Effect of Upright Patient Positioning on Intubation Success

Completed

Brief Summary: 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: 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.

Recruitment & Eligibility

Inclusion Criteria

Adult medical intubations in which the intubating resident and supervising faculty both consented to study participation.

Exclusion Criteria

Arm && Interventions

Group	Intervention	Description
Supine intubations (0-10 degrees)	Upright intubation	Intubations performed with patient positioned 0-10 degrees. Patient supine.
Inclined (11-44 degrees)	Upright intubation	Intubations performed with 11-44 degrees of elevation.
Upright (45 degrees or greater)	Upright intubation	intubations performed with patient elevated to 45 degrees or greater

Primary Outcome Measures

Name	Time	Method
First Pass Success	Immediately at the time of the procedure	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.

Secondary Outcome Measures

Name	Time	Method
overall success rate of orotracheal intubation overall success rate of orotracheal intubation overall success rate of intubation	Immediately at the time of the procedure	endotracheal tube in place
Time required for successful intubation	Immediately at the time of the procedure	endotracheal tube in place
esophageal intubation	Immediately at the time of the procedure	endotracheal tube determined to be positioned in esophagus rather
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	Immediately at the time of the procedure	Cormack-Lehane view is a scale that is used to describe the amount of vocal cords visualized during the procedure
best Percent of Glottic Opening (POGO)	obtained during the procedure	Percent of glottis opening refers to the percentage of vocal cords and surrounding anatomy which can be seen during the procedure
Resident Satisfaction with Positioning	following procedure	survey completed following the procedure by provider regarding satisfaction
death in ED	While in the emergency department (1 hour up to 1 day)
death within 5 days of intubation	Death within 5 days following intubation	any cause of death within 5 days after intubation
New pneumonia	within 5 days following intubation	new pneumonia developed within 5 days following an intubation. Not present on admission.