Comparison of Hemodynamic Stability and Intubation Timings and Cormack-Lehane Grading in Ramp Position Versus Sniffing Position
Phase: NA
Conditions: Elective Surgery, General Anesthesia
Sponsor: Shaheed Mohtarma Benazir Bhutto Institue of Trauma

COLLECE OF
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PAKISTAN
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RTMC# ,\N5-2021-292-1421
SPECtA{ltYEs] l IIsIoLoaY
NAME 
SI IA.I]AQ
slD, D/qlwy'oAl ALl lvlEMON
DATE OF COMMENCEMENT OF TRAININC JuI 2.2021
RECEISgD|]25
FCPS-r
ROLL S,r5026
sEssr0N
YEAR 5-2024
SUPERVISOR sYED ZA|AIt MEIIDI
tN sT lTLfltrmy1o1,,"-ra 
Lrcniar DIorro l)51itnre orr unra
TITLE OF 5YNOP5I5
L]O\4PAItISON OF TRACI IEAL INTUBAI tON IN ITAMP POSI']1ON USINO CUSI OMIZED PILLOW VERSUS
SNIFFING POSI l lO\ WITII fIXED PILLOW BY MACIVIOSH LARlNCOSCOPE; A nANDOVISED CONTROL
.TRIAI
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SYNOPSIS
ON
"Comparison of tracheal lntubation in ramp position
using customized pillow versus sniffing position with
fixed size pillow by Macintosh laryngoscope; a
randomized control trial"
By:
Dr. Shafaq D/O Shoukat Ali Memon
Postgraduate Student ofFCPS Part II
I,}IDER SUPERVISION OF:
Dr. Syed Zafar Mehdi
DEPARTMENT OF ANESTHESIOLOGY AND SURGICAL ICU
SHAHEED MOHTARMA BENAZIR BHUTTO INSTITUTE OF TRAUMA

f
To,
The Director,
Research, Training and Monitoring Cell,
College ofPhysician & Surgeons Pakistan,
7th Central Street Phase - II,
Defence Housing Authority, Karachi 75500.
Dear Sir,
Enclosed is a research protocol entitled: "Comparison of tracheal Intubation
in ramp position using customized pillow versus sniffing posation
with fixed size pillow by Macintosh Iaryngoscope; a randomized
control trial"
Prepared by:
fh. Shafaq D/O Shoukat Ali Memon
FCPS Part II
DI
Shoukat
i ANS.2024-292:3423
Narnq of Supervisocr i
,Di. Syed ZafarMehdi
Qualifi
Name of Institute;
Shaheedi Mohtarma Benazir Bhutto Institute of
Trauma
Anesthesioloey and'Sureical ICU
Yours Sincerely,
Supervisor's Signature
Official Stamp:

To,
The In charge,
RTMC, CPSP Defence Phase-II
Karachi-
Subj ect
CERTIX'I
TE OF NON DI]PI, CATION OF SYNOPSIS TOPIC.
It is to certify that Dr. Shafaq D/O Shoukat Ali Memon postgraduate trainee at Department of
Aresthesiology and surgical ICU, shaheed Mohtarma Benazir Bhutto Institute of rrauma
having RTMC Registration No. ANS-2024-292-3423 is working under my supervision.
Her topic for synopsis is "comparison of tracheal lntubation in ramp position using
customized pillow versus sniffing position with fixed size pillow by Macintosh
laryngoscope; a randomized control trial". The study on this topic has not been done at
our Institute by any other candidate in last five years. Therefore, I feel no hesitation in giving this
non-duplication certificate of synopsis topic,
SUPERVISOR:
Dr. Syed Zafar Mehdi
MBBS, F'CPS
Department of Anesthesia and Surgical ICU
Shaheed Mohtarma Benazir Bhutto Institute of Trauma
Si
Official stamp:

, LtJ lvi40z5
>u 0 - t46>3
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Submitted to Higher Education Commission 'l 0r,
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Student Paper
repository-tnmgrmu.ac.in
2,,
2r"
lnternet Source
E
impactfactor.org
lnternet Source
E
8.k., Arjun. "Airtraq Laryngoscope Versus
Macintosh Laryngoscope for Airway
Management: a Randomized Clinical Study",
Rajiv Gandhi University of Health Sciences
(lndia), 2023
Publication
www.th efreel i b ra ry. com
1,,
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lnternet Source
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E
www.e-sciencece ntra l. org
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Internel source
Exclude quotes
Exclude bibliography
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'.)'a

'i
SYNOPSIS
ON
a
"Comparison of tracheal lntubation in ramp position
using customized pillow versus sniffing position with
fixed size pillow by Macintosh laryngoscope; a
randomized control trial"
14 b>
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a t()
By,
Dr. Shafaq D/O Shoukat Ali Mernon
Postgraduate Student of FCPS Part II
UNDtrI{ STJPERVISION OF-:
Dr. Sved Zafar Mehdi
DI]P,\RI'N,IEN'I' OT ANES'I'HESIOI,OGY AND SIJRGICAL ICU
Sil,\tlL]ED N4OIn.ARIvlA BENr\ZIR tlilU ft'O INS'l'tTU'tlt OI. TRAt.rtvtA
reECffiIVEID
RHtJ
C I JUL !::5
CPSP. KAR.rte[41
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SHAHEED BENAZIR BHUTTO INSTITUTE OF TRAUMA
()Ptr R A TI\/tr \ralTl'q
a

I
"Comparison of tracheal lntubation in ramp position
using customized pillow versus sniffing position with
fixed size pillow by Macintosh Iaryngoscope; a
randomized control trial"
INTRODUCTION
Endotracheal intubation for airway management is a crucial skill that every clinician must
master. lnadequate airway management can result in significant complications and even death
for patlents. [1]. One of the fundamental components for successful intubation is proper patient
positioning. Correct alignment of the head and neck is vital for proper laryngeal visualization, as
it keeps the oral, laryngeal, and pharyngeal axis is in line with the observer's view during direct
laryngoscopy. [2] [3]. The most popular method in this area is the sniffing position, which
involves the patient lying supine on a flat bed with or without a pillow, with the lower cervical
spine bent and the upper cervical spine extended [4]. The most reliable explanation for this
positron is thought to be the three-axis alignment theory. [5].
on the other hand, to improve laryngeal visibility, especially in obese patients or those with
anticipated difficult airways, The head-elevated laryngoscopy position entails raising the
patient's head and neck to bring the sternal notch into alignment with the external auditory
meatus. this is typically accomplished by positioning pillows or blankets beneath the patient,s
head and shoulders. [6] [7] to aim in ramping position. Several clinical studies have shown that
the ramp position can provide better exposure of the larynx for tracheal intubation compared to
other positions.
A study by Dr. Habib at Rajput tndia reported in 2018 concluded customizing the height of the
pillow to achieve horizontal alignment between the external auditory meatusand thelternal
notch can be particularly helpful for successful first-attempt tracheal intubation in patients. [8]. A
study conducted by Elizabeth and Srinivasan done in December 2022 lg]The study
demonstrated that ln the study population, the sniffing position ,sing a 4 cm pillow height
provided improved laryngoscopic views and reduced intubation dilliculty compared to a 7 cm
pillorv height.
The purpose of this study is to evaluate the view obtained during laryngoscopy in the sniffing
position with a 4 cm fixed pillow height. versus a customized height ranging from 4 cm to g cm,
achieved by adding sheets or pillows to elevate the head for tracheal intubation. [10] to
determine whether, the ramp position improves laryngeal visualization and less time required for
intubation as compared to the sniffing position with a fixed pillow size.

The study evaluates key outcomes, visualization of the glottis measured by cormack Lehane
grading, time to successful intubation and hemodynamic changes following endotracheal
intu bat io n.
we found paucity of local data for this topic, there is a need to determine whether the ramping
position or the sniffing position offers greater advantages for patients undergoing endotracheal
intubation. ln most studies ramp position was found better for tracheal intubation in obese
patients so we conducted a research study to assess whether the ramping position enhances
laryngeal exposure and increases the success rate of the first intubation attempt, compared to
the sniffing position, for both obese and non-obese patients undergoing endotracheal intubation
The findings of this study may have significant implications for routine anesthetic practice,
potentially leading to more individualized and effective approaches to airway management with
lesser morbidity and mortality.
OBJECTIVE:
To compare the outcome of ramp position with customized pillows and sniffing position with
fixed pillows in terms of the time required for tracheal intubation., cormack Lehane grading and
the hemodynamic changes associated with laryngoscopy.
OPERATIONAL DEFINlTONS:
Time:
lntubation tjme is measured from the insertion of the laryngoscope to the confirmation of
endotracheal tube placement via capnography. Confirmation requires observing three complete
capnographic waveforms. An anesthetist will record the time using a standard stopwatch, and
tube placement will be further verified by auscultation.
Hemodvnam ic alterations observed durin q the intubation
rocess:
Hcmodvnamic alterations, including pulse ratc and blood pressure, rvill be monikrre6 at 0, 3. and
5 minutes fbllowing intubation.
Cormack Lehane Gra d inq:
. Grade 1: Visualization of entire vocal cords.
' Grade 2: Partial visibility of the glottis (only the posterior portion of the vocal cords is visible)
. Grade 3: Visualization of epiglottis.
. Grade 4: No glottic structures seen,
HYPOTHESlS:
NULL HYPOTHESIS: There is no aignificant difference between sniffing and ramp position for
tracheal intubation

I
METHODOLOGY:
STUDY SETTING:
This study wiil take place at the Department of Anesthesiology in the elective operating theaters
of SltilBBIT, Karachi
DURATION OF STUDY:
Approximately 3 to-6 months after CPSP and ERC approval of synopsis
SAMPLE SIZE:
A total of 90 participants were included, with 45 in each.!roup. The sample size calculation was
based on data from a previous study, which reported the mean intubation time in the group
using a fixed pillow height with Cormack lehane grade > 3 is 19.35 (SD:5.95) and for
customized pillow group with cormack lehane 2 3 is 15.38 (sD:5.29). The sample size was
calculated by using WHO sample size calculator with 5% level of significance and 90% power of
the test. [8]
SAMPLING
ECHNIQIJE:
Non-probability consecutive sampling
STUDY DESIGN:
Randomized control trial
INCLUSION CRITERIA:
1. ASA I and II
2. Age group between 18-60 years.
3. Mallampatti scored l and 2
4. Either gender
5. Patients who will undergo elective surgery
6. BMI betr,veen 25-30 were included
EXCLUSION CRITERI A:
1. Patienr with ASA III and IV
2. Patient with cxpected difficult intubation based on mallampatti class III antl rV
3. Patient with maxillo facial trauma, or tumors or obvious malformation of neck or face
4. Plegnant patients
5. Patient with an unstablc cervical spine

l!
The study will be conducted at the Shaheed Mohtarma Benazir Bhutto lnstitute of Trauma after
receiving approval from the GPSP (college of Physicians and surgeons of pakistan) and the
ERC (Ethical Review committee). This clinical trial will be registered @clinicaltrials.gov.
Patients who fulfill inclusion criteria, informed written consent will be taken during preoperative
assessment. Patient will be randomly allocated, aged 18-60 years who meet the inclusion
criteria by computer generated randomization. Patients will be enrolled by the primary
investigator (l myself will be the primary investigator), the day before surgery. They will be
randomly assigned to either Group A or Group B. ln group A fixed pillow size of 4 cm will be
used and in group B customized pillow height between 4cm to Bcm, in order to align external
auditory meatus and sternal notch will be used.
'fhe anesthesia protocol r.r,ill be uniform across all participants, with all patients undergoing ASA
standard monitofing. The patients will be preoxygenated for 3-5 minutes. Anesthesia will be
induced with propofol 2mglkg, and nalbuphine 0, 15 mg/kg. once mask ventilation adequacy is
confirmed, atracurium 0.5 mg/kg will be administered. positive pressure ventilation will be
applied for 3 minutes to achieve full muscle relaxation. perform lrilacintosh laryngoscopy and
grade the laryngeal view using Cormack-Lehane system. Record the time taken for intubation
(from insertton of the laryngoscope to confirmation of endotracheal intubation) by three cycles of
end{idal CO2 measurement ln the case of multiple attempts, the total time for all laryngoscopy
attempts will be recorded. Any assistance provided, such as the use of a bougie, styllt, external
laryngeal pressure, or changes in pillow height, will also be documented. patients will also be
assessed for hemodynamic parameters, including heart rate and blood pressure, at 0, 3, and 5
minutes following intubation. cormack Lehane grading will be done by primary investigator who
will do laryngoscopy, another anesthetist wlll record the timing that is hemodynamic pirameters
and time for intubation, no one is kept blind in this study as the patient is infoimed about the
procedure being performed. Data will be anonymized and confidentiality will be maintained
during and after completion of study.
Data Gatherin
Methodoloov:
DATA ANALYSIS:
sPSS version 26 will be used for data analysis. For quantitative data like age and time to
intubation, the mean and standard deviation will be computed. The median will be presented for
quantitative variables that are not regularly distributed, such as gender, hypertension, diabetes
mellitus, and Mallampatti classificatjon, whereas the mean and standard deviation will be
reported for data that is normally distributed. independent t. test will be applied to compare
glottic view by cormack Lehane classification and time of intubation. And repeated measure
Anova for hemodynamic changes between 2 groups. ln order to assess the impact of effect
modifiers on the results, the data will be stratified by age, gender, and lvlallampatti grades, post
stratification independent t-test and repeated measure Anova test will be applied, taking p-value
of <0.05 will be considered statistically significant. 
I

t
RE
RENCES:
r)
l0) Acharya l). Shr.estha A. Curung
Tsan SEH. Ng KT, Lau J. Viknaslvar.an NL. Wang Cy. Conparagdo entre a posiqao de rampa e
oll'ativa durante intubagao traqueal: revisao sistemiitica e rneta-andlise [A comparison ofrarnpin
irnd snilling position during cndotracheal intubation: a systematic review and mcta-analysis], Br
posiEao
g position
azl
2) Mookarnbika R, Kumar RVH. Areti A, Jaya V. Cornparing the posture and comfort of an aesthesiolog ists
drrr ing laryngoscopy and tracheal intubation in the head-elevarci larlngoscopy position in suplne poiition
and with a 25' backup: A, randornised clinical crossover trial. Inrlian J Anaesth. 2024 Jun:68(6t:54?-52. d€.l
l&4103/ija.ija_1 130 23. 
,,/ 
..-.-
3) Acharya P, Shrcslha A, Gurung A, Koirala M, shtestha GS, Marhatra MN, Effecr ofhead clevation ro
ditterent heights in larvngeal exposure with direcr laryngoscopy. I Nepal Health Res counc. 21x.6 aug
4; I 7(2): I 68-73. doi: I 0.:i33 I 4ijnhlc.v0 j0. I 72 l.
4) Okada Y. Nakayama Y. Hashirnoto K, Koike K, Watanabe N. Ramped versus sniffing position ibr tracheal,/
intulrirtion: A systcrnatic revierv aod rncta-analysis, Ant J llmerg Mctl. 2021 ;44:250- 6. 
,./
5) Rcddy AA, Anudecp A, Kumar v. Patel s, sharna R. Bed-up-head-r-'levated position versus supine,miffing
positior) in patients undcrgoing rapid sequencc intubation using dire,ct laryngoscopy in the crnerygni1
dcpartrnerltr A randomizcd controlled trial. J Emerg Tr.aunra S h ock. 2024; I 7(2):5 g-65. 
l
doi:10.4103/jets.iets 109 23. 
'"/
6) Lotfi SM, Mohanradi MS, Ahrnadi A, Rezvani s, schar M, Tabaraii R. Success rates ofendotrachcal
intLrbation using the standard rncthod versus the modilied-rarnped position. Ann Med Surg (Lond).2023 '-"
Novi85( I I )r549 I -6. doi: 10. 1097/M59.000000000000133 
I .
7) Chun EI I, chung MH, Kirr JE, Kirn KM, Lee IIS, son JM, €t al. Effects of hcad-elevated position on
tracheal intubation using a McGrath MAC videolaryngoscope in patients with a simulat€d d-ifficult airway: a
prospective randotnizecl crossoverstudy.BMCAnesthesiol.2U22May30;22(J)166.dei.rorr86^r2r.7t- 
_
0:2-01 706-5
8) Dhar M. Karim I IMR. Rajatarr N, Prakash A, sY-hoo sK, Narayan A. A randornised corupararive study on
cusromised versus fixed sized pillo\r'tbr tracheal intubation in the sniffing position by Micintosh
lurl rr.r:oscopl lDdian J Anaerrh.l0l8 M3v:62l,1):144-{r. drri: t.0.J l}_r#r.lte_oz: tz. pMlD: 2{){)lOlql:
I']MCID: PMC597lbll. 
\---
Anesthcsiol. 2020 Nov-Dec;70(6)166't -77 . doi 10. t0l6/j.bjan.2020.08,009
9) Vijayakurnar EN. Rarnacharrdran S. Hirernath VR, Kuppusam), S, Shantuusam B. Dhamodharan DB
Evaluation of glottic vielv and intubation conditions rvith sniIfi't
ng position using three different pillorv.
heights during direct laryngoscopy
prospectiv
t.tr
!
e
, Shrestha CS, Marhatta MN. Effect oI hcad elevation to
different hcights in Iaryngeal cxposure rvith direct laryngo scopy. J Ncpal Health Res Counc. 20 l9 Aug
4: I 7(2): I 68-72. dei:HH.3-iH{n1l+e.+si&}7}F

,
PROFORMA
"Comparison of tracheal lntubation in ramp position
using customized pillow versus sniffing position with
fixed size pillow by Macintosh laryngoscope; a
randomized control trial"
MR Number
Age (years).
Gender:
Date:
Group:
Diagnosis
Co morbids:
(l) Hypertension:_
(ll) Diabetes
ASA Class
Mallampati: 'l
2
Weight (kg):
Height (m)
BMI(ks/m2)
Time of arrival
1. Time taken from introduction of laryngoscope till three complete cycles of
capnograph (Time in sec).
Group A (Ramped position with customized pillow): _sec
Group B (Sniffing position with fixed pillow)
2. Cormack Lehane grading
Group A (Ramped position with customized pillow)
Group B (Sniffing position with fixed pi ow)
3. Hemodynamic response to laryngoscopy
Time
(9 min)
sec
Time
syltotic
Blood
Pressure
(SBP)
Diastolic
Blood
Pressure
te
Time
(3 min
Time
!!1i!)
5
(DPB)
Heart Ra

T
"Comparison of tracheal lntubation in ramp position
using customized pillow versus sniffing position with
fixed size pillow by Macintosh laryngoscope; a
randomized control trial"
CONSENT FORM FOR PARTTCIPATION IN RESEARCH
Participation in this study is purely voluntary and without any pressure. you have the right to
refuse participation in this study and this refusal will not result in any unfavorable consequences.
You may contact the investigators if you have any queries regarding this research.
I declare that I have been informed about this research, modes of treatment and possible
complications which may arise from this study and I agree to participate in this study.
DOCTERS NAME:
DOCTERS SIGNA TURE:
PATI ENT/ATTEND ANT NAME:
PATIE NT/ATTE NDANT SIGNATURE:
MR NO:
DATE: