Elsevier

Resuscitation

Volume 82, Issue 5, May 2011, Pages 593-597
Resuscitation

Simulation and education
Performance and skill retention of intubation by paramedics using seven different airway devices—A manikin study

https://doi.org/10.1016/j.resuscitation.2011.01.008Get rights and content

Abstract

Introduction

Endotracheal intubation (ETI) is the most widespread method for emergency airway management. Several studies reported that ETI requires considerable skill and experience and if performed incorrectly, may result in serious adverse events. Unrecognized tube misplacement or oesophageal intubation is associated with high prehospital morbidity. This study investigates the usability of supraglottic airway devices compared to ETI and the skill retention of 41 previously inexperienced paramedics following training using a manikin model.

Methods

41 paramedics participated in this study. None had prior experience in airway management, apart from bag-valve ventilation. After a standardised audio-visual lecture lasting 45 min, the paramedics participated in a practical demonstration using the advanced patient simulator SimMan® (Laerdal Medical, Stavanger, Norway). Afterwards, paramedics were instructed to perform airway-management using seven different techniques to secure the airway (ETI, Laryngeal mask unique [LMA], Proseal, Laryngeal tube disposable [LT-D®], I-Gel®, Combitube®, and EasyTube®) following a randomized sequence. Participants underwent reassessment after 3 months without any further training or practice in airway-management.

Results

During the initial training session, ETI was successfully performed in 78% of cases, while 3 months later the success rate was 58%. For the supraglottic airway devices, five out of six were successfully used by all paramedics at both time points, the exception being Proseal®. Our data show successful skill retention (success rate: 100%) after 3 months for five out of six supraglottic airway devices. Time to ventilation (T3) was significantly less for LMA, LT-D® and I-Gel® at all time points compared to ETI.

Conclusion

ETI performed by inexperienced paramedics is associated with a low success rate. In contrast, supraglottic airway devices like LMA, LT-D®, I-Gel®, Combitube® and EasyTube® 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 supraglottic airway devices for emergency airway management.

Introduction

In emergency situations like cardiopulmonary resuscitation (CPR), ventilation and oxygenation of patients is a potentially lifesaving procedure.1, 2, 3 Main indications for immediate airway interventions are severe trauma, cardiac arrest and other causes of coma.4 In this context, endotracheal intubation (ETI) is perceived as the optimal method for providing and maintaining a patent and secure airway.5, 6, 7 However, ETI may lead to prolonged interruptions of CPR and in some cases laryngoscopy and intubation may prove impossible or cause a life threatening deterioration in the patient's condition.8, 9 In contrast, use of supraglottic airway devices may help to reduce time to ventilation, especially in patients with a difficult airway.10, 11, 12

ETI requires highly skilled and experienced personnel, who receive regular training and practice.13, 14, 15, 16, 17, 18 Especially in prehospital emergency situations, it is mandatory to secure the airway as safely and quickly as possible. Persistent and prolonged attempts at intubation may cause catastrophic respiratory events.19

Difficulties with ETI as well as airway-associated adverse outcomes led to the concept of “difficult airway management”, where supraglottic airway devices provided valuable alternatives.20, 21, 22 Supraglottic airway devices are less invasive and technically easier to use than ETI.7

In Europe, prehospital ETI is performed by physicians and paramedics. However, endotracheal intubations by paramedics are performed infrequently.18

In consequence, we performed this manikin study in order to evaluate time to ventilation, usability and skill retention of alternate supraglottic airway devices in comparison to ETI. This evaluation was repeated after 3 months. Our aim was to assess the performance of paramedics with respect to success rate and time of insertion of the alternate airway devices as compared to ETI.

Section snippets

Methods

Following approval by ethical committee of the Medical University Vienna, 41 active voluntary paramedics of the Red Cross Vorarlberg, Austria, participated after informed consent. All of them had already completed their training within the past 5 years. In Austria, training schedules for paramedics differ from other curricula, such as in Germany or the U.S.A.: basic airway management is limited to bag-valve ventilation and advanced airway management, which includes intubation, requires further

Results

This study was conducted between September 2009 and January 2010. Forty-one paramedics (8 female and 33 male, age 30 ± 13) participated in this study.

Discussion

Following a single training session, the 41 paramedics recruited for our study were more successful at performed intubations with five out of six supraglottic airway devices than with ETI.

Up until now, no study has compared the application of widely used supraglottic airway devices with ETI by paramedics. Studies have investigated various airway devices in different settings and in different populations, with varying results of success rates. Differences appear to correlate strongly with the

Conclusion

Within the limitations of this manikin setting, it might be suggested that in emergency situations safe and effective alternatives to ETI are available. ETI should preferably only be performed by trained and experienced paramedics or physicians. In inexperienced hands and used irregularly, ETI is difficult to perform and can cause substantial morbidity and mortality if positioned incorrectly. Inexperienced medical staff including paramedics may therefore benefit from airway management using

Conflict of interest statement

Supported by a grant of the Government of Vorarlberg/Austria.

The sponsor was not involved in data collection, analysis or interpretation; the manuscript was written by the investigators.

Michael Frass is the inventor of the Combitube® and has received royalties from Covidien. This study was not influenced in any way.

None of the other authors has a personal or financial interest in this research.

Acknowledgements

The authors would like to thank the Red Cross Vorarlberg, Austria, as well as the Government of Vorarlberg/Austria for financial support of this study.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.01.008.

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