Feasibility of  upright patient positioning and intubation success rates At two academic EDs

doi:10.1016/j.ajem.2017.02.011

The American Journal of Emergency Medicine

Volume 35, Issue 7, July 2017, Pages 986-992

https://doi.org/10.1016/j.ajem.2017.02.011 Get rights and content

Abstract

Objectives

Endotracheal intubation is most commonly taught and performed in the supine position. Recent literature suggests that elevating the patient's head to a more upright position may decrease peri-intubation complications. However, there is little data on the feasibility of upright intubation in the emergency department. The goal of this study was to measure the success rate of emergency medicine residents performing intubation in supine and non-supine, including upright positions.

Methods

This was a prospective observational study. Residents performing intubation recorded the angle of the head of the bed. The number of attempts required for successful intubation was recorded by faculty and espiratory therapists. The primary outcome of first past success was calculated with respect to three groups: 0–10° (supine), 11–44° (inclined), and ≥ 45° (upright); first past success was also analyzed in 5 degree angle increments.

Results

A total of 231 intubations performed by 58 residents were analyzed. First pass success was 65.8% for the supine group, 77.9% for the inclined group, and 85.6% for the upright group (p = 0.024). For every 5 degree increase in angle, there was increased likelihood of first pass success (AOR = 1.11; 95% CI = 1.01–1.22, p = 0.043).

Conclusions

In our study emergency medicine residents had a high rate of success intubating in the upright position. While this does not demonstrate causation, it correlates with recent literature challenging the traditional supine approach to intubation and indicates that further investigation into optimal positioning during emergency department intubations is warranted.

Introduction

Endotracheal intubation via direct laryngoscopy has been an important procedure in medicine since the late 19th century [1], [2], [3]. While commonly performed in intensive care units (ICUs), emergency departments (EDs), and even procedural suites, much of what we know about endotracheal intubation comes from anesthesiology experience in the operating room (OR) and much of the practiced technique is historically driven by operative management. Most commonly, this involves supine patient positioning. Furthermore, while there have been significant advances in technology, including the advent of video laryngoscopy, many aspects of the procedure have remained unchanged for more than a century.

Endotracheal intubation in the ED, often done emergently, in contrast to the controlled context of the OR, has a higher incidence of complications (e.g., hypoxemia, aspiration, and hypotension) and difficult intubation [4], [5], [6], [7], [8], [9], [10], [11]. Increasingly reports of “bundled interventions”, “process control” of induction sequence, and even patient positioning have been levied as means to reduce complications associated with emergent endotracheal intubation [6], [12], [13], [14]. Head-elevated positioning has been shown to improve pre-oxygenation in both obese and non-obese patients [14], [15], [16], [17], improve glottic view [18], and reduce complications of intubation [14]. However, data regarding the effect of patient positioning on success rates of emergent endotracheal intubation in an ED environment are lacking.

The goal of this study was to measure the success rate of emergency medicine (EM) residents performing intubation in supine and non-supine, including upright positions. We also sought to measure provider satisfaction and complication rates with endotracheal intubation in an upright position.

Section snippets

Study design and setting

This was a prospective observational study conducted at two academic teaching hospitals affiliated with the Indiana University Emergency Medicine Residency program. The Sidney and Lois Eskenazi Hospital is a county hospital with approximately 100,000 patient visits annually. Indiana University Health Methodist Hospital is a tertiary referral center, also with approximately 100,000 patient visits annually. Data collection occurred from July 17, 2014 – July 16, 2015. The study was approved by the

Characteristics of study subjects

A total of 67 residents consented to participate in the study and 58 of these residents submitted data. Participating residents performed a range of 1–12 intubations. There were 38 residents that submitted three or more intubations, and 31 of these residents submitted intubations in multiple positions. Residents were supervised by 60 different consenting faculty. There were 253 data packets submitted over the course of the study. Of these, 15 were excluded because they were missing the

Discussion

In our study emergency medicine residents intubating patients with the head of the bed elevated to 45° or higher had a high rate of first past success and high rates of satisfaction with patient positioning. Importantly, residents received only very brief training and practice with the technique prior to participating in the study. It is possible that with additional training and experience, the rate of success would have been higher.

There are a number of potential advantages to intubating with

Conclusions

Our study adds to a growing body of evidence that there are advantages to performing endotracheal intubation in an upright rather than the traditional supine position. To our knowledge, this is the first prospective study examining success rates of upright endotracheal intubation in the ED. High success rates with upright positioning suggest this is an area that deserves further study. A randomized control trial would be the next step to more conclusively measure the benefits of upright

Conflict of interest

There is no financial support to report related to this study or manuscript. None of the authors have conflicts of interest to report.

References (25)

J. Li et al.
Complications of emergency intubation with and without paralysis
Am J Emerg Med
(Mar 1999)
B.J. Lee et al.
Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position
Br J Anaesth
(Oct 2007)
M.J. Sagarin et al.
Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts
Ann Emerg Med
(2005 Oct)
L.A. Diggs et al.
A pilot model for predicting the success of prehospital endotracheal intubation
Am J Emerg Med
(2015 Feb)
P. Szmuk et al.
A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age
Intensive Care Med
(Feb 2008)
W.G. Mouton et al.
Looking back to the advent of modern endoscopy: 150th birthday of Maximilian Nitze
World J Surg
(Dec 1998)
C.M. Burkle et al.
A historical perspective on use of the laryngoscope as a tool in anesthesiology
Anesthesiology
(Apr 2004)
T.C. Mort
Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts
Anesth Analg
(Aug 2004)
D.E. Schwartz et al.
Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations
Anesthesiology
(Feb 1995)
S. Jaber et al.
Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study
Crit Care Med
(Sep 2006)

T.C. Mort

Complications of emergency tracheal intubation: hemodynamic alterations—part I

J Intensive Care Med

(May-Jun 2007)

T.C. Mort

Complications of emergency tracheal intubation: immediate airway-related consequences: part II

J Intensive Care Med

(Jul–Aug 2007)

Cited by (39)

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I
2024, Revista Espanola de Anestesiologia y Reanimacion
La sección de Vía Aérea de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES) y la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC) presentan la Guía para el manejo integral de la vía aérea difícil en el paciente adulto. Sus principios están focalizados en el factor humano, los procesos cognitivos para la toma de decisiones en situaciones críticas y la optimización en la progresión de la aplicación de estrategias para preservar una adecuada oxigenación alveolar con el objeto de mejorar la seguridad y la calidad asistencial. El documento proporciona recomendaciones basadas en la evidencia científica actual, herramientas teórico/educativas y herramientas de implementación, fundamentalmente ayudas cognitivas, aplicables al tratamiento de la vía aérea en el campo de la anestesiología, cuidados críticos, urgencias y medicina prehospitalaria. Para ello se realizó una amplia búsqueda bibliográfica según las directrices PRISMA-R y se analizó utilizando la metodología GRADE. Las recomendaciones se formularon de acuerdo con esta metodología. Las recomendaciones de aquellas secciones con evidencia de baja calidad se basaron en la opinión de expertos mediante consenso alcanzado a través de un cuestionario Delphi.
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factor, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
Impact of video laryngoscope shape on first-attempt success during non-supine emergency department intubations
2022, American Journal of Emergency Medicine
Citation Excerpt :
VL blade types, standard geometry vs. hyperangulated, were not associated with first-attempt success in our study of NEAR patients undergoing ED intubation in the ramped or upright positions. However, studies on ramped and upright position intubation in acute care settings have conflicting results [14,32,33]. Therefore, further studies in acute care settings are necessary to investigate subgroups that may benefit from these positions (i.e., obese patients), adjuncts that facilitate intubation in these positions (i.e., bougie), and facets of positioning that facilitate intubation (i.e., bed angle and height).
Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL).
We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects.
Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events.
Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.
Comparison of supine and upright face-to-face cadaver intubation
2022, American Journal of Emergency Medicine
Citation Excerpt :
Turner et al. demonstrated a higher rate of success in the upright position amongst residents performing intubations in the emergency department. Emergency medicine residents intubating patients with the head of the bed elevated to 45° or higher had a high rate of first pass success and high rates of satisfaction with patient positioning [15]. In emergent situations, Khandelwal et al. found that intubating with the head of the bed elevated above 30° was associated with decreased peri-intubation complications, in particular decreased rates of hypoxemia and aspiration [16].
Optimal patient positioning during intubation improves laryngeal view and first pass success, as well as reducing incidence of hypoxia. In certain pre-hospital situations, it may be impractical or impossible for the operator to stand behind the patient.
We compared intubation in the supine and upright face-to-face positions, with regards to time to intubate and the view of the vocal cords obtained.
This was a pilot comparison study. One investigator intubated 25 cadavers with the use of a bougie in the supine and upright face-to-face positions. Each attempt was recorded on a video laryngoscope. Recordings of each attempt were reviewed by five blinded emergency physicians, who allocated both a percentage of glottic opening (POGO) score and Cormack-Lehane (CL) grade. Time to insertion of the endotracheal tube (ETT) through the vocal cords was measured from the video.
The median intubation time was 1 s longer for upright cadavers than for supine cadavers, with greater variation in intubation times for upright cadavers compared with supine cadavers (IQR 9.0 vs 3.5 excluding the outlier case). The mean POGO score (averaged across raters) was 4.7% lower for upright intubation attempts (excluding the outlier case) with a moderate-to-good degree of inter-rater reliability, however this difference was not statistically significant. The median CL grade (averaged across raters) was 0.2 higher for upright intubation attempts (excluding the outlier case) with a poor-to-moderate degree of inter-rater reliability, and this difference was also not statistically significant.
This pilot study suggests that upright, face-to-face intubation may be clinically similar to supine intubation in terms of time to intubation and difficulty. Further studies utilising a larger number of operators and cadaver types are indicated.
Respiratory care for the critical patients with 2019 novel coronavirus
2021, Respiratory Medicine
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted through respiratory droplets, aerosols and close contact. Cross infections occur because viruses spread rapidly among humans. Nineteen percent (19%) of the infected patients developed severe pneumonia and acute respiratory distress syndrome (ARDS). Hypoxemia usually occurs and patients may require oxygen therapy or mechanical ventilation (MV) support. In this article, recently published clinical experience and observational studies were reviewed. Corresponding respiratory therapy regarding different stages of infection is proposed. Infection control principles and respiratory strategies including oxygen therapy, non-invasive respiratory support (NIRS), intubation evaluation, equipment preparation, ventilator settings, special maneuvers comprise of the prone position (PP), recruitment maneuver (RM), extracorporeal membrane oxygenation (ECMO), weaning and extubation are summarized. Respiratory equipment and device disinfection recommendations are worked up. We expect this review article could be used as a reference by healthcare workers in patient care while minimizing the risk of environmental contamination.
Comparison of intubating conditions in supine (sniffing) and 25° back‑up position using channelled and non‑channelled video laryngoscopes ‑ A randomised controlled study
2023, Indian Journal of Anaesthesia
Bed tilt and ramp positions are associated with increased first-pass success of adult endotracheal intubation in the emergency department: A registry study
2023, EMA - Emergency Medicine Australasia

View all citing articles on Scopus

^☆: Partial data from this study was presented at the SAEM Annual Meeting, May 2015 in San Diego.

View full text

Original ContributionFeasibility of upright patient positioning and intubation success rates At two academic EDs☆

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Study design and setting

Characteristics of study subjects

Discussion

Conclusions

Conflict of interest

Am J Emerg Med

Br J Anaesth

Ann Emerg Med

Am J Emerg Med

A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age

Intensive Care Med

Looking back to the advent of modern endoscopy: 150th birthday of Maximilian Nitze

World J Surg

A historical perspective on use of the laryngoscope as a tool in anesthesiology

Anesthesiology

Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts

Anesth Analg

Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations

Anesthesiology

Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study

Crit Care Med

Complications of emergency tracheal intubation: hemodynamic alterations—part I

J Intensive Care Med

Complications of emergency tracheal intubation: immediate airway-related consequences: part II

J Intensive Care Med

Original Contribution
Feasibility of upright patient positioning and intubation success rates At two academic EDs☆