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While this large database study found no significant difference in first-pass success rates, selection bias may have driven the results. Providers traditionally perform rapid-sequence intubation (RSI) with the patient in the supine position. However, recent studies have suggested that an incline (nonsupine) position may improve laryngeal views and first-pass success (NEJM JW Emerg Med Feb 15 2017 and Am J Emerg Med 2017; 35:986). In a secondary analysis of data from the National Emergency Airway Registry, researchers assessed first-pass success stratified by patient position (supine vs. nonsupine). Of 11,480 adult emergency department intubations, nearly all (94%) were performed in the supine position and most were performed with video laryngoscopy (66%). The first-pass success rate was 87% overall and did not differ significantly between supine (87.0%) and nonsupine (87.8%) groups. Perceived difficult airway and use of direct laryngoscopy were independently associated with decreased odds of first-pass success. A higher proportion of patients in the nonsupine group were obese or very obese, had a suspected difficult airway, and were on vasopressors prior to intubation. Additionally, more patients in the nonsupine group had an adverse event, including hypoxia and hypotension. |
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This observational study showed no significant difference in first-pass success between supine and nonsupine positioning in RSI but cannot be interpreted to mean there is no benefit to nonsupine intubation. The results may have been driven by selection bias, as patients in the nonsupine group were more likely to have features associated with difficult intubation. More importantly, first-pass success is clinically relevant only in that it has been associated with decreased adverse events. Nonsupine positioning is thought to have some physiologic benefits but given that the nonsupine group was clearly more ill, this study does not provide answers.