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  • A P R O G R E S S U P D A T E

    B R I A N S A V I N O

    COMPARISON OF DIRECT VERSUS INDIRECT LARYNGOSCOPY FOR INTUBATION IN THE

    PREHOSPITAL SETTING: A SYSTEMATIC REVIEW AND META-ANALYSIS

  • BACKGROUND

    Laryngoscopy as

    practiced today was

    developed in the 1940s.

    Classically the Macintosh

    and Miller blades are

    used to intubate,

    especially in the acute-

    care settings (ED, ICU)

  • INDIRECT LARYNGOSCOPY

    National Overall Success of Direct: 85%

    Indirect video devices introduced in early 2000s and rapidly gained acceptance in ED settings.

    Hospital studies show improved first-pass success rates and time to successful intubation, especially among novice intubators.

    Brown, C. A., 3rd, A. E. Bair, D. J. Pallin, R. M. Walls, and Near Iii Investigators. "Techniques, Success, and Adverse Events of Emergency Department Adult Intubations." Ann Emerg Med 65, no. 4 (Apr 2015): 363-70 e1.

  • DIRECT VS INDIRECT LARYNGOSCOPY

    Direct

    Indirect

  • INDIRECT DEVICE EXAMPLES

    Macintosh Reusable

    Blades and Handles

    Glidescope Ranger

    AirTraq

    King Vision LT

  • PREHOSPITAL INTUBATION

    Studies show paramedics outcomes are worse than

    physicians.

    Can we apply hospital success with novice

    intubators to the prehospital setting?

    Is there evidence for benefit for indirect

    laryngoscopy in the prehospital setting when

    compared to direct?

  • WHY LOOK INTO THIS?

    Prehospital treatment isnt always the same as in-

    hospital treatment.

    EMS systems vary whats good for one isnt

    necessarily good for all.

    Cost/Benefit: These Indirect devices cost money

    and require training!

  • RESEARCH QUESTION

    For definitive airway management in the

    prehospital setting, does indirect laryngoscopy lead

    to better overall intubation success and first-pass

    success than direct laryngoscopy?

    PICO

    P patients requiring intubation in the prehospital setting

    I Indirect Laryngoscopy

    C Direct Laryngoscopy

    O Overall Success, First-pass success

  • WHAT RESEARCH EXISTS?

    We can do: A Systematic Review and Meta-analysis

  • DEFINITIONS

    Direct Laryngoscopy: Insertion of the endotracheal tube by a method of directly visualizing the vocal cords. Examples: Macinotosh blade, Miller Blade.

    Indirect Laryngoscopy: Insertion of the endotracheal tube by a method of indirectly visualizing the vocal cord, either using a video camera or optics (mirrors). Examples: (GlideScope, Airtraq, King Vision LT)

  • SYSTEMATIC REVIEW

    Inclusion Criteria: Prehospital Setting

    Human Studies

    Exclusion Criteria: No comparison to direct laryngoscopy

    Case Reports and Case Series studies

    Studies restricted to pediatrics

    Studies comparing indirect laryngoscopy to rescue airway devices (supraglottic airways, oral airways, bag-valve mask)

    In-hospital settings (ED, OR, ICU etc.)

    Non-human studies, manikin studies

    Cadaver Studies

  • SYSTEMATIC REVIEW

    Outcomes: Overall Success

    First Pass Success

    Search Terms: EMS, Emergency Medical Services, Prehospital, Pre-hospital,

    Paramedic, Air Medical, Helicopter, Out-of-Hospital/Out of Hospital AND Video laryngoscopy

    Video Intubation Indirect Laryngoscopy Indirect Intubation Glidescope Airtraq

    Vividtrac CMAC, C-MAC King Vision

  • OUTCOME DEFINITIONS

    Overall Success Rate: Proportion of patients

    successfully intubated with the intended device

    First-Pass Success Rate: Proportion of patients

    successfully intubated with the intended device on

    the first attempt.

  • WHY THE PROXY MEASURES OF OUTCOME?

    Traditionally, EMS and Hospital systems do not share data. This is starting to change, but still very difficult to follow up on patients.

    Developing a proxy measure of outcome versus longitudinal follow-up is more cost-effective, especially for regular QI activities.

    Acute-care in-hospital studies show the most predictive variable for poor outcomes is the number of intubation attempts: 1 attempt: 14% adverse event rate

    2 attempts or more: 47% adverse event rate

  • SYSTEMATIC REVIEW STUDY CHARACTERISTICS

  • META-ANALYSIS OVERALL SUCCESS WITH IDL VS DL

    Favors DL Favors IDL Favors DL Favors IDL

  • META-ANALYSIS OVERALL SUCCESS WITH IDL VS DL

  • OBSERVATIONS

    Significant heterogeneity when physician/non-

    physicians grouped together, but not when

    separated.

    Physicians (experienced operators) do better with

    DL for overall success while non-physicians

    (inexperienced operators) do better with IDL.

    RCTs show better results with DL than observational

    studies (although RCTs both used physicians).

  • META-ANALYSIS FIRST-PASS SUCCESS WITH IDL VS DL

  • META-ANALYSIS FIRST-PASS SUCCESS WITH IDL VS DL

  • OBSERVATIONS

    Only one study used physicians, only study is an

    RCT.

    Again, non-physicians seem to perform better with

    IDL than DL.

    Still some significant heterogeneity.

  • SO WHAT SHOULD WE DO?

    There is not currently evidence to support or discourage the use of indirect laryngoscopy in the prehospital setting. Studies are heterogeneous.

    Medical directors and EMS/Public Health agencies interested in

    deploying these devices should consider looking at studies that mirror their systems (i.e. helicopter, physician-based etc, experience)

    Training is crucial. Many studies suggested the reason for their results had to do with inadequate training.

    Non-studied benefits: Recording intubations for QI/Training, more unified training, ease/quickness of learning skill

    Non-studied harms: Device failure, cost, loss of skills

    MORE STUDIES ARE NEEDED HERE!

  • REFERENCES

    1. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation 2014;85(7): 885-92.

    2. Bernhard M, Becker TK, Gries A, et al. The First Shot Is Often the Best Shot: First-Pass Intubation Success in Emergency Airway Management. Anesth Analg 2015;121(5):1389-93.

    3. Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20(1):71-8.

    4. Macintosh RR. A New Laryngoscope. The Lancet 1943;241(6233):205.

    5. Miller RA. The development of the laryngoscope. Anaesthesist 1972;21(3):145-7.

    6. Brown CA, 3rd, Bair AE, Pallin DJ, et al. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015;65(4):363-70 e1.

    7. De Jong A, Molinari N, Conseil M, et al. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Med 2014;40(5):629-39.

    8. Griesdale DE, Liu D, McKinney J, et al. Glidescope(R) video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth 2012;59(1):41-52.

    9. Selde W, English K, Heffelfinger M, et al. Successful airtraq use in an air medical transport system. Air medical journal 2014;33(6):331-4.

    10. Boedeker BH, Berg BW, Bernhagen M, et al. Endotracheal intubation comparing a prototype storz CMAC and a GlideScope videolaryngoscope in a medical transport helicopter - A pilot study. Presented at Studies in Health Technology and Informatics2009.

    11. Burnett AM, Frascone RJ, Wewerka SS, et al. Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial. Prehosp Emerg Care 2014;18(2):231-8.

    12. Bernhard M, Mohr S, Weigand MA, et al. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand 2012;56(2):164-71.

    13. Arima T, Nagata O, Miura T, et al. Comparative analysis of airway scope and Macintosh laryngoscope for intubation primarily for cardiac arrest in prehospital setting. The American journal of emergency medicine 2013;32(1):40-3.

    14. Jarvis JL, McClure SF, Johns D. EMS Intubation Improves with King Vision Video Laryngoscopy. Prehosp Emerg Care 2015;19(4):482-9.

    15. Wayne MA, McDonnell M. Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation. Prehospital Emergency Care 2010;14(2):278-82.

    16. Boehringer B, Choate M, Hurwitz S, et al. Impact of Video Laryngoscopy on Advanced Airway Management by Critical Care Transport Paramedics and Nurses Using the CMAC Pocket Monitor. BioMed Research International 2015;2015.

    17. Guyette FX, Farrell K, Carlson JN, et al. Comparison of video laryngoscopy and direct laryngoscopy in a critical care transport service. Prehospital Emergency Care 2013;17(2):149-54.

    18. Trimmel H, Kreutziger J, Fertsak G, et al. Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: A randomized control trial. Critical Care Medicine 2011;39(3):489-93.

  • WIDE CI

    Failure Success

    IDL 56 50 106

    DL 1 105 106

    57 155

    RR = (56/106)/(1/106) = .5283/.009433 = 56

    Ln(56) +/- 1.96 (50/56)/106 + (105/1)/106 =

    4.02535 +/- 1.959 = (e2.066,e5.98435)

    95% CI = (7.896,397.1543)