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• W4252136763 abstract "We appreciate the interest demonstrated by Dr Abdulmahdi et al in our recent multicenter randomized trial comparing ramped position to sniffing position during endotracheal intubation of critically ill adults.1Semler M.W. Janz D.R. Russell D.W. et al.A multicenter, randomized trial of ramped position vs sniffing position during endotracheal intubation of critically ill adults.Chest. 2017; 152: 712-722Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Our trial found no difference in lowest oxygen saturation but a worse glottic view and an increased number of laryngoscopy attempts with a ramped position. Abdulmahdi et al highlight two important considerations: (1) the BMI of the patients and (2) their precise position during intubation. First, they point out that several prior studies of ramped position during endotracheal intubation in the operating room focused on obese patients2Collins J.S. Lemmens H.J.M. Brodsky J.B. Brock-Utne J.G. Levitan R.M. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions.Obes Surg. 2004; 14: 1171-1175Crossref PubMed Scopus (270) Google Scholar, 3Rao S.L. Kunselman A.R. Schuler H.G. DesHarnais S. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial.Anesth Analg. 2008; 107: 1912-1918Crossref PubMed Scopus (78) Google Scholar, 4Boyce J.R. Ness T. Castroman P. Gleysteen J.J. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient.Obes Surg. 2003; 13: 4-9Crossref PubMed Scopus (107) Google Scholar and that the benefit of a ramped position might be greatest in this subgroup. In our trial, 95 patients (37.1%) had a BMI ≥ 30 kg/m2. Thus, the number of obese patients in our trial was greater than in any of the prior studies specifically targeting obese patients (sample sizes ranging from 26-85 patients).2Collins J.S. Lemmens H.J.M. Brodsky J.B. Brock-Utne J.G. Levitan R.M. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions.Obes Surg. 2004; 14: 1171-1175Crossref PubMed Scopus (270) Google Scholar, 3Rao S.L. Kunselman A.R. Schuler H.G. DesHarnais S. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial.Anesth Analg. 2008; 107: 1912-1918Crossref PubMed Scopus (78) Google Scholar, 4Boyce J.R. Ness T. Castroman P. Gleysteen J.J. A preliminary study of the optimal anesthesia positioning for the morbidly obese patient.Obes Surg. 2003; 13: 4-9Crossref PubMed Scopus (107) Google Scholar, 5Cattano D. Melnikov V. Khalil Y. Sridhar S. Hagberg C.A. An evaluation of the rapid airway management positioner in obese patients undergoing gastric bypass or laparoscopic gastric banding surgery.Obes Surg. 2010; 20: 1436-1441Crossref PubMed Scopus (35) Google Scholar Moreover, our prespecified analysis by BMI did not suggest the ramped position to be beneficial for obese patients (Fig 4, e-Fig 3 in original manuscript). The best position in which to intubate critically ill adults at the extremes of BMI, however, remains unknown. Second, Abdulmahdi et al inquire about the positioning of patients in both study arms. They worry that our trial “did not permit torso elevation in the sniffing position cohort,” impairing optimal airway alignment, which would bias the trial in favor of the ramped positon. They also worry that the approach to ramped positioning in our trial may have resulted in suboptimal head and neck positioning for optimal airway alignment, which would bias the trial in favor of the sniffing position. Each of the prior trials comparing ramped position to sniffing position in the operating room used differing definitions of ramped position and sniffing position.2Collins J.S. Lemmens H.J.M. Brodsky J.B. Brock-Utne J.G. Levitan R.M. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions.Obes Surg. 2004; 14: 1171-1175Crossref PubMed Scopus (270) Google Scholar, 3Rao S.L. Kunselman A.R. Schuler H.G. DesHarnais S. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial.Anesth Analg. 2008; 107: 1912-1918Crossref PubMed Scopus (78) Google Scholar, 5Cattano D. Melnikov V. Khalil Y. Sridhar S. Hagberg C.A. An evaluation of the rapid airway management positioner in obese patients undergoing gastric bypass or laparoscopic gastric banding surgery.Obes Surg. 2010; 20: 1436-1441Crossref PubMed Scopus (35) Google Scholar We did not attempt to redefine the ramped or sniffing position for our trial and simply provided operators with figures and instructions about each position from prior studies and guidelines. We agree that patient positioning may exert independent effects on physiology (eg, functional residual capacity) and anatomy (eg, upper airway alignment). We also agree that a likely explanation for the difference in findings between our trial and prior trials in the operating room may be the challenge of achieving optimal head and neck alignment in the ramped position during endotracheal intubation of critically ill adults. A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill AdultsCHESTVol. 152Issue 4PreviewHypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room. Full-Text PDF Optimal Position for Intubation in the ICU: An Uneven Playing Field?CHESTVol. 152Issue 6PreviewWe read with great interest the article, “A Multicenter, Randomized Trial of Ramped Position vs Sniffing Position During Endotracheal Intubation of Critically Ill Adults,” published in a recent issue of CHEST (April 2017).1 This prospective multicenter randomized trial compared the ramped position to the sniffing position in 260 patients undergoing endotracheal intubation performed by pulmonary and critical care fellows in ICUs. Although this study found that the median lowest oxygen saturation by pulse oximetry during intubation did not differ between positions, the ramped position increased the incidence of the grade III or IV view, increased the incidence of difficult intubation, and decreased the intubation rate on the first attempt. Full-Text PDF" @default.
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