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Our hypothesis is that the view of the glottis may be improved by putting all patients requiring intubation in the ramped or back up position while maintaining the classic sniffing position.
The sniffing position has traditionally been considered the optimal head position for direct laryngoscopy and is the usual patient position preferred by most anaesthetists. In theory, neck flexion aligns the pharyngeal and laryngeal axes, and head extension at the atlanto-occipital joint aligns the oral axis with these two axes allowing the line of sight to fall on the glottis. It is recognized as the starting head position for direct laryngoscopy because it provides the best chance of adequate exposure.
However the sniffing position does not guarantee adequate exposure in all patients because many other anatomical factors control the final degree of visualization.
To achieve a proper sniffing position in obese patients, the "ramped" (or the back-up) position has been used as this produces better neck flexion and head extension in these patients when compared to the horizontal supine position. Also the forces required to elevate and move the tongue and other tissues out of the line of sight are less when the patients are ramped.
Our hypothesis is that the view of the glottis may be improved by putting all (ie not only obese) patients requiring intubation in the ramped or back up position while maintaining the classic sniffing position.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Supine | A baseline group of adult patients who required intubation as part of their routine anaesthesia who were intubated in the standard horizontal sniffing position. | ||
| Back-up | A subsequent group of similar the patients who had their anaesthesia induced and tracheas intubated in a 25 degree back-up position achieved by flexion of the operating table at the hips |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| 25 degree back-up position | Procedure | To test whether a 25 degree back-up position improves laryngeal views and makes intubation easier compared to the standard horizontal position |
| Measure | Description | Time Frame |
|---|---|---|
| The Best Glottic View Obtained During Laryngoscopy | The best glottic view obtained during laryngoscopy was assessed using the Cormack and Lehane classification by the anaesthetist performing the laryngoscopy. The Cormack and Lehane classifies glottic views as follows: Grade 1: Most of the glottis is visible, Grade 2: At best almost half of the glottis is seen, at worst only the posterior tip of the arytenoids is seen., Grade 3: Only the epiglottis is visible, Grade 4: No laryngeal structures are visible. | The view of the glottis was measured once while the patient was being intubated |
| Measure | Description | Time Frame |
|---|---|---|
| The Number of Attempts at Both Laryngoscopy and Tracheal Intubation | The number of attempts at both laryngoscopy and tracheal intubation were recorded | Once at intubation |
| The Use of Ancillary Equipment |
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Inclusion Criteria:
Exclusion Criteria:
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Adult patients who required intubation as part of their routine anaesthesia
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| Name | Affiliation | Role |
|---|---|---|
| Raj M Reddy, FRCA | Anaesthetic Department, Glan Clwyd Hospital, Betsi Cadwaladr University Health Board | Principal Investigator |
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| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 11605921 | Background | Adnet F, Baillard C, Borron SW, Denantes C, Lefebvre L, Galinski M, Martinez C, Cupa M, Lapostolle F. Randomized study comparing the "sniffing position" with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology. 2001 Oct;95(4):836-41. doi: 10.1097/00000542-200110000-00009. | |
| Background | Bannister FB, Macbeth RG. Direct laryngoscopy and tracheal intubation. Lancet 1944; 2: 651-4 | ||
| 20846964 |
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Publish anonymised raw data as supplementary file
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| ID | Title | Description |
|---|---|---|
| FG000 | Supine | A baseline group of adult patients who required intubation as part of their routine anaesthesia who were intubated in the standard horizontal sniffing position. |
| FG001 | Back-up | A subsequent group of similar the patients who had their anaesthesia induced and tracheas intubated in a 25 degree back-up position achieved by flexion of the operating table at the hips |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Supine | A baseline group of adult patients who required intubation as part of their routine anaesthesia who were intubated in the standard horizontal sniffing position. |
| BG001 | Back-up |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | The Best Glottic View Obtained During Laryngoscopy | The best glottic view obtained during laryngoscopy was assessed using the Cormack and Lehane classification by the anaesthetist performing the laryngoscopy. The Cormack and Lehane classifies glottic views as follows: Grade 1: Most of the glottis is visible, Grade 2: At best almost half of the glottis is seen, at worst only the posterior tip of the arytenoids is seen., Grade 3: Only the epiglottis is visible, Grade 4: No laryngeal structures are visible. | Adult patients who required intubation as part of their routine anaesthesia | Posted | Number | participants | The view of the glottis was measured once while the patient was being intubated |
|
Any adverse events relating to assessing the glottic view were recorded. Such assessment occurred during intubation which took a minimum of 4 secs and an maximum of 7 mins 34 sec.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Supine | A baseline group of adult patients who required intubation as part of their routine anaesthesia who were intubated in the standard horizontal sniffing position. |
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The present study was under-powered to detect small differences in glottic views.
There would be additional variation as the results were reported by the whole Anaesthetic Dept rather than a few investigators
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr Raj Reddy | Glan Clwyd Hospital, Betsi Cadwaladr University Health Board | 01745 583910 | Rajashekhar.Reddy@wales.nhs.uk |
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The use of ancillary equipment (e.g. bougie, alternative laryngoscope blades) and manoeuvres (e.g. laryngeal manipulation) were recorded but applied at the intubating anaesthetist's discretion
| Once at intubation |
| The Time Between the Beginning of Laryngoscopy and Detection of Carbon Dioxide on the End-tidal Carbon Dioxide Monitor | The time between the beginning of laryngoscopy and detection of carbon dioxide on the end-tidal carbon dioxide monitor after the successful placement of the tracheal tube was recorded | Once at intubation |
| Background |
| Greenland KB, Edwards MJ, Hutton NJ, Challis VJ, Irwin MG, Sleigh JW. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications. Br J Anaesth. 2010 Nov;105(5):683-90. doi: 10.1093/bja/aeq239. Epub 2010 Sep 15. |
| Background | Jackson C. Bronchoscopy and Esophagoscopy: A Manual of Peroral Endoscopy and Laryngeal Surgery. Philadelphia and London: WB Saunders; 1922 |
| 17611252 | Background | Lee BJ, Kang JM, Kim DO. Laryngeal exposure during laryngoscopy is better in the 25 degrees back-up position than in the supine position. Br J Anaesth. 2007 Oct;99(4):581-6. doi: 10.1093/bja/aem095. Epub 2007 Jul 4. |
| 24355831 | Background | Lee HC, Yun MJ, Hwang JW, Na HS, Kim DH, Park JY. Higher operating tables provide better laryngeal views for tracheal intubation. Br J Anaesth. 2014 Apr;112(4):749-55. doi: 10.1093/bja/aet428. Epub 2013 Dec 18. |
| 19020138 | Background | Rao SL, Kunselman AR, Schuler HG, DesHarnais S. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg. 2008 Dec;107(6):1912-8. doi: 10.1213/ane.0b013e31818556ed. |
| 15527629 | Background | Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg. 2004 Oct;14(9):1171-5. doi: 10.1381/0960892042386869. |
| 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. |
| 22301204 | Background | Lebowitz PW, Shay H, Straker T, Rubin D, Bodner S. Shoulder and head elevation improves laryngoscopic view for tracheal intubation in nonobese as well as obese individuals. J Clin Anesth. 2012 Mar;24(2):104-8. doi: 10.1016/j.jclinane.2011.06.015. Epub 2012 Feb 1. |
| 27852241 | Derived | Reddy RM, Adke M, Patil P, Kosheleva I, Ridley S; Anaesthetic Department at Glan Clwyd Hospital. Comparison of glottic views and intubation times in the supine and 25 degree back-up positions. BMC Anesthesiol. 2016 Nov 16;16(1):113. doi: 10.1186/s12871-016-0280-4. |
A subsequent group of similar the patients who had their anaesthesia induced and tracheas intubated in a 25 degree back-up position achieved by flexion of the operating table at the hips
| BG002 | Total | Total of all reporting groups |
| years |
|
| Sex: Female, Male | One patient's gender was not recorded | Count of Participants | Participants | No |
|
| Region of Enrollment | Number | participants |
|
| BMI | Mean | Standard Deviation | Kg/m^2 |
|
| Type of surgery | Number | participants |
|
| Grade of intubating anaesthetist | Senior anaesthetists were permanent fulled trained members of staff capable of independent practice. Trainee anaesthetists were on approved training programmes, required supervision by a nominated senior anaesthetist and rotated to Glan Clwyd Hospital for a fixed period of training. | Number | participants |
|
| OG001 | Back-up | A subsequent group of similar the patients who had their anaesthesia induced and tracheas intubated in a 25 degree back-up position achieved by flexion of the operating table at the hips |
|
|
|
| Secondary | The Number of Attempts at Both Laryngoscopy and Tracheal Intubation | The number of attempts at both laryngoscopy and tracheal intubation were recorded | Adult patients who required intubation as part of their routine anaesthesia | Posted | Number | participants | Once at intubation |
|
|
|
|
| Secondary | The Use of Ancillary Equipment | The use of ancillary equipment (e.g. bougie, alternative laryngoscope blades) and manoeuvres (e.g. laryngeal manipulation) were recorded but applied at the intubating anaesthetist's discretion | Adult patients who required intubation as part of their routine anaesthesia | Posted | Number | participants | Once at intubation |
|
|
|
|
| Secondary | The Time Between the Beginning of Laryngoscopy and Detection of Carbon Dioxide on the End-tidal Carbon Dioxide Monitor | The time between the beginning of laryngoscopy and detection of carbon dioxide on the end-tidal carbon dioxide monitor after the successful placement of the tracheal tube was recorded | Adult patients who required intubation as part of their routine anaesthesia | Posted | Median | Inter-Quartile Range | seconds | Once at intubation |
|
|
|
|
| 0 |
| 374 |
| 0 |
| 374 |
| EG001 | Back-up | A subsequent group of similar the patients who had their anaesthesia induced and tracheas intubated in a 25 degree back-up position achieved by flexion of the operating table at the hips | 0 | 407 | 0 | 407 |
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| >2 Laryngoscopy attempts |
|
| Laryngoscopy attempts Not recorded |
|
| 1 Intubation attempt |
|
| 2 Intubation attempts |
|
| >2 Intubation attempts |
|
| Intubation attempts Not recorded |
|
| Ancillary equipment: 'Not Used' |
|
| Ancillary equipment use not recorded |
|
| Ancillary manoeuvre: Cricoid |
|
| Ancillary manoeuvre: BURP |
|
| External laryngeal manipulation |
|
| Ancillary manoeuvres: 'Not Used' |
|
| Ancillary manoeuvres not recorded |
|
| Senior & Trainee combined |
|