SummaryTwo consecutive, randomised, cross-over trials compared intubation success rates in third-year paramedic students and experienced prehospital practitioners using the Airtraq or a Macintosh laryngoscope with flexible stylet in a manikin model of a Cormack and Lehane grade III ⁄ IV laryngoscopic view. First-time intubation rates for the Macintosh and Airtraq for students were 0 ⁄ 23 (0%) vs 10 ⁄ 23 (44%) (44% difference, 95% CI 26-63%, p < 0.001) and for experienced laryngoscopists were 14 ⁄ 56 (25%) vs 47 ⁄ 56 (84%) (59% difference, 95% CI 42-72%, p < 0.0001), respectively. First-time oesophageal intubation rates for students were 15 ⁄ 23 (65%) vs 3 ⁄ 23 (13%) () 52% difference, 95% CI ) 25 to ) 72%, p < 0.001) and for experienced practitioners 9 ⁄ 56 (16%) vs 0 ⁄ 56 (0%) () 16% difference, 95% CI ) 9 to ) 28%, p = 0.0014). Student paramedics and experienced prehospital laryngoscopists managing a manikin model of a grade III ⁄ IV view had increased first-time intubation rates and had lower rates of oesophageal intubation with the Airtraq compared with a standard laryngoscope. One of the main criticisms of paramedics' tracheal intubation skills concerns the frequency of unrecognised misplaced tracheal tubes. An observational study of 108 paramedic tracheal intubations identified that 25% of patients had misplaced tracheal tubes, of which 67% were noted to be in the oesophagus [1]. A similar study of 167 paramedic tracheal intubations reported that 12% were misplaced with > 75% in the oesophagus [2], and a prospective observational study of 208 paramedic tracheal intubations reported unrecognised misplaced tracheal tubes in 5.8% of patients (95% CI = 2.6-8.9%) [3].A UK study of paramedic tracheal intubation in 52 patients reported a cumulative success rate of only 71.2% after two attempts [4]. This research also found that although 87.5% of patients with a Cormack and Lehane grade I view and 56.3% of patients with a grade II view were successfully intubated, no patient with a grade III or IV view had a tracheal tube correctly placed. These findings led the authors to suggest that intubation be withdrawn from the UK paramedic skill base. A recent literature review examining out-of-hospital intubation has also identified concerns about 'adverse events and errors, interaction with other important resuscitation interventions, and challenges in providing and maintaining procedural skill ' [5]. The review highlighted the need for new strategies to improve airway management in this setting.
SummaryThis study evaluated the ability of prehospital providers who had no previous training in intubation, to use an Airtraq laryngoscope to intubate a manikin model of a Cormack and Lehane grade III ⁄ IV view. Volunteers attending the Australian College of Ambulance Professionals conference, Adelaide, in November 2006 received approximately 5 min of Airtraq training. First-time intubation success rate was 26 ⁄ 33 (79%) (95% CI 61-91%); oesophageal intubation rate was 0 ⁄ 33 (0%) (95% CI 0-11%); median time to intubation was 17 s (IQR 10-25 s (range 5-30 s)); and median subject-rated difficulty of use score was 21 out of a maximum of 100 (IQR 7.5-35.5 (range 1-65)). Pre-hospital providers without previous laryngoscopy training achieved high first-time intubation success rates when managing a model of a grade III ⁄ IV difficult intubation with an Airtraq laryngoscope. Users evaluated it as easy to use and achieved intubation within an acceptable breathto-breath interval.
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