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Background: Optimal head and neck positioning and clinical experience are important factors for successful endotrachealintubation in patients with a difficult airway. This study aimed to investigate the rate of successful endotrachealintubation between the sniffing and ramped positions in patients with an expected difficult intubation. Methods: The study included 204 patients with an expected difficult intubation (airway difficulty score ≥ 8) based on thepreoperative airway assessment. The patients were randomized into the following groups: group S was placed in the sniffingposition, and group R was placed in the ramped position during direct laryngoscopy. The primary outcome was successfulendotracheal intubation and the secondary measure was laryngeal view in the ramped or sniffing position whenthe operating table was placed at two different heights. Results: Group R showed a higher rate of successful endotracheal intubation and better laryngeal view than group S (P <0.05). The rate of successful endotracheal intubation was higher in group R than in group S at both heights of the operatingtable; but, it was not different within each group. Laryngeal view was not different between the two groups and withineach group when the two heights of the operating table were used. Fully trained and experienced attending anesthesiologistsachieved a higher rate of successful endotracheal intubation than less experienced residents in group R (P < 0.05)but not in group S. Conclusions: Ramped position and clinical experience can be important factors for laryngeal view and success rate ofendotracheal intubation in patients with an expected difficult intubation.

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