A comparison of ramping position and sniffing position during endotracheal intubation: a systematic review and meta-analysis
Comparação entre a posição de rampa e posição olfativa durante intubação traqueal: revisão sistemática e meta-análise
Samuel Ern Hung Tsan, Ka Ting Ng, Jiaying Lau, Navian Lee, Viknaswaran, Chew Yin Wang
Abstract
Objectives
Positioning during Endotracheal Intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position.
Methods
PubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack-Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4) and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary manoeuvres and complications during ETI.
Results
Seven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta-analysis was conducted by pooling the effect estimates for all 4 included RCTs (n = 632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway manoeuvres and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR = 2.05, 95% CI 1.26 to 3.32,p = 0.004) and lower likelihood of CLG 3/4 (OR = 0.49, 95% CI 0.30 to 0.79, p = 0.004), moderate quality of evidence.
Conclusion
Our meta-analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI, by improving laryngeal exposure. Large-scale well-designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.
Keywords
Resumo
Objetivos
A posição do paciente durante a Intubação Traqueal (IT) é fundamental para o sucesso do procedimento. Nosso objetivo foi determinar se a posição de rampa melhorou a visualização laríngea e o êxito na primeira tentativa de intubação quando comparada à posição olfativa.
Métodos
Os bancos de dados PubMed, EMBASE e Cochrane CENTRAL foram pesquisados de forma sistemática a partir da data em que os bancos de dados foram estabelecidos até janeiro de 2020. Nossos desfechos primários incluíram a visualização laríngea avaliada como Cormack-Lehane Grau 1 ou 2 (CLG 1/2), Cormack-Lehane Grau 3 ou 4 (CLG 3/4) e o êxito na primeira tentativa de intubação. Os desfechos secundários foram o tempo de intubação, uso de dispositivos adjuvantes para manuseio de vias aéreas, manobras auxiliares e complicações durante a IT.
Resultados
Sete estudos preencheram nossos critérios de inclusão, dos quais 4 eram Estudos Clínicos Randomizados (ECR) e 3 eram estudos de coorte. A meta-análise foi conduzida combinando as estimativas de efeito para todos os 4 ECR incluídos (n = 632). Não foram encontradas diferenças entre as posições de rampa e olfativa para razão de chances de CLG 1/2, CLG 3/4, sucesso na primeira tentativa de intubação, tempo de intubação, uso de manobras auxiliares das vias aéreas e uso de dispositivos adjuvantes de vias aéreas, havendo evidência de alta heterogeneidade nos estudos. No entanto, a posição de rampa em pacientes cirúrgicos está associada com maior probabilidade de CLG 1/2 (OR = 2,05; 95% IC 1,26 a 3,32;p = 0,004) e menor probabilidade de CLG 3/4 (OR = 0,49; 95% IC 0,30 a 0,79; p = 0,004), com qualidade moderada de evidência.
Conclusão
Nossa meta-análise demonstrou que a posição de rampa pode beneficiar pacientes cirúrgicos submetidos a IT, melhorando a visualização laríngea. ECR multicêntricos bem projetados com amostras grandes devem ser realizados para esclarecer ainda mais os benefícios da posição de rampa nos pacientes cirúrgicos e na unidade de terapia intensiva.
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References
1 C. Frerk, V.S. Mitchell, A.F. McNarry, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth., 115 (2015), pp. 827-848
2 D. Cattano, V. Melnikov, Y. Khalil, S. Sridhar, C.A. Hagberg An evaluation of the rapid airway management positioner in obese patients undergoing gastric bypass or laparoscopic gastric banding surgery Obes Surg., 20 (2010), pp. 1436-1441
3 J.S. Collins, H.J.M. Lemmens, J.B. Brodsky, J.G. Brock-Utne, R.M. Levitan Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions Obes Surg., 14 (2004), pp. 1171-1175
4 M. Dhar, H.M.R. Karim, N. Rajaram, A. Prakash, S.K. Sahoo, A. Narayan A randomised comparative study on customised versus fixed sized pillow for tracheal intubation in the sniffing position by Macintosh laryngoscopy Indian J Anaesth., 62 (2018), p. 344
5 P.W. Lebowitz, H. Shay, T. Straker, D. Rubin, S. Bodner Shoulder and head elevation improves laryngoscopic view for tracheal intubation in nonobese as well as obese individuals J Clin Anesth., 24 (2012), pp. 104-108
6 B. Lee, J.M. Kang, D.O. Kim Laryngeal exposure during laryngoscopy is better in the 25º back-up position than in the supine position Br J Anaesth., 99 (2007), pp. 581-586
7 J.-H. Lee, H.-C. Jung, J.-H. Shim, J.-H. Lee Comparison of the rate of successful endotracheal intubation between the "sniffing" and "ramped" positions in patients with an expected difficult intubation: a prospective randomized study Korean J Anesth., 68 (2015), p. 116
8 S.E.H. Tsan, S.M. Lim, M.F.Z. Abidin, S. Ganesh, C.Y. Wang Comparison of Macintosh laryngoscopy in bed-up-head-elevated position with GlideScope laryngoscopy: a randomized, controlled, noninferiority trial Anesth Analg. (2019), 10.1213/ANE.0000000000004349 E-Pub ahead of print
9 N Khandelwal, S Khorsand, Sh Mitchell, Am. Joffe Head-elevated patient positioning decreases complications of emergent tracheal intubation in the ward and intensive care unit Anesth Analg., 122 (2016), pp. 1101-1107
10 S. Lane, D. Saunders, A. Schofield, R. Padmanabhan, A. Hildreth, D. Laws A prospective, randomised controlled trial comparing the efficacy of pre‐oxygenation in the 20° head‐up vs supine position Anaesthesia., 60 (2005), pp. 1064-1067
11 V. Ramkumar, G. Umesh, F.A. Philip Preoxygenation with 20º head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults J Anesth., 25 (2011), pp. 189-194
12 R.M. Reddy, M. Adke, P. Patil, I. Kosheleva, S. Ridley Comparison of glottic views and intubation times in the supine and 25-degree back-up positions BMC Anesthesiology., 16 (2016), p. 113
13 M.W. Semler, D.R. Janz, D.W. Russell, et al. A multicenter, randomized trial of ramped position vs sniffing position during endotracheal intubation of critically ill adults Chest., 152 (2017), pp. 712-722
14 D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, Prisma Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement Annals Internal Med., 151 (2009), pp. 264-269
15 R.S. Cormack, J. Lehane Difficult tracheal intubation in obstetrics Anaesthesia., 39 (1984), pp. 1105-1111
16 Wells G.A., Shea B., O’Connell D., et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses, Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (assessed 3 May 2019).
17 H. Schünemann, J. Brożek, G. Guyatt, A. Oxman (Eds.), GRADE handbook for grading quality of evidence and strength of recommendations, The GRADE Working Group, editor (2013)
18 L.K. Nayak, D.C. Desingh, N. Narang, A. Sethi Comparison of laryngoscopic view obtained by conventional head rise to that obtained by horizontal alignment of external auditory meatus and sternal notch Anesth Essays Res., 13 (2019), pp. 535-538
19 JPA Ioannidis, TA Trikalinos The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey Canad Med Association J., 176 (2007), pp. 1091-1096
20 J. Lau, J.P.A. Ioannidis, N. Terrin, C.H. Schmid, I. Olkin The case of the misleading funnel plot Br Med J., 333 (2006), pp. 597-600
21 J.A.C. Sterne, A.J. Sutton, J.P.A. Ioannidis, et al. Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials British Medical Journal., 343 (2011), p. d4002
22 K.N. Williams, F. Carli, R.S. Cormack Unexpected, difficult laryngoscopy: a prospective survey in routine general surgery Br J Anaesth., 66 (1991), pp. 38-44
23 J.L. Apfelbaum, C.A. Hagberg, R.A. Caplan, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists task force on management of the difficult airway Anesthesiology., 118 (2013), pp. 251-270
24 F. Adnet, S.W. Borron, S.X. Racine, et al. The intubation difficulty scale (IDS): Proposal and evaluation of a new score characterizing the complexity of endotracheal intubation Anesthesiology., 87 (1997), pp. 1290-1297
25 M. Taboada, P. Doldan, A. Calvo, et al. Comparison of tracheal intubation conditions in operating room and intensive care unit: a prospective, observational study Anesthesiology., 129 (2018), pp. 321-328
26 TM Cook, SR MacDougall-Davis Complications and failure of airway management Br J Anaesth., 109 (2012), pp. i68-i85
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