Background: Endotracheal intubation is a common life-saving procedure performed in the emergency department. Recent studies have found that ramped positioning during intubation may present benefits over traditional supine positioning. However, the results of previous studies have differed depending on setting and study design.

Objective: The authors compared the first-pass success rates of ramped and supine positioning in intubation. Secondary outcomes included Cormack-Lehane grade of the glottic view and endotracheal intubation (ETI)-related adverse events in each position.

Materials and Methods: This was a prospective observational study of non-traumatic, non-arrest patients intubated by trained
emergency medicine residents or an experienced attending emergency physician at the emergency department between April 2018 and April 2019. The intubation position used – i.e., ramped (head of the bed elevated 20 to 30 degrees) or supine – was decided upon by the attending physician.

Results: A total of 267 patients were enrolled, 135 (50.6%) and 132 (49.4%) who were intubated in the ramped and supine position, respectively. The first-pass success rates of patients the two positions were similar (ramped = 86.7% vs. supine = 78.0%, p = 0.066). Multivariate analysis showed no significant relationship between position and first-pass success. However, intubation in the ramped position resulted in better laryngoscopic visualization (81.5% vs. 62.9%, p = 0.001), though a higher percentage of patients experienced minor airway trauma (3% vs. 0% p = 0.046).

Conclusion: Ramped positioning improved laryngoscopic visualization but did not improve first-pass success compared with supine positioning for intubation performed at the emergency department.

Keywords: Endotracheal intubation, First-pass success, Ramped position, Patient positioning