctors practicing at a local Accident and Emergency Department were recruited into a crossover randomised study. They were asked to perform intubations on a manikin in four scenarios. The manikin was put in a ramp or supine position. In addition, the manikin settings were adjusted to normal and difficult airways. Results: A total of 39 Accident and Emergency Department doctors were recruited. There was no statistically significant difference in the first-attempt success rates using the ramped position compared to supine position in either airway scenario (100% vs. 97.4%, P = 1 in normal airway, 79.5% vs. 74.4%, P = 0.789 in difficult airway). The mean intubation time in difficult airway setting was shorter when the manikin was put into ramped position (28.3 s vs. 38.4 s, P = 0.134). The ramped position improved the glottic view in the difficult airway setting ( P = 0.017). More intubators preferred to place the manikin into a ramped position during difficult airway setting (67%, P = 0.007). Experienced male intubators performed better in normal airway scenarios, whereas Accident and Emergency Department fellows performed better in difficult airway scenarios. Conclusion: The ramped position improves glottic view and operator ease when intubating a simulated difficult airway.
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Affiliation(s)
- Carolyn Cheuk Lam Hung
- Department of Accident and Emergency, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Anthony Wong
- Department of Accident and Emergency, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
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Nikolla DA, Beaumont RR, Lerman JL, Datsko JS, Carlson JN. Impact of bed angle and height on intubation success during simulated endotracheal intubation in the ramped position. J Am Coll Emerg Physicians Open 2020; 1:257-262. [PMID: 33000040 PMCID: PMC7493484 DOI: 10.1002/emp2.12035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/29/2020] [Accepted: 02/11/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The ramped position is often used during endotracheal intubation to improve oxygenation, improve laryngeal views, and reduce airway complications. We sought to compare the impact of ramp angle and bed height on intubation outcomes during simulated endotracheal intubation. METHODS We enrolled emergency medicine residents and fourth-year medical students to perform simulated direct laryngoscopy and endotracheal intubation in random order with the mannequin in the following combinations of ramp angles and bed heights; ramp angles of 25° and 45° at bed heights including knee, mid-thigh, umbilicus, xiphoid, and nipple/intermammary fold. Our primary outcome was the reported percentage of glottic opening (POGO) score. Secondary outcomes included number of laryngoscopy attempts and intubation time. RESULTS We enrolled 25 participants. There was no difference in reported POGO scores at 25° between bed heights, but at 45°, the umbilicus bed height had an improved reported POGO score (20; 95% confidence interval [CI] 7-33, P < 0.01) relative to xyphoid. The nipple/inframammary fold height required longer intubation times in seconds (mean difference [MD] 95% CI) at 25°, (MD, 23.9 [4.6-37.6], P < 0.01) and more laryngoscopy attempts at 45° (MD, 0.48 [0.16-0.79], P < 0.01) relative to xyphoid. There was no difference in laryngoscopy attempts and video POGO between 25° and 45° at all bed heights, but reported POGO at the umbilicus position was better at 25° than 45° (12 [1-23], P = 0.03). CONCLUSION The umbilicus bed height resulted in the highest reported POGO at 45°. Nipple/inframammary fold height resulted in worse intubating conditions.
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Affiliation(s)
- Dhimitri A. Nikolla
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Ryann R. Beaumont
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Jessica L. Lerman
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Joseph S. Datsko
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
| | - Jestin N. Carlson
- Department of Emergency MedicineAllegheny Health Network—Saint Vincent Hospital, EriePennsylvania
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