Abstract
BackgroundEndotracheal intubation requires optimum position of the head and neck. In obese females, the usual ramped position might not provide adequate intubating conditions. We hypothesized that a new position, termed modified-ramped position, during induction of anesthesia would facilitate endotracheal intubation through bringing the breasts away from the laryngoscope and would also improve the laryngeal visualization.MethodsSixty obese female patients scheduled for general anesthesia were randomly assigned into either ramped or modified-ramped position during induction of anesthesia. In the ramped position (n = 30), the patient head and shoulders were elevated to achieve alignment of the sternal notch and the external auditory meatus; while in the modified-ramped position (n = 30), the patient shoulders were elevated using a special pillow, and the head was extended to the most possible range. Our primary outcome was the incidence of failed laryngoscopic insertion in the oral cavity (the need for patient repositioning). Other outcomes included time till vocal cord visualization, time till successful endotracheal intubation, difficulty of the mask ventilation, and Cormack-Lehane grade for laryngeal view.ResultsFourteen patients (47%) in ramped group required repositioning to facilitate introduction of the laryngoscope in the oral cavity in comparison to one patient (3%) in the modified-ramped position (p < 0.001). Modified-ramped position showed lower incidence of difficult mask ventilation, shorter time for glottic visualization, and shorter time for endotracheal tube insertion compared to the ramped position. The Cormack-Lehane grade was better in the modified-ramped position.ConclusionModified-ramped position provided better intubating conditions, improved the laryngeal view, and eliminated the need for repositioning of obese female patients during insertion of the laryngoscope compared to ramped position.Clinical trial registrationIdentifier: NCT03640442. Date: August 2018.
Highlights
Endotracheal intubation requires optimum position of the head and neck
According to a pilot study, we found that the incidence of difficult laryngoscopy in obese females is 80%
The modifiedramped group showed lower incidence of difficult laryngoscopy (3% versus 47%, p < 0001), lower incidence of difficult mask ventilation (20% versus 83%, p < 0.001), shorter time for glottic visualization (13 ± 3 s versus 17 ± 2 s, p < 0.001), and shorter time for endotracheal tube insertion compared to the ramped position (Table 2)
Summary
Endotracheal intubation requires optimum position of the head and neck. The usual ramped position might not provide adequate intubating conditions. Adequate conditions for endotracheal intubation require appropriate positioning of head and neck. The most appropriate position for laryngeal visualization, termed “sniffing position” [1], requires flexion of the neck by 35° (achieved by head elevation), and extension of the head by 15° [2] to have the sternum at the same level of the external auditory meatus [3, 4]. The ramped position was suggested to achieve better intubating conditions [3, 5]. The data for the optimum position for intubating patients with obesity are conflicting [3, 5, 6]. It had been suggested that more research and modifications are warranted to reach the proper intubating position [7, 8]
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