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Video laryngoscopy for endotracheal intubation of adult patients with suspected/ confirmed COVID-19. A systematic review and meta-analysis of randomized controlled trials
, 2, 3, 14, 51, 16, 17, 8, 19
Affiliations- Polish Society of Disaster Medicine, Warsaw, Poland
- Department of Anaesthesiology and Critical Care, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia, Zabrze, Poland
- Department of Nephrology Nursing, Medical University of Warsaw, Warsaw, Poland
- Department of Emergency Medical Service, Wroclaw Medical University, Wroclaw, Poland
- Chair and Department of Medical Education, Poznan University of Medical Sciences, Poznan, Poland
- Department of Medical Rescue, Chair of Emergency Medicine, Poznan University of Medical Sciences, Poznan, Poland
- Clinic of Emergency Medicine, Medical University of Bialystok, Bialystok, Poland
- Departments of Outcomes Research and General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Faculty of Medicine, Lazarski University, Warsaw, Poland
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Abstract
Study objective: During a pandemic, medical personnel while in contact with patients with suspected/confirmed COVID-19 should wear full personal protective equipment (PPE) for aerosol-generating procedures to reduce the risk of infection. Most studies of intubation in level C PPE conditions have been relatively small. Our aim is to quantify the available data on success rates in order to provide an evidence-based benchmark to gauge performance in the published literature.
Methods: A structured literature search was performed with PubMed, Scopus, Embase, Web of Science, and Cochrane databases. The electronic database search was supplemented by searching Google Scholar and by back-searching the reference lists of identified studies for suitable articles. Data were evaluated and extracted by two independent reviewers on the basis of qualitative and quantitative variables of interest. Q statistic and I2 statistics were used to assess the heterogeneity between the studies.
Results : Fifteen randomized controlled trials were included. The use of PPE during intubation as compared with intubation without PPE reduced intubation efficacy (90.0% vs. 97.9%; RR = 0.94; 95%CI: 0.90–0.99; p < 0.001) and increased the procedure time (MD = 7.73; 95%CI: 4.98–10.47; p < 0.001). Direct laryngoscopy compared with video laryngoscopes offered similar intubation success rate (93.6% vs. 92.3%; RR = 0.99; 95%CI: 0.97–1.02; p = 0.66) and shorter intubation time (MD = 63; 95%CI: -0.77–12.03; p = 0.08). However, subgroup analysis showed that intubation with Macintosh blade video laryngoscopes was more effective than that with direct laryngoscopes (98.1% vs. 96.4%; RR = 1.00; 95%CI: 0.97–1.03; p = 0.90).
Conclusions: Our meta-analysis suggests that PPE reduces the effectiveness of endotracheal intubation. The use of direct laryngoscopy for intubating patients with suspected/confirmed COVID-19 by an intubator wearing level C PPE is associated with overall intubation time reduction and an increase in intubation success rate compared with video laryngoscopes. However, the findings suggest that Macintosh blade video laryngoscopes during endotracheal intubation with PPE may be an alternative to direct laryngoscopes. Video laryngoscopy can be helpful for less experienced personnel.
Abstract
Study objective: During a pandemic, medical personnel while in contact with patients with suspected/confirmed COVID-19 should wear full personal protective equipment (PPE) for aerosol-generating procedures to reduce the risk of infection. Most studies of intubation in level C PPE conditions have been relatively small. Our aim is to quantify the available data on success rates in order to provide an evidence-based benchmark to gauge performance in the published literature.
Methods: A structured literature search was performed with PubMed, Scopus, Embase, Web of Science, and Cochrane databases. The electronic database search was supplemented by searching Google Scholar and by back-searching the reference lists of identified studies for suitable articles. Data were evaluated and extracted by two independent reviewers on the basis of qualitative and quantitative variables of interest. Q statistic and I2 statistics were used to assess the heterogeneity between the studies.
Results : Fifteen randomized controlled trials were included. The use of PPE during intubation as compared with intubation without PPE reduced intubation efficacy (90.0% vs. 97.9%; RR = 0.94; 95%CI: 0.90–0.99; p < 0.001) and increased the procedure time (MD = 7.73; 95%CI: 4.98–10.47; p < 0.001). Direct laryngoscopy compared with video laryngoscopes offered similar intubation success rate (93.6% vs. 92.3%; RR = 0.99; 95%CI: 0.97–1.02; p = 0.66) and shorter intubation time (MD = 63; 95%CI: -0.77–12.03; p = 0.08). However, subgroup analysis showed that intubation with Macintosh blade video laryngoscopes was more effective than that with direct laryngoscopes (98.1% vs. 96.4%; RR = 1.00; 95%CI: 0.97–1.03; p = 0.90).
Conclusions: Our meta-analysis suggests that PPE reduces the effectiveness of endotracheal intubation. The use of direct laryngoscopy for intubating patients with suspected/confirmed COVID-19 by an intubator wearing level C PPE is associated with overall intubation time reduction and an increase in intubation success rate compared with video laryngoscopes. However, the findings suggest that Macintosh blade video laryngoscopes during endotracheal intubation with PPE may be an alternative to direct laryngoscopes. Video laryngoscopy can be helpful for less experienced personnel.
Keywords
endotracheal intubation, laryngoscope, infected patient, COVID-19, personal protective equipment, meta-analysis
About this articleTitle
Video laryngoscopy for endotracheal intubation of adult patients with suspected/ confirmed COVID-19. A systematic review and meta-analysis of randomized controlled trials
Journal
Disaster and Emergency Medicine Journal
Issue
Article type
Research paper
Pages
85-97
Published online
2020-05-21
Page views
2594
Article views/downloads
1159
DOI
Bibliographic record
Disaster Emerg Med J 2020;5(2):85-97.
Keywords
endotracheal intubation
laryngoscope
infected patient
COVID-19
personal protective equipment
meta-analysis
Authors
Kobi Ludwin
Szymon Bialka
Lukasz Czyzewski
Jacek Smereka
Marek Dabrowski
Agata Dabrowska
Jerzy Robert Ladny
Kurt Ruetzler
Lukasz Szarpak
References (47)- Szarpak L. Laryngoscopes for difficult airway scenarios: a comparison of the available devices. Expert Rev Med Devices. 2018; 15(9): 631–643.
- Madziala M, Okruznik M, Cobo SA, et al. Gold rules for pediatric endotracheal intubation. Am J Emerg Med. 2016; 34(8): 1711–1712.
- Natt BS, Malo J, Hypes CD, et al. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth. 2016; 117 Suppl 1: i60–i68.
- Russell TM, Hormis A. Rotherham NHS Foundation Trust. Should the Glidescope video laryngoscope be used first line for all oral intubations or only in those with a difficult airway? A review of current literature. J Perioper Pract. 2018; 28(12): 322–333.
- Ruetzler K, Rivas E, Cohen B, et al. McGrath Video Laryngoscope Versus Macintosh Direct Laryngoscopy for Intubation of Morbidly Obese Patients: A Randomized Trial. Anesth Analg. 2020 [Epub ahead of print].
- Ruetzler K, Szarpak L, Filipiak K, et al. The COVID-19 pandemic — a view of the current state of the problem. Disaster and Emergency Medicine Journal. 2020.
- Szarpak L, Smereka J, Filipiak KJ, et al. Cloth masks versus medical masks for COVID-19 protection. Cardiol J. 2020 [Epub ahead of print].
- Li Li, Gong S, Yan J. Covid-19 in China: ten critical issues for intensive care medicine. Crit Care. 2020; 24(1): 124.
- Smereka J, Szarpak L. COVID 19 a challenge for emergency medicine and every health care professional. Am J Emerg Med. 2020 [Epub ahead of print].
- Chen X, Liu Y, Gong Y, et al. Chinese Society of Anesthesiology, Chinese Association of Anesthesiologists. Perioperative Management of Patients Infected with the Novel Coronavirus: Recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists. Anesthesiology. 2020; 132(6): 1307–1316.
- Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth. 2020; 67(5): 568–576.
- Castle N, Owen R, Hann M, et al. Impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of low- and high-dexterity airway and vascular access skills. Resuscitation. 2009; 80(11): 1290–1295.
- Moher D, Shamseer L, Clarke M, et al. PRISMA-P Group. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015; 4: 1.
- Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977; 33(1): 159–174.
- Higgins JPT, Altman DG, Gøtzsche PC, et al. Cochrane Bias Methods Group, Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011; 343: d5928.
- Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005; 5: 13.
- Koo A, Walsh R, Knutson T, et al. Comparison of Intubation Using Personal Protective Equipment and Standard Uniform in Simulated Cadaveric Models. Mil Med. 2018; 183(suppl_1): 216–218.
- Scott Taylor R, Pitzer M, Goldman G, et al. Comparison of intubation devices in level C personal protective equipment: A cadaveric study. Am J Emerg Med. 2018; 36(6): 922–925.
- Aberle SJ, Sandefur BJ, Sunga KL, et al. Intubation Efficiency and Perceived Ease of Use of Video Laryngoscopy vs Direct Laryngoscopy While Wearing HazMat PPE: A Preliminary High-fidelity Mannequin Study. Prehosp Disaster Med. 2015; 30(3): 259–263.
- Burns JB, Branson R, Barnes SL, et al. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010; 25(1): 92–95.
- Castle N, Pillay Y, Spencer N. What is the optimal position of an intubator wearing CBRN-PPE when intubating on the floor: a manikin study. Resuscitation. 2011; 82(5): 588–592.
- Castle N, Pillay Y, Spencer N. Comparison of six different intubation aids for use while wearing CBRN-PPE: a manikin study. Resuscitation. 2011; 82(12): 1548–1552.
- Claret PG, Bobbia X, Asencio R, et al. Comparison of the Airtraq laryngoscope versus the conventional Macintosh laryngoscope while wearing CBRN-PPE. Eur J Emerg Med. 2016; 23(2): 119–123.
- Garner A, Laurence H, Lee A. Practicality of performing medical procedures in chemical protective ensembles. Emerg Med Australas. 2004; 16(2): 108–113.
- Greenland KB, Tsui D, Goodyear P, et al. Personal protection equipment for biological hazards: does it affect tracheal intubation performance? Resuscitation. 2007; 74(1): 119–126.
- Grillet G, Marjanovic N, Diverrez JM, et al. Intensive care medical procedures are more complicated, more stressful, and less comfortable with Ebola personal protective equipment: A simulation study. J Infect. 2015; 71(6): 703–706.
- Plazikowski E, Greif R, Marschall J, et al. Emergency Airway Management in a Simulation of Highly Contagious Isolated Patients: Both Isolation Strategy and Device Type Matter. Infect Control Hosp Epidemiol. 2018; 39(2): 145–151.
- Schröder H, Zoremba N, Rossaint R, et al. Intubation performance using different laryngoscopes while wearing chemical protective equipment: a manikin study. BMJ Open. 2016; 6(3): e010250.
- Schumacher J, Arlidge J, Garnham F, et al. A randomised crossover simulation study comparing the impact of chemical, biological, radiological or nuclear substance personal protection equipment on the performance of advanced life support interventions. Anaesthesia. 2017; 72(5): 592–597.
- Shin DH, Choi PC, Na JiU, et al. Utility of the Pentax-AWS in performing tracheal intubation while wearing chemical, biological, radiation and nuclear personal protective equipment: a randomised crossover trial using a manikin. Emerg Med J. 2013; 30(7): 527–531.
- Szarpak L, Madziała M, Smereka J. Comparison of endotracheal intubation performed with 3 devices by paramedics wearing chemical, biological, radiological, and nuclear personal protective equipment. Am J Emerg Med. 2016; 34(9): 1902–1903.
- Udayasiri R, Knott J, McD Taylor D, et al. Emergency department staff can effectively resuscitate in level C personal protective equipment. Emerg Med Australas. 2007; 19(2): 113–121.
- Wang CC, Chaou CH, Tseng CY, et al. The effect of personal protective equipment on emergency airway management by emergency physicians: a mannequin study. Eur J Emerg Med. 2016; 23(2): 124–129.
- Weaver KR, Barr GC, Long KR, et al. Comparison of airway intubation devices when using a biohazard suit: a feasibility study. Am J Emerg Med. 2015; 33(6): 810–814.
- Yousif S, Machan JT, Alaska Y, et al. Airway Management in Disaster Response: A Manikin Study Comparing Direct and Video Laryngoscopy for Endotracheal Intubation by Prehospital Providers in Level C Personal Protective Equipment. Prehosp Disaster Med. 2017; 32(4): 352–356.
- Suzuki K, Kusunoki S, Tanigawa K, et al. Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study. BMJ Open. 2019; 9(3): e024927.
- Hoshijima H, Mihara T, Maruyama K, et al. C-MAC videolaryngoscope versus Macintosh laryngoscope for tracheal intubation: A systematic review and meta-analysis with trial sequential analysis. J Clin Anesth. 2018; 49: 53–62.
- Hoshijima H, Denawa Y, Tominaga A, et al. Videolaryngoscope versus Macintosh laryngoscope for tracheal intubation in adults with obesity: A systematic review and meta-analysis. J Clin Anesth. 2018; 44: 69–75.
- Breeman W, Van Vledder MG, Verhofstad MHJ, et al. First attempt success of video versus direct laryngoscopy for endotracheal intubation by ambulance nurses: a prospective observational study. Eur J Trauma Emerg Surg. 2020 [Epub ahead of print].
- Min BC, Park JE, Lee GT, et al. C-MAC Video Laryngoscope versus Conventional Direct Laryngoscopy for Endotracheal Intubation During Cardiopulmonary Resuscitation. Medicina (Kaunas). 2019; 55(6).
- Sakles JC, Mosier J, Patanwala AE, et al. Learning curves for direct laryngoscopy and GlideScope® video laryngoscopy in an emergency medicine residency. West J Emerg Med. 2014; 15(7): 930–937.
- Szarpak L, Smereka J, Ladny JR. Comparison of Macintosh and Intubrite laryngoscopes for intubation performed by novice physicians in a difficult airway scenario. Am J Emerg Med. 2017; 35(5): 796–797.
- Khan NU, Khan UR, Ejaz K, et al. Intubation in emergency department of a tertiary care hospital in a low-income country. J Pak Med Assoc. 2013; 63(3): 306–309.
- Hoshijima H, Mihara T, Maruyama K, et al. McGrath videolaryngoscope versus Macintosh laryngoscope for tracheal intubation: A systematic review and meta-analysis with trial sequential analysis. J Clin Anesth. 2018; 46: 25–32.
- Collopy KT, Kivlehan SM, Snyder SR. Surgical cricothyrotomies in prehospital care. Surgical airway placement is indicated when you cannot intubate or ventilate. EMS World. 2015; 44(1): 42–49.
- Jiang J, Kang Na, Li Bo, et al. Comparison of adverse events between video and direct laryngoscopes for tracheal intubations in emergency department and ICU patients-a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med. 2020; 28(1): 10.
- Michailidou M, O'Keeffe T, Mosier JM, et al. A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients. World J Surg. 2015; 39(3): 782–788.