Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis

Sanfilippo, Filippo; Tigano, Stefano; Rosa, Valeria La; Morgana, Alberto; Murabito, Paolo; Oliveri, Francesco; Longhini, Federico; Astuto, Marinella

doi:10.1016/j.bjane.2021.08.017

home Sumário navigate_before Anterior Atual Seguinte navigate_next

home Sumário

SYSTEMATIC REVIEW • para Braz. J. Anesthesiol. 72 (02) • Mar-Apr 2022 • https://doi.org/10.1016/j.bjane.2021.08.017 linkcopy

Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background: Tracheal intubation in patients with coronavirus disease-19 is a high-risk procedure that should be performed with personal protective equipment (PPE). The influence of PPE on operator’s performance during tracheal intubation remains unclear.

Methods: We conducted a systematic review and meta-analysis of simulation studies to evaluate the influence of wearing PPE as compared to standard uniform regarding time-to-intubation (TTI) and success rate. Subgroup analyses were conducted according to device used and operator’s experience.

Results: The TTI was prolonged when wearing PPE (eight studies): Standard Mean Difference (SMD)-0.54, 95% Confidence Interval [-0.75,-0.34], p < 0.0001. Subgroup analyses according to device used showed similar findings (direct laryngoscopy, SMD-0.63 [-0.88,-0.38], p < 0.0001; videolaryngoscopy, SMD-0.39 [-0.75,-0.02], p = 0.04). Considering the operator’s experience, non-anesthesiologists had prolonged TTI (SMD-0.75 [-0.98,-0.52], p < 0.0001) while the analysis on anesthesiologists did not show significant differences (SMD-0.25 [-0.51, 0.01], p = 0.06). The success rate of tracheal intubation was not influenced by PPE: Risk Ratio (RR) 1.02 [1.00, 1.04]; p = 0.12). Subgroup analyses according to device demonstrated similar results (direct laryngoscopy, RR 1.03 [0.99, 1.07], p = 0.15, videolaryngoscopy, RR 1.01 [0.98, 1.04], p = 0.52). Wearing PPE had a trend towards negative influence on success rate in non-anesthesiologists (RR 1.05 [1.00, 1.10], p = 0.05), but not in anesthesiologists (RR 1.00 [0.98, 1.03], p = 0.84). Trial-sequential analyses for TTI and success rate indicated robustness of both results.

Conclusions: Under simulated conditions, wearing PPE delays the TTI as compared to dressing standard uniform, with no influence on the success rate. However, certainty of evidence is very low. Performing tracheal intubation with direct laryngoscopy seems influenced to a greater extent as compared to videolaryngoscopy. Similarly, wearing PPE affects more the non-anesthesiologists subgroup as compared to anesthesiologists.

KEYWORDS Direct laryngoscopy; Videolaryngoscopy; Anesthesiologists; Paramedics; Time to intubation; Success rate

First Author, Year	PPE(s) level	Device(s) for tracheal intubation	Outcome reported
Journal		Operator’s experience
Schumacher, 2020	B, C	DL; VLSs	TTI,
Anaesthesia		25 Anaesthesiologists	Success rate
Plazikowski, 2018	C	DL; VLS	TTI,
Inf Control and Hosp		30 Anaesthesiologists	Success rate
Taylor, 2018	C	DL; VLS	-
Am J Emerg Med		19 (15 EM residents; 4 EMS personnel)	Success rate
Wang, 2016	C	DL^+stylet	TTI,
Eur J Emerg Med		40 EM residents	Success rate
Shin, 2013	C	DL^+stylet; VLS	TTI,
Emerg Med J		31 medical doctors passing the national boards exam	Success rate
Castle, 2011 Dec	A	DL, DL^+stylet, DL^+bougie; McCoy; VLS	TTI,
Resuscitation		66 final-year paramedic students	Success rate
Castle, 2011 May^a a This study evaluated the tracheal intubation in four different manikin’s positions. We used the values reported in the ambulance trolley (60 cm height) position and discarded results reported regarding the intubation performed lying prone, kneeling and sitting.	A	DL	TTI,
Resuscitation		48 final-year paramedic students	Success rate
Burns, 2010	C	DL	TTI
Prehosp and Disaster Med		47 EMS personnel	-
Garner, 2004	A, B, C	DL	TTI
Emerg Med Australasia		16 mixed (3 paramedics; 8 prehospital doctor; 3 EM physicians; 2 anaesthesiologists)	-

Outcome and type of PPE	Overall	DL	VLS	Anesthesiologists	Non-anesthesiologists
TTI	SMD-0.54 [-0.75,-0.34]	SMD-0.63 [-0.88,-0.38]	SMD-0.39 [-0.75,-0.02]	SMD-0.25 [-0.51, 0.01]	SMD-0.75 [-0.98,-0.52]
PPE all types (n = 19)	p < 0.00001; I² = 69%	p < 0.0001; I² = 67%	p = 0.04; I² = 72%	p = 0.06; I² = 46%	p < 0.00001; I² = 61%
TTI	SMD-0.37 [-0.62,-0.12]	SMD-0.35 [-0.61,-0.09]	SMD-0.40 [-0.95, 0.15]	SMD-0.27 [-0.66, 0.13]	SMD-0.47 [-0.79,-0.15]
PPE C (n = 10)	p = 0.004; I² = 56%	p = 0.008; I² = 37%	p = 0.16; I² = 76%	p = 0.19; I² = 62%	p = 0.005; I² = 52%
TTI	SMD-0.27 [-0.56,-0.02]	SMD-0.51 [-0.95,-0.07]	SMD-0.08 [-0.47, 0.31]	SMD-0.22 [-0.57, 0.12]	not reported as based on one study only
PPE B (n = 4)	p = 0.07; I² = 0%	p = 0.02; I² = 0%	p = 0.69; I² = 0%	p = 0.21; I² = 14%
TTI	SMD-1.03 [-1.21,-0.84]	SMD-1.09 [-1.31,-0.88]	not reported as based on one study only	no studies on anesthesiologists	SMD-1.03, [-1.21,-0.84]
PPE A (n = 5)	p < 0.00001; I² = 0%	p < 0.00001; I² = 0%			p < 0.00001; I² = 0%
TTI	SMD-0.74 [-1.01,-0.46]	SMD-0.97 [-1.18,-0.76]	SMD-0.36 [-0.94, 0.21]	SMD-0.22 [-0.57, 0.12]	SMD-0.99 [-1.17,-0.82]
PPE A/B (n = 9)	p < 0.00001; I² = 65%	p < 0.00001; I² = 15%	p = 0.22; I² = 77%	p = 0.21; I² = 14%	p < 0.00001; I² = 0%
Success rate	RR 1.02 [1.00, 1.04]	RR 1.03 [0.99, 1.07]	RR 1.01 [0.98, 1.04]	RR 1.00 [0.98, 1.03]	RR 1.05 [1.00, 1.10]
PPE all types (n = 17)	p = 0.12; I² = 25%	p = 0.15; I² = 49%	p = 0.52; I² = 0%	p = 0.84; I² = 0%	p = 0.05; I² = 57%
Success rate	RR 1.01 [0.98, 1.04]	RR 1.01 [0.97, 1.05]	RR 1.02 [0.97, 1.06]	RR 1.00 [0.97, 1.04]	RR 1.04 [0.97, 1.11]
PPE C (n = 10)	p = 0.43; I² = 0%	p = 0.59; I² = 0%	p = 0.52; I² = 21%	p = 0.79; I² = 0%	p = 0.28; I² = 44%
Success rate	RR 1.00 [0.96, 1.04]	not reported as based on one study only	RR 1.00 [0.95, 1.06]	RR 1.00 [0.96, 1.04]	no studies on non-anesthesiologists
PPE B (n = 3)	p = 1.00; I² = 0%		p = 1.00; I² = 0%	p = 1.00; I² = 0%
Success rate	RR 1.06 [0.98, 1.15]	RR 1.07 [0.96, 1.20]	not reported as based on one study only	no studies on anesthesiologists	RR 1.06 [0.99, 1.14]
PPE A (n = 4)	p = 0.15; I² = 73%	p = 0.20; I² = 82%			p = 0.09; I² = 71%
Success rate	RR 1.03 [0.99, 1.08]	RR 1.05 [0.97, 1.14]	RR 1.01 [0.96, 1.06]	RR 1.00 [0.96, 1.04]	RR 1.06 [0.99, 1.14]
PPE A/B (n = 7)	p = 0.19; I² = 53%	p = 0.21; I² = 75%	p = 0.75; I² = 0%	p = 1.00; I² = 0%	p = 0.09; I² = 71%

Does wearing PPE compared to standard uniform influence the operator's performances during tracheal intubation?
Patient or population: Operators performing tracheal intubation	Setting: Simulation studies
Intervention: Wearing PPE	Comparison: Wearing standard uniform

Outcomes	Difference wearing PPE as compared to standard uniform	Relative effect (95% CI)	N. of participants (studies)	Certainty of the evidence (GRADE)	Comments
Time to intubation	SMD 0.54 SD lower (0.75 lower to 0.34 lower)	-	1306 (19 RCTs)	⨁◯◯◯ VERY LOW^a a As per RoB 2.0. , ^b b Different levels of operator’s experience. , ^c c Findings are from simulation studies.	Quality of evidence was downgraded because the high-risk bias in included studies, the inconsistency due to the different level of experience in airway management across studies' participants, and the indirectness of findings due to the simulation environment. Result of the trial sequential analysis shows that the meta-analysis is well-powered.
Success rate	19 more per 1.000	RR 1.02 (1.00 to 1.04)	1192 (17 RCTs)	⨁◯◯◯ VERY LOW^a a As per RoB 2.0. , ^b b Different levels of operator’s experience. , ^c c Findings are from simulation studies.	Quality of evidence was downgraded because the high-risk bias in included studies, the inconsistency due to the different level of experience in airway management across studies' participants, and the indirectness of findings due to the simulation environment. Result of the trial sequential analysis shows that the meta-analysis is well-powered.

vertical_align_top file_download show_chart

more_horizclose
- image
- translate
- link
- article
- vertical_align_top
- file_download
- show_chart
- image
- translate
- link
- article

location_on

Sociedade Brasileira de Anestesiologia (SBA) Rua Professor Alfredo Gomes, 36, Botafogo , CEP: 22251-080 , tel: +55 (21) 97977-0024 - Rio de Janeiro - RJ - Brazil
E-mail: editor.bjan@sbahq.org

rss_feed Acompanhe os números deste periódico no seu leitor de RSS

Acessibilidade / Reportar erro

[TFN1] ^a
This study evaluated the tracheal intubation in four different manikin’s positions. We used the values reported in the ambulance trolley (60 cm height) position and discarded results reported regarding the intubation performed lying prone, kneeling and sitting.