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      Intubation performance using different laryngoscopes while wearing chemical protective equipment: a manikin study

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          Abstract

          Objectives

          This study aimed to compare visualisation of the vocal cords and performance of intubation by anaesthetists using four different laryngoscopes while wearing full chemical protective equipment.

          Setting

          Medical simulation center of a university hospital, department of anaesthesiology.

          Participants

          42 anaesthetists (15 females and 27 males) completed the trial. The participants were grouped according to their professional education as anaesthesiology residents with experience of <2 years or <5 years, or as anaesthesiology specialists with experience of >5 years.

          Interventions

          In a manikin scenario, participants performed endotracheal intubations with four different direct and indirect laryngoscopes (Macintosh (MAC), Airtraq (ATQ), Glidescope (GLS) and AP Advance (APA)), while wearing chemical protective gear, including a body suit, rubber gloves, a fire helmet and breathing apparatus.

          Primary and secondary outcome measures

          With respect to the manikin, setting time to complete ‘endotracheal intubation’ was defined as primary end point. Glottis visualisation (according to the Cormack-Lehane score (CLS) and impairments caused by the protective equipment, were defined as secondary outcome measures.

          Results

          The times to tracheal intubation were calculated using the MAC (31.4 s; 95% CI 26.6 to 36.8), ATQ (37.1 s; 95% CI 28.3 to 45.9), GLS (35.4 s; 95% CI 28.7 to 42.1) and APA (23.6 s; 95% CI 19.1 to 28.1), respectively. Intubation with the APA was significantly faster than with all the other devices examined among the total study population (p<0.05). A significant improvement in visualisation of the vocal cords was reported for the APA compared with the GLS.

          Conclusions

          Despite the restrictions caused by the equipment, the anaesthetists intubated the manikin successfully within adequate time. The APA outperformed the other devices in the time to intubation, and it has been evaluated as an easily manageable device for anaesthetists with varying degrees of experience (low to high), providing good visualisation in scenarios that require the use of chemical protective equipment.

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          Most cited references22

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          Expected difficult tracheal intubation: a prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients.

          A Jungbauer, M Schumann, V Brunkhorst … (2009)
          The Berci-Kaplan video laryngoscope was developed to improve the visualization of the glottis and ease tracheal intubation. Whether this technique is also effective in patients with an expected difficult intubation is unclear. We have prospectively evaluated the conditions and success rate of tracheal intubation in patients with a Mallampati score of III or IV. Two hundred patients, undergoing general anaesthesia, were randomized to be intubated using direct laryngoscopy (n=100) or video laryngoscopy (n=100). Visualization of the vocal cords, success rate, time for intubation, and the need for additional manoeuvres (laryngeal manipulations, head positioning, and Eschmann stylet) were evaluated. Video laryngoscopy produced better results for the visualization of the glottis using Cormack and Lehane criteria (P<0.001), success rate (n=92 vs 99, P=0.017), and the time for intubation [60 (77) vs 40 (31) s, P=0.0173]. In addition, the number of optimizing manoeuvres was also significantly decreased [1.2 (1.3) vs 0.5 (0.7), P<0.001]. Video laryngoscopy, when compared with direct laryngoscopy for difficult intubations, provides a significantly better view of the cords, a higher success rate, faster intubations, and less need for optimizing manoeuvres. Therefore, we feel that the video laryngoscopy leads to a clinically relevant improvement of intubation conditions and can be recommended for difficult airway management.
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            Comparison of the Glidescope, the Pentax AWS, and the Truview EVO2 with the Macintosh laryngoscope in experienced anaesthetists: a manikin study.

            M.A Malik, C. O’Donoghue, J. Carney … (2009)
            The Pentax Airwayscope, the Glidescope, and the Truview EVO2 constitute three novel laryngoscopes that facilitate visualization of the vocal cords without alignment of the oral, pharyngeal, and tracheal axes. We compared these devices with the Macintosh laryngoscope in a simulated easy and difficult laryngoscopy. Thirty-five experienced anaesthetists were allowed up to three attempts to intubate in each of four laryngoscopy scenarios in a Laerdal SimMan manikin. The time required to perform tracheal intubation, the success rate, number of intubation attempts and of optimization manoeuvres, and the severity of dental compression were recorded. In the simulated easy laryngoscopy scenarios, there was no difference between the study devices and the Macintosh in success of tracheal intubation. In more difficult tracheal intubation scenarios, the Glidescope and Pentax AWS, and to a lesser extent the Truview EVO2 laryngoscope demonstrated advantages over the Macintosh laryngoscope including a better view of the glottis, greater success of tracheal intubation, and ease of device use. The Pentax AWS was more successful in achieving tracheal intubation, required less time to successfully perform tracheal intubation, caused less dental trauma, and was considered by the anaesthetists to be easier to use. The Pentax AWS laryngoscope demonstrated more advantages over the Macintosh laryngoscope than either the Truview EVO2 or the Glidescope laryngoscope, when used by experienced anaesthetists in difficult tracheal intubation scenarios.
            Article 0 comments Cited 33 times – based on 0 reviews     Review now
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              The incidence of regurgitation during cardiopulmonary resuscitation: a comparison between the bag valve mask and laryngeal mask airway.

              B.J. Stone, P.J Chantler, P.J.F. Baskett (1998)
              The risk of gastric regurgitation and subsequent pulmonary aspiration is a recognised complication of cardiac arrest--a risk which may be further increased by the resuscitative procedure itself. The purpose of this study was to compare the incidence of gastric regurgitation between the bag valve mask (BVM) and laryngeal mask airway (LMA). The resuscitation data collection forms of 996 patients who underwent in-hospital cardiopulmonary resuscitation over a 3.5 year period were reviewed. Of these, 199 patients were excluded from the study because there was no airway management involving a BVM or LMA. The incidence and timing of regurgitation was studied in the remaining 797 patients. Regurgitation was recorded to have occurred at some stage in 180 of these patients (22.6%). However, 84 regurgitated prior to CPR (46.7% of those patients who regurgitated). These patients were excluded from further analysis as regurgitation could not have been affected by any form of ventilation. Of the remaining 713 patients, BVM ventilation was used in 636 cases. In 170 of these the LMA was also used following the BVM. Where the patient was ventilated with the BVM alone or BVM followed by ETT the incidence of regurgitation during CPR was 12.4%. The LMA was used during resuscitation in 256 cases of which 170 had BVM ventilation prior to the LMA. Where the patient was ventilated with the LMA alone or LMA followed by ETT the incidence of regurgitation during CPR was 3.5%. The study confirms experience reported in earlier studies that when an LMA is used as a first line airway device, regurgitation is relatively uncommon.
              Article 0 comments Cited 30 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2016
                Publication date (Electronic): 15 March 2016
                Volume: 6
                Issue: 3
                Electronic Location Identifier: e010250
                Affiliations
                [1 ]Department of Anesthesiology, University Hospital RWTH Aachen , Aachen, Germany
                [2 ]Department of Operative Intensive Care and Intermediate Care, University Hospital RWTH Aachen , Aachen, Germany
                [3 ]Department of Anesthesiology and Intensive Care, St Elisabeth Hospital , Gütersloh, Germany
                [4 ]Department of Internal Medicine, Aachen District Medical Center , Würselen, Germany
                Author notes
                [Correspondence to ] Dr G Schälte; gschaelte@ 123456ukaachen.de
                Article
                Publisher ID: bmjopen-2015-010250
                DOI: 10.1136/bmjopen-2015-010250
                PMC ID: 4800129
                PubMed ID: 27008688
                SO-VID: 44455460-0135-45ea-a111-66c1ba39a4a4
                Copyright © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 12 October 2015
                Date revision received : 8 January 2016
                Date accepted : 14 January 2016
                Categories
                Subject: Emergency Medicine
                Subject: Research
                Subject: 1506
                Subject: 1691
                Subject: 1709
                Subject: 1682

                ScienceOpen disciplines: Medicine
                Keywords: accident & emergency medicine,trauma management,cbrn,videolaryngoscopy,manikin study,chemical protective equipment
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: accident & emergency medicine, trauma management, cbrn, videolaryngoscopy, manikin study, chemical protective equipment

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