Airtraq vs standard laryngoscopy by student paramedics and experienced prehospital laryngoscopists managing a model of difficult intubation*

Abstract

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 These findings led the authors to suggest that intubation be withdrawn from the UK paramedic skill base.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.

Direct and Indirect Laryngoscopy: Equipment and TechniquesDiscussion

“…77 Similar findings were reported with the Airtraq optical laryngoscope 78,79 using difficult intubation models, as well as with the Airtraq 80 and Pentax AWS 81 in patients with normal-appearing airways. Multiple-comparison studies between the Macintosh laryngoscope and various video laryngoscopes in mannequin studies also show evidence that intubation skills with the new devices are rapidly mastered and that video laryngoscopes provide superior laryngeal views, although intubation times may be longer.…”

Comparison of two methods of gum elastic bougie aided endotracheal intubation using Airtraq® video laryngoscope

“…12 In spite of better glottic view, intubation using Airtraq ® may not always be successful although it reduces intubation time. 13,14 GEB when used along with Airtraq ® aids in intubation and prevents repeated attempts. 10 Durga P et al reported the use of GEB in combination with the Airtraq ® in ten patients who required multiple intubation attempts.…”

Intubation of a Pediatric Manikin in Tongue Edema and Face-to-Face Simulations by Emergency Medical Staff: A Comparison of the Glidescope, Airtraq and Direct Laryngoscopy

“…Glideskop ile entübasyon süresi üç modelde de diğer havayolu araçlarından daha uzundu (p=0,001, p=0,02, p=0,02). Grup içi karşılaştırmada, Glideskop'un entübasyon süresinin normalden yüzyüzeye gidildikçe göreceli olarak uzadığı tespit edildi (16 [14,5] saniye vs. 31 [18,3] saniye, 57 [43,0-71,0] saniye; p<0,001). Bu, diğer havayolu araçları için söz konusu olmadı.…”

“…Additionally, their superiorities to Macintosh laryngoscopy in situati ons involving tongue edema and cervical trauma have been validated. [1][2][3][4][5][6] In this article, we aimed to compare the tracheal intubation successes by emergency staff with these two video laryngoscopes in normal airway, tongue edema and face-to-face intubation models in a pediatric manikin.…”