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© Borgis - Postępy Nauk Medycznych 3/2018, s. 128-132 | DOI: 10.25121/PNM.2018.31.3.128
Andrzej Bielski1, Marcin Madziala1, 2, Karol Bielski3, 4, Jacek Smereka5, Klaudiusz Nadolny6, *Lukasz Szarpak2, 3
Blind intubation via iGEL laryngeal mask performed by novice physicians: A randomized, crossover, manikin trial
Intubacja na ślepo z zastosowaniem maski krtaniowej iGEL wykonywana przez lekarzy stażystów: randomizowane, krzyżowe badanie symulacyjne
1Polish Society of Disaster Medicine, Warsaw, Poland
2Lazarski University, Warsaw, Poland
3MEDITRANS The Voivodship Emergency Medical Service and Sanitary Transport, Warsaw, Poland
4Department of Administrative Law, Lazarski University, Warsaw, Poland
5Department of Emergency Medical Service, Wroclaw Medical University, Poland
6Department of Emergency Medicine, Medical University of Bialystok, Poland
Streszczenie
Wstęp. Wykonanie intubacji dotchawiczej w oparciu o laryngoskopię bezpośrednią jest procedurą wymagającą dużego doświadczenia od personelu medycznego. Alternatywą dla tej metody może być wykonywanie intubacji na ślepo z zastosowaniem nadgłośniowych urządzeń do wentylacji jako swoistej prowadnicy dla rurki intubacyjnej.
Cel pracy. Celem badania była ocena skuteczności intubacji na ślepo z zastosowaniem maski krtaniowej iGEL, wykonywanej przez lekarzy stażystów w warunkach symulowanej resuscytacji krążeniowo-oddechowej.
Materiał i metody. W badaniu zaprojektowanym jako prospektywne, randomizowane, krzyżowe badanie symulacyjne udział wzięło 42 lekarzy stażystów. Uczestnicy badania wykonywali intubację na ślepo, stosując maskę krtaniową iGEL jako prowadnicę dla rurki intubacyjnej. Intubacja odbywała się podczas symulowanej resuscytacji krążeniowo-oddechowej osoby dorosłej w dwóch scenariuszach: scenariusz A – bez uciskania klatki piersiowej, scenariusz B – ciągłe uciskanie klatki piersiowej. Protokół badania został zaakceptowany przez Radę Programową Polskiego Towarzystwa Medycyny Katastrof (zgoda: 32.03.2018.IRB). Uzyskano także pisemną zgodę od 42 uczestników.
Wyniki. Skuteczność pierwszej próby zabezpieczenia drożności dróg oddechowych za pomocą maski iGEL wynosiła 100% podczas obu scenariuszy badawczych. W przypadku intubacji na ślepo skuteczność ta wynosiła 80,9% dla scenariusza A oraz 73,8% dla scenariusza B (p = 0,056). Czas wykonania intubacji na ślepo wynosił w scenariuszu A – 29,5 s (IQR: 24-41), zaś w przypadku scenariusza B – 31 s (23-45,5; p = 0,318).
Wnioski. W przeprowadzonym badaniu symulacyjnym uczestnicy badania byli w stanie z wysoką skutecznością i w krótkim czasie wykonywać intubację dotchawiczą na ślepo z wykorzystaniem maski krtaniowej iGEL jako prowadnicy dla rurki intubacyjnej.
Summary
Introduction. Performing endotracheal intubation based on direct laryngoscopy is a procedure that requires extensive experience from medical personnel. An alternative to this method may be performing blind intubation using supraglottic ventilation devices as a specific guide for the endotracheal tube.
Aim. The aim of the study was to evaluate the efficacy of blind intubation using the iGEL laryngeal mask performed by trainee doctors in simulated cardiopulmonary resuscitation conditions.
Material and methods. In a study designed as a prospective, randomized, cross-study simulation, forty-two interns participated. The participants of the study performed blind intubation using the iGEL laryngeal mask as a guide for the endotracheal tube. Intubation was carried out during simulated CPR in an adult scenario: scenario A – without chest compressions; scenario B – continuous chest compressions. After approval from the Institutional Review Board of the Polish Society of Disaster Medicine (Approval no. 32.03.2018.IRB), written informed consent was obtained from 42 participants.
Results. The effectiveness of the first attempt to protect the airway patency with the iGEL mask was 100% during both research scenarios. In the case of blind intubation, the effectiveness was 80.9% for scenario A, and 73.8% for scenario B (p = 0.056). The duration of blind intubation was 29.5 s (IQR: 24-41), while scenario B took 31 s (23-45.5, p = 0.318).
Conclusions. In the conducted simulation experiment, the participants were able to perform endotracheal intubation blindly with the use of the iGEL as a guide for the endotracheal tube with high efficiency and in a short period of time.
INTRODUCTION
The ability to protect airway patency in both pre-hospital and hospital settings is one of the basic skills of medical personnel. In normothermic conditions, oxygen reserves are sufficient enough for only 3-5 minutes. After this time, irreversible changes associated with progressive hypoxia occur. The central nervous system is the most susceptible organ for hypoxia, therefore it is the first organ to become damaged. In relation to above, quick protection of airway patency and implementation of oxygen therapy is a key element in the management of the patient, especially regarding to a patient with cardiac arrest. According to the guidelines for cardiopulmonary resuscitation published by the European Resuscitation Council (1) as well as the American Heart Association (2), the gold standard for protecting the airways during resuscitation is endotracheal intubation. It allows you to perform asynchronous resuscitation in addition to achieving adequate final pressure in the airway. The guidelines mentioned above recommend that endotracheal intubation be performed during uninterrupted chest compressions or only with a short break in compressions to allow the insertion of the endotracheal tube between the vocal folds, which in turn minimizes breaks in chest compressions. However, as indicated by numerous studies, a more preferred method is the interruption of chest compressions at the time of intubation, due to the fact that continuous chest compressions reduce the effectiveness of the first endotracheal intubation attempt and extend the duration of the procedure (3-5).
Another important factor that may influence the effectiveness of intubation is the experience of the individual performing endotracheal intubation. The ERC and AHA guidelines recommend that it be performed by the most experienced person on the team. This is important due to the potential complications of intubation, such as damage to the teeth, damage to soft tissues and the induction of bleeding, epiglottis detachment, dislocation of the cartilage, or tearing of the trachea. In the case of inability to perform standard intubation guided by direct laryngoscopy, medical personnel may use various alternative methods such as supraglottic ventilation devices or video laryngoscopy. The use of video laryngoscopes, as indicated by numerous studies, increases the effectiveness of intubation, especially for patients with difficult airways, however, due to the price, they are rarely encountered in pre-hospital care.
AIM
The aim of the study was to assess the effectiveness of blind intubation via iGEL laryngeal mask by physicians during simulated cardiopulmonary scenarios.
MATERIAL AND METHODS
After approval from the Institutional Review Board of the Polish Society of Disaster Medicine (Approval no. 32.03.2018.IRB), written informed consent was obtained from 42 participants. All participants had limited clinical experience in endotracheal intubation. Before recruitment into our trial, all participants had never attempted airway management using supraglottic airway devices.
During the experiment, we used iGEL size 4 (Intersurgical, Wokingham, Berkshire, United Kingdom) and a standard intubation tube (7.0ID; Sumi, Sulejowek, Poland). In order to simulate the patient in cardiac arrest, Resusci Anne Simulator (Laerdal, Stavanger, Norway) was used, which has been designed to simulate the adult patient. In order to simulate cardiopulmonary resuscitation and the need to secure the airway in conditions of uninterrupted chest compressions, the chest compression device LUCAS3 (Physio-Control, Redmond, WA, USA) was used. Protection of airway patency occurred in two scenarios: scenario A – without chest compressions; scenario B – protection of airway patency during uninterrupted chest compressions (6, 7).
Prior to the study, all participants took part in theoretical training in the field of airway obstruction using supraglottic ventilation devices. Theoretical training was completed with a tutorial given by an experienced instructor. Practical exercises were not allowed.
In the study, the participants performed blind intubation using the supraglottic airway device as a guide for the endotracheal tube. The procedure consisted of securing airway patency using the iGEL device and then performing the blind intubation procedure (fig. 1). The procedure was completed with confirmation of the precision of endotracheal intubation by ventilation with a self-expanding mask and the obstructing simulator indicators responsible for the ventilation of the “patient” lungs. The test was carried out on the basis of a randomized, cross-over study. For this purpose, both the order of the participants and the research scenarios were random. As a result, the coin tossing method was used. A detailed randomization procedure for the study is shown on figure 2.
Fig. 1. iGEL laryngeal mask as a conduct for endotracheal tube
Fig. 2. Randomization flow chart
During the experiment, both the blind intubation effectiveness and the duration of the procedure were evaluated. Two time parameters were analyzed: Time T1 – time to protect the patency of the airway using a supraglottic ventilation device, defined as the time from taking the device into the hand until the device is introduced to the airway and the respiratory tract is secured. The second-time parameter was time T2 – duration of the whole procedure, defined as the time from taking the device to the blind intubation and attempting to confirm the effectiveness of intubation with a ventilation test using a self-expanding bag.
Descriptive data is given as median and interquartile range (IQR). The McNemar’s test was used for statistical analysis of success rates of intubation under cardiopulmonary resuscitation scenarios with and without chest compressions. For analysis of the duration of the blind intubation as well as the airway management using iGEL, the Student’s paired t test was utilized. Calculations were done with the statistical package STATISTICA 13.0EN (StatSoft, Tulusa, OK, USA). P ≤ 0.05 were considered statistically significant.
RESULTS

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otrzymano: 2018-05-07
zaakceptowano do druku: 2018-05-28

Adres do korespondencji:
*Łukasz Szarpak
Uczelnia Łazarskiego
ul. Świeradowska 43, 02-662 Warszawa
tel.: +48 500-186-225
lukasz.szarpak@gmail.com

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