Comparing post-induction hypoxemia between ramped and supine position endotracheal intubations with apneic oxygenation in the emergency department

Dhimitri A Nikolla DO,Jestin N Carlson MD, MS,Paul M Jimenez Stuart DO,Irtaza Asar DO,Michael D April MD, PhD,Amy H Kaji MD, PhD,Calvin A Brown III MD



Ramped position and apneic oxygenation are strategies to mitigate hypoxemia; however, the benefits of these strategies when utilized together remain unclear. Therefore, we compared first attempt, post-induction hypoxemia between adult emergency department (ED) endotracheal intubations performed with apneic oxygenation in the ramped vs. supine positions.


We used the National Emergency Airway Registry (NEAR), a multicenter registry of data on ED intubations from 25 academic and community sites. We included first attempt intubations with direct (DL) and video (VL) laryngoscopy in subjects ≥18-years-old with non-trauma indications receiving apneic oxygenation. We examined patient characteristics (e.g., sex, obesity, etc.) and key intubation outcomes, including hypoxemia (primary outcome), first pass success, and other adverse events (e.g., bradycardia). In addition, we examined unadjusted odds ratios (OR) and adjusted ORs (aOR) for key variables and stratified by laryngoscope type.


We included 210 ramped cases and 1820 supine cases in the DL cohort and 202 ramped and 1626 supine cases in the VL cohort. Rates of post-induction hypoxemia were similar between supine and ramped position in both the DL cohort (supine 6.5% and ramped 7.6%, aOR 0.96 [95% CI 0.55, 1.67]) and VL cohort (supine 10.1% and ramped 12.4%, aOR 0.97 [0.60, 1.56]). Other outcomes were also similar between groups.


Using this large national dataset, we did not identify a difference in post-induction hypoxemia between ramped and supine positions in this cohort of ED intubations with apneic oxygenation.

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