Comparison of RAMP and New Modified RAMP Positioning in Laryngoscopic View During Intubation in Patients with Morbid Obesity: A Randomized Clinical Trial

Abstract

Background: The prevalence of obesity is increasing worldwide, and anesthesiologists are facing challenges in the airway management of such patients. Excessive adipose tissue influences pharyngeal spaces and affects the laryngoscopic grade. Standard ramp positioning is time-consuming and difficult to prepare, and requires expensive equipment. Objectives: The aim of this study was to compare the standard ramp position with the proposed low-cost and easily accessible modified ramp position in laryngoscopic view during the intubation of patients with morbid obesity. Methods: In this single-blind clinical trial, 84 patients candidate for bariatric surgery at Rasoul Akram Hospital in 2020 were assigned to the rapid airway management positioner (RAMP) (R) and new modified RAMP (MR) groups by the block randomization method. The laryngoscopic view of the glottis based on the Cormack-Lehane scale, ventilation quality, duration of intubation, intubation attempts, oxygen saturation at the end of intubation, and the need for backward, upward, rightward pressure (BURP) maneuver for successful intubation were recorded. Normal distribution tests and Mann-Whitney and Kruskal-Wallis tests were used to analyze the data. Results: The results showed no significant differences between the two groups regarding ventilation score, laryngoscopy grade, number of intubation attempts, duration of intubation, and the need for BURP maneuvers during intubation (P > 0.05). Conclusions: The two methods are not significantly different, and the new modified ramp position can be used with more ease and availability and less cost.

Success rates of endotracheal intubation using the standard method versus the modified-ramped position

“…The results showed no significant differences between the two groups in terms of ventilation score, laryngoscopy grade, number of intubation attempts, duration of intubation, and the need for Backwards, Upwards, Rightwards, Pressure manoeuvres during intubation. Therefore, the new modified RAMP position can be easily accessible and cost-effective to use 16 .…”

Challenge of Lung Isolation in Patients with Vocal Cord Implants

“…The complications of DLT include malposition, increased airway resistance due to the narrower lumen, and airway injury. Airway trauma includes tracheal mucosa erosion (cuff inflation with 2 mL of air can generate a pressure of 50 mmHg) and laryngeal injury during both intubation and extubation (14,15). When a DLT causes airway rupture, the mortality has been reported to be 8.8% (16).…”

Bed tilt and ramp positions are associated with increased first‐pass success of adult endotracheal intubation in the emergency department: A registry study

“…In larger patients, this optimal airway positioning requires a ‘ramp’ position with bed tilting and pillows to elevate the head and shoulders to ensure the EAM and sternal notch are aligned 10,12 . The ramp position during intubation is commonly used in anaesthetic practices in obese patients and has been shown to improve intubation success when airway was predicted to be difficult 13–15 . Higher rates of hypoxaemic complications are associated with difficult intubations due to prolonged time to intubation and limited preoxygenation 16 .…”

“…10,12 The ramp position during intubation is commonly used in anaesthetic practices in obese patients and has been shown to improve intubation success when airway was predicted to be difficult. [13][14][15] Higher rates of hypoxaemic complications are associated with difficult intubations due to prolonged time to intubation and limited preoxygenation. 16 Hypoxaemic complications can be minimised with ramping.…”