Effect of Upright Patient Positioning on Intubation Success

Study Overview
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Brief Summary
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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.

Detailed Description
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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. 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.

Official Title
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Prospective Observational Study of the Effect of Upright Patient Positioning on Intubation Success Rates at Two Academic Emergency Departments

Conditions
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Intubation

Intervention / Treatment
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* Procedure: Upright intubation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult medical intubations in which the intubating resident and supervising faculty both consented to study participation. Exclusion Criteria: Pediatric patients Obstetric patients Trauma patients

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Supine intubations (0-10 degrees)<br>Intubations performed with patient positioned 0-10 degrees. Patient supine. | Procedure: Upright intubation<br>* 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<br>|
| Inclined (11-44 degrees)<br>Intubations performed with 11-44 degrees of elevation. | Procedure: Upright intubation<br>* 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<br>|
| Upright (45 degrees or greater)<br>intubations performed with patient elevated to 45 degrees or greater | Procedure: Upright intubation<br>* 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<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | 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 | 

Secondary Outcome Measures

| Outcome Measure | 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 | 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 |