View source for EBQ:A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults.

{{JC info
| title= A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults.
| abbreviation=Check-UP
| expansion=Checklists and Upright Positioning in endotracheal intubation of critically ill patients
| published= May 6th, 2017
| author= Semler MW, Janz DR, Russell DW, Casey JD, Lentz RJ, Zouk AN, deBoisblanc BP, Santanilla JI, Khan YA, Joffe AM, Stigler WS, Rice TW
| journal= Chest
| year= 2017
| volume= epublished ahead of print
| issue=
| pages= 
| pmid= 28487139
| fulltexturl= https://www.ncbi.nlm.nih.gov/pubmed/28487139
| pdfurl=http://journal.chestnet.org/article/S0012-3692(17)30881-4/pdf
}}
==Clinical Question==
In critically ill patients, does the ramped position allow for a higher lowest arterial saturation during intubation as compared to the sniffing position?
*Population: critically ill ICU patients
*Intervention: ramped position during intubation
*Comparison: sniffing position during intubation
*Outcome: lowest SPO2%
*Secondary outcomes:
**Cormack-Lehane grade of glottic view
**difficulty of intubation
**number of laryngoscopy attempts
==Conclusion==
*Primary outcome: The ramped position (as compared to sniffing position) did NOT improve oxygenation during endotracheal intubation in critical ICU patients.
*Secondary outcomes:
**The ramped position may worsen glottic view.
**The ramped position may increase the number of laryngoscopy attempts prior to intubation
==Major Points== 

==Study Design==
*multicenter randomized control study
**computer randomized to ramped vs. sniffing in 1:1 ratio
**sequentially numbered opaque envelopes
*pragmatic trial
*written preintubation checklist: pictures provided at bedside for specific position
*operator-reported subjective difficulty of intubation, airway complications, Cormack-Lehane
*powered to detect 5% difference in SPO2 at α level of 0.05
==Population==
*ICU patients requiring endotracheal inbutation in four tertiary centers
**Vanderbilt, LSU, Oschner, UAB
===Patient Demographics===
≥18 y.o. in ICU at 4 tertiary centers undergoing endotracheal intubation by a pulmonary/crit care fellow
===Inclusion Criteria===
*≥18 y.o.
*ICU patient
*intubated by pulm/crit care fellow
*sedation and neuromuscular blockade
===Exclusion Criteria===
*intubation required too urgently to obtain randomization envelope
**cardiac arrest, respiratory arrest, post extubation stridor, massive hemoptysis/hematemesis, hemodynamic instability)
*thought to need a specific position
**supine for cervical instability (3)
**ramped for ICH (1)
**ramped for severe hypoxemia (1)
**upright for aspiration (1)
==Interventions== 
*ramped positioning for endotracheal intubation: ICU beds with heads electronically raised to 25°
**patient's occiput ramped on top of mattress so that face is parallel to ceiling
**lower half of bed parallel to floor
*sniffing position:  entire bed horizontal with blankets/towels beneath head and neck
**neck flexion, slight head extension relative to the neck. 
**elevation of the shoulders or torso was not permitted.

==Outcomes==
===Primary Outcome===
*lowest arterial oxygen saturation during intubation as measured by pulse oximetry 92% (sniffing) vs. 93% (ramped) p=0.27
**from moment of induction until 2 minutes after intubation
===Secondary Outcomes=== 
*Secondary outcomes all worse in ramped as compared to sniffing
**Cormack-Lehane grade of laryngoscopic view p=0.01
**difficulty of intubation p=0.04
**number of laryngoscopy attempts: first pass success 76.2% (ramped) vs 85.4% (sniffing)  p=0.02
*several procedural outcomes showed advantage in sniffing position as well
**bougie required in 19.2% (ramped) vs. 6.2% (sniffing) p=0.002
**second laryngoscopy technique required in 16.2% (ramped) vs. 6.2% (sniffing) p=0.01
===Subgroup analysis===
*Patients very similar in demographics, vasopressor use, active medical conditions, indication for intubation, recent hypoxemia, preoxygenation, and clinical outcomes
*Operators very similar in duration of training, previous intubations,
==Criticisms & Further Discussion==
*well-designed multi-center RCT showing nonsuperiority of ramp vs. sniffing position in ICU intubation
**concealed allocation prevents selection bias
**end points collected by blinded, independent observer, eliminating observer bias
*previous OR trials showing improved lowest SPO2 in ramped position are in stable, surgically-cleared patients
**this study may be more generalizable to the patients requiring intubation in the ED
*non-patient focused 2ndary outcomes: how much do quality of view, subjective difficulty, first pass success, and procedural outcomes affect patient morbidity/mortality? Especially given the reported statistical equivalence of clinical outcomes in this trial.
*excluded patients requiring urgent intubation
*subjective secondary outcomes
*fellows intubating: how generalizable are these to more experienced practitioners?
*practitioners baseline more experienced in sniffing position: median 37 (sniffing) vs. 10 (ramped)
**in post hoc analysis, previous experience with sniffing vs. ramped did not affect lowest SPO2 or procedural outcome
==External Links==
https://emcrit.org/emnerd/cc-nerd-case-anatomic-inaccuracy/
==See Also==
[[intubation]]
==Funding==

==References==
<references/>

[[Category:EBQ]]