Comparison of glottic views and intubation times in the supine and 25 degree back-up positions

Raj M Reddy, Manish Adke, Pranava Patil, Irina Kosheleva, Saxon Ridley, Anaesthetic Department at Glan Clwyd Hospital, S Agarwal, S Ajam, A Bhatnager, L Bandara, C Beaton, G Bugelli, S Burgess, J Butler, S Chugani, D Cliciovans, D Counsell, J Dougherty, L Dumby, A Evans, C Fulton, S Ganesh, C Goodman, L Griffiths, I Gyorimolnar, Z Hajat, P Hamer, E Hosking, S Hugo, A Idries, A Jacob, P Jirasck, D John, N Juganaru, N Kelly, A Khalil, I Khan, M Khater, P Kucharski, G Leslie, M Liutkus, V Machineni, M Marimuthu, P Michael, A Moss, G Mula, N Murphy, D Pausan, R Pugh, M Quarmby, K Rafferty, A Rajpal, S Raza, D Redfern, N Roy, A Sampath, R Scale, S Shenoy, R Shobha, A Slater, Y Soon, A Sultanpori, L Tee, D Thaker, U Ramesh, C Variu, C Von Sass, D Zabauski, Raj M Reddy, Manish Adke, Pranava Patil, Irina Kosheleva, Saxon Ridley, Anaesthetic Department at Glan Clwyd Hospital, S Agarwal, S Ajam, A Bhatnager, L Bandara, C Beaton, G Bugelli, S Burgess, J Butler, S Chugani, D Cliciovans, D Counsell, J Dougherty, L Dumby, A Evans, C Fulton, S Ganesh, C Goodman, L Griffiths, I Gyorimolnar, Z Hajat, P Hamer, E Hosking, S Hugo, A Idries, A Jacob, P Jirasck, D John, N Juganaru, N Kelly, A Khalil, I Khan, M Khater, P Kucharski, G Leslie, M Liutkus, V Machineni, M Marimuthu, P Michael, A Moss, G Mula, N Murphy, D Pausan, R Pugh, M Quarmby, K Rafferty, A Rajpal, S Raza, D Redfern, N Roy, A Sampath, R Scale, S Shenoy, R Shobha, A Slater, Y Soon, A Sultanpori, L Tee, D Thaker, U Ramesh, C Variu, C Von Sass, D Zabauski

Abstract

Background: We explored whether positioning patients in a 25° back-up sniffing position improved glottic views and ease of intubation.

Methods: In the first part of the study, patients were intubated in the standard supine sniffing position. In the second part, the back of the operating table was raised 25° from the horizontal by flexion of the torso at the hips while maintaining the sniffing position. The best view obtained during laryngoscopy was assessed using the Cormack and Lehane classification and Percentage of Glottic Opening (POGO) score. The number of attempts at both laryngoscopy and tracheal intubation, together with the use of ancillary equipment and manoeuvres were recorded. The ease of intubation was indirectly assessed by recording the time interval between beginning of laryngoscopy and insertion of the tracheal tube.

Results: Seven hundred eighty one unselected surgical patients scheduled for non-emergency surgery were included. In the back-up position, ancillary laryngeal manoeuvres, which included cricoid pressure, backwards upwards rightward pressure and external laryngeal manipulation, were required less frequently (19.6 % versus 24.6 %, p = 0.004). The time from beginning of laryngoscopy to insertion of the tracheal tube was 14 % shorter (median time 24 versus 28 s, p = 0.031) in the back-up position. There was no significant difference in glottic views.

Conclusions: The 25° back-up position improved the ease of intubation as judged by the need for fewer ancillary manoeuvres and shorter time for intubation.

Trial registration: ClinicalTrials.gov Identifier: NCT02934347 registered retrospectively on 14th Oct 2016.

Keywords: Back-up position; Glottis; Intubation; View.

Figures

Fig. 1
Fig. 1
The 25° back-up position. Note flexion of the torso at the hips and the line joining external auditory meatus to the sternal notch being parallel with the operating table
Fig. 2
Fig. 2
Distribution of POGO scores shown as cumulative frequency curves (Supine red, back-up green)
Fig. 3
Fig. 3
Distribution of POGO scores grouped by Cormack and Lehane Grades (Grade I red, Grade II green, Grade III purple, Grade IV blue)

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Source: PubMed

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