+ Existing solutions

A ramped position is essential but can be difficult to achieve with static foam products or stacking linen. Experts agree that this is a best practice positioning technique that improves the rate of successful endotracheal intubation, especially in obese patients.

Used with the permission by Rich Levitan, MD

+ Ear to Sternal Notch

The ideal "ramped" position is one in which the upper body, neck and head are elevated to a point where an imaginary horizontal line can be drawn from the external auditory meatus to the sternal notch.

The historical basis for ramping can be traced back to Alfred Kirstein, MD in his seminal work from 1897, Autoscopy of the Larynx and Trachea.

+ Safe Apnea Period

The safe apnea period refers to the time available until critical desaturation occurs in the absence of ventilation. A ramped position increases the safe apnea time for obese patiens, which can be critical if multiple intubation attempts are required.

+ Improved Laryngeal View

A ramped position is essential for successful airway management and can dramatically improve laryngeal view. The below videos show Rich Levitan, MD disucussing how head elevated laryngoscopy improves landmark recognition for the laryngoscopist. The term "ear to sternal notch position" was coined by Dr. Levitan.

Click on the following links to watch the videos:

• Video 1: The importance of HELP "Head Elevated Laryngoscopy Position"
• Video 2: Airwaycam views pre/post ramping with an early generation RAMP prototype

Photos and Videos used with permission from Rich Levitan, MD. Videos filmed at Practical Emergency Airway Management Course.

+ Physiological Challenges

Important Pathophysiologic Considerations in Obesity Emergency Management

1. Decreased respiratory reserve is secondary to diminished totl lung capacity and functional residual capacity. The decreased reserve compromisses an obese patient's ability to tolerate respiratory insults such as pneumonia.
2. Increased airway pressures are a result of increased airway resistance (heavier chest walls, increased abdominal girth, atelactatic lung bases). The increased pressures lead to:
   • smaller oxygen reserves at baseline
   • increased work breathing
   • shorter time to desaturation during induction and a shorter Safe Apnea Time
3. Higher incidence of hypoxemia and hypercapnia at baseline
4. Higher risk of aspiration pneumonitis
5. More difficult to ventilate with BMV

+ Professional Society Recommendations

+ Improved Safety During Extubation

Extubation can be risky, especially in obese patients. Desaturation after premature extubation can cause a host of adverse postoperative events, including higher cost of care, prolonged hospital stay, and greater risks for adverse discharge, ICU admissions and respiratory complications. The PPS RAMP can be easily reinflated at the end of a case so that the ideal ramped position may be reconstituted prior to extubation. This mitigates the sequel of premature extubation or an unexpected complication.