Comparison of intubation through the McGrath MAC, GlideScope, AirTraq, and Miller Laryngoscope by paramedics during child CPR: a randomized crossover manikin trial

doi:10.1016/j.ajem.2015.04.017

The American Journal of Emergency Medicine

Volume 33, Issue 7, July 2015, Pages 946-950

https://doi.org/10.1016/j.ajem.2015.04.017 Get rights and content

Abstract

Backgroud

Advanced airway management and endotracheal intubation (ETI) during cardiopulmonary resuscitation (CPR) is more difficult than, for example, during anesthesia. However, new devices such as video laryngoscopes should help in such circumstances. The aim of this study was to compare the performance of 4 intubation devices in pediatric manikin-simulated CPR.

Methods

One hundred two paramedics participated in this study. None had prior experience in video laryngoscopy. After a standardized audiovisual lecture lasting 45 minutes, the paramedics participated in a practical demonstration using the advanced pediatric patient simulator PediaSIM CPR (FCAE HealthCare, Sarasota, FL), which was designed to be an accurate representation of a 6-year-old child. Cardiopulmonary resuscitation was performed using LUCAS-2 (Physio-Contro, Redmond, WA). Afterward, paramedics were instructed to perform ETI using 4 intubation devices (MacGrathMAC, GlideScope, AirTraq, and Miller Laryngoscope Blade [Miller]) in a randomized sequence. The primary outcome was the success rate of tracheal intubation. The secondary outcome was the time to intubation.

Results

The mean time to intubation was 30.7 ± 15.3, 28.6 ± 15.9, 24.1 ± 5.0, and 39.3 ± 14.7 seconds (McGrath, GlideScope, AirTraq, and Miller, respectively); and the success ratio of intubation for the devices was 100% vs 100% vs 100% vs 77.5%, respectively.

Conclusions

Child ETI performed by paramedics during uninterrupted chest compression often has a low success rate. In contrast, McGrath, GlideScope, and AirTraq intubation devices are fast, safe, and easy to use. Within the limitations of a manikin study, this study suggests that inexperienced medical staff might benefit from using video laryngoscopy devices for child emergency airway management.

Introduction

According to the 2010 European Resuscitation Council guidelines on resuscitation, endotracheal intubation (ETI) is still regarded as the criterion standard for securing the airway in prehospital emergency medicine [1]. Consideration should be given to the fact that pediatric intubation is a difficult skill to learn and requires continual exposure to maintain competence [2], as a lack of exposure results in a high failure rate, regardless of the professional background of the intubator [3].

However, a different approach to the standard adult Macintosh laryngoscopy [4], [5] is needed for children because of anatomical differences in the throats of children. Miller’s laryngoscope blade has been a commonly used laryngoscope blade for pediatric intubation since 1941 [6], but this form of direct laryngoscopy requires great skill from the intubator. In many cases, it is impossible to see the glottis using this laryngoscope; therefore video laryngoscopes (ie, McGraph or GlideScope) or optical laryngoscopes (ie, AirTraq) that make it possible for the intubator to observe the glottis might facilitate the process of intubation [7], [8].

The aim of the study was to compare time and success rates of different available video laryngoscopes and the Miller laryngoscope for emergency intubation during simulated pediatric cardiopulmonary resuscitation (CPR).

Section snippets

Study population

The participants in this trial were recruited from resuscitation trainees at the International Institute of Rescue Research and Education (Warsaw, Poland). A randomized crossover trial design was chosen, and the study was approved by the institutional review board of the International Institute of Rescue Research and Education (Warsaw, Poland; Prot. No.: 12.2014.06.24).

After written informed consent was obtained, 102 paramedics participated in the study. All participants had previous experience

Demographic data

One hundred two paramedics (43 female, 42.2%) participated in this study. The characteristics of participants are shown in Table 1. No participant had previously performed a video intubation with any video laryngoscopes. Each participant inserted all 4 intubation devices in a computer-generated randomized sequence (Figure). Sixty-nine participants (27 female, 39.1%) worked in teams of EMS, and 33 participants (16 female, 69.6%) worked in hospital EDs. Mean age was 32.7 ± 9.8 years, and mean

Discussion

Current European Resuscitation Council 2010 guidelines emphasize the delivery of continuous chest compression with as few interruptions as possible, including pauses for airway management efforts [1]. Airway management is considered to be an essential element of both in-hospital and prehospital CPR for pediatric intubation. Intubation is a technically challenging skill to learn and requires continued exposure to prevent skill deterioration [9], [10], [11]. Hubble et al [9] identified that 1 in

Conclusions

Within the limitations of this manikin setting, it might be suggested that, in emergency situations, safe and effective alternatives to ETI are available. Endotracheal intubation should preferably only be performed by trained and experienced physicians or paramedics. The data obtained in our manikin study show that McGrath, GlideScope, and AirTraq are alternatives to Miller that are equally as easy to use and effective during ongoing child chest compressions. Clinical accumulation and

Acknowledgements

The authors would like to thank the participants.

References (30)

D. Biarent et al.
European Resuscitation Council guidelines for resuscitation 2010 section 6. Paediatric life support
Resuscitation
(2010)
C. Eich et al.
Characteristics and outcome of pre-hospital paediatric tracheal intubation attended by anaesthesia-trained emergency physicians
Resuscitation
(2009)
T.A. Leone et al.
Neonatal intubation: success of pediatric trainees
Pediatrics
(2005)
C.D. Deakin et al.
European Resuscitation Council guidelines for resuscitation 2010 section 4. Adult advanced life support
Resuscitation
(2010)
Y.F. Huang et al.
Prevention of dental damage and improvement of difficult intubation using a paraglossal technique with a straight Miller blade
J Chin Med Assoc
(2010)
G.A. Orliaguet et al.
Endotracheal intubation with the GlideScope®®, the AirTraq®®, the McGrath®® videolaryngoscope and direct laryngoscopy: a comparative study on an infant manikin
Ann Fr Anesth Reanim
(2013)
I. Ng et al.
Randomized controlled trial comparing the McGrath® videolaryngoscope with the C-MAC videolaryngoscope in intubating adult patients with potential difficult airways
Br J Anaesth
(2012)
W. Kim et al.
Can the new McGrath® laryngoscope rival the GlideScope® Ranger portable video laryngoscope? A randomized manikin study
Am J Emerg Med
(2014)
N. Komasawa et al.
Comparison of optic laryngoscope AirTraq®(®) and Miller laryngoscope for tracheal intubation during infant cardiopulmonary resuscitation
Resuscitation
(2011)
N. Castle et al.
Intubation using the Miller and AirTraq®™ laryngoscopes: a paediatric manikin study
Afr J Emerg Med
(2011)

M.Á. Gómez-Ríos et al.

A simple method for performing orotracheal intubation using the AirTraq® optical laryngoscope in the pediatric airway when the glottis is off-center in the viewer

Rev Esp Anestesiol Reanim

(2014)

K.P. Rothfield et al.

Videolaryngoscopy: should it replace direct laryngoscopy? A pro-con debate

J Clin Anesth

(2012)

A.J. Donoghue et al.

Videolaryngoscopy versus direct laryngoscopy in simulated pediatric intubation

Ann Emerg Med

(2013)

E. Cavus et al.

The development of direct laryngoscopy

Trends Anaesth Crit Care

(2014)

J. Mosier et al.

A comparison of the GlideScope® video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department

Ann Emerg Med

(2013)

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^☆: Funding: This study was financed by the authors' own resources. There was no financial support by any of the companies mentioned in this manuscript.

^☆☆: Authors’ contributions: conception and design: KK, TE, LS, AK, LC; analysis and interpretation: LS; drafting the manuscript for important intellectual content: KK, TE, LS, AK, LC.

^★: Conflict of interest statement: The authors declare that they have no conflicts of interest. There are no sources of financial and material support to be declared. None of the companies were involved in any way in the study design, planning, execution, or analysis as well as in the writing of this manuscript.

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Original ContributionComparison of intubation through the McGrath MAC, GlideScope, AirTraq, and Miller Laryngoscope by paramedics during child CPR: a randomized crossover manikin trial☆,☆☆,★

Abstract

Backgroud

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Demographic data

Discussion

Conclusions

Acknowledgements

Resuscitation

Resuscitation

Pediatrics

Resuscitation

J Chin Med Assoc

Ann Fr Anesth Reanim

Br J Anaesth

Am J Emerg Med

Resuscitation

Afr J Emerg Med

Rev Esp Anestesiol Reanim

J Clin Anesth

Ann Emerg Med

Trends Anaesth Crit Care

Ann Emerg Med

Original Contribution
Comparison of intubation through the McGrath MAC, GlideScope, AirTraq, and Miller Laryngoscope by paramedics during child CPR: a randomized crossover manikin trial☆,☆☆,★