Hands-Off Time for Endotracheal Intubation during CPR Is Not Altered by the Use of the C-MAC Video-Laryngoscope Compared to Conventional Direct Laryngoscopy. A Randomized Crossover Manikin Study

Comparison of the UEScope videolaryngoscope with the Macintosh laryngoscope during simulated cardiopulmonary resuscitation: A randomized, cross-over, multi-center manikin study

BACKGROUND

Endotracheal intubation (ETI) can be challenging, especially in life-threatening situations such as cardiopulmonary resuscitation (CPR). Videolaryngoscopes aim to ease ETI, but effort is still widely discussed. This study intended to investigate 2 different airway devices regarding the success rate of ETI during ongoing chest compressions.

METHODS

This randomized, cross-over, multi-center manikin trial included 85 experienced paramedics actively working in the emergency medicine service. After a standardized training session, all paramedics underwent 3 airway scenarios using both, direct laryngoscopy using a Macintosh blade and videolaryngoscope (the UEScope): normal airway without chest compressions, normal airway with uninterrupted chest compressions, and difficult airway with uninterrupted chest compressions. The primary outcome was successful ETI, defined as successful placement of the endotracheal tube within the manikin's trachea. Secondary outcomes were number of intubation attempts, time to successful ETI, time to best glottis view, best percent of glottic opening, best glottic view score (Cormack and Lehane), occurrence of dental trauma, ease of use, and willing to reuse in real-life situations.

RESULTS

The UEScope provided a better glottis visualization, and higher first pass intubation success rate compared to direct laryngoscopy in all 3 scenarios. The overall intubation success was higher, and the intubation time was shorter with the UEScope in scenario B and scenario C, but was comparable in scenario A. Dental compression occurred less often using the UEScope and paramedics rated intubation using the UEScope easier compared to direct laryngoscopy in all 3 airway scenarios.

CONCLUSION

In simulated CPR scenarios, intubation with the UEScope resulted in a better glottis visualization, a higher intubation success, and a shorter intubation time compared to Macintosh laryngoscope (MAC). Moreover, in situations where the airway is difficult for ETI especially by the paramedic, the UEScope would be a better choice than the MAC. Further studies are needed to confirm these results in real-life patients.

The role of videolaryngoscope in endotracheal intubation training programs

Background

Macintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education.

Methods

Endotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC^® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group-MM and Group-MV used Macintosh laryngoscopes; Group-VV and Group-VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group-MM and Group-VM and videolaryngoscopes used in Group-VV and Group-MV.

Results

Success rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p = 0.011; p = 0.021, p = 0.290 respectively) whereas a decrease was observed in group-VM (p = 0.008).

Conclusions

The success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

[The role of videolaryngoscope in endotracheal intubation training programs]

BACKGROUND

Macintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education.

METHODS

Endotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC^® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group-MM and Group-MV used Macintosh laryngoscopes; Group-VV and Group-VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group-MM and Group-VM and videolaryngoscopes used in Group-VV and Group-MV.

RESULTS

Success rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p=0.011; p=0.021, p=0.290 respectively) whereas a decrease was observed in group-VM (p=0.008).

CONCLUSIONS

The success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

C-MAC videolaryngoscope compared with direct laryngoscopy for rapid sequence intubation in an emergency department: A randomised clinical trial

BACKGROUND

Airway management in the emergency room can be challenging when patients suffer from life-threatening conditions. Mental stress, ignorance of the patient's medical history, potential cervical injury or immobilisation and the presence of vomit and/or blood may also contribute to a difficult airway. Videolaryngoscopes have been introduced into clinical practice to visualise the airway and ultimately increase the success rate of airway management.

OBJECTIVE

The aim of this study was to test the hypothesis that the C-MAC videolaryngoscope improves first-attempt intubation success rate compared with direct laryngoscopy in patients undergoing emergency rapid sequence intubation in the emergency room setting.

DESIGN

A randomised clinical trial.

SETTING

Emergency Department of the University Hospital, Zurich, Switzerland.

PATIENTS

With approval of the local ethics committee, we prospectively enrolled 150 patients between 18 and 99 years of age requiring emergency rapid sequence intubation in the emergency room of the University Hospital Zurich. Patients were randomised (1 : 1) to undergo tracheal intubation using the C-MAC videolaryngoscope or by direct laryngoscopy.

INTERVENTIONS

Owing to ethical considerations, patients who had sustained maxillo-facial trauma, immobilised cervical spine, known difficult airway or ongoing cardiopulmonary resuscitation were excluded from our study. All intubations were performed by one of three very experienced anaesthesia consultants.

MAIN OUTCOME MEASURES

First-attempt success rate served as our primary outcome parameter. Secondary outcome parameters were time to intubation; total number of intubation attempts; Cormack and Lehane score; inadvertent oesophageal intubation; ease of intubation; complications including violations of the teeth, injury/bleeding of the larynx/pharynx and aspiration/regurgitation of gastric contents; necessity of using further alternative airway devices for successful intubation; maximum decrease of oxygen saturation and technical problems with the device.

RESULTS

A total of 150 patients were enrolled, but three patients had to be excluded from the analysis, resulting in 74 patients in the C-MAC videolaryngoscopy group and 73 patients in the direct laryngoscopy group. Tracheal intubation was achieved successfully at the first attempt in 73 of 74 patients in the C-MAC group and all patients in the direct laryngoscopy group (P = 1.0). Time to intubation was similar (32 ± 11 vs. 31 ± 9 s, P = 0.51) in both groups. Visualisation of the vocal cords, represented as the Cormack and Lehane score, was significantly better using the C-MAC videolaryngoscope (P < 0.001).

CONCLUSION

Our study demonstrates that visualisation of the vocal cords was improved by using the C-MAC videolaryngoscope compared with direct laryngoscopy. Better visualisation did not improve first-attempt success rate, which in turn was probably based on the high level of experience of the participating anaesthesia consultants.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT02297113.