Comparison of different airway-management devices used by non-anaesthetist personnel: A crossover manikin study
hospitals and health professional organizations have to provide rules, regulations and policies on the use of social media keeping in mind the ethical aspects, security and privacy [4]. Also, the hospitals and health care providers shall take efforts to display relevant/authenticated information and use innovative methods or channels to disseminate in- formation for empowering patients.
Various accrediting/awarding agencies at national or global levels before finalising their report/award shall consider the rating [5] as well as the comments and views of the respective hospital or heath care provider in social media in order to avoid conflicts. Future research shall focus on methodological issues related to location of all web pages and social media which display the remarks of the hospital and/or health care providers as well as the materials described by them, and the characteristics of the end users. As the suggestions made by the end users are likely beneficial, these shall be considered while preparing or revising guidelines for illnesses.
The most important aspect is the sensitization of health science stu- dents and health care providers on the utilization of internet and social media by various categories of citizens all over the globe, and prepare them to come up to the expectations and get higher rating through pro- fessional services. Unless and until we change our attitude, we are likely to be the victims of litigation. Let us recall Swami Vivekananda’s verse “Arise, awake and stop not till the goal is reached”.
Subramanian Senthilkumaran
Department of Emergency and Critical Care, Bewell Hospitals, Erode,
Tamil Nadu, India Corresponding author at: Department of Emergency & Critical Care Medicine, Bewell Hospitals, Erode, Tamil Nadu, India.
E-mail address: maniansenthil@yahoo.co.in
Florence Benita
Department of Emergency Medicine, Hamad Medical Corporation,
Doha, Qatar
Namasivayam Balamurugan
Department of Neurosciences, SIMS Chellam Hospital, Salem,
Tamil Nadu, India
Ponniah Thirumalaikolundusubramanian Department of Internal Medicine, Chennai Medical College Hospital and Research Center, Irungalur, Trichy, Tamil Nadu, India
26 June 2017
http://dx.doi.org/10.1016/j.ajem.2017.07.027
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- Moorehead SA, Hazlett DE, Harrison L, Caroll JK, Irwin A, Holing C. A new dimension of healthcare: systematic review other uses, benefits and limitations of social media for health communications. J Med Internet Res 2013;23;15(4):e85.
- Martinez-Millana A, Fernandez-Liatas C, Bilbao IB, Salcedo MT, Salcedo VT. Evaluating the socialmedia performance of hospitals in spain: a longitudinal and comparative study. J Med Internet Res 2017;19(5):e181.
- Verhoef LM, Van de Belt TH, Engelen LJ, Schoonhoven L, Kool RB. Social media and rat- ing sites as tools to understanding quality of care: a scoping review. J Med Internet Res 2014;16(2):e56.
Comparison of different airway- management devices used by non- anaesthetist personnel: A crossover manikin study
It is widely described in literature that increasing the number of attempts in orotracheal intubation considerably increases the inci- dence of complications [1,2]. There are many devices on the mar- ket which promise to improve the performance of intubation but not all these devices are sufficiently tested. Our study aimed to compare select devices for airway management used by inexpert personnel in two simulated airway scenarios on manikin. Thirty non-expert volunteers (Table 1) participated in this study. (See Tables 2 and 3.)
The tested devices were: a Macintosh laryngoscope with blade n. 4 (Karl Storz GmbH & Co., Tuttlingen, Germany); a regular (n. 3) Airtraq(R) (Prodol Meditec S.A., Vizcaya, Spain); King Vision with a channelled blade (n. 3) and a standard blade (n. 3) (King Systems, Noblesville, IN, USA); a Bonfils(R) optical stylet (Karl Storz GmbH & Co., Tuttlingen, Germany). An ACLS course manikin (ALS Skill Master 4000; Laerdal Medical, Stavanger, Norway) was used. To simulate a difficult airway scenario, an adult cervical spine collar was used (Ambu Perfit, Ambu, Copenaghen, Denmark). All intubations were performed with an ade- quately pre-lubricated cuffed standard endotracheal tube, with an in- ternal diameter of 8 mm (Safety Clear Rusch; Teleflex Medical, Wayne, Pennsylvania, US), and a disposable intubation stylet for the Macintosh and the King Vision(R) with a standard blade. All partici- pants received a standardised 5 min demonstration by one of the in- vestigators (DO) of every device. Every participant was allowed three attempts to practice using the devices before the trial.
Both participants and investigators were blinded to device order which was randomised. For each device, six attempts were made on a manikin in both scenarios. One attempt failed in the following two cases: when the intubation took more than the time limit of 60 s, and when the operator performed an accidental oesophageal in- tubation. No external laryngeal pressure was allowed.
The primary endpoint was the average time to successful tra- cheal intubation. The investigator started timing as soon as the blade of the device was positioned between the teeth of the man- ikin. Timing ended when the operator declared the trachea to be intubated. A second primary endpoint was the rate of successful intubations for every device in both conditions. Secondary end- points were: the average Cormack-Lehane grade for every device; a score rank given by the operators (in a Lickert grading fashion in 5 points: from 1 grade – a very easy to use device – to 5 – a very difficult to use device); the number of oesophageal intuba- tions; the time to successful intubation and the successful rate in the first attempt.
The statistical analyses were performed using the Tukey’s multiple comparison test using ANOVA or general linear models. Non-normality was corrected by Box-Cox method. Skewness was corrected by a covari- ance matrix analysis. A two tales p <= 0.05 was considered statistically significant. In order to control the type I error in the case of multiple comparisons, the Hommel correction was applied. Estimating a conven- tional effect size of 10% between at least one of the comparisons made, for a desired power of 97%, we calculated a sample size of 30 operators in each group. All statistical analyses were performed using R-CRAN project ver. 3.3.1 (R Core Team, 2016. URL: https://www.R-project. org/). The used packages were: “multcomp”; “MASS”; “sandwich”; “car”; “pwr”.
In our study, the Airtraq(R) and the King Vision(R) with a channelled blade have shown the best performances (Tables 4 and 5, Figs. 1 and 2). The King Vision(R) with a standard blade has revealed to be the worst device for the considered primary endpoints. However, the King Vision(R) has shown a good performance in visualization of the vocal cords. It has, in fact, an optical lens with a quite wide angle of view
Descriptive table for the population of involved operators.
Category
Amount
Airway
ALS/ACLS
Macintosh
Airtraq
King Vision
Bonfils
Young attending physicians
2 (7%)a
1 (50%)
2 (100%)
2 (100%)
2 (100%)
2 (100%)
2 (100%)
EM residents
4 (13%)a
1 (25%)
1 (25%)
4 (100%)
2 (50%)
1 (25%)
1 (25%)
1 (3%)a
0
0
1
0
0
0
Nurses
23 (77%)a
8 (35%)
20 (86%)
23 (100%)
19 (83%)
18 (78%)
8 (35%)
Total
30
10 (33%)
23 (77%)
30 (100%)
23 (77%)
21 (70%)
11 (37%)
Table 1: Airway: any specified course on the airway management achieved in the past; ACLS/ALS: any ACLS/ALS course achieved in the past; Macintosh/Airtraq/King Vision/Bonfils: the knowledge and experience with these devices. Young attending physicians: physicians with less than three years of working experience; EM residents: residents in Emergency Medicine; IM residents: resident in Internal medicine; Nurses: nurses with retrieval and pre-hospital competence but no or very scarce experience in advanced airway management (b10 intubations per year).
a These percentages refer to the total numbers of the operators.
Table 2
Results for each considered outcome for every device in the scenario without a cervical spine collar.
W.O. c-spine collar
Average time
Success
Failures
Cormack-Lehane
Score
Oesophageal
Success first
Time first
(s)
(%)
(n)
(1-4)
(1-5)
(n)
(%)
(s)
L
10.63
100
0
1.24
2.00
0
100
13.00
(6.44-14.8)
(100-100)
(0-0)
(1.00-2.00)
(2.00-3.00)
(0-0)
(100-100)
(8.00-21.00)
A
7.00
100
0
1.00
1.00
0
100
9.00
(4.88-11.31)
(100-100)
(0-0)
(1.00-1.00)
(1.00-2.00)
(0-0)
(100-100)
(6-14.25)
B
20.88
100
0
1.00
3.00
0
100
27.50
(13.69-27.25)
(83.00-100)
(0-1)
(1.00-1.35)
(2.00-3.00)
(0-0.25)
(0-100)
(17.50-60.00)
K
10.13
100
0
1.00
2.00
0
100
10.50
(6.25-15.75)
(100-100)
(0-0)
(1.00-1.00)
(1.00-3.00)
(0-0)
(100-100)
(8.00-23.00)
KN
34.13
67.00
2
1.00
4.00
0
50.00
52.00
(22.75-45.00)
(45.75-87.27)
(0.75-4.00)
(1.00-1.53)
(3.75-5.00)
(0-1)
(0-100)
(15.25-60.00)
The results are listed in median (IQR) or in percentage. Devices: L = Macintosh laryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channelled blade; KN = King Vision(R) with a standard blade.
Table 3
Results for each considered outcome for every device in the scenario with a cervical spine collar.
W. c-spine collar
Average time
Success
Failures
Cormack-Lehane
Score
Oesophageal
Success first
Time first
(s)
(%)
(n)
(1-4)
(1-5)
(n)
(%)
(s)
L
9.88
100
0
1.92
2.50
0
100
13.00
(7.63-19.88)
(95.75-100)
(0-0)
(1.00-2.43)
(2.00-3.00)
(0-0)
(100-100)
(8.75-19.50)
A
5.75
100
0
1.00
1.00
0
100
8.00
(4.25-8.19)
(100-100)
(0-0)
(1.00-1.00)
(1.00-2.00)
(0-0)
(100-100)
(6.00-11.25)
B
14.50
100
0
1.00
3.00
0
100
16.50
(10.75-21.75)
(95.75-100)
(0-0.25)
(1.00-1.78)
(2.00-3.00)
(0-0.25)
(0-100)
(12.00-25.00)
K
7.25
100
0
1.00
2.00
0
100
8.50
(5.63-10.69)
(100-100)
(0-0)
(1.00-1.00)
(1.75-3.00)
(0-0)
(100-100)
(5.00-12.50)
KN
37.38
50
3
1.00
4.00
0
0
60.00
(17.44-50.13)
(33.00-100)
(0.00-4.00)
(1.00-2.00)
(4.00-5.00)
(0-1.00)
(0-100)
(16.50-60.00)
The results are listed in median (IQR) or in percentage. Devices: L = Macintosh laryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channelled blade; KN = King Vision(R) with a standard blade.
Table 4
Summary table with regard to the p-values in the select device comparisons for the time to successful intubation. Statistically significant values.
Col w.o. col
L
A
B
K
KN
L
0.0059?
0.7092
0.0857
b 0.001?
A 0.2584 b 0.001? 0.6736
b 0.001?
B b 0.001? b 0.001? 0.0018?
b 0.001?
K
0.9987
0.2077
b 0.001? b 0.001?
KN
b 0.001?
b 0.001?
0.0208? b 0.001?
On the horizontal axis are the values of the scenario with a cervical spine collar and on the vertical axis those of the scenario without a cervical spine collar. Devices: L = Macintosh la- ryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channelled blade; KN = King Vision(R) with a standard blade.
Summary table with regard to the p-values in the select device comparisons for the successful rate.
Col w.o. col
L
A
B
K
KN
L
0.6830
1.0000
0.1810
b 0.001?
A
0.8123
0.6410
0.7330
b 0.001?
B
0.0771
0.0177?
0.1621
b 0.001?
K
0.9855
0.5891
0.3311
b 0.001?
KN
b 0.001?
b 0.001?
b 0.001?
b 0.001?
On the horizontal axis the values of the scenario with cervical spine collar, on the vertical axis those of the scenario without cervical spine collar. Devices: L = Macintosh laryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channelled blade; KN = King Vision(R) with a standard blade.
that could distort the perception of the distances between the anatom- ical structures [3]. This difference could explain the difficulty to insert the endotracheal tube through the vocal cords [4]. Contrary to the spec- ulation by Liu et al. [5], Levitan et al. emphasize the importance of the passage of the endotracheal tube through the vocal cords [3]. Healy et
al., in their review, highlight the little predictability to the success of in- tubation by the Cormack-Lehane grade [6]. We agree with this asser- tion: several other factors influence the success of intubation. However, the King Vision(R) does not seem a device sufficiently studied in clinical trials yet [7-9].
Fig. 1. Fig. 1a – Box plots for the time to successful intubation in manikin without a cervical spine collar. Legend: The letters above the top line indicate the devices significantly different from the others groups. Devices: L = Macintosh laryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channeled blade; KN = King Vision(R) with a standard blade. Fig. 1b – Box plots for the Successful rate of intubation in manikin without a cervical spine collar. Legend: The letters above the top line indicate the devices significantly different from the others groups. Devices: L = Macintosh laryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channeled blade; KN = King Vision(R) with a standard blade.
Fig. 2. Fig. 2c – Box plots for the time to successful intubation in manikin with a cervical spine collar. Legend: The letters above the top line indicate the devices significantly different from the others groups. Devices: L = Macintosh laryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channeled blade; KN = King Vision(R) with a standard blade. Fig. 2d – Box plots for the successful rate of intubation in manikin with a cervical spine collar. Legend: The letters above the top line indicate the devices significantly different from the others groups. Devices: L = Macintosh laryngoscope; A = Airtraq(R); B = Bonfils(R); K = King Vision(R) with a channeled blade; KN = King Vision(R) with a standard blade.
The new videolaryngoscopic devices can be useful in environments where intubation is notoriously more difficult such as the ED or the pre-hospital setting [10]. Wolf et al. demonstrated that the videolaryngoscopes is a proper training system for inexperienced opera- tors [11], but several factors should be considered and studied before introducing new airway management devices in a specific Clinical context.
The authors report no conflicts of interest. The authors alone are re- sponsible for the content and writing of the paper.
Acknowledgement
The authors thank Manuela Tolomeo for her writing assistance and language editing.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2017.07.028.
Daniele Orso* Lorenzo Cristiani Francesco L. Cilenti Nicola Federici Elena Cecchin Nicola Guglielmo Roberto Copetti
Department of Emergency Medicine, Ospedale Civile di Latisana (UD), AAS 2 “Bassa Friulana – Isontina“, via Sabbionera 45, 33053 Latisana,
Udine, Italy
*Corresponding author.
E-mail address: sd7782.do@gmail.com (Orso, D.)
Tommaso Piani Pre-Hospital and Retrieval Medicine Division, Department of Anaesthesia and Intensive Care Medicine, AOU “Santa Maria della Misericordia“, Piazzale Santa Maria della Misericordia 15, 33010 Udine, Italy
http://dx.doi.org/10.1016/j.ajem.2017.07.028
Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown III CA, et al, Japanese Emergency Medicine Research Alliance Investigators. Association between repeated intubation attempts and adverse events in Emergency Departments: an analysis of a Multicenter prospective observational study. Ann Emerg Med 2012; 60:749-54.
- Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004;99:607-13.
- Levitan RM, Heitz JW, Sweeney M, Cooper RM. The complexities of tracheal intuba- tion with direct laryngoscopy and alternative Intubation devices. Ann Emerg Med 2011;57:240-7.
- Pieters BMA, Wilbers NER, Huijzer M, Winkens B, van Zundert AAJ. Comparison of seven videolaryngoscopes with the Mcintosh laryngoscope in manikins by experi- enced and novice personnel. Anaesthesia 2016;71:556-64.
- Liu L, Tanigawa K, Kusunoki S, et al. Tracheal intubation of a difficult airway using airway scope, Airtraq, and Macintosh laryngoscope: a comparative manikin study of inexperienced personnel. Anesth Analg 2010;110:1049-55.
- Healy DW, Maties O, Hovord D, Kheterpal S. A systematic review of the role of videolaryngoscopy in successful orotracheal intubation. BMC Anesthesiol 2012;12: 32.
- Akihisa Y, Maruyama K, Koyama Y, Yamada R, Ogura A, Andoh T. Comparison of intubation performance between the King Vision and Macintosh laryngoscopes in novice personnel: a randomized, crossover manikin study. J Anesth 2014; 28:51-7.
- Schoettker P, Corniche J. The AirView study: comparison of intubation conditions and ease between the Airtraq-Air View and the King Vision. Biomed Res Int 2015; 2015:284142.
- Murphy LD, Kovacs GJ, Reardon PM, Law JA. Comparison of the King Vision video la- ryngoscope with the Macintosh laryngoscope. J Emerg Med 2014;47:239-46.
- Gaszynski T, Toker K, Carassiti M, Chalkias A, Carlson JN. Advances in airway man- agement and ventilation strategies in Emergency Medicine. Biomed Res Int 2015; 2015:425715.
- Wolf LE, Aguirre JA, Vogt C, Keller C, Borgeat A, Bruppacher HR. Transfer of skills and comparison of performance between King Vision(R) video laryngoscope and Macin- tosh blade following an AHA airway management course. BMC Anesthesiol 2017; 17:5.
Education innovation: A four week point-
of-care ultrasound mini-fellowship for physicians in practice ?,??
Point-of-care ultrasound has been a defined sub compe- tency for emergency medicine (EM) residency graduates since 2012 [1]. The American College of Emergency Physicians (ACEP) has delin- eated a practice-based pathway for physicians, who completed training without POCUS education [2]. However, physicians in prac- tice may find this pathway to competency challenging, especially at non-academic institutions. Obstacles include: a lack of access to training, supervision, or mentorship, and a lack of a structured qual- ity assessment and Review process.
We developed a four-week mini-fellowship for physicians in practice. These are providers, who wish to demonstrate basic POCUS application competency, and who wish to learn administra- tive aspects of POCUS quality assessment (QA) program develop- ment. The four weeks are divided into one-week blocks during one academic year.
? Prior presentations: None.
?? Funding sources/disclosures: None.
Few opportunities exist for training. The Ultrasound Leadership Academy is a 12-month POCUS education curriculum [3]. We are aware of at least one other institution, which has created a similar mini-fellowship to the one described here, however, curricular em- phasis and training goals differ from our innovative education course [4].
For basic POCUS application competency assessment, the learner completes flipped classroom assignments ahead of time. Resources in- clude the Introduction to Bedside Ultrasound iBooks, [5,6] and specified free online narrated lectures [7]. At the beginning of week 1 and week 2, content comprehension is assessed using game-style quizzes developed for this purpose [8]. We determined the education and specific POCUS application according to the fellow preference, and as advised by the CORD-AEUS consensus document [9]. In person, the mini-fellow meets with POCUS educators for hands on scanning sessions. Prior to scanning in the Emergency Department (ED), the mini-fellow obtained hospital privileges and malpractice coverage to perform educational ul- trasounds on patients. Bedside sessions are taught by emergency med- icine faculty, with advanced training in POCUS, critical care, sports medicine, and pediatrics. Additionally, hospitalist and cardiac anesthe- sia faculty participate as educators.
The fellow completes a small number of studies during the fellow-
ship; however, the majority are completed and overread by a subject matter expert at the home institution. The fellow then provides a letter attesting to the completion of at least 25 technically adequate applica- tion specific studies. This is in accordance with the 2016 ACEP Ultra- sound guidelines [2]. We then utilize three main competency assessment tools: real time quality assessment (QA) review, bedside sessions with the completion of a Standardized Direct Observation Tool (SDOT) check list [10], and direct observation of performance on human model volunteers. This allows immediate determination of image acquisition, Image quality, and interpretation review.
The fellow learns how to develop a POCUS QA program. We orga- nize meetings with key individuals at our institution: leaders in op- erations, business, and administration, biomedical engineering, and coders and billers. There are direct conversations on program devel- opment specific to the fellow’s practice site. Relationship building with analogous individuals at the fellow’s home site is encouraged. The fellow heavily concentrates on QA program development. We discuss topics such as, equipment acquisition and maintenance, fi- nancial management of POCUS program, coding for specific exami- nations and quality assurance.
We first review our institution peer reviewed minimal criteria [11]. This teaches the fellow a standard for technically acceptable and technically limited ultrasound examinations. The fellow then reads POCUS examinations alone, alongside a subject matter expert, and in group QA meetings. The fellow performs an initial read and to- gether we overread the examinations. The fellow also drafts direct feedback messages via electronic mail to the providers. At the com- pletion of the mini-fellowship, the fellow receives a signed letter of completion.
Conclusion
A mini-fellowship is an excellent way to further the knowledge and expertise of a physician in practice. Ideally, the individual is motivated, has the support from a home institution, and the tools to implement a POCUS program. A mini-fellowship has certain limitations. The fellow is learning in an environment that may not be similar to the home institu- tion. Four weeks may not be enough for learners. Our curriculum requires that the fellow have prior POCUS experience, and demonstrate evidence of completing a minimum number of ultrasounds prior to the mini-fel- lowship. The fellowship provides ongoing remote mentorship; however, there may not be mentorship at the home institution. We believe the mini-fellowship is an excellent launch-board to initiate a POCUS program in a community setting.
