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Endotracheal intubation is most commonly taught and performed with the patient supine. 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 success rates of upright intubation in the emergency department. The goal of this study was to measure the association of head positioning with intubation success rates among emergency medicine residents.
Endotracheal intubation is most commonly taught and performed with the patient supine. 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 success rates of upright intubation in the emergency department. The goal of this study was to measure the association of head positioning with intubation success rates among emergency medicine residents. Study design was a prospective observational study. Residents performing intubation recorded the angle of the head of the bed, and the number of attempts required for successful intubation was recorded by faculty and respiratory therapists. The primary outcome of first past success was calculated with respect to three groups: 0-10 degrees (supine), 11-44 degrees (inclined), and ≥45 degrees (upright); first past success was also analyzed in 5 degree angle increments.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Supine intubations (0-10 degrees) | Intubations performed with patient positioned 0-10 degrees. Patient supine. |
| |
| Inclined (11-44 degrees) | Intubations performed with 11-44 degrees of elevation. |
| |
| Upright (45 degrees or greater) | intubations performed with patient elevated to 45 degrees or greater |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Upright intubation | Procedure | Upright Intubation procedure performed with patient elevated above the supine position. Defined as upright greater to or equal to 45 degrees or inclined 10-44 degrees |
| Measure | Description | Time Frame |
|---|---|---|
| First Pass Success | An attempt was defined as anytime the laryngoscope blade was placed in the patient's mouth. At the beginning of the study residents, faculty, and RTs were educated on this definition. | Immediately at the time of the procedure |
| Measure | Description | Time Frame |
|---|---|---|
| overall success rate of orotracheal intubation overall success rate of orotracheal intubation overall success rate of intubation | endotracheal tube in place | Immediately at the time of the procedure |
| Time required for successful intubation |
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Inclusion Criteria:
Exclusion Criteria:
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Intubation events that were eligible for enrollment included adult medical intubations performed at participating hospitals in which the intubating resident and supervising faculty both consented to study participation.
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| Name | Affiliation | Role |
|---|---|---|
| Joseph Turner, MD | Indiana University | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 17999050 | Background | Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med. 2008 Feb;34(2):222-8. doi: 10.1007/s00134-007-0931-5. Epub 2007 Nov 13. | |
| 9841754 | Background | Mouton WG, Bessell JR, Maddern GJ. Looking back to the advent of modern endoscopy: 150th birthday of Maximilian Nitze. World J Surg. 1998 Dec;22(12):1256-8. doi: 10.1007/s002689900555. |
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| ID | Type | URL | Comment |
|---|---|---|---|
| Study Protocol | View IPD |
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endotracheal tube in place
| Immediately at the time of the procedure |
| esophageal intubation | endotracheal tube determined to be positioned in esophagus rather | Immediately at the time of the procedure |
| cardiac arrest within 30 minutes of the intubation attempt | cardiac arrest within 30 minutes of intubation |
| decrease in oxygen saturation during the procedure | Immediately at the time of the procedure |
| best Cormack-Lehane view | Cormack-Lehane view is a scale that is used to describe the amount of vocal cords visualized during the procedure | Immediately at the time of the procedure |
| best Percent of Glottic Opening (POGO) | Percent of glottis opening refers to the percentage of vocal cords and surrounding anatomy which can be seen during the procedure | obtained during the procedure |
| Resident Satisfaction with Positioning | survey completed following the procedure by provider regarding satisfaction | following procedure |
| death in ED | While in the emergency department (1 hour up to 1 day) |
| death within 5 days of intubation | any cause of death within 5 days after intubation | Death within 5 days following intubation |
| New pneumonia | new pneumonia developed within 5 days following an intubation. Not present on admission. | within 5 days following intubation |
| 15087639 | Background | Burkle CM, Zepeda FA, Bacon DR, Rose SH. A historical perspective on use of the laryngoscope as a tool in anesthesiology. Anesthesiology. 2004 Apr;100(4):1003-6. doi: 10.1097/00000542-200404000-00034. No abstract available. |
| 15271750 | Background | Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004 Aug;99(2):607-13, table of contents. doi: 10.1213/01.ANE.0000122825.04923.15. |
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| 7856895 | Background | Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology. 1995 Feb;82(2):367-76. doi: 10.1097/00000542-199502000-00007. |
| 17562739 | Background | Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations--part I. J Intensive Care Med. 2007 May-Jun;22(3):157-65. doi: 10.1177/0885066607299525. |
| 17712056 | Background | Mort TC. Complications of emergency tracheal intubation: immediate airway-related consequences: part II. J Intensive Care Med. 2007 Jul-Aug;22(4):208-15. doi: 10.1177/0885066607301359. |
| 18604519 | Background | Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med. 2008 Oct;34(10):1835-42. doi: 10.1007/s00134-008-1205-6. Epub 2008 Jul 5. |
| 23184440 | Background | Dargin JM, Emlet LL, Guyette FX. The effect of body mass index on intubation success rates and complications during emergency airway management. Intern Emerg Med. 2013 Feb;8(1):75-82. doi: 10.1007/s11739-012-0874-x. Epub 2012 Nov 25. |
| 19921148 | Background | Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, Verzilli D, Jonquet O, Eledjam JJ, Lefrant JY. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010 Feb;36(2):248-55. doi: 10.1007/s00134-009-1717-8. Epub 2009 Nov 17. |
| 24339292 | Background | Kim GW, Koh Y, Lim CM, Han M, An J, Hong SB. Does medical emergency team intervention reduce the prevalence of emergency endotracheal intubation complications? Yonsei Med J. 2014 Jan;55(1):92-8. doi: 10.3349/ymj.2014.55.1.92. |
| 26866753 | Background | Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184. |
| 16229689 | Background | Lane S, Saunders D, Schofield A, Padmanabhan R, Hildreth A, Laws D. A prospective, randomised controlled trial comparing the efficacy of pre-oxygenation in the 20 degrees head-up vs supine position. Anaesthesia. 2005 Nov;60(11):1064-7. doi: 10.1111/j.1365-2044.2005.04374.x. |
| 15915022 | Background | Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, Laurie CP, O'Brien PE. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005 Jun;102(6):1110-5; discussion 5A. doi: 10.1097/00000542-200506000-00009. |
| 21293885 | Background | Ramkumar V, Umesh G, Philip FA. Preoxygenation with 20 masculine head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults. J Anesth. 2011 Apr;25(2):189-94. doi: 10.1007/s00540-011-1098-3. Epub 2011 Feb 4. |
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| 25488339 | Background | Diggs LA, Viswakula SD, Sheth-Chandra M, De Leo G. A pilot model for predicting the success of prehospital endotracheal intubation. Am J Emerg Med. 2015 Feb;33(2):202-8. doi: 10.1016/j.ajem.2014.11.020. Epub 2014 Nov 20. |
| 19762747 | Background | Neligan PJ, Porter S, Max B, Malhotra G, Greenblatt EP, Ochroch EA. Obstructive sleep apnea is not a risk factor for difficult intubation in morbidly obese patients. Anesth Analg. 2009 Oct;109(4):1182-6. doi: 10.1213/ane.0b013e3181b12a0c. |
| 18420866 | Background | Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope. Anesth Analg. 2008 May;106(5):1495-500, table of contents. doi: 10.1213/ane.0b013e318168b38f. |
Study protocol can be provided via email if requested. Please email turnjose@iu.edu |