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

Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review

Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results.

Life-Saving Procedures Performed While Wearing CBRNe Personal Protective Equipment: A Mannequin Randomized Trial

INTRODUCTION

Chemical-biological-radiological-nuclear-explosive (CBRNe) are complex events. Decontamination is mandatory to avoid harm and contain hazardous materials, but can delay care. Therefore, the stabilization of patients in the warm zone seems reasonable, but research is limited. Moreover, subjects involved in biological events are considered infectious even after decontamination and need to be managed while wearing personal protective equipment (PPE), as seen with Ebola and COVID-19 pandemic. With this simulation mannequin trial, we assessed the impact of CBRNe PPE on cardiopulmonary resuscitation and combat casualty care procedures.

METHODS

We compared procedures performed by emergency medicine and anesthesiology senior residents, randomized in 2 groups (CBRNe PPE vs. no PPE). Chest compression (CC) depth was defined as the primary outcome. Time to completion was calculated for the following: tourniquet application; tension pneumothorax needle decompression; peripheral venous access (PVA) and intraosseous access positioning; and drug preparation and administration. A questionnaire was delivered to evaluate participants' perception.

RESULTS

Thirty-six residents participated. No significant difference between the groups in CC depth (mean difference = 0.26 cm [95% confidence interval = -0.26 to 0.77 cm, P = 0.318]), as well as for CC rate, CC complete release, and time for drugs preparation and administration was detected. The PPE contributed to significantly higher times for tourniquet application, tension pneumothorax decompression, peripheral venous access, and intraosseous access positioning. The residents found simulation relevant to the residencies' core curriculum.

CONCLUSIONS

This study suggests that cardiopulmonary resuscitation can be performed while wearing PPE without impacting quality, whereas other tasks requiring higher dexterity can be significantly impaired by PPE.Trial Registration Number: NCT04367454, April 29, 2020 (retrospectively registered).

Orotracheal tube versus supraglottic devices in biological, chemical and radiological disasters: meta-analysis in manikin-based studies

OBJECTIVE

To compare the mean time of orotracheal intubation and insertion of supraglottic airway devices, considering healthcare providers wearing waterproof overall, gloves, boots, eye protection and mask at the Chemical, Biological, Radiological and Nuclear context in simulation setting.

METHODS

Six databases were searched. The selected studies were put in a pool of results using a random-effects meta-analysis, with standardized mean differences and calculation of 95% confidence intervals.

RESULTS

Nine observational studies were included. Regarding reducing time to provide ventilatory support, subgroup analyses were made. The emergency setting subgroup: -12.97 [-16.11; -9.83]; I2 = 64%. The surgery setting subgroup: -14.96 [-18.65; -11.27]; I2 = 75%. Another analysis was made by reproductive methodology subgroups. Ophir's subgroup: -15.70 [-17.04; -14.37]; I2 = 0%. All meta-analyses had orotracheal tube as comparator.

CONCLUSION

Moderate level of evidence was in favor of insertion of supraglottic devices because of fast application.

Comparative evaluation of intubation performances using two different barrier devices used in the COVID-19 era: A manikin based pilot study

Background and Aims:

Protection of anaesthesiologists from contaminated aerosols of COVID 19 patients during endotracheal intubation has spurred the development of barrier devices like aerosol boxes and clear transparent plastic sheets and usage of videolaryngoscopes in COVID 19 patients. However, the efficiency, feasibility and difficulties faced by anaesthesiologist while performing endotracheal intubations under barrier devices require scientific validation. This manikin-based pilot study aims to assess the laryngoscopic performances of experienced anaesthesiologists under two different barrier enclosures.

Methods and Materials:

53 anaesthesiologists (14 Consultants and 39 Senior Residents) who were undergoing an airway training module as a part of preparedness for handling the COVID 19 pandemic were recruited. Using an aerosol box over a manikin, the participants attempted intubation using a Glidescope Videolaryngoscope and Macintosh laryngoscopes (GA and MA Groups). Subsequently, intubation was attempted under a transparent plastic sheet using both laryngoscopes (GP and MP groups). Time required for intubation, first pass success rates, subjective ease of intubation and the feedback obtained from the participants were recorded and analysed.

Results:

Time required for accomplishing successful intubation was 38.55 ± 12.16 seconds, 26.58 ± 5.73 seconds, 46.89 ± 15.23 seconds and 37.26 ± 8.71 seconds for GA, MA, GP and MP groups respectively. Time for intubation and difficulty (VAS) was least for Macintosh group with aerosol box (MA) and maximum time was taken in Glidescope group with transparent polythene drape (GP). First attempt success rate for Glidescope groups (GP and GA) were 100% and in MA and MP group was 98% and 96% respectively. Restriction in hand movement and stylet removal were the major difficulties reported

Conclusion:

Longer intubation times were observed while using Glidescope Videolaryngoscopes with either of the two barrier devices in place compared to Macintosh laryngoscopes.

Systematic review and meta-analysis comparing ventilatory support in chemical, biological and radiological emergencies

Objective:

to compare the mean development time of the techniques of direct laryngoscopy and insertion of supraglottic devices; and to evaluate the success rate in the first attempt of these techniques, considering health professionals wearing specific personal protective equipment (waterproof overalls; gloves; boots; eye protection; mask).

Method:

meta-analysis with studies from LILACS, MEDLINE, CINAHL, Cochrane, Scopus and Web of Science. The keywords were the following: personal protective equipment; airway management; intubation; laryngeal masks.

Results:

in the “reduction of the time of the procedures” outcome, the general analysis of the supraglottic devices in comparison with the orotracheal tube initially presented high heterogeneity of the data (I²= 97%). Subgroup analysis had an impact on reducing heterogeneity among the data. The “laryngeal mask as a guide for orotracheal intubation” subgroup showed moderate heterogeneity (I²= 74%). The “2^ndgeneration supraglottic devices” subgroup showed homogeneity (I²= 0%). All the meta-analyses favored supraglottic devices. In the “success in the first attempt” outcome, moderate homogeneity was found (I²= 52%), showing a higher proportion of correct answers for supraglottic devices.

Conclusion:

in the context of chemical, biological or radiological disaster, the insertion of the supraglottic device proved to be faster and more likely to be successful by health professionals. PROSPERO record (CRD42019136139).

Emergency Airway Management in a Simulation of Highly Contagious Isolated Patients: Both Isolation Strategy and Device Type Matter

OBJECTIVE To compare 6 airway-management devices in 3 isolation scenarios regarding their effect on airway management: portable isolation unit (PIU), personal protective equipment (PPE), and standard protection measures METHODS In total, 30 anesthesiologists working in emergency medical services performed airway management on mannequins in 3 isolation settings using 6 different airway management devices (in random order): (1) standard Macintosh laryngoscope; (2) Airtraq SP-video-laryngoscope; (3) i-gel; (4) LMA-Fastrach; (5) Ambu fiberoptic-aScope; and (6) Melker cricothyrotomy-set. Each was assessed regarding time-to-ventilate (primary outcome) and rating of difficulty handling the device. RESULTS In 86% (standard protection) and 85% (PPE) of attempts, airway management was achieved in <60 seconds, irrespective of the device used. In the PIU setting, only 69% of attempts succeeded within this time frame (P<.05). Median time-to-ventilate was shorter for standard protection (23 seconds) and PPE (25 seconds) compared to the PIU (38 seconds; P<.001). In the PIU setting, the fiberscope took the longest (median, 170 seconds), while i-gel was the quickest (median, 13 seconds). The rating of difficulty (visual analogue scale [VAS], 0-100) differed significantly between the isolation scenarios: Airway management was most difficult with PIU (VAS, 76), followed by PPE (VAS, 35), and standard protection (VAS, 9) (P<.01). CONCLUSION Wearing PPE produced similar times-to-ventilate as standard protection among anesthesiologists, but it was subjectively rated more difficult. The portable isolation unit permitted acceptable times-to-ventilate when excluding fiberscope and cricothyrotomy. Supraglottic airway devices allowed the fastest airway management in all isolation scenarios, thus being highly recommendable if a portable isolation unit is used and emergency airway management becomes necessary. Infect Control Hosp Epidemiol 2018;39:145-151.