Intubation : Optimal position and Bougie

Endotracheal intubation is one of the most common and critical procedure performed in intensive care unit. Two recent studies provide some insight in to the ideal position and use of bougie in intubation.

Semler MW and Janz DR et el published in this month’s Chest about optimal positioning for successful intubation. 

In this Multi center, randomized trial they compared a total of 260 patients undergoing endotracheal intubation in two different positions ( Ramped up position in which the head of bed was elevated to 25° Versus Torso was supine neck was flexed and head was extended, See pictures below).

They found that ramped up position was associated with increased incidence of difficult intubation (12.3 vs 4.6%), increased incidence of grade 3 or 4 view  (25.4 % vs 11.5%) and decreased rate of intubation on the first attempt( 76.2 versus 85.4%).

Sniffing position was obtained by pillows and/or blankets  placed under the patient’s head and/or neck. Initially, a goal of 7 cm of head elevation was targeted with the goal of flexion of the neck at 35° relative to the torso and head extension to position the face at a 15° angle to the ceiling.

There are some caveats to the study.

  1. The procedure was performed by pulmonary and critical care fellows(Who only had 30 intubations under their belt).
  2. And 25% of the patient’s they used a video laryngoscopy (Which by definition takes away the need for Axial alignment).


The second study was published by Brian Driver ,Kenneth Dodd et el in Annals of Emergency Medicine. 

In this single center retrospective observational study , Using existing Videos available for the ED  intubations,  593 patients were reviewed.

Study was conducted at Hennepin County Medical Center in which all emergency physicians/ trainee Physicians use bougie as the primary mode of Intubation.

They  used CMAC Videolaryngoscope (which has a Macintosh blade) for all intubations but video was not available to the Performing physician.  In a few of the  intubations the video was available,  but the results were the same.

They found that first pass success rate was greater than without bougie use ( 95% versus 86% Absolute difference 9% confidence interval 2 – 16%).

However, the median attempt duration when bougie was used was 14 seconds longer than without a bougie.

Use of bougie has been  advocated  in the difficult intubation situation.   This is the first study of its kind looking at use of bougie as a primary  intubation modality.

As with any single center  retrospective observational study,  one would hope that  there will be more  studies to look at the possibility  of use of  bougie as the primary modality.

Ramped up position

Sniffing Position

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