Pilot Study Examining Bed Angles and Heights During Ramped Position Intubation in the Emergency Department

Ramped positioning during emergent endotracheal intubation has been associated with fewer peri-intubation complications, including a decrease in difficult intubations, esophageal intubations, pulmonary aspiration, and hypoxemia. However, the optimal bed angle and height for ramped position intubation have not been determined. Our objective was to examine the effect bed angle and height in the ramped position may have on laryngeal views during emergent intubation in the emergency department (ED).

We performed a secondary analysis of prospectively collected quality improvement data on intubations from our ED. All adult medical intubations performed with ramped positioning in the ED over a 24-month study period (September 1, 2020, through August 30, 2022) were eligible. We compared laryngeal views using the percentage of glottic opening (POGO) score between ramp angles (≥30° and <30° from horizontal) and bed heights (relative to the intubator, including xiphoid or above, umbilicus or below, and between xiphoid and umbilicus).

Of the 251 patients intubated during the study period, 201 were intubated in the supine position and 50 in the ramped position. Data forms were completed for 25 patients intubated using ramped position in the ED during the study period. The median ramp angle was 30° (interquartile range (IQR) 25, 40) with 16 (64%) subjects intubated at ≥30° and 9 (36%) subjects at <30°. The median POGO scores for bed angles ≥30° and <30° were 95% (IQR 79, 100) and 90% (IQR 75, 100), respectively. Bed heights varied, with four (16%) intubated at the xiphoid or above height, one (4%) at the umbilicus or below, and 20 (80%) between the xiphoid and umbilicus. The median POGO scores at each position were 95% (IQR 76, 100), 0% (IQR 0, 0), and 95% (IQR 79, 100), respectively.

ED clinicians use a variety of bed angles and heights when intubating in the ramped position. More robust investigations are necessary to determine the optimal bed angle and height for ramped position intubation in the ED.