Emergency Airway Management in a Simulation of Highly Contagious Isolated Patients: Both Isolation Strategy and Device Type Matter

Abstract

OBJECTIVE To compare 6 airway-management devices in 3 isolation scenarios regarding their effect on airway management: portable isolation unit (PIU), personal protective equipment (PPE), and standard protection measures METHODS In total, 30 anesthesiologists working in emergency medical services performed airway management on mannequins in 3 isolation settings using 6 different airway management devices (in random order): (1) standard Macintosh laryngoscope; (2) Airtraq SP-video-laryngoscope; (3) i-gel; (4) LMA-Fastrach; (5) Ambu fiberoptic-aScope; and (6) Melker cricothyrotomy-set. Each was assessed regarding time-to-ventilate (primary outcome) and rating of difficulty handling the device. RESULTS In 86% (standard protection) and 85% (PPE) of attempts, airway management was achieved in <60 seconds, irrespective of the device used. In the PIU setting, only 69% of attempts succeeded within this time frame (P<.05). Median time-to-ventilate was shorter for standard protection (23 seconds) and PPE (25 seconds) compared to the PIU (38 seconds; P<.001). In the PIU setting, the fiberscope took the longest (median, 170 seconds), while i-gel was the quickest (median, 13 seconds). The rating of difficulty (visual analogue scale [VAS], 0-100) differed significantly between the isolation scenarios: Airway management was most difficult with PIU (VAS, 76), followed by PPE (VAS, 35), and standard protection (VAS, 9) (P<.01). CONCLUSION Wearing PPE produced similar times-to-ventilate as standard protection among anesthesiologists, but it was subjectively rated more difficult. The portable isolation unit permitted acceptable times-to-ventilate when excluding fiberscope and cricothyrotomy. Supraglottic airway devices allowed the fastest airway management in all isolation scenarios, thus being highly recommendable if a portable isolation unit is used and emergency airway management becomes necessary. Infect Control Hosp Epidemiol 2018;39:145-151.

Transport of COVID-19 and other highly contagious patients by helicopter and fixed-wing air ambulance: a narrative review and experience of the Swiss air rescue Rega

“…Plazikowski et al compared airway management in the Rega PIU with airway management under standard protective measures [7]. The study compared intubation of mannequins using a standard laryngoscope, a video laryngoscope, or cricothyrotomy.…”

Systematic review of simulated airway management whilst wearing personal protective equipment

“…Interestingly, we found only one study performed with anaesthesiologists as subjects. 13 Two studies have confirmed that even staff with prior experience took significantly longer to achieve successful airway management whilst wearing PPE compared with not wearing it. 17,18 Clinical studies with risk of contamination with highly infectious pathogens would be unethical, so simulation studies should be encouraged for two main reasons.…”

“…Five studies investigated only intubation, 11,12,14e16 one evaluated only supraglottic airway device placement, 10 and one included both intubation, supraglottic airway device placement and cricothyroidotomy. 13 The participants in these studies ranged from paramedic students (with no airway management experience 1011 ) to anaesthesiologists 13 ; the number of participants ranged from 1616 to 66. 11 The type of PPE worn also varied considerably.…”

“…Four different videolaryngoscopy devices were evaluated in five studies: Airtraq®, 11,13 Pentax-AWS®, 15 KingVision®, 12,14 and Glidescope®. 12,14 Time to intubation varied substantially between devices: Airtraq® 29e69 s, Pentax-AWS® 18 s, King-Vision® 30 s, and Glidescope® 8e36 s. The success rate was 80e90% for Airtraq®, and 100% for Pentax-AWS®, KingVision® and Glidescope®.…”

“…14,15 In one study both KingVision® and Glidescope® had a better success rate than direct laryngoscopy but longer time to intubation. 12 In the remaining two studies, Airtraq® had poorer performances than direct laryngoscopy both in terms of success rate and time to success 11,13 Two studies evaluated the intubating laryngeal mask airway 11,16 with divergent findings in time to intubation (one study included paramedic students 11 and one involved emergency medicine residents with prior airway experience 16 ). The only study evaluating the positioning of six supraglottic airway devices for ventilation found that i-gel® had the best performances, with 100% success rate within 60 s and the shortest time to placement (19 s).…”