Skip to main content
SpringerLink
Log in

An Evaluation of the Rapid Airway Management Positioner in Obese Patients Undergoing Gastric Bypass or Laparoscopic Gastric Banding Surgery

  • Case Report
  • Published:
Obesity Surgery Aims and scope Submit manuscript

Abstract

A new positioning device, the Rapid Airway Management Positioner (RAMP, Airpal Inc., Center Valley, PA) was evaluated to determine if there was an improvement in either mask ventilation, direct laryngoscopy, or both with the use of the RAMP in this patient population. Fifty-one morbidly obese patients (BMI > 35 kg/m2) undergoing elective bariatric surgery were enrolled. Ventilation and laryngoscopy was performed in the neutral and head-elevated laryngoscopy position (HELP). Direct laryngoscopy was performed noting the glottic view according to the Cormack–Lehane classification (Samsoon and Young, Anesthesiology 42:487, 1987). Mask ventilation was then recommenced. The HELP, or “ramped,” position was achieved by inflating the RAMP, which was placed underneath the patient prior to entering the OR. Once proper HELP position was achieved, a second laryngoscopy was performed followed by endotracheal intubation. Two main outcomes were noted in the neutral and HELP positions: (1) laryngoscopic view and (2) ease of ventilation. The inflated ramped position provided greater ease of ventilation as compared to the neutral position (p = 0.0003). There was also a significant improvement in the glottic view in the ramped position (p = 0.04). Ease of intubation was perceived to be severely difficult among two, and overall use of the positioning device was found to be difficult among seven of the residents. The RAMP effectively positions morbidly obese patients in the HELP position. Ease of ventilation and laryngoscopic view were both improved with its use in this patient population.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

References

  1. Wilson ME, Spiegelhalter D, Robertson JA, et al. Predicting difficult intubation. Br J Anaesth. 1988;61:211–6.

    Article  CAS  PubMed  Google Scholar 

  2. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anesthesia. 1987;42:487.

    Article  CAS  Google Scholar 

  3. Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000;92:1229–36.

    Article  CAS  PubMed  Google Scholar 

  4. Rocke DA, Murray WB, Rout CC, et al. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology. 1992;77:67.

    Article  CAS  PubMed  Google Scholar 

  5. Benumof JL. Difficult laryngoscopy: obtaining the best view. Can J Anaesth. 1994;41:361–5.

    Article  CAS  PubMed  Google Scholar 

  6. Voyagis GS, Kyriakis KP, Dimitriou V, et al. Value of oropharyngeal Mallampati classification in predicting difficult laryngoscopy among obese patients. Eur J Anaesthesiol. 1998;15(3):330–4.

    CAS  PubMed  Google Scholar 

  7. Ezri T, Gewurtz G, Sessler DI, et al. Prediction of difficult laryngoscopy in obese patients by ultrasound quantification of anterior neck soft tissue. Anaesthesia. 2003;58:1111–4.

    Article  CAS  PubMed  Google Scholar 

  8. Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600.

    Article  PubMed  Google Scholar 

  9. Shiga T, Zen’ichiro W, Tetsuo I. Predicting difficult intubation. Anesthesiology. 2006;104:618–619.

    Article  Google Scholar 

  10. Levitan RM, Mechem CC, Ochroch EA, et al. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann. Emerg. Med. 2003;41(3):322–30.

    Article  PubMed  Google Scholar 

  11. Ochroch EA, Hollander JE, Levitan R. POGO score as a predictor of intubation difficulty and need for rescue devices. Ann. Emerg. Med. 2000;36(Suppl):S52.

    Google Scholar 

  12. Rich JM. Use of an elevation pillow to produce the head-elevated laryngoscopy position for airway management in morbidly obese and large-framed patients. Anesth Analg. 2004;98(1):264–5.

    Article  PubMed  Google Scholar 

  13. Levitan RM, Ochroch AE. Airway management and direct laryngoscopy: a review and update. Crit Care Clin North Am. 2000;16:373–88.

    Article  CAS  Google Scholar 

  14. Levitan R, Dominici P, Kelly J, et al. Feasibility of an inflatable ramp for positioning obese patients for emergency intubation. Acad Emerg Med. 2006;13(5):406.

    Google Scholar 

  15. Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg. 2004;14(9):1171–5.

    Article  PubMed  Google Scholar 

  16. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can J Anaesth. 1985;32:429–34.

    Article  CAS  Google Scholar 

  17. Nissen M, Gayes J. An Inflatable, multichambered upper body support for the placement of the obese patient in the head-elevated laryngoscopy position. Anesth Analg. 2007;104:1305–6.

    Article  PubMed  Google Scholar 

  18. Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732–6.

    Article  PubMed  Google Scholar 

  19. Hagberg C, Rainer G, Krier C. Complications of manageing the airway. Best Practice and Research Clinical Anesthesiology. 2005;19:641–59.

    Article  Google Scholar 

  20. Jense HG, Dubin SA, Silverstein PI, et al. Effect of obesity on safe duration of apnea in anesthetized humans. Anesth Analg. 1971;72:89–93.

    Google Scholar 

  21. Kheterpal S, Han R, Tremper K, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105:885–91.

    Article  PubMed  Google Scholar 

  22. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102:1110–5.

    Article  PubMed  Google Scholar 

  23. Levitan RM. Direct laryngoscopy imaging: teaching and research applications. Educational Synopses in Anesthesiology and Critical Care Medicine (June, 1998): The On-line Anesthesia Journal. Available at: http://gasnet.med.yale.edu/esia/1998/june/samart.html

  24. Han R, Tremper KK, Kheterpal S, et al. Grading scale for mask ventilation. Anesthesiology. 2004;101:267.

    Article  PubMed  Google Scholar 

Download references

Acknowledgement

The authors would like to acknowledge Dawn Iannucci, Daniel Contreras, and Matthew Schilling for their assistance in conducting this study and preparing the manuscript.

Financial statement

Airpal, Inc. (Center Valley, PA) provided financial support for this study and the RAMP devices for use in this study.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, The University of Texas Medical School at Houston, 6431 Fannin, MSB 5.020, Houston, TX, 77030, USA

    Davide Cattano, Vladimir Melnikov, Yameen Khalil, Srikanth Sridhar & Carin A. Hagberg

Authors
  1. Davide Cattano
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vladimir Melnikov
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yameen Khalil
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Srikanth Sridhar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Carin A. Hagberg
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carin A. Hagberg.

Additional information

All works are attributed to The University of Texas at Houston Medical School Department of Anesthesiology.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Cattano, D., Melnikov, V., Khalil, Y. et al. An Evaluation of the Rapid Airway Management Positioner in Obese Patients Undergoing Gastric Bypass or Laparoscopic Gastric Banding Surgery. OBES SURG 20, 1436–1441 (2010). https://doi.org/10.1007/s11695-009-9885-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11695-009-9885-8

Keywords

Search

Navigation