Intubation using the gum-elastic bougie while wearing personal protective equipment
DOI:
https://doi.org/10.5055/ajdm.2020.0358Keywords:
chemical incident, airway control, intubation, bougie, personal protective equipmentAbstract
Objective: To determine whether application of a gum-elastic bougie (GEB), a visual stylet used to improve success rates of difficult intubations, reduces the time, and number of attempts to achieve successful intubation while wearing personal protective equipment (PPE).
Design: A randomized cross-over study comparing orotracheal intubations performed on an AirMan® Mannequin, using either a semirigid stylet or a GEB, while wearing an active hood with a charcoal impregnated suit and butyl rubber gloves.
Setting: Simulation training field of the Israel Defense Force Medical Corps.
Participants: 27 military physicians and 23 paramedics (PMs).
Interventions: Comparing intubation with and without using the GEB while wearing PPE.
Main outcome measure(s): Airway (AW) control was considered successful if the “lungs” of the mannequin expanded during bag ventilation. Three unsuccessful attempts or a procedure exceeding 60 seconds were regarded as a failure. Correlations between parameters of self-assessment of skills and successful intubation were also determined.
Results: With the GEB, success rate was lower (82 percent versus 100 percent, p = 0.002), more attempts were needed (1.4 ± 0.7 versus 1.0 ± 0.2, p = 0.005) and time-to-achieve AW control was longer (43.6 ± 14.6 seconds versus 23.1 ± 10.5 seconds, P < 0.001) than without it. Participants with high self-assessment of GEB-assisted AW management skills needed less attempts to perform successful intubation with GEB than participants with low self-assessment (1.0 ± 0.0 versus 1.4 ± 0.8, p = 0.001), but not less time to achieve it.
Conclusions: While donning PPE, the use of GEB (versus semirigid stylets) did not reduce the time or the number of attempts necessary to achieve successful intubation.
References
Morita H, Yanagisawa N, Nakajima T, et al.: Sarin poisoning in Matsumoto, Japan. Lancet (London, England). 1995; 346(8970): 290-293.
Suzuki J, Kohno T, Tsukagosi M, et al.: Eighteen cases exposed to sarin in Matsumoto, Japan. Intern Med. 1997; 36(7): 466-470.
Okumura T, Takasu N, Ishimatsu S, et al.: Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med. 1996; 28(2): 129-135.
Ohbu S, Yamashina A, Takasu N, et al.: Sarin poisoning on Tokyo subway. South Med J. 1997; 90(6): 587-593.
Report of the United Nations Mission to Investigate Allegations of the Use of Chemical Weapons in the Syrian Arab Republic on the alleged use of chemical weapons in the Ghouta area of Damascus on 21 August 2013. Available at https://www.un.org/zh/focus/northafrica/cwinvestigation.pdf. Accessed May 16, 2020.
Rosman Y, Eisenkraft A, Milk N, et al.: Lessons learned from the Syrian sarin attack: Evaluation of a clinical syndrome through social media. Ann Intern Med. 2014; 160(9): 644-648.
Varma R: The Bhopal Disaster of 1984. Bull Sci Technol Soc. 2005; 25(1): 37-45.
Flaishon R, Sotman A, Ben-Abraham R, et al.: Antichemical protective gear prolongs time to successful airway management: A randomized, crossover study in humans. Anesthesiology. 2004; 100(2): 260-266.
Talmor D: Airway management during a mass casualty event. Respir Care. 2008; 53(2): 226-231; discussion 231.
Markel G, Krivoy A, Rotman E, et al.: Medical management of toxicological mass casualty events. Isr Med Assoc J. 2008; 10(11): 761-766.
Coates MJ, Jundi AS, James MR: Chemical protective clothing: A study into the ability of staff to perform lifesaving procedures. J Accid Emerg Med. 2000; 17(2): 115-118.
Hendler I, Nahtomi O, Segal E, et al.: The effect of full protective gear on intubation performance by hospital medical personnel. Mil Med. 2000; 165(4): 272-274.
Berkenstadt H, Ziv A, Barsuk D, et al.: The use of advanced simulation in the training of anesthesiologists to treat chemical warfare casualties. Anesth Analg. 2003; 96(6): 1739-1742.
Castle N, Owen R, Hann M, et al.: Impact of chemical, biological, radiation, and nuclear personal protective equipment on the performance of low- and high-dexterity airway and vascular access skills. Resuscitation. 2009; 80(11): 1290-1295.
Ophir N, Ramaty E, Rajuan-Galor I, et al.: Airway control in case of a mass toxicological event: Superiority of second-generation supraglottic airway devices. Am J Emerg Med. 2014; 32(12): 1445-1449.
MacDonald RD, LeBlanc V, McArthur B, et al.: Performance of resuscitation skills by paramedic personnel in chemical protective suits. Prehosp Emerg Care. 2006; 10(2): 254-259.
Garner A, Laurence H, Lee A: Practicality of performing medical procedures in chemical protective ensembles. Emerg Med Australas. 2004; 16(2): 108-113.
Goldik Z, Bornstein J, Eden A, et al.: Airway management by physicians wearing anti-chemical warfare gear: Comparison between laryngeal mask airway and endotracheal intubation. Eur J Anaesthesiol. 2002; 19(3): 166-169.
Wedmore IS, Talbo TS, Cuenca PJ: Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment. Mil Med. 2003; 168(11): 876-879.
Flaishon R, Sotman A, Friedman A, et al.: Laryngeal mask airway insertion by anesthetists and nonanesthetists wearing unconventional protective gear: A prospective, randomized, crossover study in humans. Anesthesiology. 2004; 100(2): 267-273.
Castle N, Pillay Y, Spencer N: Insertion of six different supraglottic airway devices whilst wearing chemical, biological, radiation, nuclear-personal protective equipment: A manikin study. Anaesthesia. 2011; 66(11): 983-988.
Katzenell U, Lipsky AM, Abramovich A, et al.: Prehospital intubation success rates among Israel Defense Forces providers: Epidemiologic analysis and effect on doctrine. J Trauma Acute Care Surg. 2013; 75(2 Suppl 2): S178-S183.
Shin DH, Choi PC, Na JU, et al.: Utility of the Pentax-AWS in performing tracheal intubation while wearing chemical, biological, radiation and nuclear personal protective equipment: A randomized crossover trial using a manikin. Emerg Med J. 2013; 30(7): 527-531.
Henderson JJ, Popat MT, Latto IP, et al.: Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004; 59(7): 675-694.
Brazil V, Grobler C, Greenslade J, et al.: Comparison of intubation performance by junior emergency department doctors using gum elastic bougie versus stylet reinforced endotracheal tube insertion techniques. Emerg Med Australas. 2012; 24(2): 194-200.
Niven AS, Doerschug KC: Techniques for the difficult airway. Curr Opin Crit Care. 2013; 19(1): 9-15.
Abdulla S, Abdulla S, Schwemm KP, et al.: Making endotracheal intubation easy and successful, particularly in unexpected difficult airway. Int J Crit Illn Inj Sci. 2014; 4(1): 24-28.
Messa MJ, Kupas DF, Dunham DL: Comparison of Bougie-assisted intubation with traditional endotracheal intubation in a simulated difficult airway. Prehospital Emerg Care. 2011; 15(1): 30-33.
Dexheimer Neto FL, de Andrade JMS, Raupp ACT, et al.: Use of a homemade introducer guide (bougie) for intubation in emergency situation in patients who present with difficult airway: a case series. Braz J Anesthesiol (English Ed). 2016; 66(2): 204-207.
Phelan MP, Popat M, Christiansen G, et al.: Use of the endotracheal bougie introducer for difficult intubations. Am J Emerg Med. 2004; 22(6): 479-482.
Jabre P, Combes X, Leroux B, et al.: Use of gum elastic bougie for prehospital difficult intubation. Am J Emerg Med. 2005; 23(4): 552-555.
Komasawa N, Cho T, Mihara R, et al.: Utility of gum-elastic bougie for tracheal intubation during chest compressions in a manikin: A randomized crossover trial. Am J Emerg Med. 2016; 34(1): 54-56.
Castle N, Pillay Y, Spencer N: Comparison of six different intubation aids for use while wearing CBRN-PPE: A manikin study. Resuscitation. 2011; 82(12): 1548-1552.
Kidd JF, Dyson A, Latto IP: Successful difficult intubation. Anaesthesia. 1988; 43(6): 437-438.
Wamg HE, Reitz SR, Hostler D, et al.: Defining the learning curve for paramedic student endotracheal intubation. Prehospital Emerg Care. 2005; 9(2): 156-162.
Warner KJ, Carlbom D, Cooke CR, et al.: Paramedic training for proficient prehospital endotracheal intubation. Prehosp Emerg Care. 2009; 14(1): 103-108.
Kim SJ, Choi SH, Lee SW, et al.: The analysis of self and tutor assessment in the skill of basic life support (BLS) and endotracheal intubation: Focused on the discrepancy in assessment. Resuscitation. 2011; 82(6): 743-748.
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