Short report 371
Emergency airway management by paramedics: comparison between standard endotracheal intubation, laryngeal mask airway, and I-gel Charalampos Leventis*, Athanasios Chalkias*, Michail A. Sampanis, Xanthipi Foulidou and Theodoros Xanthos The aim of this study was to investigate whether briefly trained paramedics would be able to successfully intubate by endotracheal intubation (ETI) and using the laryngeal mask airway (LMA) and the I-gel in a manikin model. After the completion of a questionnaire, a brief educational session, and presentation of ETI, LMA, and I-gel, 72 paramedics were randomly allocated to intubate an adult manikin. The success rate for I-gel was higher than that for LMA (P < 0.001) and ETI (P < 0.001), and the insertion time for I-gel was significantly shorter than that for LMA (P < 0.001) or during ETI (P < 0.001). There was a statistically significant association between the experience level of paramedics and insertion time only for the LMA (P = 0.012). In addition, the mean insertion time values were significantly affected by the accuracy of the answers to the theoretical questions (P < 0.05 for all questions). Paramedics should lay greater emphasis on airway
management using supraglottic devices, especially I-gel because of its shorter time of insertion. European Journal c 2014 Wolters Kluwer of Emergency Medicine 21:371–373 Health | Lippincott Williams & Wilkins.
Introduction
the National Emergency Medical System Service in Patra, Greece. The primary endpoint of the study was to assess the effect of brief training on airway device placement by paramedics. Secondary outcomes were time to successful device placement and the effect of other factors on this time (the methods of this study are presented in detail in the Supplementary material, Supplemental digital content 1, http://links.lww.com/EJEM/A62).
Endotracheal intubation (ETI) is still considered as the golden standard in airway management. However, this technique has been questioned in recent years and remains a matter of extensive discussion, especially as far as the prehospital setting and emergency medical service (EMS) providers are concerned [1]. Supraglottic airway devices have been used with increasing frequency following the success of the laryngeal mask airway (LMA). These devices are easy to use, have a high success rate of insertion, require little training for use, and are capable of providing effective ventilation in various situations [2]. The aim of the present study was to investigate whether briefly trained paramedics would be able to successfully intubate by ETI and using the LMA and I-gel in a manikin model.
Methods From May 2012 to May 2013, 72 paramedics were randomly selected and invited to participate in the study. The study was approved by the Postgraduate Study Program (MSc) ‘Cardiopulmonary Resuscitation’ of the National and Kapodistrian University of Athens and Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.euro-emergencymed.com). c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546
European Journal of Emergency Medicine 2014, 21:371–373 Keywords: endotracheal intubation, I-gel, laryngeal mask airway, paramedics, prehospital National and Kapodistrian University of Athens, Medical School, ‘Cardiopulmonary Resuscitation’, Athens, Greece Correspondence to Athanasios Chalkias, PhD, MSc, ‘Cardiopulmonary Resuscitation’, National and Kapodistrian University of Athens, Medical School, Hospital ‘Henry Dunant’, 107 Mesogion Av., 115 26 Athens, Greece Tel: + 30 210 4133992; fax: + 30 210 6972396, e-mail: [email protected] *Charalampos Leventis and Athanasios Chalkias contributed equally to the writing of this article. Received 11 September 2013 Accepted 11 November 2013
Pre-evaluation training
To reinforce the theoretical background of the participants and to ensure, as much as possible, a uniform theoretical knowledge among them, three 20-min lectures preceded the demonstration of the tested techniques. Subsequently, a standardized demonstration in ETI and the use of LMA and I-gel in an adult manikin (Resusci Anne, Laerdal, Stavanger, Norway) was conducted. Evaluation
The order of interventions for each participant was determined by the sealed envelope method. Thus, three different groups of participants were formed: one group intubating using the ETI method, one group intubating using LMA, and one group intubating using I-gel. Subsequently, the participants switched groups randomly so as to attempt intubation using all techniques. DOI: 10.1097/MEJ.0000000000000101
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
372 European Journal of Emergency Medicine 2014, Vol 21 No 5
Randomization for intubating LMA (ILMA) or I-gel was achieved using special computer-based software. In our study, ETI was performed using a conventional Macintosh laryngoscope with a curved blade No. 4 and a 7.5-mm endotracheal tube (Mallinckrodt Medical, Athlone, Ireland), whereas both LMA (Teleflex Medical, Athlone, Ireland) and I-gel (Intersurgical Ltd, Berkshire, UK) were of size 4.0. A 10-ml syringe was used to inflate the cuff of the tracheal tube and a 50-ml syringe to inflate the cuff of the LMA. The devices were used according to the directions of the manufacturers. In this study, time measurements were made for all methods of tracheal intubation and success rates were recorded. Time was recorded by an observer using the same stopwatch. For ETI, the duration of intubation was considered as the time taken from placement of the blade of the laryngoscope between the teeth of the manikin until inflation of the cuff of the tube. The time taken from placement of the supraglottic device between the teeth until inflation of the cuff of the tracheal tube was considered as the duration of intubation, and in the case of LMA it included inflation of the cuff. Thereafter, the success of intubation was checked using the self-inflating bag. Equal lung inflation on both sides of the chest was indicative of proper ILMA, I-gel, and tracheal tube positioning. For each method, every effort was repeated until a successful outcome was reached. Attempts resulting in esophageal intubation or of duration greater than 30 s were considered failures. Statistical analysis
Continuous data are expressed as the number of participants (n), means, SDs, and medians, whereas categorical data are expressed as frequencies and percentages. Categorical variables were compared using Pearson’s w2-test. To assess the levels of correlation and statistical significance, one-way analysis of variance and Pearson’s test were used. In addition, post-hoc analyses were carried out according to the Bonferroni method. Statistical analysis was carried out using SPSS 16.0 (SPSS Inc., Chicago, Illinois, USA). A P-value of less than 0.05 was considered statistically significant.
Results The mean age of the participants was 32.8 years; 47 (65.3%) of them were men. Of note, most of the paramedics had at least 5 years of experience in the service and had undergone at least 4 years of training on airway management. The degree of theoretical knowledge of the participants depended significantly on the time since their last update on emergency airway management (P < 0.05). In our study, 54 (75%) paramedics successfully intubated the manikin in the first attempt by ETI, whereas only two needed at least three attempts (Table 1). In addition,
Success at each attempt of airway device placement by the participants
Table 1
First attempt
Second attempt
Third attempt
54 (77.1) 24.3 5.04 14.3 35.8
16 (22.8) 25.1 6.1 15.3 39.6
2 (2.8) 29.4 10.08 20.8 46.9
69 (95.8) 13.3 2.03 8.07 18.4
3 (4.1) 11.3 2.85 8.5 14.2
0 (0)
72 (100) 6.6 1.36 3.2 13.4
0 (0)
0 (0)
Endotracheal intubation N (%) Mean time (s) SD Minimum (s) Maximum (s) LMA N (%) Mean time (s) Standard deviation Minimum (s) Maximum (s) I-gel N (%) Mean time (s) SD Minimum (s) Maximum (s) LMA, laryngeal mask airway.
69 (95.8%) paramedics successfully placed the LMA at the first attempt, whereas none of them needed a third attempt (P < 0.001). The time required for I-gel insertion at the first attempt was significantly shorter compared with that required for LMA insertion or ETI (6.6±1.36, 13.3±2.03, and 24.3±5.04 s, respectively; P < 0.001). We compared the insertion times for ETI with those of first attempt intubation using the other two devices, as the majority of the participants successfully intubated the manikin at the first attempt. We found a statistically significant association between the experience of paramedics and insertion time only for LMA (P = 0.012), which was confirmed on post-hoc analysis. Moreover, the insertion time during the first attempt at ETI was significantly associated with the time elapsed since the last training session on the technique (P = 0.003; Table 2). Also, there was a statistically significant correlation between the accuracy of the answers to the theoretical questions and insertion times (P < 0.022).
Discussion In our study, paramedics had 100% success rate with I-gel and 95.8% success rate with LMA, whereas the rate fell to 75% for ETI. This is consistent with the results of Deakin et al. [3], who found that even under optimal conditions, 30% of attempts at intubation by paramedics were unsuccessful. A recent study investigating the usability of several supraglottic airway devices compared with ETI and the skill retention of 41 previously inexperienced paramedics following training found that ETI performed by inexperienced paramedics is associated with a low success rate, whereas supraglottic airway devices like LMA and I-gel were fast, safe, and easy to use [4]. Bosch et al. [5] evaluated the effectiveness and suitability of LMA-supreme device for emergency
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Prehospital airway management Leventis et al. 373
Table 2
Association of insertion time with time since last training F
Significance
The effect of previous experience with the technique on time to intubation ETI – first attempt 1.053 0.308 ETI – second attempt 0.442 0.516 ETI – third attempt 0.087 0.788 LMA – first attempt 6.724 0.012 I-gel – first attempt 0.884 0.351 The effect of the time that has passed since the last training on time to intubation ETI – first attempt 4.541 0.003 ETI – second attempt 1.779 0.221 LMA – first attempt 0.884 0.479 I-gel – first attempt 1.401 0.244 ETI, endotracheal intubation; LMA, laryngeal mask airway.
medical services in daily out-of-hospital emergency practice after a period of theoretical and practical training and reported a 100% success rate with 98% success in the first attempt. In our study, the mean insertion times of supraglottic devices were much shorter than the times reported in the literature. Further, we found insertion time to be significantly shorter with I-gel. Castle et al. [6] compared insertion times between I-gel and LMA in 36 paramedic students and reported that I-gel was consistently the fastest airway device, taking a mean of 12.3 s to insert compared with 33.8 s for LMA. Chauhan et al. [7] compared the insertion characteristics of I-gel and proseal LMA and reported that the mean insertion time for I-gel was significantly shorter than that for proseal LMA, and I-gel was easier to insert with a better anatomic fit. In addition, our research group recently assessed the use of LMA and I-gel in experienced and novice doctors in a manikin setting and found that the first attempt success rate was significantly higher for I-gel and that the use of I-gel reduced insertion time [8]. Our results add to the increasing evidence that paramedics may effectively use supraglottic airway devices after a brief training period, especially I-gel [4,8,9]. I-gel requires significantly less manipulations during insertion, mainly because of the simple insertion technique, the firmer grip by the rescuer, and the absence of a cuff [7]. As no cuff inflation is required on using I-gel, an effective airway is achieved faster with minimal risk for tissue compression [10]. We recognize that there are several limitations to our study. First, the sample size, even if powered to detect statistical significances, is small and safe conclusions cannot be extracted. There may be selection bias as only 72 of 105 paramedics agreed to participate, therefore making this a self-selected group. Second, our study was carried out on manikins and not on humans; therefore,
it is difficult to predict the actual performance of the devices in the clinical setting. In general, we would expect intubation times to be longer in patients, as interventions in manikins are quicker and easier. For the same reasons, success rates in patients may be lower than those reported in this study. However, manikins allow for strict standardization of the study conditions, and the manikins used seem to perform adequately in the tasks scheduled in this study. Further, although manikin studies may not exactly be correlated with clinical trials, their results constitute an invaluable tool for planning clinical trials. In addition, regression toward the mean as a result of repeated testing and learning/practice effect should be taken into account when interpreting the results. Conclusion
Our results indicate that paramedics may effectively use the supraglottic airway devices, especially I-gel, because of their ease of insertion and the brief training requirement.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References Raatiniemi L, La¨nkima¨ki S, Martikainen M. Pre-hospital airway management by non-physicians in Northern Finland – a cross-sectional survey. Acta Anaesthesiol Scand 2013; 57:654–659. 2 Deakin CD, Clarke T, Nolan J, Zideman DA, Gwinnutt C, Moore F, et al. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008. Emerg Med J 2010; 27:226–233. 3 Deakin CD, Peters R, Tomlinson P, Cassidy M. Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emerg Med J 2005; 22:64–67. 4 Ruetzler K, Roessler B, Potura L, Priemayr A, Robak O, Schuster E, et al. Performance and skill retention of intubation by using seven different airway devices – a manikin study. Resuscitation 2011; 82:593–597. 5 Bosch J, de Nooij J, de Visser M, Cannegieter SC, Terpstra NJ, Heringhaus C, et al. Prehospital use in emergency patients of a laryngeal mask airway by ambulance paramedics is a safe and effective alternative for endotracheal intubation. Emerg Med J 2013 [Epub ahead of print]. 6 Castle N, Owen R, Hann M, Naidoo R, Reeves D. Assessment of the speed and ease of insertion of three supraglottic airway devices by paramedics: a manikin study. Emerg Med J 2010; 27:860–863. 7 Chauhan G, Nayar P, Seth A, Gupta K, Panwar M, Agrawal N. Comparison of clinical performance of the I-gel with LMA proseal. J Anaesthesiol Clin Pharmacol 2013; 29:56–60. 8 Stroumpoulis K, Isaia C, Bassiakou E, Pantazopoulos I, Troupis G, Mazarakis A, et al. A comparison of the I-gel and classic LMA insertion in manikins by experienced and novice physicians. Eur J Emerg Med 2012; 19:24–27. 9 Murray MJ, Vermeulen MJ, Morrison LJ, Waite T. Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training. CJEM 2002; 4:338–343. 10 Stewat A, Lindsay WA. Bilateral hypoglossal nerve injury following the use of laryngeal mask airway. Anaesthesia 2002; 57:264–265. 1
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Emergency airway management by paramedics: comparison between standard endotracheal intubation, laryngeal mask airway, and I-gel Charalampos Leventis*, Athanasios Chalkias*, Michail A. Sampanis, Xanthipi Foulidou and Theodoros Xanthos The aim of this study was to investigate whether briefly trained paramedics would be able to successfully intubate by endotracheal intubation (ETI) and using the laryngeal mask airway (LMA) and the I-gel in a manikin model. After the completion of a questionnaire, a brief educational session, and presentation of ETI, LMA, and I-gel, 72 paramedics were randomly allocated to intubate an adult manikin. The success rate for I-gel was higher than that for LMA (P < 0.001) and ETI (P < 0.001), and the insertion time for I-gel was significantly shorter than that for LMA (P < 0.001) or during ETI (P < 0.001). There was a statistically significant association between the experience level of paramedics and insertion time only for the LMA (P = 0.012). In addition, the mean insertion time values were significantly affected by the accuracy of the answers to the theoretical questions (P < 0.05 for all questions). Paramedics should lay greater emphasis on airway
management using supraglottic devices, especially I-gel because of its shorter time of insertion. European Journal c 2014 Wolters Kluwer of Emergency Medicine 21:371–373 Health | Lippincott Williams & Wilkins.
Introduction
the National Emergency Medical System Service in Patra, Greece. The primary endpoint of the study was to assess the effect of brief training on airway device placement by paramedics. Secondary outcomes were time to successful device placement and the effect of other factors on this time (the methods of this study are presented in detail in the Supplementary material, Supplemental digital content 1, http://links.lww.com/EJEM/A62).
Endotracheal intubation (ETI) is still considered as the golden standard in airway management. However, this technique has been questioned in recent years and remains a matter of extensive discussion, especially as far as the prehospital setting and emergency medical service (EMS) providers are concerned [1]. Supraglottic airway devices have been used with increasing frequency following the success of the laryngeal mask airway (LMA). These devices are easy to use, have a high success rate of insertion, require little training for use, and are capable of providing effective ventilation in various situations [2]. The aim of the present study was to investigate whether briefly trained paramedics would be able to successfully intubate by ETI and using the LMA and I-gel in a manikin model.
Methods From May 2012 to May 2013, 72 paramedics were randomly selected and invited to participate in the study. The study was approved by the Postgraduate Study Program (MSc) ‘Cardiopulmonary Resuscitation’ of the National and Kapodistrian University of Athens and Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.euro-emergencymed.com). c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins 0969-9546
European Journal of Emergency Medicine 2014, 21:371–373 Keywords: endotracheal intubation, I-gel, laryngeal mask airway, paramedics, prehospital National and Kapodistrian University of Athens, Medical School, ‘Cardiopulmonary Resuscitation’, Athens, Greece Correspondence to Athanasios Chalkias, PhD, MSc, ‘Cardiopulmonary Resuscitation’, National and Kapodistrian University of Athens, Medical School, Hospital ‘Henry Dunant’, 107 Mesogion Av., 115 26 Athens, Greece Tel: + 30 210 4133992; fax: + 30 210 6972396, e-mail: [email protected] *Charalampos Leventis and Athanasios Chalkias contributed equally to the writing of this article. Received 11 September 2013 Accepted 11 November 2013
Pre-evaluation training
To reinforce the theoretical background of the participants and to ensure, as much as possible, a uniform theoretical knowledge among them, three 20-min lectures preceded the demonstration of the tested techniques. Subsequently, a standardized demonstration in ETI and the use of LMA and I-gel in an adult manikin (Resusci Anne, Laerdal, Stavanger, Norway) was conducted. Evaluation
The order of interventions for each participant was determined by the sealed envelope method. Thus, three different groups of participants were formed: one group intubating using the ETI method, one group intubating using LMA, and one group intubating using I-gel. Subsequently, the participants switched groups randomly so as to attempt intubation using all techniques. DOI: 10.1097/MEJ.0000000000000101
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
372 European Journal of Emergency Medicine 2014, Vol 21 No 5
Randomization for intubating LMA (ILMA) or I-gel was achieved using special computer-based software. In our study, ETI was performed using a conventional Macintosh laryngoscope with a curved blade No. 4 and a 7.5-mm endotracheal tube (Mallinckrodt Medical, Athlone, Ireland), whereas both LMA (Teleflex Medical, Athlone, Ireland) and I-gel (Intersurgical Ltd, Berkshire, UK) were of size 4.0. A 10-ml syringe was used to inflate the cuff of the tracheal tube and a 50-ml syringe to inflate the cuff of the LMA. The devices were used according to the directions of the manufacturers. In this study, time measurements were made for all methods of tracheal intubation and success rates were recorded. Time was recorded by an observer using the same stopwatch. For ETI, the duration of intubation was considered as the time taken from placement of the blade of the laryngoscope between the teeth of the manikin until inflation of the cuff of the tube. The time taken from placement of the supraglottic device between the teeth until inflation of the cuff of the tracheal tube was considered as the duration of intubation, and in the case of LMA it included inflation of the cuff. Thereafter, the success of intubation was checked using the self-inflating bag. Equal lung inflation on both sides of the chest was indicative of proper ILMA, I-gel, and tracheal tube positioning. For each method, every effort was repeated until a successful outcome was reached. Attempts resulting in esophageal intubation or of duration greater than 30 s were considered failures. Statistical analysis
Continuous data are expressed as the number of participants (n), means, SDs, and medians, whereas categorical data are expressed as frequencies and percentages. Categorical variables were compared using Pearson’s w2-test. To assess the levels of correlation and statistical significance, one-way analysis of variance and Pearson’s test were used. In addition, post-hoc analyses were carried out according to the Bonferroni method. Statistical analysis was carried out using SPSS 16.0 (SPSS Inc., Chicago, Illinois, USA). A P-value of less than 0.05 was considered statistically significant.
Results The mean age of the participants was 32.8 years; 47 (65.3%) of them were men. Of note, most of the paramedics had at least 5 years of experience in the service and had undergone at least 4 years of training on airway management. The degree of theoretical knowledge of the participants depended significantly on the time since their last update on emergency airway management (P < 0.05). In our study, 54 (75%) paramedics successfully intubated the manikin in the first attempt by ETI, whereas only two needed at least three attempts (Table 1). In addition,
Success at each attempt of airway device placement by the participants
Table 1
First attempt
Second attempt
Third attempt
54 (77.1) 24.3 5.04 14.3 35.8
16 (22.8) 25.1 6.1 15.3 39.6
2 (2.8) 29.4 10.08 20.8 46.9
69 (95.8) 13.3 2.03 8.07 18.4
3 (4.1) 11.3 2.85 8.5 14.2
0 (0)
72 (100) 6.6 1.36 3.2 13.4
0 (0)
0 (0)
Endotracheal intubation N (%) Mean time (s) SD Minimum (s) Maximum (s) LMA N (%) Mean time (s) Standard deviation Minimum (s) Maximum (s) I-gel N (%) Mean time (s) SD Minimum (s) Maximum (s) LMA, laryngeal mask airway.
69 (95.8%) paramedics successfully placed the LMA at the first attempt, whereas none of them needed a third attempt (P < 0.001). The time required for I-gel insertion at the first attempt was significantly shorter compared with that required for LMA insertion or ETI (6.6±1.36, 13.3±2.03, and 24.3±5.04 s, respectively; P < 0.001). We compared the insertion times for ETI with those of first attempt intubation using the other two devices, as the majority of the participants successfully intubated the manikin at the first attempt. We found a statistically significant association between the experience of paramedics and insertion time only for LMA (P = 0.012), which was confirmed on post-hoc analysis. Moreover, the insertion time during the first attempt at ETI was significantly associated with the time elapsed since the last training session on the technique (P = 0.003; Table 2). Also, there was a statistically significant correlation between the accuracy of the answers to the theoretical questions and insertion times (P < 0.022).
Discussion In our study, paramedics had 100% success rate with I-gel and 95.8% success rate with LMA, whereas the rate fell to 75% for ETI. This is consistent with the results of Deakin et al. [3], who found that even under optimal conditions, 30% of attempts at intubation by paramedics were unsuccessful. A recent study investigating the usability of several supraglottic airway devices compared with ETI and the skill retention of 41 previously inexperienced paramedics following training found that ETI performed by inexperienced paramedics is associated with a low success rate, whereas supraglottic airway devices like LMA and I-gel were fast, safe, and easy to use [4]. Bosch et al. [5] evaluated the effectiveness and suitability of LMA-supreme device for emergency
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Prehospital airway management Leventis et al. 373
Table 2
Association of insertion time with time since last training F
Significance
The effect of previous experience with the technique on time to intubation ETI – first attempt 1.053 0.308 ETI – second attempt 0.442 0.516 ETI – third attempt 0.087 0.788 LMA – first attempt 6.724 0.012 I-gel – first attempt 0.884 0.351 The effect of the time that has passed since the last training on time to intubation ETI – first attempt 4.541 0.003 ETI – second attempt 1.779 0.221 LMA – first attempt 0.884 0.479 I-gel – first attempt 1.401 0.244 ETI, endotracheal intubation; LMA, laryngeal mask airway.
medical services in daily out-of-hospital emergency practice after a period of theoretical and practical training and reported a 100% success rate with 98% success in the first attempt. In our study, the mean insertion times of supraglottic devices were much shorter than the times reported in the literature. Further, we found insertion time to be significantly shorter with I-gel. Castle et al. [6] compared insertion times between I-gel and LMA in 36 paramedic students and reported that I-gel was consistently the fastest airway device, taking a mean of 12.3 s to insert compared with 33.8 s for LMA. Chauhan et al. [7] compared the insertion characteristics of I-gel and proseal LMA and reported that the mean insertion time for I-gel was significantly shorter than that for proseal LMA, and I-gel was easier to insert with a better anatomic fit. In addition, our research group recently assessed the use of LMA and I-gel in experienced and novice doctors in a manikin setting and found that the first attempt success rate was significantly higher for I-gel and that the use of I-gel reduced insertion time [8]. Our results add to the increasing evidence that paramedics may effectively use supraglottic airway devices after a brief training period, especially I-gel [4,8,9]. I-gel requires significantly less manipulations during insertion, mainly because of the simple insertion technique, the firmer grip by the rescuer, and the absence of a cuff [7]. As no cuff inflation is required on using I-gel, an effective airway is achieved faster with minimal risk for tissue compression [10]. We recognize that there are several limitations to our study. First, the sample size, even if powered to detect statistical significances, is small and safe conclusions cannot be extracted. There may be selection bias as only 72 of 105 paramedics agreed to participate, therefore making this a self-selected group. Second, our study was carried out on manikins and not on humans; therefore,
it is difficult to predict the actual performance of the devices in the clinical setting. In general, we would expect intubation times to be longer in patients, as interventions in manikins are quicker and easier. For the same reasons, success rates in patients may be lower than those reported in this study. However, manikins allow for strict standardization of the study conditions, and the manikins used seem to perform adequately in the tasks scheduled in this study. Further, although manikin studies may not exactly be correlated with clinical trials, their results constitute an invaluable tool for planning clinical trials. In addition, regression toward the mean as a result of repeated testing and learning/practice effect should be taken into account when interpreting the results. Conclusion
Our results indicate that paramedics may effectively use the supraglottic airway devices, especially I-gel, because of their ease of insertion and the brief training requirement.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References Raatiniemi L, La¨nkima¨ki S, Martikainen M. Pre-hospital airway management by non-physicians in Northern Finland – a cross-sectional survey. Acta Anaesthesiol Scand 2013; 57:654–659. 2 Deakin CD, Clarke T, Nolan J, Zideman DA, Gwinnutt C, Moore F, et al. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008. Emerg Med J 2010; 27:226–233. 3 Deakin CD, Peters R, Tomlinson P, Cassidy M. Securing the prehospital airway: a comparison of laryngeal mask insertion and endotracheal intubation by UK paramedics. Emerg Med J 2005; 22:64–67. 4 Ruetzler K, Roessler B, Potura L, Priemayr A, Robak O, Schuster E, et al. Performance and skill retention of intubation by using seven different airway devices – a manikin study. Resuscitation 2011; 82:593–597. 5 Bosch J, de Nooij J, de Visser M, Cannegieter SC, Terpstra NJ, Heringhaus C, et al. Prehospital use in emergency patients of a laryngeal mask airway by ambulance paramedics is a safe and effective alternative for endotracheal intubation. Emerg Med J 2013 [Epub ahead of print]. 6 Castle N, Owen R, Hann M, Naidoo R, Reeves D. Assessment of the speed and ease of insertion of three supraglottic airway devices by paramedics: a manikin study. Emerg Med J 2010; 27:860–863. 7 Chauhan G, Nayar P, Seth A, Gupta K, Panwar M, Agrawal N. Comparison of clinical performance of the I-gel with LMA proseal. J Anaesthesiol Clin Pharmacol 2013; 29:56–60. 8 Stroumpoulis K, Isaia C, Bassiakou E, Pantazopoulos I, Troupis G, Mazarakis A, et al. A comparison of the I-gel and classic LMA insertion in manikins by experienced and novice physicians. Eur J Emerg Med 2012; 19:24–27. 9 Murray MJ, Vermeulen MJ, Morrison LJ, Waite T. Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training. CJEM 2002; 4:338–343. 10 Stewat A, Lindsay WA. Bilateral hypoglossal nerve injury following the use of laryngeal mask airway. Anaesthesia 2002; 57:264–265. 1
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
