The University of Sydney School of Pharmacy Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
From the Departments of Emergency Medicine.
Pediatr Emerg Care. 2023 Jun 1;39(6):423-427. doi: 10.1097/PEC.0000000000002802. Epub 2022 Jul 15.
Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI.
This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct.
Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm).
Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.
儿科急诊插管是一项高难度、低频率的操作。尽管技术有所进步，但该操作的成功率仍然较低，不良事件发生率非常高。在儿童中进行的前瞻性观察研究表明，与直接喉镜相比，使用视频喉镜（VL）可提高成功率，但首次通过成功率（FPS）较低，这可能部分是由于婴儿的喉部位置较高，难以将气管导管引导至喉入口。使用气道辅助工具，如儿科刚性插管器（PRS）或气管导管导入器（TTI），在进行 VL 时可能有助于将气管导管插入头侧定位的气道。本研究的目的是评估在使用标准可弯曲插管器（SMS）与 PRS 和 TTI 插管婴儿模型时，FPS 和插管时间。
这是一项在学术机构进行的随机交叉研究，涉及急诊医学（EM）和儿科和 EM 联合住院医师培训项目（EM&PEDS）。招募急诊医学和 EM&PEDS 住院医师参加。每位住院医师使用标准几何 C-MAC 米勒 1 视频喉镜和 3 种不同的插管辅助工具（SMS、PRS、TTI），以随机方式对 6 个月大的婴儿模拟器进行插管。所有手术均进行视频记录，以便进行数据分析。主要结果是使用 3 种不同插管辅助工具的 FPS。次要结果是每个辅助工具的平均插管时间（以秒为单位）。
51 名参与者共进行了 227 次插管。使用 SMS 的首次通过成功率为 73%（37/51），FPS 为 94%（48/51），PRS 为 29%（15/51）。使用 SMS 的首次通过成功率较低（-43%；95%置信区间，-63%至-23%；P<0.01），与 PRS 相比，使用 TTI 的成功率明显较低（差异-65%；95%置信区间，-81%至-49%；P<0.01）。使用 PRS 的首次通过成功率高于 SMS（差异 22%；7%至 36%；P<0.01）。使用 SMS 的平均插管时间为 44±13 秒，PRS 为 38±11 秒，TTI 为 59±15 秒。使用 SMS 的平均插管时间较长（差异 15 秒；95%置信区间，10 至 20 秒；P<0.01），与 PRS 相比，使用 TTI 的时间明显更长（差异 21 秒；95%置信区间，17 至 26 秒；P<0.01）。与 TTI 相比，PRS 的使用时间较短（差异-7 秒；95%置信区间，-11 至-2 秒；P<0.01）。操作人员使用视觉模拟量表对 PRS 和 TTI 进行评分时，PRS 的易用性明显高于 TTI（91 分对 20 分）。
EM 和 EM&PEDS 住院医师在婴儿模拟器上使用 PRS 与 FPS 增加和插管时间缩短有关。需要进行临床研究比较这些在儿童中的插管辅助工具。
