Does Head-Elevation Improve Intubation Outcomes? A Systematic Review and Meta-Analysis

Document Type

Conference Proceeding

Publication Date

5-2026

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Rationale: Endotracheal intubation is a common life-saving procedure but carries risks such as hypoxemia, aspiration, and cardiac arrest, especially when first-pass success is not achieved. Patient positioning is a modifiable factor that may affect these outcomes. The supine position remains standard, while head-elevated positioning is often used in obese or difficult airway cases. Although head elevation may improve glottic view and pre-oxygenation, available evidence remains inconsistent. This review aimed to compare head-elevated and supine positions during intubation. Methods: PubMed, Google Scholar, the Cochrane Library, and MEDLINE were searched through August 2025 for randomized controlled trials (RCTs) and cohort studies comparing head-elevated and supine positions during intubation. Continuous outcomes were pooled using the inverse-variance method to calculate standardized mean differences (SMDs) with 95% confidence intervals (CIs), and dichotomous outcomes were analyzed using the Mantel-Haenszel method to obtain odds ratios (ORs). Study quality was assessed using the Cochrane risk-of-bias tool and the Newcastle-Ottawa Scale (NOS). Results: Eleven studies (eight RCTs and three cohort studies) with 17,367 participants met inclusion criteria. Risk of bias was low in half of the RCTs, and all observational studies had high NOS scores despite inherent design limitations. Head-elevated positioning showed no significant difference in intubation time (SMD = −0.09; 95% CI − 0.58 to 0.44; p = 0.59), first-pass success (OR = 1.10; 95% CI 0.74- 1.63; p = 0.08), optimal glottic view (OR = 1.27; 95% CI 0.97-1.68; p = 0.08), or adverse events (OR = 0.80; 95% CI 0.43-1.50; p = 0.49). Subgroup analysis showed consistent results between RCTs and cohorts: First-pass success: RCTs OR = 1.08 (0.57-2.05) vs. Cohorts OR = 1.15 (0.95-1.38), Adverse events: significantly reduced in RCTs (OR = 0.32; 0.11-0.97; p = 0.04) but not in cohorts (OR = 0.95; 0.49-1.84), suggesting possible bias or confounding in observational data. Reported complications included hypoxemia, aspiration, esophageal intubation, airway trauma, hypotension, and cardiac arrest. Heterogeneity was minimal to moderate and did not affect overall outcomes. Conclusion: Head-elevated and supine positions yield comparable results during endotracheal intubation. Most studies did not assess operator-perceived difficulty or use validated tools such as the Intubation Difficulty Scale. Future RCTs should include both subjective and objective measures to better define the role of head-elevated positioning.

Volume

212

Issue

S1

First Page

S3557

Last Page

S3557

Comments

American Thoracic Society International Conference, May 15-20, 2026, Orlando, FL

DOI

10.1093/ajrccm/aamag162.4724

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