“The role of a clown and a physician are the same – it’s to elevate the possible and to relieve suffering.”
Do you regularly raise the head of the bed when you intubate? Well, maybe you should!
A recent manuscript in the American Journal of Emergency Medicine (Turner et al. 2017) actually found a greater first-pass success rate with inclination at or above 45 degrees (also called “upright” intubation). This particular study involved 231 intubations distributed over 58 residents in two different hospital settings. First-pass success was 65.8% for the “supine” group (0-10 degrees of elevation), 77.9% for the “inclined” group (11-44 degrees of elevation), and 85.6% for the upright group. They also note that for every 5 degrees of inclination, there was a marginal improvement in first-pass success.
So why would we expect this and what are the theoretical benefits here? Well, raising the head of the bed should improve your view. The posterior pharyngeal and glottic structures should be in your line-of-sight more easily (Lee et al. 2007). Head of bed elevation may also be associated with decreased peri-intubation complications (Khandelwal et al. 2016). Lastly, upright positioning has been associated with longer times to desaturation (Altermatt et al. 2005, Dixon et al. 2005, Lane et al. 2005).
Unfortunately, as expected, more research is still needed here – ideally a randomized control trial. That being said, try in your practice if you are not already doing it. Raising the head of the bed may drastically improve your first-pass success rate. It certainly has for me!
Altermatt, F. R., et al. “Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea.” British journal of anaesthesia 95.5 (2005): 706-709.
Cleary, Ben. “Bed-Up-Head-Elevated Position for Emergent Intubation.” Core EM. N.p., 19 May 2016. Web. 06 Feb. 2017. <https://coreem.net/journal-reviews/buhe-position>.
Dixon, Benjamin J., et al. “Preoxygenation Is More Effective in the 25° Head-up Position Than in the Supine Position in Severely Obese PatientsA Randomized Controlled Study.” The Journal of the American Society of Anesthesiologists 102.6 (2005): 1110-1115.
“Head-up Intubation.” ScanCrit. N.p., 11 June 2016. Web. 06 Feb. 2017. <http://www.scancrit.com/2016/06/10/head-up-intubation>.
Khandelwal, Nita, et al. “Head-elevated patient positioning decreases complications of emergent tracheal Intubation in the ward and intensive care unit.” Anesthesia & Analgesia 122.4 (2016): 1101-1107.
Lane, S., et al. “A prospective, randomised controlled trial comparing the efficacy of pre‐oxygenation in the 20° head‐up vs supine position.” Anaesthesia 60.11 (2005): 1064-1067.
Lee, B. J., J. M. Kang, and D. O. Kim. “Laryngeal exposure during laryngoscopy is better in the 25 back-up position than in the supine position.” British journal of anaesthesia 99.4 (2007): 581-586.
Milliner, Brendan. “Keep Your (patient’s) Head Up for better intubations.” SinaiEM. N.p., 11 Apr. 2016. Web. 06 Feb. 2017. <http://sinaiem.org/keep-your-patients-head-up-for-better-intubations>.
Strayer, Reuben. “Intubate with the head of the bed elevated.” Emergency Medicine Updates. N.p., 20 Aug. 2011. Web. 06 Feb. 2017. <http://emupdates.com/2011/08/20/intubate-with-the-head-of-the-bed-elevated>.
Turner, Joseph S., et al. “Feasibility of upright patient positioning and intubation success rates at two academic emergency departments.” The American Journal of Emergency Medicine (2017). Accepted 4 Feb. 2017.
Cropped image taken from Turner et al. 2017.