Cuffed oropharyngeal airway (COPA) placement is delayed by wearing antichemical protective gear

Assessing the New Norm: A Simulation Study to Assess Pediatric Emergency Physician Success in Critical Procedures With an Air Purifying Respirator

INTRODUCTION

Physicians caring for patients with COVID-19 are at high risk for contracting the disease, thus, significant emphasis has been placed on personal protective equipment (PPE). The study aims to assess the impact of advanced PPE across 4 common procedures: endotracheal intubation, bag-valve mask ventilation, intraosseous (IO) insertion, and lumbar puncture (LP) performed by pediatric emergency physicians.

METHOD

Physicians performed the procedures in a simulated environment. Lumbar puncture and IO were performed with standard precautions versus an air purifying respirator (APR). A direct comparison was drawn for endotracheal intubation and bag-valve mask ventilation between 2 commonly used APRs. Success rate and number of attempts toward successful completion was recorded for all 4 procedures. Physicians filled out a postprocedure survey to assess their ease of use of the APR.

RESULTS

Twenty participants performed IO and LP using an APR and standard precautions. There was no statistical difference in the success rate, number of attempts, average time, or maintenance of sterility (LP only) for both procedures. Twenty total participants divided across 2 types of APR groups performed intubation and BMV. Success rate and number of attempts had no statistical difference for both procedures. Physician feedback surveys to assess the ease of use of APR compared with standard precautions had no statistically significant difference for all 4 procedures.

CONCLUSIONS

Wearing increased levels of PPE did not impact procedural success, length of time, sterility, number of attempts, or the physicians' ease in our study. Physicians should be encouraged to wear all appropriate PPE.

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).

Impact of Clinician Personal Protective Equipment on Medical Device Use During Public Health Emergency: A Review

The aim of this systematic review is to evaluate the impact of personal protective equipment (PPE) on medical device use during public health emergency responses. We conducted a systematic literature search of peer-reviewed journals in PubMed, Web of Science, and EBSCO databases. Twenty-nine of 92 articles published between 1984 and 2015 met the inclusion criteria for the review. Although many medical device use impacts were reported, they predominantly fell into 3 categories: airway management, drug administration, and diagnostics and monitoring. Chemical, biological, radiological, and nuclear (CBRN)-PPE increased completion times for emergency clinical procedures by as much as 130% and first attempt failure rates by 35% (anesthetist) versus 55% (non-anesthetist). Effects of CBRN-PPE use depend on device, CBRN-PPE level, and clinician experience and training. Continuous clinical training of responders in CBRN-PPE and device modifications can improve safety and effectiveness of medical device use during public health emergency response.

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

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.

Intubation Efficiency and Perceived Ease of Use of Video Laryngoscopy vs Direct Laryngoscopy While Wearing HazMat PPE: A Preliminary High-fidelity Mannequin Study

INTRODUCTION

Management of contaminated patients in the decontamination corridor requires the use of hazardous material (HazMat) personal protective equipment (PPE). Previous studies have demonstrated that HazMat PPE may increase the difficulty of airway management. This study compared the efficiency of video laryngoscopy (VL) with traditional direct laryngoscopy (DL) during endotracheal intubation (ETI) while wearing HazMat PPE.

METHODS

Post-graduate year (PGY) 1-3 Emergency Medicine residents were randomized to VL or DL while wearing encapsulating PPE. Video laryngoscopy was performed using the GlideScope Cobalt AVL video laryngoscope. The primary outcome measure was time to successful ETI in a high-fidelity simulation mannequin. Three time points were utilized in the analysis: Time 0 (blade at lips), Time 1 (blade removed from lips after endotracheal tube placement), and Time 2 (bag valve mask [BVM] attached to endotracheal tube). Secondary outcome measures were perceived ease of use and feasibility of VL and DL ETI modalities.

RESULTS

Twenty-one of 23 (91.3%) eligible residents participated. Mean time to ETI was 10.0 seconds (SD=5.3 seconds) in the DL group and 7.8 seconds (SD=3.0 seconds) in the VL group (P=.081). Mean times from blade insertion until BVM attachment were 17.4 seconds (SD=6.0 seconds) and 15.6 seconds (SD=4.6 seconds), respectively (P=.30). There were no unsuccessful intubation attempts. Seventeen out of 20 participants (85.0%) perceived VL to be easier to use when performing ETI in PPE. Twelve out of 20 participants (60%) perceived DL to be more feasible in an actual HazMat scenario.

CONCLUSION

The time to successful ETI was not significantly different between VL and DL. Video laryngoscopy had a greater perceived ease of use, but DL was perceived to be more feasible for use in actual HazMat situations. These findings suggest that both DL and VL are reasonable modalities for use in HazMat situations, and the choice of modality could be based on the clinical situation and provider experience.

Cuffed oropharyngeal airway for difficult airway management

Difficulties with airway management are often caused by anatomic abnormalities due to previous oral surgery. We performed general anesthesia for a patient who had undergone several operations such as hemisection of the mandible and reconstructive surgery with a deltopectoralis flap, resulting in severe maxillofacial deformation. This made it impossible to ventilate with a face mask and to intubate in the normal way. An attempt at oral awake intubation using fiberoptic bronchoscopy was unsuccessful because of severe anatomical abnormality of the neck. We therefore decided to perform retrograde intubation and selected the cuffed oropharyngeal airway (COPA) for airway management. We inserted the COPA, not through the patient's mouth but through the abnormal oropharyngeal space. Retrograde nasal intubation was accomplished with controlled ventilation through the COPA, which proved to be very useful for this difficult airway management during tracheal intubation even though the method was unusual.

Airway control in case of a mass toxicological event: superiority of second-generation supraglottic airway devices

INTRODUCTION

Early respiratory support and airway (AW) control with endotracheal intubation (ETI) are crucial in mass toxicology events and must be performed while wearing chemical personal protective equipment (C-PPE).

AIM

The aim of this study is to evaluate the efficiency of AW control by using second-generation supraglottic AW devices (SADs) as compared with ETI and first-generation SAD while wearing C-PPE.

METHODS

This is a randomized crossover trial involving 117 medical practitioners. Four AW management devices were examined: endotracheal tube, the first-generation SAD, laryngeal mask AW unique and 2 second-generation SAD, the laryngeal tube suction disposable, and supreme laryngeal mask AW (SLMA). Primary end point measured were success or failure, number of attempts, and time needed to achieve successful device insertion. Secondary end point was a subjective appraisal of the AW devices by study population.

RESULTS

More attempts were required to achieve AW control with endotracheal tube, with and without C-PPE (P<.001). Time to achieve AW control with ETI was, on average, 88% longer than required with other devices and improved with practice. The mean times to achieve an AW were longer when operators were equipped with C-PPE as compared with standard clothing. Subjectively, difficulty levels were significantly higher for ETI than for all other devices (P<.0001).

CONCLUSIONS

When compared with ETI, the use of SADs significantly shortened the time for AW control while wearing C-PPE. Second-generation SAD were superior to laryngeal mask AW unique. These finding suggest that SADs may be used in a mass toxicology event as a bridge, until definite AW control is achieved.

Insertion of six different supraglottic airway devices whilst wearing chemical, biological, radiation, nuclear-personal protective equipment: a manikin study

Six different supraglottic airway devices: Combitube™, laryngeal mask airway, intubating laryngeal mask airway (Fastrach™), i-gel™, Laryngeal Tube™ and Pro-Seal™ laryngeal mask airway were assessed by 58 paramedic students for speed and ease of insertion in a manikin, whilst wearing either chemical, biological, radiation, nuclear-personal protective equipment (CBRN-PPE) or a standard uniform. All devices took significantly longer to insert when wearing CBRN-PPE compared with standard uniform (p < 0.001). In standard uniform, insertion time was shorter than 45 s in 90% of attempts for all devices except the Combitube, for which 90% of attempts were completed by 53 s. Whilst wearing CBRN-PPE the i-gel was the fastest device to insert with a mean (SD (95% CI)) insertion time of 19 (8 (17-21))s, p < 0.001, with the Combitube the slowest with mean (65 (23 (59-71))s. Wearing of CBRN-PPE has a negative impact on supraglottic airway insertion time.

Comparison of techniques for securing the endotracheal tube while wearing chemical, biological, radiological, or nuclear protection: a manikin study

OBJECTIVE

The objective of this study was to assess the impact of chemical, biological, radiological, nuclear personal protective equipment (CBRN-PPE) on the ability to secure an endotracheal tube (ETT) with either the Thomas Tube Holder™ or cotton tape tied in a knot.

METHODS

Seventy-five clinicians secured an ETT in a previously intubated manikin with the Thomas Tube Holder™ and cotton tape. A mixed quantitative and qualitative research design was used to gauge actual performance times and perceptions of difficulties. Following completion of the study, 25 clinicians were interviewed to gauge their experiences of securing the ETT with both devices while wearing CBRN-PPE.

RESULTS

The mean time to apply the Thomas Tube Holder was 29.02 seconds, compared with tape which took a mean of 58 seconds (p=0.001). Clinicians rated the Thomas Tube Holder as easier to use than tape (Mann-Whitney z=9.934; p<0.001), which was confirmed during interviews. Of the clinicians interviewed, 92% perceived that the Thomas Tube Holder provided the better method for securing an ETT, none of the clinicians identified the tape as the best method for securing the endotracheal tube while wearing CBRN-PPE. Clinicians identified that the design of the Thomas Tube Holder facilitated the gross motor movement required for application.

CONCLUSIONS

The Thomas Tube Holder is easier and faster to apply when wearing CBRN-PPE when compared with cotton, and the Thomas Tube Holder is perceived by the participants as being more effective at preventing accidential extubation.