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Original Research |

A Multicenter, Randomized Trial of Ramped Position versus Sniffing Position during Endotracheal Intubation of Critically Ill Adults

Matthew W. Semler, MD, MSc; David R. Janz, MD, MSc; Derek W. Russell, MD; Jonathan D. Casey, MD; Robert J. Lentz, MD; Aline N. Zouk, MD; Bennett P. deBoisblanc, MD; Jairo I. Santanilla, MD; Yasin A. Khan, MD; Aaron M. Joffe, DO; William S. Stigler, MD; Todd W. Rice, MD, MSc
Author and Funding Information

Conflicts of Interest: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors declare no potential conflicts of interest relevant to the current study. T.W.R. reported serving on an advisory board for Avisa Pharma, LLC and as the Director of Medical Affairs for Cumberland Pharmaceuticals, Inc.

Sources of Funding: MWS was supported by a National Heart, Lung, and Blood Institute (NHLBI) T32 award (HL087738 09). Data collection utilized the Research Electronic Data Capture (REDCap) tool developed and maintained with Vanderbilt Institute for Clinical and Translational Research grant support (UL1 TR000445 from NCATS/NIH). Funding institutions had no role in conception, design, or conduct of the study; collection, management, analysis, interpretation, or presentation of the data; or preparation, review, or approval of the manuscript.

CLINICAL TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT02497729

1Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN

2Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA

3Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL

4Department of Pulmonary/Critical Care, Ochsner Health System, New Orleans, LA

5Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA

Corresponding author: Matthew W. Semler, MD, MSc C-1216 MCN, 1161 21st Ave S., Nashville, TN 37232-2650.


Copyright 2017, . All Rights Reserved.


Chest. 2017. doi:10.1016/j.chest.2017.03.061
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Abstract

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 ramped position (head of the bed elevated to 25 degrees) to sniffing position (torso supine, neck flexed, head extended) among 260 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows in four intensive care units between July 22, 2015 and July 19, 2016. The primary outcome was lowest arterial oxygen saturation between induction and two 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% [IQR 84-99%] with ramped position versus 92% [IQR 79-98%] with sniffing position (P = .27). 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).

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


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