Comparison of ramped and sniffing position for endotracheal intubation in obese patients: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of the ramp position over the sniffing position for endotracheal intubation in obese patients. METHODS: We performed a systematic review and meta-analysis comparing ramping with sniffing position for endotracheal intubation in obese patients. We systematically searched PubMed®, Embase, and the Cochrane Library. Primary outcomes included Cormack-Lehane grading and first-pass success. We applied a random-effects model to pool relative risks and mean differences with 95% confidence intervals. Statistical analyses were performed using R 4.4.2. RESULTS: We included four randomized controlled trials and two cohort studies. Of the 938 participants, 54.16% (508) were intubated in the ramp position. Ramping did not improve first pass success (RR 1.07; 95%CI 0.98 - 1.16; p = 0.14; I2 = 61.6%), Cormack-Lehane grades 1 - 2 (RR 0.99; 95%CI 0.97 - 1.02; p = 0.61; I2 = 0%), or Cormack-Lehane grades 3 - 4 (RR 1.94; 95%CI 0.86 - 4.37; p = 0.11; I2 = 0%). Although ramping decreased mean tube insertion and intubation time, these results did not persist in the sensitivity analyses. However, ramping decreased the number of intubation attempts in the operating room subgroup (RR 0.33; 95%CI 0.19 - 0.58; p < 0.001; I2 = 0%) and video-laryngoscopy subgroup (RR 0.33; 95%CI 0.15 - 0.70; p = 0.02; I2 = 0%). CONCLUSION: Our results suggest that ramping offers first-pass success and laryngeal view rates comparable to those of the sniffing position. In terms of secondary outcomes, patients in the operating room or those intubated with a video-laryngoscopy may benefit from decreased intubation attempts. Future studies with standardized definitions are required to evaluate these findings in different settings.PROSPERO register: CRD42025638839.