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Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis
  1. Joseph S Turner1,
  2. Benton R Hunter1,
  3. Ian D Haseltine1,
  4. Christine A Motzkus1,
  5. Hannah M DeLuna1,
  6. Dylan D Cooper1,
  7. Timothy J Ellender1,
  8. Elisa J Sarmiento1,
  9. Laura M Menard2,
  10. Jonathan M Kirschner1
  1. 1Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
  2. 2Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana, USA
  1. Correspondence to Dr Joseph S Turner, Indiana University School of Medicine, Indianapolis, Indiana, USA; turnjose{at}iu.edu

Abstract

Background Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation.

Methods A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach.

Results A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes.

Conclusions This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.

  • airway

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study. Not applicable.

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Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study. Not applicable.

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Footnotes

  • Handling editor Katie Walker

  • Contributors JST: project conception, project oversight, abstract screening, data abstraction, GRADE analysis, manuscript drafting, manuscript editing, project guarantor. BRH: project oversight, full-text review, manuscript drafting, manuscript editing. IDH: abstract screening, quality appraisal, manuscript drafting, manuscript editing. CAM: abstract screening, data abstraction, manuscript drafting, manuscript editing. HMDeL: abstract screening, full-text review, manuscript drafting, manuscript editing. DDC: abstract screening, figure generation, table generation, manuscript drafting, manuscript editing. TJE: abstract screening, quality appraisal, manuscript drafting, manuscript editing. EJS: statistical analysis, manuscript drafting, manuscript editing. LMM: literature search, manuscript drafting, manuscript editing. JMK: project oversight, abstract screening, quality appraisal, GRADE analysis, manuscript drafting, manuscript editing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.