Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials

L Suppan, M R Tramèr, M Niquille, O Grosgurin, C Marti, L Suppan, M R Tramèr, M Niquille, O Grosgurin, C Marti

Abstract

Background: Immobilization of the cervical spine worsens tracheal intubation conditions. Various intubation devices have been tested in this setting. Their relative usefulness remains unclear.

Methods: We searched MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials comparing any intubation device with the Macintosh laryngoscope in human subjects with cervical spine immobilization. The primary outcome was the risk of tracheal intubation failure at the first attempt. Secondary outcomes were quality of glottis visualization, time until successful intubation, and risk of oropharyngeal complications.

Results: Twenty-four trials (1866 patients) met inclusion criteria. With alternative intubation devices, the risk of intubation failure was lower compared with Macintosh laryngoscopy [risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35-0.80]. Meta-analyses could be performed for five intubation devices (Airtraq, Airwayscope, C-Mac, Glidescope, and McGrath). The Airtraq was associated with a statistically significant reduction of the risk of intubation failure at the first attempt (RR 0.14; 95% CI 0.06-0.33), a higher rate of Cormack-Lehane grade 1 (RR 2.98; 95% CI 1.94-4.56), a reduction of time until successful intubation (weighted mean difference -10.1 s; 95% CI -3.2 to -17.0), and a reduction of oropharyngeal complications (RR 0.24; 95% CI 0.06-0.93). Other devices were associated with improved glottis visualization but no statistically significant differences in intubation failure or time to intubation compared with conventional laryngoscopy.

Conclusions: In situations where the spine is immobilized, the Airtraq device reduces the risk of intubation failure. There is a lack of evidence for the usefulness of other intubation devices.

Keywords: airway; complications, spinal injury; intubation, tracheal tube; trauma.

© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

Figures

Fig 1
Fig 1
Study flow chart. RCT, randomized controlled trial.
Fig 2
Fig 2
Intubation failure at first attempt; alternative devices vs Macintosh laryngoscopy.
Fig 3
Fig 3
Intubation failure at first attempt; individual alternative devices vs Macintosh laryngoscopy.
Fig 4
Fig 4
Cormack grade 1; individual alternative devices vs Macintosh laryngoscopy.

References

    1. Hastings RH, Kelley SD. Neurologic deterioration associated with airway management in a cervical spine-injured patient. Anesthesiology 1993; 78: 580–3
    1. Mock C, Lormand J, Goossen J, Joshipura M, Peden M. Guidelines for Essential Trauma Care. Geneva: World Health Organization, 2004
    1. Mayglothling J, Duane TM, Gibbs M, et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73: S333–40
    1. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. J Neurosurg 2001; 94: 265–70
    1. Gerling MC, Davis DP, Hamilton RS, et al. Effects of cervical spine immobilization technique and laryngoscope blade selection on an unstable cervical spine in a cadaver model of intubation. Ann Emerg Med 2000; 36: 293–300
    1. Thiboutot F, Nicole PC, Trepanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth 2009; 56: 412–8
    1. Heath KJ. The effect of laryngoscopy of different cervical spine immobilisation techniques. Anaesthesia 1994; 49: 843–5
    1. Goutcher CM, Lochhead V. Reduction in mouth opening with semi-rigid cervical collars. Br J Anaesth 2005; 95: 344–8
    1. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement. Int J Surg 2010; 8: 336–41
    1. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105–11
    1. Elia N, Tramer MR. Ketamine and postoperative pain – a quantitative systematic review of randomised trials. Pain 2005; 113: 61–70
    1. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959; 22: 719–48
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. Br Med J 2003; 327: 557–60
    1. Taylor AM, Peck M, Launcelott S, et al. The McGrath® Series 5 videolaryngoscope vs the Macintosh laryngoscope: a randomised, controlled trial in patients with a simulated difficult airway. Anaesthesia 2013; 68: 142–7
    1. Amor M, Nabil S, Bensghir M, et al. [A comparison of Airtraq laryngoscope and standard direct laryngoscopy in adult patients with immobilized cervical spine]. Ann Fr Anesth Reanim 2013; 32: 296–301
    1. Aoi Y, Inagawa G, Nakamura K, Sato H, Kariya T, Goto T. Airway Scope versus Macintosh laryngoscope in patients with simulated limitation of neck movements. J Trauma 2010; 69: 838–42
    1. Bharti N, Arora S, Panda NB. A comparison of McCoy, TruView, and Macintosh laryngoscopes for tracheal intubation in patients with immobilized cervical spine. Saudi J Anaesth 2014; 8: 188–92
    1. Byhahn C, Nemetz S, Breitkreutz R, Zwissler B, Kaufmann M, Meininger D. Brief report: tracheal intubation using the Bonfils intubation fibrescope or direct laryngoscopy for patients with a simulated difficult airway. Can J Anaesth 2008; 55: 232–7
    1. Gercek E, Wahlen BM, Rommens PM. In vivo ultrasound real-time motion of the cervical spine during intubation under manual in-line stabilization: a comparison of intubation methods. Eur J Anaesthesiol 2008; 25: 29–36
    1. Gupta N, Rath GP, Prabhakar H. Clinical evaluation of C_MAC videolaryngoscope with or without the use of stylet for endotracheal intubation in patients with cervical spine immobilization. J Anesth 2013; 27: 663–70
    1. Ilyas S, Symons J, Bradley WP, et al. A prospective randomised controlled trial comparing tracheal intubation plus manual in-line stabilisation of the cervical spine using the Macintosh laryngoscope vs the McGrath® Series 5 videolaryngoscope. Anaesthesia 2014; 69: 1345–50
    1. Kihara S, Yaguchi Y, Taguchi N, Brimacombe JR, Watanabe S. The StyletScope is a better intubation tool than a conventional stylet during simulated cervical spine immobilization. Can J Anaesth 2005; 52: 105–10
    1. Koh JC, Lee JS, Lee YW, Chang CH. Comparison of the laryngeal view during intubation using Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation. Korean J Anesthesiol 2010; 59: 314–8
    1. Kok T, George RB, McKeen D, Vakharia N, Pink A. Effectiveness and safety of the Levitan FPS Scope for tracheal intubation under general anesthesia with a simulated difficult airway. Can J Anaesth 2012; 59: 743–50
    1. Lim Y, Yeo SW. A comparison of the GlideScope with the Macintosh laryngoscope for tracheal intubation in patients with simulated difficult airway. Anaesth Intensive Care 2005; 33: 243–7
    1. Maharaj CH, Buckley E, Harte BH, Laffey JG. Endotracheal intubation in patients with cervical spine immobilization: a comparison of Macintosh and Airtraq laryngoscopes. Anesthesiology 2007; 107: 53–9
    1. Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison of Macintosh®, Truview EVO2®, Glidescope®, and Airwayscope® laryngoscope use in patients with cervical spine immobilization. Br J Anaesth 2008; 101: 723–30
    1. Malik MA, Subramaniam R, Churasia S, Maharaj CH, Harte BH, Laffey JG. Tracheal intubation in patients with cervical spine immobilization: a comparison of the Airwayscope®, LMA CTrach®, and the Macintosh laryngoscopes. Br J Anaesth 2009; 102: 654–61
    1. Maruyama K, Yamada T, Kawakami R, Hara K. Randomized cross-over comparison of cervical-spine motion with the AirWay Scope or Macintosh laryngoscope with in-line stabilization: a video-fluoroscopic study. Br J Anaesth 2008; 101: 563–7
    1. McElwain J, Laffey JG. Comparison of the C-MAC®, Airtraq®, and Macintosh laryngoscopes in patients undergoing tracheal intubation with cervical spine immobilization. Br J Anaesth 2011; 107: 258–64
    1. Robitaille A, Williams SR, Tremblay MH, Guilbert F, Thériault M, Drolet P. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope® videolaryngoscopy. Anesth Analg 2008; 106: 935–41, table of contents
    1. Smith CE, Pinchak AB, Sidhu TS, Radesic BP, Pinchak AC, Hagen JF. Evaluation of tracheal intubation difficulty in patients with cervical spine immobilization: fiberoptic (WuScope) versus conventional laryngoscopy. Anesthesiology 1999; 91: 1253–9
    1. Tolon MA, Zanaty OM, Shafshak W, Arida EE. Comparative study between the use of Macintosh Laryngoscope and Airtraq in patients with cervical spine immobilization. Alexandria Journal of Medicine 2012; 48: 179–85
    1. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005; 101: 910–5, table of contents
    1. Turkstra TP, Pelz DM, Jones PM. Cervical spine motion: a fluoroscopic comparison of the AirTraq laryngoscope versus the Macintosh laryngoscope. Anesthesiology 2009; 111: 97–101
    1. Turkstra TP, Pelz DM, Shaikh AA, Craen RA. Cervical spine motion: a fluoroscopic comparison of Shikani Optical Stylet vs Macintosh laryngoscope. Can J Anaesth 2007; 54: 441–7
    1. Watts AD, Gelb AW, Bach DB, Pelz DM. Comparison of the Bullard and Macintosh laryngoscopes for endotracheal intubation of patients with a potential cervical spine injury. Anesthesiology 1997; 87: 1335–42
    1. Gaszynska E, Stankiewicz-Rudnicki M, Wieczorek A, Gaszynski T. A comparison of conventional tube and EndoFlex tube for tracheal intubation in patients with a cervical spine immobilisation. Scand J Trauma Resusc Emerg Med 2013; 21: 79.
    1. Lu Y, Jiang H, Zhu YS. Airtraq laryngoscope versus conventional Macintosh laryngoscope: a systematic review and meta-analysis. Anaesthesia 2011; 66: 1160–7
    1. Norman A, Date A. Use of the Airtraq laryngoscope for anticipated difficult laryngoscopy. Anaesthesia 2007; 62: 533–4
    1. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995; 273: 408–12
    1. Hurford D, Cook T, Nolan J, Mihai R. Control group bias: a potential cause of over-estimating the benefit of videolaryngoscopy on laryngeal view. Br J Anaesth 2013; 111: 124–5
    1. Hirabayashi Y, Fujita A, Seo N, Sugimoto H. A comparison of cervical spine movement during laryngoscopy using the Airtraq or Macintosh laryngoscopes. Anaesthesia 2008; 63: 635–40
    1. Hirabayashi Y, Fujita A, Seo N, Sugimoto H. Cervical spine movement during laryngoscopy using the Airway Scope compared with the Macintosh laryngoscope. Anaesthesia 2007; 62: 1050–5
    1. Prasarn ML, Conrad B, Rubery PT, et al. Comparison of 4 airway devices on cervical spine alignment in a cadaver model with global ligamentous instability at C5–C6. Spine (Phila Pa 1976) 2012; 37: 476–81

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