Ramped positioning modifies the effect of cricoid and left paratracheal pressure on perceived glottic-view quality during videolaryngoscopy in adults with obesity: a secondary image-based analysis.

BACKGROUND: In adults with obesity, the combined effect of patient positioning and external laryngeal compression during videolaryngoscopy (VL) remains unclear. We assessed whether ramped positioning modifies the perceived effects of no pressure (NP), left paratracheal pressure (LPP), and cricoid pressure (CP) on perceived glottic-view quality. METHODS: This retrospective, image-based secondary analysis included de-identified VL images from 91 adults with obesity, grouped into six manoeuvre-position combinations: supine or Rapid Airway Management Position (RAMP), each with no pressure, left paratracheal pressure, or cricoid pressure. Blinded anaesthesia clinicians rated perceived glottic-view quality on a three-point scale. Ratings were analysed using cumulative ordinal models with threshold-specific effects and robust standard errors clustered by rater. RESULTS: We analysed 59,956 ratings from 340 raters across 273 images. NP yielded the highest proportion of favourable ratings in both positions. In the supine position, LPP was rated more favourably than CP, whereas in the ramped position, CP and LPP produced broadly similar proportions of favourable ratings despite a statistically significant but small absolute difference. The CP × RAMP interaction indicated attenuation of the adverse CP-associated effect in the ramped position. Inter-rater agreement was fair to moderate. CONCLUSIONS: In adults with obesity, ramped positioning modified the effect of external laryngeal compression on perceived glottic-view quality during VL. NP yielded the most favourable ratings overall. When CP is required, ramped positioning may mitigate its adverse effect on perceived glottic-view quality. Prospective studies using clinical outcomes are warranted.