Clay Smith ofEM Topics joins us today for a first-ever crossover post. His amazingly well-done blog with daily posts on clinically important papers is a must to subscribe. In today's post, we cover a review he is also publishing today regarding ramping in intubations. In this RCT, there is no benefit in the primary outcome (lowest oxygen saturation) when comparing ramping versus sniffing position. However, there is a lot more to the paper as discussed in this blog and podcast.
When discussing the paper, "A Multicenter, Randomized Trial of Ramped Position versus Sniffing Position during Endotracheal Intubation of Critically Ill Adults" we find a few issues. As noted in Clay's post on this paper, they performed the ramped position differently than the anesthesia studies. The problem is this could have led to excessive cervical extension rather than head elevation, which may have degraded laryngoscopic view. The MRI images (taken from this study) below helps demonstrates this better with next hyperextension on the left and sniffing position on the right.
Although there was not a statistically significant difference between ramping versus sniffing position, there was a trend towards better intubations with ramping. Keep in mind mortality rates and other patient oriented outcomes were worse in the sniffing position. These are concerning findings and although they do not meet statistical significance, they are still potentially clinically significant and should be observed with caution.
It is also worth noting that this study used those who were less experienced with this method which could also play a role as why ramping was different and more difficult. By itself, ramping is not enough. You have to do it in the standard fashion that is recommended in anesthesia and emergency medicine articles to find similar results. Ramping is most likely still efficacious and other #FOAMed resources such as EM Nerd has covered this in detail. What are your thoughts regarding this paper? Will you still be doing ramping? Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page. Also, please check our bandwith sponsor, FunnyRx. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere. 
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