Patrycja Szalast1, Jacek Smereka2, Kurt Ruetzler3, Elzbieta Makomaska-Szaroszyk1, Kacper Kranc1, Kacper Stolarek1, Michal Paprocki1, *Lukasz Szarpak 1
Comparison of Airtraq® and Macintosh laryngoscope applied by nurses in manikins with normal and difficult airways: pilot data
Porównanie intubacji z wykorzystaniem Airtraq® i laryngoskopu Macintosha w warunkach normalnych i trudnych dróg oddechowych wykonywanej przez pielęgniarki. Badanie pilotażowe
1Lazarski University, Warsaw, Poland
2Department of Emergency Medical Service, Wroclaw Medical University, Poland
3Departments of Outcomes Research and General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
Streszczenie
Wstęp. Zabezpieczenie dróg oddechowych z wykorzystaniem rurki intubacyjnej stanowi obecnie złoty standard postępowania. Intubacja z wykorzystaniem laryngoskopii bezpośredniej w warunkach przedszpitalnych jest obarczona niewystarczającą skutecznością.
Cel pracy. Celem pracy było porównanie laryngoskopii bezpośredniej i wideolaryngoskopii podczas intubacji dotchawiczej w warunkach normalnych i trudnych dróg oddechowych wykonywanej przez pielęgniarki.
Materiał i metody. W badaniu udział wzięło 27 pielęgniarek. Protokół badania został zaakceptowany przez Radę Programową Polskiego Towarzystwa Medycyny Katastrof (zgoda: 32.04.2018.IRB). Badanie przeprowadzono w oparciu o randomizowany krzyżowy model badania. Jego uczestnicy wykonywali intubację z wykorzystaniem laryngoskopu z łopatką Macintosha (MAC) oraz wideolaryngoskopu Airtraq® (ATQ) w dwóch scenariuszach badawczych: scenariusz A – normalne drogi oddechowe, scenariusz B – trudne drogi oddechowe. W tym celu „pacjent” miał unieruchomiony odcinek szyjny kręgosłupa za pomocą standardowego jednoczęściowego kołnierza szyjnego.
Wyniki. Skuteczność pierwszej próby intubacji z wykorzystaniem MAC i ATQ była zróżnicowana zarówno w przypadku scenariusza A: odpowiednio 66,7 i 92,6% (p = 0,007), jak i podczas scenariusza B: 14,8 i 70,4% (p = 0,001). Mediana czasu intubacji podczas scenariusza A wynosiła odpowiednio 23 sek. (IQR: 22-33,5) dla MAC oraz 17 sek. (IQR: 15,5-25) dla ATQ (p = 0,031). W przypadku scenariusza B mediana czasu intubacji dla MAC i ATQ wynosiła odpowiednio: 53 sek. (IQR: 48-67) i 26 sek. (IQR: 24-49; p < 0,001).
Wnioski. W przeprowadzonym badaniu symulacyjnym pielęgniarki były w stanie z większą skutecznością wykonać intubację dotchawiczą z zastosowaniem wideolaryngoskopu Airtraq® aniżeli w oparciu o laryngoskopię bezpośrednią – zależność ta była obserwowana zarówno w warunkach normalnych, jak i trudnych dróg oddechowych.
Summary
Introduction. Endotracheal intubation is currently the gold standard of airway management. In direct laryngoscopy in pre-hospital settings, though, it turns out insufficiently effective.
Aim. The study purpose was to compare direct laryngoscopy and videolaryngoscopy for endotracheal intubation performed by nurses in normal and difficult airway conditions.
Material and methods. This randomized cross-over study involved 27 nurses. The protocol was approved by the Institutional Review Board of the Polish Society of Disaster Medicine (approval number: 32.04.2018.IRB). The participants performed intubation using a Macintosh laryngoscope (MAC) and an Airtraq® videolaryngoscope (ATQ) in 2 study scenarios: A – normal airway; B – difficult airway. For this latter purpose, the manikin had the cervical spine immobilized with a standard one-piece cervical collar.
Results. The effectiveness of the first intubation attempt with MAC and ATQ was varied both in scenario A: 66.7 and 92.6% (p = 0.007) and in scenario B: 14.8 and 70.4% (p = 0.001). The median intubation time in scenario A was 23 s (IQR: 22-33.5) for MAC and 17 s (IQR: 15.5-25) for ATQ (p = 0.031), respectively. In scenario B, this parameter value equaled 53 s (IQR: 48-67) for MAC and 26 s (IQR: 24-49) for ATQ (p < 0.001).
Conclusions. In the simulation study, nurses were able to perform endotracheal intubation with the use of ATQ with higher efficacy compared with direct laryngoscopy – this relationship was observed under both normal and difficult airway conditions.
INTRODUCTION
Tracheal intubation is currently one of the basic methods of airway management both in children and adults (1, 2). In some cases, such as cardiopulmonary resuscitation, endotracheal intubation is considered the gold standard of airway management. It allows for continuous chest compressions without the need for any interruptions for emergency breaths (3-5). However, it is recommended that endotracheal intubation should be performed by the most experienced person in the team (6, 7). This is due to the possibility of numerous potential complications, such as tooth injury, soft tissue damage and bleeding, epiglottis injury resulting from arytenoid cartilage dislocation or tracheal rupture and pneumomediastinum (8, 9).
Owing to its common availability, the most commonly applied endotracheal intubation technique is direct laryngoscopy with the use of Miller or Macintosh (MAC) blade laryngoscopes. However, the effectiveness of this method of intubation in pre-hospital conditions is insufficient (10, 11).
Alter et al. (12) indicate that the effectiveness of the first intubation attempt was 86% with the use of a MAC curved blade laryngoscope and 73% in the case of Miller laryngoscope. Sakles et al. (13), on the other hand, evaluated the effectiveness of intubation in an emergency department, indicating that the effectiveness of direct laryngoscopy was 86.6%. In the case of pediatric patients, the effectiveness of intubation is even lower than in adults (13-15). However, it is worth noting that in hospital conditions endotracheal intubation is usually performed by anesthesiologists or emergency physicians. In airway management applied in pre-hospital conditions, in an outpatient clinic, or by emergency medical service teams, paramedics and nurses can only rely on their own skills and knowledge. Therefore, the search for alternative endotracheal intubation methods is so important from the point of view of emergency medicine.
AIM
The aim of the study was to compare the effectiveness of endotracheal intubation based on direct laryngoscopy and videolaryngoscopy performed by nurses in normal and difficult airway conditions.
MATERIAL AND METHODS
Study design and participants
The study was designed as a prospective randomized cross-over simulation study. The protocol was approved by the Institutional Review Board of the Polish Society of Disaster Medicine (approval number: 32.04.2018.IRB). The research involved 27 nurses. Voluntary written informed consent was obtained from each participant. All participants were specialized in nursing in anesthesiology and intensive care or emergency medicine.
Simulation devices
Before the study, all participants took part in a training in endotracheal intubation with the use of direct laryngoscopy and videolaryngoscopy. At the end of the training, the correct technique of intubation with the use of MAC and ATQ was demonstrated. In the case of ATQ intubation, a special overlay was used for smartphone imaging (fig. 1).
Fig. 1. Airtraq videolaryngoscope
Then the participants took part in a 30-minute practical training, during which they had the opportunity to practice intubation with the use of the tested techniques. For this purpose, an AT Kelly Torso (Laerdal, Stavanger, Norway) airway management manikin was used.
One week after the practical training, the nurses participated in the target study, during which they were asked to perform endotracheal intubation with the use of MAC and ATQ in 2 research scenarios: A – normal airway, B – difficult airway. For the latter purpose, the manikin had the cervical spine immobilized with a standard one-piece cervical collar.
An adult Resusci Anne simulator (Laerdal, Stavanger, Norway) was used to simulate a patient requiring immediate endotracheal intubation. The simulator was placed on a flat floor in a brightly lit room.
The participants were allowed one endotracheal intubation attempt. The order of both the participants and the research methods was random, determined with the coin toss technique. The detailed procedure of randomization is presented in figure 2.
Fig. 2. Randomization flow chart
Measurements
The main parameter measured during the study was the effectiveness of the first endotracheal intubation attempt, defined by effective ventilation with a self-inflating bag connected to the endotracheal tube and the manikin chest rise during the ventilation attempt.
Additionally, the effectiveness of intubation was confirmed by specialized simulator software. Intubation time, defined as the time from grasping a laryngoscope to the chest rise with a ventilation attempt, was also measured, as well as the degree of glottis visibility in accordance with the Cormack-Lehane scale (16). After the intubation attempts, the participants evaluated the ease of intubation using a 100-degree visual analog scale (VAS), where 1 marked a procedure easy to perform and 100 – a procedure impossible to perform.
Statistical analysis
All statistical analyses were performed with the STATISTICA ver. 13.3 EN (StatSoft, Tulsa, OK, USA) software. All data are described as median values with an interquartile range (IQR) or numbers and percentages. Categorical variables were analyzed with the chi-square test. The Kruskal-Wallis test was applied to analyze differences in continuous variables between the 2 groups. Thereafter, post-hoc tests for the 2 groups were performed with the Mann-Whitney test. Statistical significance was assumed when the p-value was less than 0.05 in the two-sided test.
RESULTS
Study participants
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Piśmiennictwo
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