Learning curves of the Glidescope, the McGrath and the Airtraq laryngoscopes: a manikin study

Learning tracheal intubation with a hyperangulated videolaryngoscopy blade: sub-analysis of a randomised controlled trial

INTRODUCTION

The number of tracheal intubation attempts required to reach proficiency in videolaryngoscopy with hyperangulated blades is unknown. Understanding this training requirement might guide training for clinicians who perform laryngoscopy. We therefore performed a planned sub-analysis of a randomised controlled trial comparing tracheal intubation success with videolaryngoscopy vs. direct laryngoscopy to determine the number of tracheal intubations with a hyperangulated videolaryngoscope blade needed to provide an acceptable first-attempt success rate.

METHODS

We included clinicians from a randomised controlled trial who were familiar with direct laryngoscopy and Macintosh-blade videolaryngoscopy but inexperienced with hyperangulated videolaryngoscopy. Cumulative sum statistics were used to generate learning curves with acceptable success rates of 85% and unacceptable success rates of 70% for the primary outcome of first-attempt tracheal intubation success.

RESULTS

We included 223 clinicians (25 consultants; 35 certified registered nurse anaesthetists; 36 student registered nurse anaesthetists; 46 fellows; and 81 residents) who attempted tracheal intubation in 4312 procedures. The median (IQR [range]) number of tracheal intubations per clinician was 15 (8-25 [1-77]). First-attempt failure was low, with only 72 failed first attempts overall, and was comparable across clinician groups. In total, 133 (60%) clinicians crossed the acceptable success rate boundary while the remaining 90 (40%) clinicians crossed neither the acceptable nor unacceptable success rate boundaries. Among clinicians who crossed the acceptance boundary, the median (IQR [range]) number of attempts for learning was 12 (12-12 [12-26]).

DISCUSSION

Clinicians experienced in tracheal intubation with direct laryngoscopy but unfamiliar with hyperangulated-blade videolaryngoscopy can achieve proficiency after approximately 12 attempts.

Articulating Video Stylets in the Setting of Simulated Traumatic Cervical Spine Injury: A Comparison with Four Other Devices and Approaches to Endotracheal Intubation

Background: Simulation offers the opportunity to train healthcare professionals in complex scenarios, such as those with as traumatized patients. Methods: We conducted an observational cross-sectional research simulating trauma with cervical immobilization. We compared five techniques/devices: direct laryngoscopy (DL), videolaryngoscopy (VLS, Glidescope or McGrath), combined laryngo-bronchoscopy intubation (CLBI) and articulating video stylet (ProVu). The primary outcomes were as follows: (1) success rate (SR) by third attempt (each lasting up to 60 s), and (2) corrected time-to-intubation (cTTI, accounting for failed attempts). Results: In a single center, we enrolled 42 consultants experienced in DL/VLS, but reporting no experience with ProVu, and hypothesized that ProVu would have offered encouraging performances. By the third attempt, ProVu had a SR of 73.8%, identical to Glidescope (p = 1.00) and inferior only to McGrath (97.6%; p = 0.003). The cTTI (seconds) of ProVu (57.5 [45-174]) was similar to Glidescope (51.2 [29-159]; p = 0.391), inferior to DL and McGrath (31.0 [22-46]; p = 0.001; and 49.6 [27-88]; p = 0.014, respectively), and superior to CLBI (157.5 [41-180]; p = 0.023). Conclusions: In consultants with no experience, as compared to DL and VLS, the video stylet ProVu showed encouraging results under simulated circumstances of cervical immobilization. The results should be interpreted in light of the participants being novices to ProVu and skilled in DL/VLS. Adequate training is required before the clinical introduction of any airway device.

Routine Use of Videolaryngoscopy in Airway Management

Tracheal intubation is a fundamental facet of airway management, for which the importance of achieving success at the first attempt is well recognized. Failure to do so can lead to significant morbidity and mortality if there is inadequate patient oxygenation by alternate means. The evidence supporting the benefits of a videolaryngoscope in attaining this objective is now overwhelming (in adults). This has led to its increasing recognition in international airway management guidelines and its promotion from an occasional airway rescue tool to the first-choice device during routine airway management. However, usage in clinical practice does not currently reflect the increased worldwide availability that followed the upsurge in videolaryngoscope purchasing during the coronavirus disease 2019 pandemic. There are a number of obstacles to widespread adoption, including lack of adequate training, fears over de-skilling at direct laryngoscopy, equipment and cleaning costs, and concerns over the environmental impact, among others. It is now clear that in order for patients to benefit maximally from the technology and for airway managers to fully appreciate its role in everyday practice, proper training and education are necessary. Recent research evidence has addressed some existing barriers to default usage, and the emergence of techniques such as awake videolaryngoscopy and video-assisted flexible (bronchoscopic) intubation has also increased the scope of clinical application. Future studies will likely further confirm the superiority of videolaryngoscopy over direct laryngoscopy, therefore, it is incumbent upon all airway managers (and their teams) to gain expertise in videolaryngoscopy and to use it routinely in their everyday practice..

Articulating Video Stylet Compared to Other Techniques for Endotracheal Intubation in Normal Airways: A Simulation Study in Consultants with No Prior Experience

Simulation for airway management allows for acquaintance with new devices and techniques. Endotracheal intubation (ETI), most commonly performed with direct laryngoscopy (DL) or video laryngoscopy (VLS), can be achieved also with combined laryngo-bronchoscopy intubation (CLBI). Finally, an articulating video stylet (ProVu) has been recently introduced. A single-center observational cross-sectional study was performed in a normal simulated airway scenario comparing DL, VLS-Glidescope, VLS-McGrath, CLBI and ProVu regarding the success rate (SR) and corrected time-to-intubation (cTTI, which accounts for the SR). Up to three attempts/device were allowed (maximum of 60 s each). Forty-two consultants with no experience with ProVu participated (15 ± 9 years after training completion). The DL was significantly faster (cTTI) than all other devices (p = 0.033 vs. VLSs, and p < 0.001 for CLBI and Provu), no differences were seen between the two VLSs (p = 0.775), and the VLSs were faster than CLBI and ProVu. Provu had a faster cTTI than CLBI (p = 0.004). The DL and VLSs showed similar SRs, and all the laryngoscopes had a higher SR than CLBI and ProVu at the first attempt. However, by the third attempt, the SR was not different between the DL/VLSs and ProVu (p = 0.241/p = 0.616); ProVu was superior to CLBI (p = 0.038). In consultants with no prior experience, ProVu shows encouraging results compared to DL/VLSs under simulated normal airway circumstances and further studies are warranted.

Airway Management: The Current Role of Videolaryngoscopy

Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research.

Comparison of Intubation Conditions Between Airtraq, McGrath Video Laryngoscopes, and Macintosh Under Conditions of Simulated Trauma Airway and Rapid Sequence Induction Intubation

BACKGROUND

Patients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (Airtraq^Ⓡ; Prodol Meditec) and nonchanneled (McGrath^Ⓡ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated.

OBJECTIVE

Our aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway.

METHODS

A prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18-60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted.

RESULTS

Mean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0-1 for group M and median IDS score of 1; IQR 0-2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A.

CONCLUSIONS

The performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques.

A Prospective Observational Crossover Study Comparing Intubation by Pediatric Residents Using Video Laryngoscopy and Direct Laryngoscopy on a Pierre Robin Simulation Manikin

INTRODUCTION

Video laryngoscopy (VL) has been proposed to increase the likelihood of successful intubation in patients with predicted difficult airways such as those with Pierre Robin sequence (PRS). Prior studies have focused on the performance of anesthesiologists, who are generally considered airway experts. Our primary aim was to investigate the success rate of intubation using VL compared with direct laryngoscopy (DL) when attempted by pediatric residents on a PRS model.

METHODS

Participants were administered a 5-minute refresher video on 2 VL techniques (CMAC, conventional geometry VL, and McGrath, unconventional geometry VL) and DL. The participants were asked to intubate the AirSim PRS infant manikin. The order of VL and DL use was randomly selected. All intubations were video recorded, and the recordings were analyzed by 3 anesthesiologists blinded to the participant's identity and previous experience.

RESULTS

Seventeen of 23 residents succeeded in intubating the PRS model using DL. Only 9 residents succeeded in intubating the PRS model using VL (conventional or unconventional geometry). Intubation success rate was higher when comparing DL with VL ( P = 0.04) and similar when comparing VL devices ( P = 0.69).

DISCUSSION

Contrary to expectation, the intubation success rate was lower using VL than with DL among pediatric residents. This should be considered when designing residency training and in real-life resuscitation.

Which Device Is Favorable for Intubation Attempts of Pediatric Residents on Four Different Pediatric Airway Simulations?

OBJECTIVES

Endotracheal intubation is an essential skill for the pediatric airway management. Although direct laryngoscopy (DL) is the standard method, several videolaryngoscopes (VLs) have been recently enhanced as an alternative especially for difficult intubations. We aimed to compare McGrath MAC (McG) and Storz C-MAC PM (ST) VLs with DL in terms of intubation success rate, time to intubation (TTI), and duration of obtaining glottis view of intubation attempts performed by pediatric residents on different pediatric airway manikins.

METHODS

The pediatric residents with no experience in videolaryngoscopy were included. After a brief demonstration, intubation attempts with 3 randomly handled different devices with 6 different blades were performed on a child manikin, an infant manikin, a Pierre-Robin sequence infant manikin, and a child manikin with cervical immobilization sequentially.

RESULTS

Fifty pediatric residents were enrolled. The attempts of DL on child manikin and attempts of all devices on child with cervical immobilization simulation were completely successful. For the attempts on both infant manikin and Pierre-Robin sequence infant manikin, the success rate of McG was significantly lower than ST and DL (P = 0.011 and P = 0.001). In the child manikin, McG and ST had prolonged TTI compared with DL (P = 0.016 and P = 0.001). For the child with cervical immobilization simulation, TTI of DL was significantly shorter than McG and ST (P = 0.011 and P = 0.001). Time to intubation of McG was significantly longer than DL and ST for the attempts on both 2 infant manikins. The rate of Cormack-Lehane grade I glottis view was similar for the attempts on both 2 child airway simulations. For infant manikin and Pierre-Robin sequence infant simulation, the rate of Cormack-Lehane grade I of ST was higher than attempts of DL and McG.

CONCLUSIONS

The attempts of pediatric residents on infant normal airway and Pierre-Robin sequence infant airway simulations resulted with enhanced glottis view by the utilization of Storz C-MAC PM, but both 2 VLs did not provide the improvement of intubation success rate and TTI compared with DL on these 4 different pediatric manikins. Further clinical studies of different VLs in different clinical courses are required for a reliable utilization in children.

Intubation using VieScope vs. Video laryngoscopy in full personal protective equipment - a randomized, controlled simulation trial

BACKGROUND

VieScope is a new type of laryngoscope, with a straight, transparent and illuminated blade, allowing for direct line of sight towards the larynx. In addition, VieScope is disposed of after single patient use, which can avoid cross-contaminations of contagious material. This has gained importance especially when treating patients with highly contagious infectious diseases, such as during the SARS-CoV2 pandemic. In this context, VieScope has not been evaluated yet in a clinical study.

MATERIAL AND METHODS

This study compared intubation with VieScope to video-laryngoscopy (GlideScope) in normal and difficult airway in a standardized airway manikin in a randomized controlled simulation trial. Thirty-five medical specialists were asked to perform endotracheal intubation in full personal protective equipment (PPE). Primary endpoint was correct tube position. First-pass rate (i.e., success rate at the first attempt), time until intubation and time until first correct ventilation were registered as secondary endpoints.

RESULTS

For correct tracheal tube placement, there was no significant difference between VieScope and GlideScope in normal and difficult airway conditions. VieScope had over 91% fist-pass success rate in normal airway setting. VieScope had a comparable success rate to GlideScope in difficult airway, but had a significantly longer time until intubation and time until ventilation.

CONCLUSION

VieScope and GlideScope had high success rates in normal as well as in difficult airway. There was no unrecognized esophageal intubation in either group. Overall time for intubation was longer in the VieScope group, though in an acceptable range given in literature. Results from this simulation study suggest that VieScope may be an acceptable alternative for tracheal intubation in full PPE.

TRIAL REGISTRATION

The study was registered at the German Clinical Trials Register www.drks.de (Registration date: 09/11/2020; TrialID: DRKS00023406 ).

Comparison of a New Video Intubation Stylet and McGrath® MAC Video Laryngoscope for Intubation in an Airway Manikin with Normal Airway and Cervical Spine Immobilization Scenarios by Novice Personnel: A Randomized Crossover Study

The use of both a video laryngoscope and a video intubation stylet, compared with the use of a direct laryngoscope, is not only easier to learn but also associated with a higher success rate in performing endotracheal intubation for novice users. However, data comparing the two video devices used by novice personnel are rarely found in literature. Nondelayed intubation is an important condition to determine the prognosis in critically ill patients; hence, exploring intubation performance in various situations is of clinical significance. This study is aimed at comparing a video stylet and a video laryngoscope for intubation in an airway manikin with normal airway and cervical spine immobilization scenarios by novice personnel. We compared the performance of intubation by novices between the Aram Video Stylet and the McGrath® MAC video laryngoscope in an airway manikin. Thirty medical doctors with minimal experience of endotracheal intubation attempted intubation on a manikin five times with each device in each setting (normal airway and cervical spine immobilization scenarios). The order of use of the devices in each scenario was randomized for each participant. In the normal airway scenario, the Aram stylet showed a significantly higher rate of successful intubation than the McGrath® (98.7% vs. 92.0%; odds ratio (95% CI): 6.4 (1.4-29.3); p = 0.006). The intubation time was shorter using the Aram Stylet than that using the McGrath® video laryngoscope (p < 0.001). In the cervical immobilization scenario, successful endotracheal intubation was also more frequent using the Aram stylet than with the McGrath® (96.0% vs. 87.3%; odds ratio (95% CI): 3.5 (1.3-9.0); p = 0.007). The Aram Stylet intubation time was shorter (p < 0.001). In novice personnel, endotracheal intubation appears to be more successful and faster using the Aram Video Stylet than the McGrath® MAC video laryngoscope.

Comparison of the novel VieScope with conventional and video laryngoscope in a difficult airway scenario - a randomized, controlled simulation trial

Background

Endotracheal intubation continues to be the gold standard for securing the airway in emergency situations. Difficult intubation is still a dreadful situation when securing the airway.

Objective

To compare VieScope with Glidescope and conventional Macintosh laryngoscopy (MAC) in a simulated difficult airway situation.

Methods

In this randomized controlled simulation trial, 35 anesthesiologists performed endotracheal intubation using VieScope, GlideScope and MAC in a randomized order on a certified airway manikin with difficult airway.

Results

For the primary endpoint of correct tube position, no statistical difference was found (p = 0.137). Time until intubation for GlideScope (27.5 ± 20.3 s) and MAC (20.8 ± 8.1 s) were shorter compared to the VieScope (36.3 ± 10.1 s). Time to first ventilation, GlideScope (39.3 ± 21.6 s) and MAC (31.9 ± 9.5 s) were also shorter compared to the VieScope (46.5 ± 12.4 s). There was no difference shown between handling time for VieScope (20.7 ± 7.0 s) and time until intubation with GlideScope or MAC. Participants stated a better Cormack & Lehane Score with VieScope, compared to direct laryngoscopy.

Conclusion

Rate of correct tracheal tube position was comparable between the three devices. Time to intubation and ventilation were shorter with MAC and Glidescope compared to VieScope. It did however show a comparable handling time to video laryngoscopy and MAC. It also did show a better visualization of the airway in the Cormack & Lehane Score compared to MAC.

Trial registration

The study was registered at the German Clinical Trials Register www.drks.de (Identifier: DRKS00024968) on March 31st 2021.

Impact of Videolaryngoscopy Expertise on First-Attempt Intubation Success in Critically Ill Patients

OBJECTIVES

The use of a videolaryngoscope in the ICU on the first endotracheal intubation attempt and intubation-related complications is controversial. The objective of this study was to evaluate the first intubation attempt success rate in the ICU with the McGrath MAC videolaryngoscope (Medtronic, Minneapolis, MN) according to the operators' videolaryngoscope expertise and to describe its association with the occurrence of intubation-related complications.

DESIGN

Observational study.

SETTING

Medical ICU.

SUBJECTS

Consecutive endotracheal intubations in critically ill patients.

INTERVENTIONS

Systematic use of the videolaryngoscope.

MEASUREMENTS AND MAIN OUTCOMES

We enrolled 202 consecutive endotracheal intubations. Overall first-attempt success rate was 126 of 202 (62%). Comorbidities, junior operator, cardiac arrest upon admission, and coma were associated with a lower first-attempt success rate. The first-attempt success rate was less than 50% in novice operators (1-5 previous experiences with videolaryngoscope, independently of airway expertise with direct laryngoscopies) and 87% in expert operators (> 15 previous experiences with videolaryngoscope). Multivariate analysis confirmed the association between specific skill training with videolaryngoscope and the first-attempt success rate. Severe hypoxemia and overall immediate intubation-related complications occurred more frequently in first-attempt failure intubations (24/76, 32%) than in first-attempt success intubations (14/126, 11%) (p < 0.001).

CONCLUSIONS

We report for the first time in the critically ill that specific videolaryngoscopy skill training, assessed by the number of previous videolaryngoscopies performed, is an independent factor of first-attempt intubation success. Furthermore, we observed that specific skill training with the McGrath MAC videolaryngoscope was fast. Therefore, future trials evaluating videolaryngoscopy in ICUs should consider the specific skill training of operators in videolaryngoscopy.

The impact of a barrier enclosure on time to tracheal intubation: a randomized controlled trial

Purpose

Novel devices such as the barrier enclosure were developed in hopes of improving provider safety by limiting SARS-CoV-2 transmission during tracheal intubation. Nevertheless, concerns arose regarding a lack of rigorous efficacy and safety data for these devices. We conducted a randomized controlled trial to evaluate the impact of the barrier enclosure on time to tracheal intubation.

Method

After Research Ethics Board approval, elective surgical patients with normal airway predictors were randomly allocated 1:1 to tracheal intubation with or without a barrier enclosure. The primary outcome was time to tracheal intubation. Secondary outcomes included first-pass success rate, total time of airway manipulation, anesthesiologists’ perception of intubation difficulty, likelihood of use in SARS-CoV-2-positive patients, and patients’ perception of comfort and acceptability.

Results

There were 48 participants in the barrier enclosure group and 46 participants in the control group. The mean (standard deviation [SD]) time to tracheal intubation was 62 (29) sec with barrier closure and 53 (27) sec without barrier enclosure (mean difference, 9 sec; 95% confidence interval, − 3 to 20; P = 0.14). Anesthesiologists rated the difficulty of intubation higher with barrier enclosure (mean [SD] visual analogue scale score, 27 [26] mm vs 9 [17] mm; P < 0.001). There were no significant differences in other secondary outcomes.

Conclusion

In healthy surgical patients with normal airway predictors, the use of a barrier enclosure during tracheal intubation did not significantly prolong time to intubation or decrease first-pass intubation success. Nevertheless, there was an increase in difficulty of intubation perceived by the anesthesiologists with use of a barrier enclosure.

Trial registration

www.clinicaltrials.gov (NCT04366141); registered 28 April 2020.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02024-z.

Nationwide survey on training and device utilization during tracheal intubation in French intensive care units

Background

Intubation is a lifesaving procedure that is often performed in intensive care unit (ICU) patients, but leads to serious adverse events in 20–40% of cases. Recent trials aimed to provide guidance about which medications, devices, and modalities maximize patient safety. Videolaryngoscopes are being offered in an increasing range of options and used in broadening indications (from difficult to unremarkable intubation). The objective of this study was to describe intubation practices and device availability in French ICUs.

Materials and methods

We conducted an online nationwide survey by emailing an anonymous 26-item questionnaire to physicians in French ICUs. A single questionnaire was sent to either the head or the intubation expert at each ICU.

Results

Of 257 ICUs, 180 (70%) returned the completed questionnaire. The results showed that 43% of intubators were not fully proficient in intubation; among them, 18.8% had no intubation training or had received only basic training (lectures and observation at the bedside). Among the participating ICUs, 94.4% had a difficult intubation trolley, 74.5% an intubation protocol, 92.2% a capnography device (used routinely to check tube position in 69.3% of ICUs having the device), 91.6% a laryngeal mask, 97.2% front-of-neck access capabilities, and 76.6% a videolaryngoscope. In case of difficult intubation, 85.6% of ICUs used a bougie (154/180) and 7.8% switched to a videolaryngoscope (14/180). Use of a videolaryngoscope was reserved for difficult intubation in 84% of ICUs (154/180). Having a videolaryngoscope was significantly associated with having an intubation protocol (P = 0.043) and using capnography (P = 0.02). Airtraq^® was the most often used videolaryngoscope (39.3%), followed by McGrath^®Mac (36.9%) then by Glidescope^® (14.5%).

Conclusion

Nearly half the intubators in French ICUs are not fully proficient with OTI. Access to modern training methods such as simulation is inadequate. Most ICUs own a videolaryngoscope, but reserve it for difficult intubations.

Comparison of King Vision video laryngoscope (channeled blade) with Macintosh laryngoscope for tracheal intubation using armored endotracheal tubes

Background and Aims

During direct laryngoscopy (DL), intubation using armored endotracheal tubes (ETTs) requires help of bougies, stylets, or Magill's forceps, which leads to unnecessary prolongation in the intubation times. The channeled blade of King Vision (KV) video laryngoscope is likely to obviate the need of these equipments for a successful intubation using armored tubes.

Material and Methods

After approval from Institutional Ethics Committee and informed consent, 100 patients were randomized to receive endotracheal intubation using armored ETTs either with KV video laryngoscope (VL) channeled blade or with Macintosh laryngoscope. Time to intubation, success rate, time for best glottis view, number of attempts, optimization maneuvers, or complications if any were recorded. Ease of device use was also assessed in terms of insertion, glottis visualization, and intubation. Continuous variables were tested using unpaired t-test and categorical variables with Pearson's Chi-square test. P ≤ 0.05 was considered significant.

Result

First attempt success rate was 92% in group KV and 74% in group DL (P = 0.017). Time for successful intubation was less in group KV as compared with group DL (P < 0.0001). Optimization maneuvers such as "BURP" was needed in three patients of group KV and 11 patients of group DL (P = 0.0218). Bougie was needed in 13 patients of group DL and none from group KV (P = <0.001). Ease of device use was similar in the two groups.

Conclusion

KVVL offers faster intubating conditions for tracheal intubation requiring armored ETTs in comparison to DL using Macintosh blade.

Glidescope versus Airtraq DL for double-lumen tracheal tube insertion in patients with a predicted or known difficult airway: A randomised study

BACKGROUND

Double-lumen tracheal tube (DLT) insertion can be managed with videolaryngoscopes such as the Glidescope or indirect laryngoscopes like the Airtraq DL. No study has compared both devices when a difficult intubation is predicted.

OBJECTIVE

Our hypothesis was that the Glidescope is superior to the Airtraq for double-lumen tube insertion in patients with a predicted or known difficult airway.

DESIGN

Randomised study.

PATIENTS

Adults scheduled for thoracic elective surgery, requiring one-lung ventilation with a predicted difficult intubation score of at least 7 (Arné risk index).

INTERVENTION

Between March 2014 and March 2015, adult patients, scheduled for elective thoracic surgery, requiring double-lumen tracheal tube placement, and with a predicted risk (evaluated preoperatively using the Arné score) or a history of difficult intubation, were allocated to a Glidescope or an Airtraq group.

MAIN OUTCOME MEASURES

The primary outcome was the overall success rate of tracheal intubation after two attempts. Secondary outcomes were success rates on the first attempt, duration of intubation, need for laryngeal pressure, Cormack and Lehane grade and side-effects.

RESULTS

Of 277 patients, 78 were predicted to have a difficult airway. Finally, 72 patients were enrolled. Neither the overall success rates of tracheal intubation [Glidescope group 31/36 (86%) versus Airtraq group 34/36 (94%), P = 0.43] nor the side-effects differed between groups. There was no difference concerning visualisation of the glottis using the Cormack and Lehane grade (P = 0.18) or intubation time [Glidescope group 67 s (49 to 90) versus Airtraq group 81 s (59 to 101), P = 0.28]. All patients with a previous history of difficult intubation were intubated successfully.

CONCLUSION

There is no difference in success rates of tracheal intubation with a double-lumen tube in patients with a predicted or known difficult airway when using either a Glidescope or Airtraq device.

TRIAL REGISTRATION

National register of the French National Agency for Medicines and Health Products Safety No. 2014-A00143-44.

Improving pediatric resident laryngoscopy training through the use of a video laryngoscope

IMPORTANCE

Opportunities for pediatric residents to perform direct laryngoscopy and tracheal intubation (DLTI) are few and the success rate is low.

OBJECTIVE

We hypothesize that incorporation of video laryngoscope (McGrath MAC) into pediatric residents DLTI simulation course will improve the simulated DLTI success rate.

METHODS

Residents were given 3 attempts at DLTI: (1) baseline using a conventional laryngoscope (CL); (2) using a video laryngoscope (VL); and (3) again using the CL. Residents were given up to 120 seconds to complete each DLTI attempt. Time to successful DLTI was collected. Residents recorded their best view (larynx, epiglottis, vocal cords) with each DLTI attempt.

RESULTS

Prior to the intervention, 15/17 (88.2%) and 16/17 (94.1%) of the participants reported prior exposure to DLTI as "less than 10 total attempts" in simulated and live patients respectively. Seventeen pediatric residents performed 51 DLTI attempts (34 with a CL and 17 with the VL). Success rates for DLTI are as follows: Baseline with CL 11/17 (64.7%), VL 12/17 (70.6%), and last attempt with CL 13/17 (76.5%) (P = 0.15). Compared to the baseline, the use of VL resulted in a shorter but non-significant decrease in time to successful DLTI (Mean 34.2 sec [SD, 22.0] vs. 56.5 sec [SD, 40.2]; P = 0.08). Repeat attempts at DLTI with the CL, however, were significantly shorter than baseline (Mean 20.3 sec [SD, 12.8] vs. 56.5 sec [SD, 40.2]; P = 0.003). Using the VL, more residents could visualize the vocal cords compared to the baseline (14/17 [82.3%] vs. 9/17 [52.9%]; P = 0.03).

INTERPRETATION

Repeated training is certainly a way to improve successful DLTI. Use of VL as a new teaching method led to greater visualization of the vocal cords, shortening operating time and raising self-confidence.

Supraglottic airway device versus a channeled or non-channeled blade-type videolaryngoscope for accidental extubation in the prone position: A randomized crossover manikin study

BACKGROUND

It is very rare but challenging to perform emergency airway management for accidental extubation in a patient whose head and neck are fixed in the prone position when urgently turning the patient to the supine position would be unsafe. The authors hypothesized that tracheal intubation with a videolaryngoscope would allow effective airway rescue in this situation compared with a supraglottic airway device and designed a randomized crossover manikin study to test this hypothesis.

METHODS

The authors compared airway rescue performances of the 3 devices-the ProSeal laryngeal mask airway (PLMA; Teleflex Medical, Westmeath, Ireland) as a reference; the Pentax AWS (AWS; Nihon Kohden, Tokyo, Japan) as a channeled blade-type videolaryngoscope; and the McGRATH videolaryngoscope (McGRATH; Medtronic, Minneapolis, MN) as a nonchanneled blade type in a manikin fixed to the operating table in the prone position. Twenty-one anesthesiologists performed airway management on the prone manikin with the 3 devices, and the time required for intubation/ventilation and the success rates were recorded.

RESULTS

The median (range) intubation/ventilation times with the PLMA, AWS, and McGRATH were 24.5 (13.5-89.5) s, 29.9 (17.1-79.8) s, and 46.7 (21.9-211.7) s, respectively. There was no significant difference in intubation/ventilation times between the PLMA and AWS. The AWS permitted significantly faster tracheal intubation than did the McGRATH (P = 0.006). The success rates with the PLMA (100%) and AWS (100%) were significantly greater than that with the McGRATH (71.4%). Airway management performance of the PLMA and AWS was comparable between devices and better than that of the McGRATH in the prone position.

CONCLUSIONS

Considering that tracheal intubation can provide a more secure airway and more stable ventilation than the PLMA, re-intubation with a channeled blade-type videolaryngoscope such as the AWS may be a useful method of airway rescue for accidental extubation in patients in the prone position.

Fluoroscopic Comparison of Cervical Spine Motion Using LMA CTrach, C-MAC Videolaryngoscope and Macintosh Laryngoscope

Objective

Endotracheal intubation should be performed with care when cervical spine (C-spine) injury is suspected. The aim of this study was to evaluate the movement of the C-spine using fluoroscopy during intubation with Laryngeal Mask Airway (LMA) CTrach, C-MAC videolaryngoscope and Macintosh laryngoscope.

Methods

This was a single-centre, prospective, observational, controlled trial. In total, 22 surgical patients aged 18-65 years planned to undergo operation under general anaesthesia, were enrolled. X-ray images of the C-spine were obtained using fluoroscopy with the patients' head in a neutral position. All patients underwent laryngoscopy using a Macintosh blade, LMA CTrach and C-MAC videolaryngoscope, and fluoroscopic images of the C-spine were obtained. All the patients were intubated at the last laryngoscopy simulation (using the C-MAC). The atlanto-occipital distance (AOD) and angles between C₀C₁, C₀C₂, C₀C₃, C₀C₄, C₁C₂ and C₂C₃ lines were measured and compared between each device.

Results

The mean AOD was measured as 20.4 mm in a neutral position, which decreased to 13.1, 17.2 and 12.3 mm after the insertion of the Macintosh laryngoscope, LMA CTrach and C-MAC videolaryngoscope, respectively. The differences were significant (p<0.001). Moreover, significant difference was noted in C₀C₂, C₀C₃ and C₁C₂ angles with the insertion of the three devices (p<0.001). The LMA CTrach resulted in significantly lesser C-spine movements in C₀C₂, C₀C₃ and C₀C₄ angles compared to the Macintosh laryngoscope and C-MAC videolaryngoscope (p<0.001).

Conclusion

The LMA CTrach resulted in lesser C-spine movements compared to Macintosh laryngoscope and C-MAC videolaryngoscope. In case of the C-spine injury, LMA CTrach may be preferred and may cause fewer traumas during endotracheal intubation.

Comparison of the GlideScope® with the Macintosh Laryngoscope in Endotracheal Intubation during Uninterrupted Mechanical Chest Compression: A Randomised Crossover Manikin Study

Background

The GlideScope® (GS) has been shown to improve the first-attempt success rate of endotracheal intubation during continuous mechanical chest compressions compared with the conventional Macintosh laryngoscope (ML) in inexperienced hands. Yet, its value for operators with experience of emergency airway management has remained uncertain. We set out to compare their performance in the hands of experienced operators in a manikin receiving continuous mechanical chest compressions delivered by LUCAS®.

Method

This was a randomised crossover study. Thirty-five emergency physicians and intensivists performed intubation using GS and ML in 3 different scenarios: (1) normal airway without chest compressions; (2) normal airway with uninterrupted mechanical chest compressions; and (3) normal airway with cervical spine (C-spine) immobilisation and uninterrupted mechanical chest compressions. The sequence of scenarios and devices used were randomised. The primary outcome was the first-attempt success rate of intubation. Other data including demographics, the time required for successful intubation, complications during intubation, the visual analog scale of perceived difficulty of intubation and the preference on devices in each scenario were also collected and analyzed.

Results

In scenario 1, the first-attempt success rate with both laryngoscopes was 100%. In scenario 2, there was a higher first-attempt success rate with ML but it was not statistically significant (GS 97.14% vs ML 100%, p=1.00). In scenario 3, one participant failed to intubate in the first attempt with each of the laryngoscopes (GS 97.14% vs ML 97.14%, p=0.754). More dental compression was noted with GS but the difference was not statistically significant (GS 42.86% vs ML 22.86%, p=0.126). Overall, the median time for intubation with GS was significantly longer in all 3 scenarios (Scenario 1: GS 18.5s; interquartile range [IQR] 13.8 -22.2s vs ML 11.2s, IQR 9.5-14.2s, p<0.001; Scenario 2: GS 18.7s, IQR 13.1-25.2s vs ML 13.4s, 10.3-15.8s, p<0.001; Scenario 3: GS 20.8s, IQR 16.5-29.2s vs ML 14.0s, IQR 10.5-18.0s, p<0.001). More participants preferred GS in scenario 3, while ML remained the device of choice in the other two scenarios. Conclusion: GS is not superior to ML in terms of the first-attempt success rate of intubation and it takes significantly longer to intubate for experienced operator. Yet more participants prefer its use when the C-spine motion is limited. Further studies are warranted to explore its role in trauma resuscitation. (Hong Kong j.emerg.med. 2016;23:159-167)

Faucial Pillar Perforation by Glidescope Intubation with Incorrectly Placed Stylet

Glidescope GVL® is frequently used in intubation of difficult airway. We report a case of right side of faucial pillar perforation during intubation with Glidescope®. A rigid stylet can facilitate placing of endotracheal tube quickly but it may also penetrate the soft tissue to cause injuries.

Airtraq Laryngoscope Versus the Conventional Macintosh Laryngoscope During Pediatric Intubation Performed by Nurses: A Randomized Crossover Manikin Study With Three Airway Scenarios

OBJECTIVES

We hypothesized that the Airtraq laryngoscope (Airtraq LLC, Bonita Springs, Fla) is beneficial for intubation of pediatric manikins while performing cardiopulmonary resuscitation (CPR). In the present study, we evaluated the effectiveness of the Macintosh (MAC) laryngoscope (HEINE Optotechnik, Munich, Germany) and Airtraq in 3 simulated CPR scenarios.

METHODS

A randomized crossover simulation trial was designed. Eighty-three nurses intubated the trachea of a PediaSIM CPR training manikin (FCAE HealthCare, Sarasota, Fla) using the MAC and Airtraq in a normal airway scenario, normal airway with chest compression scenario, and difficult airway with chest compression scenario. The participants were directed to perform a maximum of 3 attempts in each scenario. The success rate, time to intubation, Cormack & Lehane grade, dental compression, and the ease of intubation were measured.

RESULTS

All participants performed successful intubation with the Airtraq in all 3 scenarios. In all scenarios, the success rate was significantly higher and the time to intubation was significantly shorter with the Airtraq than with the MAC. Glottic visualization using the Cormack-Lehane scale was also better when using Airtraq in all scenarios.

CONCLUSIONS

In this manikin study, we found that the Airtraq can be used successfully for the intubation of pediatric manikins with normal and difficult airways by medical staff without previous experience in pediatric intubation. Moreover, intubation can be achieved without interrupting chest compression. The use of the Airtraq compared with the MAC led to faster time to intubation. Nevertheless, we recommend that the performance of the Airtraq and the MAC during CPR should be further evaluated in a clinical setting.

Using King Vision video laryngoscope with a channeled blade prolongs time for tracheal intubation in different training levels, compared to non-channeled blade

Purpose

It is generally accepted that using a video laryngoscope is associated with an improved visualization of the glottis. However, correctly placing the endotracheal tube might be challenging. Channeled video laryngoscopic blades have an endotracheal tube already pre-loaded, allowing to advance the tube once the glottis is visualized. We hypothesized that use of a channel blade with pre-loaded endotracheal tube results in a faster intubation, compared to a curved Macintosh blade video laryngoscope.

Methods

After ethical approval and informed consent, patients were randomized to receive endotracheal Intubation with either the King Vision^® video laryngoscope with curved blade (control) or channeled blade (channeled). Success rate, evaluation of the glottis view (percentage of glottic opening (POGO), Cormack&Lehane (C&L)) and intubating time were evaluated.

Results

Over a two-month period, a total of 46 patients (control n = 23; channeled n = 23) were examined. The first attempt success rates were comparable between groups (control 100% (23/23) vs. channeled 96% (22/23); p = 0.31). Overall intubation time was significantly shorter with control (median 40 sec; IQR [24–58]), compared to channeled (59 sec [40–74]; p = 0.03). There were no differences in glottis visualization between groups.

Conclusion

Compared with the King Vision channeled blade, time for tracheal intubation was shorter with the control group using a non-channeled blade. First attempt success and visualization of the glottis were comparable. These data do not support the hypothesis that a channeled blade is superior to a curved video laryngoscopic blade without tube guidance.

Trial registration

ClinicalTrials.gov NCT02344030

Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: the randomised multicentre EMMA trial study protocol

INTRODUCTION

The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients.

METHODS AND ANALYSIS

The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications.

ETHICS AND DISSEMINATION

The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT 02611986; pre-results.

An observational study of feasibility of tracheal intubation using Airtraq in pediatric population

BACKGROUND AND AIM

There is a paucity of observational studies for the use of Airtraq (AT) in children, especially infants. We undertook a prospective observational study to compare ease of use of infant (size 0), pediatric (size 1), and small (size 2) AT.

MATERIAL AND METHODS

AT was used for endotracheal intubation in healthy pediatric patients of 3 months to 18 years age. The primary outcome was success of intubation which was noted as number (%) and analyzed using Fisher's exact test. The secondary outcomes were percentage of glottis opening (POGO) score, visual analog scale (VAS) for field of view, time to best view (TTBV), time to intubation (TTI), and VAS for ease of use and were presented as median (interquartile range) in each subgroup of sizes and analyzed using Kruskal-Wallis test.

RESULTS

Overall POGO score was 100 (100, 100 [50-100]) %, VAS field of view was 10 (10, 10 [5-10]), and TTBV was 6 (4, 10 [1.5-24]) s. There was no statistically significant difference in any of the subgroups. The success rate of intubation with AT was 100% with AT size 1 and 2, whereas 45% with AT 0, P < 0.001. VAS for ease of use was 5 (4, 10 [3-10]) with AT 0 compared to 10 (10, 10 [9-10]) with AT 1 and 10 (10, 10 [6-10]) with AT 2 (P < 0.001). TTI was 28 (20, 36 [11.8-59]) s in those who could be successfully intubated.

CONCLUSIONS

All sizes of AT provide quick, easy, and excellent glottic visualization. However, failure rate for intubation with infant (size 0) is high compared to nil with pediatric (size 1) and small (size 2).

A comparison of the Airtraq®, McGrath®, and Macintosh laryngoscopes for difficult paediatric intubation: A manikin study

BACKGROUND

The efficacy of devices for difficult intubation in paediatric patients, especially with a Cormack-Lehane grade 4 view, has yet to be established. We compared intubating parameters among three devices (the Airtraq®, McGrath®, and Macintosh laryngoscopes).

METHODS

This study is a randomised cross-over trial. Participants were 20 anaesthetists. Each device was tested three times using a paediatric manikin with a Cormack-Lehane grade 4 view. The order to use each device was randomised by a computer-generated random sequence. The primary endpoint was the rate of successful intubation. Secondary endpoints included the time taken to intubate, percentage of glottic opening score, and severity of potential dental trauma.

RESULTS

The successful intubation rates of the Airtraq®, McGrath®, and Macintosh laryngoscopes were 100%, 72%, and 45%, respectively. The risk ratio of the success rates of Airtraq® compared with McGrath® and Macintosh laryngoscopes were 1.40 (95% CI; 1.19-1.64, P < 0.001) and 2.22 (95% CI; 1.68-2.94, P < 0.001), respectively. The modified Cormack-Lehane grade and percentage of the glottic opening score were better for the Airtraq® than for the other devices. The dental trauma score was lower for the Airtraq® than for the other devices. There were no significant differences in the intubation time among the groups.

CONCLUSIONS

The Airtraq® had higher success rate, had better visibility, and was associated with less dental trauma than the other devices in a difficult paediatric intubation model with a Cormack-Lehane grade 4 view.

McGrath Series 5 videolaryngoscope vs Airtraq DL videolaryngoscope for double-lumen tube intubation: A randomized trial

BACKGROUND

Many studies have shown Airtraq videolaryngoscope provided faster tracheal intubation and a higher success rate than other videolaryngoscopes. Recently, different types of videolaryngoscopes have been reported for use in double-lumen tube (DLT) intubation. However, the advantages and disadvantages between them remain undetermined for DLT intubation. In this study, we compared the Airtraq DL videolaryngoscope with the McGrath Series 5 videolaryngoscope for DLT intubation by experienced anesthesiologists.

METHODS

Ninety patients with expected normal airways were randomly allocated to either the Airtraq or McGrath group. The primary outcome was DLT intubation time. The secondary outcomes were glottic view, success rate, subjective ease of intubation (100-mm visual analog scale, 0 = easy; 100 = difficult), incidence of DLT malposition, and postoperative intubation-related complication.

RESULTS

The airway characteristics were comparable between the 2 groups. Cormack and Lehane grades significantly improved with the use of the McGrath and Airtraq videolaryngoscopes, compared with the Macintosh laryngoscope. The intubation success rate on the first attempt was 93% in the Airtraq group and 95% in the McGrath group (P > 0.05). The intubation time in the McGrath group is longer than that in the Airtraq group (39.9 [9.1]s vs 28.6 [13.6]s, P < 0.05). But intubation difficulty score, the incidence of DLT malposition and intubation-related complication were comparable between groups (P > 0.05).

CONCLUSIONS

When using videolaryngoscopes for DLT intubation, the Airtraq DL is superior to the McGrath Series 5 in intubation time, but it does not decrease intubation difficulty.

Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting

OBJECTIVE

This study attempts to determine if newer indirect laryngoscopes or intubating devices are superior to a standard laryngoscope for intubation success among helicopter emergency medical service (HEMS) personnel.

METHODS

Flight nurses and paramedics intubated standardized mannequins with a normal airway, a trauma airway, and a difficult airway using a standard laryngoscope, a gum elastic bougie, the Airtraq laryngoscope (King System Corp, Noblesville, IN), the Glidescope Ranger laryngoscope (Verathon Inc, Bothell, WA), and the S.A.L.T. device (Microtek Medical, Inc, Lehmberg, IN) in grounded helicopters wearing helmets and flight gear. Participant demographics, time to glottic view, the modified Cormack-Lehane score, total intubation time, number of attempts, and overall successful intubation were recorded for each type of airway.

RESULTS

Two-hundred thirty-six subjects were initially enrolled across 107 bases in 15 states, and 177 completed the study. First-attempt success rates did not vary by device for the normal airway (P = .203), but the Airtraq laryngoscope and the S.A.L.T. device were highest in the difficult airway (82.0% and 85.0%, respectively; P < .0001). The time to first-attempt success in the difficult airway was lowest for the S.A.L.T. device and the Airtraq laryngoscope (mean = 9.72 seconds and 19.70 seconds, respectively; P < .0001).

CONCLUSION

Using HEMS providers, the Airtraq laryngoscope and the S.A.L.T. device showed the fastest and highest intubation success on the first attempt in difficult simulated HEMS airway scenarios.

Comparison of the ease of tracheal intubation by postgraduate residents of anesthesiology using Airtraq™ and Macintosh laryngoscopes: An observational study

CONTEXT

Airtraq™ (Prodol Meditec, Vizcaya, Spain) is a recently developed laryngoscope, which facilitates easy visualization of glottis through a matrix of sequentially arranged lenses and mirrors. In this observatory study, we sought to compare the ease of tracheal intubation with Airtraq™ and Macintosh laryngoscope when performed by 2(nd) year postgraduate residents of Anesthesiology in NRI Medical College, Mangalagiri.

AIMS

To compare the ease of tracheal intubation by Airtraq™ laryngoscope with that by Macintosh laryngoscope among the 2(nd) year postgraduate residents of anesthesiology in terms of time taken for intubation and the rise of rate-pressure product (RPP) with intubation.

SETTINGS AND DESIGN

Prospective randomized observational study.

SUBJECTS AND METHODS

Eighty adult and healthy patients with an easy airway, scheduled for general anesthesia were allocated into two groups A, and M. Patients in Group A were intubated with Airtraq™ laryngoscope and those in Group M were intubated with Macintosh laryngoscope by the 2(nd) year postgraduate residents of anesthesiology. The time taken for intubation, the RPPs at baseline, after induction of general anesthesia, postintubation, at 3 and 5 min after intubation, the rise of RPP to intubation and the occurrence of a sore throat were compared between the two groups.

STATISTICAL ANALYSIS USED

Descriptive and inferential statistical methods were used to analyze the data.

RESULTS

The mean time for intubation in Macintosh group was 28.18 s and was 40.98 s in Airtraq group. The mean rise of RPP to intubation was 4644.83 in Airtraq group and 2829.27 in Macintosh group. The incidence of a sore throat was equal in both the groups.

CONCLUSIONS

The time for intubation and the sympathetic response to airway instrumentation were more with Airtraq™ laryngoscope than with Macintosh laryngoscope.

Airtraq, LMA CTrach and Macintosh Laryngoscopes in Tracheal Intubation Training: A Randomized Comparative Manikin Study

OBJECTIVE

Training students on simulators before allowing their direct contact with patients is well accepted. There is no clinical or manikin-based simulation study in the literature comparing tracheal intubation with Airtraq, laryngeal mask airway (LMA) CTrach and Macintosh laryngoscopes performed by medical students having no prior intubation experience.

METHODS

After obtaining written informed consents, 123 participants were included in the study. The participants were asked to intubate the manikin five times with each device randomly. After all the participants had completed their fifth intubations, the measurements were performed. The primary outcome variables were the first-attempt success rate and the time for a successful intubation, while the secondary outcome variables were to determine the scores of dental trauma, the difficulty visual analogue scale and the optimization manoeuvres.

RESULTS

The LMA CTrach group revealed a significantly higher number of intubation attempts. The mean time for a successful intubation was the longest in the LMA CTrach group (17.66±8.22 s, p<0.05). Students defined the Airtraq as the easiest to use and the Macintosh laryngoscope as the most difficult device to use and learn. Dental trauma severity was significantly lower in the Airtraq group than in the other groups (p<0.05), and it was found to be 0 in 81.1% in the Airtraq group. The head extension optimization manoeuvre rate was significantly higher with the Macintosh laryngoscope than with the Airtraq laryngoscope (p<0.05).

CONCLUSION

This study, in which different types of laryngoscopes were compared, revealed that the Airtraq laryngoscope has advantages, such as shorter intubation duration, less additional optimization manoeuvres, less dental trauma intensity and is easier to learn compared with the LMA CTrach and Macintosh laryngoscopes.

Intubation of a Paediatric Manikin in Tongue Oedema and Face-to-Face Simulations by Novice Personnel: a Comparison of Glidescope, Airtraq and Direct Laryngoscopy

OBJECTIVE

Glidescope and Airtraq were designed for facilitating intubation and for teaching regarding the airway anatomy. We aimed to evaluate their efficacy in normal airway, tongue oedema and face-to-face orotracheal intubation models when used by novice personnel.

METHODS

After the local human research ethics committee approval, 36 medical students who were in the beginning of their third year were enrolled in this study. After watching a video regarding intubation using one of these devices, the students intubated a paediatric manikin with a Glidescope or Airtraq via the normal airway, tongue oedema and face-to-face approach.

RESULTS

Although the insertion and intubation times were similar among the groups, the intubation success rate of the Glidescope was higher in the normal airway (100% vs 67%) and tongue oedema (89% vs. 50%) compared with the Airtraq (p=0.008 and p=0.009). The success rates with the paediatric manikin by the face-to-face approach were similar among the groups (50%) (p=0.7). The need for manoeuvres in the Glidescope was lower in the normal and tongue oedema models (p=0.02 and p=0.002). In addition, oesophageal intubation was low in the control and tongue oedema models with the Glidescope (p=0.03 and p<0.001).

CONCLUSION

Novice personnel could more easily intubate the trachea with the Glidescope than with the Airtraq. Intubation with the Glidescope was superior to that with the Airtraq in the normal and tongue oedema models. The face-to-face intubation success rates were both low with both the Glidescope and Airtraq groups.

[A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin]

OBJECTIVE

Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios.

METHODS

Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway.

RESULTS

Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001).

CONCLUSION

In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

A comparison of the McGrath-MAC and Macintosh laryngoscopes for child tracheal intubation during resuscitation by paramedics. A randomized, crossover, manikin study

INTRODUCTION

Prehospital tracheal intubation by paramedics during cardiopulmonary resuscitation (CPR) in children is challenging. The potential role of new intubation devices during CPR is unclear. Our objective was to assess the impact of CPR (with and without chest compressions [CCs]) on the success and time to intubation (TTI) with the Macintosh laryngoscope vs the McGrath video laryngoscope on a pediatric manikin.

METHODS

This was an open, prospective, randomized, crossover, manikin trial involving 95 paramedics who performed intubations in a PediaSIM pediatric high-fidelity manikin with Macintosh and McGrath laryngoscopes, with and without concomitant mechanical CCs. Primary outcome was the TTI, and secondary outcome was success of the attempt. Participants rated their best glottic view, the severity of the potential dental trauma, and subjective opinion about the difficulty of the procedure.

RESULTS

The median TTI with the Macintosh in the scenario with uninterrupted CC was 33 (interquartile range [IQR], 24-36) seconds, which is significantly longer than TTI in the scenario with interrupted CC (23 [IQR, 20-29] seconds, P < .001). Time to intubation using the McGrath was similar in both scenarios: 20 (IQR, 17-23) seconds vs 19.5 (IQR, 17-22) seconds (P = .083). A statistically significant difference between McGrath and Macintosh was noticed in TTI both in scenario with (P < .001) and without CC (P = .017).

CONCLUSIONS

McGrath video laryngoscope helps paramedics to intubate a pediatric manikin in a CPR scenario in less time and with fewer attempts than with the classical Macintosh, both in case of ongoing or stopped CC. McGrath use in actual patients could improve CPR quality by paramedics.

Survey of video laryngoscopy use by U.S. critical care fellowship training programs

RATIONALE

Recent studies on video laryngoscopy have demonstrated improvements in both safety and success of endotracheal intubation in the critically ill.

OBJECTIVES

We assessed the use of video laryngoscopy among internal medicine fellowship programs training physicians in critical care medicine.

METHODS

A 19-question survey was e-mailed to program directors of pulmonary/critical care and internal medicine critical care fellowship training programs.

MEASUREMENTS AND MAIN RESULTS

A completed survey was returned by 36% of invited program directors. Sixty-nine percent of respondents reported a change in their approach to intubation training over the prior 3 years, with 56% of changes attributed to the adoption of a video laryngoscope. Other reported changes include new training methods (23%) and adoption of a checklist (10%). A video laryngoscope is available for clinical use in 89% of the responding programs. The video scope is used as the primary device in 16% and is never used in 9%. In the remainder of programs, the video laryngoscope is only used for difficult intubations or after failure of direct laryngoscopy (32%) or the primary device is determined by the preference of the operator (32%).

CONCLUSIONS

The majority of internal medicine critical care program directors who recently responded to an e-mail survey reported that they have changed their approach to teaching endotracheal intubation, driven largely by the adoption of video laryngoscopy for upper airway visualization. Nevertheless, despite widespread availability, video laryngoscopy is used uncommonly as the primary visualization device for intubation at the programs represented by the respondents to this survey.

The AirView Study: Comparison of Intubation Conditions and Ease between the Airtraq-AirView and the King Vision

We conducted a study assessing the quality and speed of intubation between the Airtraq with its new iPhone AirView app and the King Vision in a manikin. The primary endpoint was reduction of time needed for intubation. Secondary endpoints included times necessary for intubation. 30 anaesthetists randomly performed 3 intubations with each device on a difficult airway manikin. Participants had a professional experience of 12 years: 60.0% possessed the Airtraq in their hospital, 46.7% the King Vision, and 20.0% both. Median time difference [IQR] to identify glottis (1.1 [-1.3; 3.9] P = 0.019), for tube insertion (2.1 [-2.6; 9.4] P = 0.002) and lung ventilation (2.8 [-2.4; 11.5] P = 0.001), was shorter with the Airtraq-AirView. Median time for glottis visualization was significantly shorter with the Airtraq-AirView (5.3 [4.0; 8.4] versus 6.4 [4.6; 9.1]). Cormack Lehane before intubation was better with the King Vision (P = 0.03); no difference was noted during intubation, for subjective device insertion or quality of epiglottis visualisation. Assessment of tracheal tube insertion was better with the Airtraq-AirView. The Airtraq-AirView allows faster identification of the landmarks and intubation in a difficult airway manikin, while clinical relevance remains to be studied. Anaesthetists assessed the intubation better with the Airtraq-AirView.

A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin

OBJECTIVE

Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios.

METHODS

Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway.

RESULTS

Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001).

CONCLUSION

In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.