Feasibility of  upright patient positioning and intubation success rates At two academic EDs.

OBJECTIVES: Endotracheal intubation is most commonly taught and performed in the supine position. 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 the feasibility of upright intubation in the emergency department. The goal of this study was to measure the success rate of emergency medicine residents performing intubation in supine and non-supine, including upright positions.

METHODS: This was a prospective observational study. Residents performing intubation recorded the angle of the head of the bed. The number of attempts required for successful intubation was recorded by faculty and espiratory therapists. The primary outcome of first past success was calculated with respect to three groups: 0-10° (supine), 11-44° (inclined), and ≥45° (upright); first past success was also analyzed in 5 degree angle increments.

RESULTS: A total of 231 intubations performed by 58 residents were analyzed. First pass success was 65.8% for the supine group, 77.9% for the inclined group, and 85.6% for the upright group (p=0.024). For every 5 degree increase in angle, there was increased likelihood of first pass success (AOR=1.11; 95% CI=1.01-1.22, p=0.043).

CONCLUSIONS: In our study emergency medicine residents had a high rate of success intubating in the upright position. While this does not demonstrate causation, it correlates with recent literature challenging the traditional supine approach to intubation and indicates that further investigation into optimal positioning during emergency department intubations is warranted.