Semiprone position is superior to supine position for paediatric endotracheal intubation during massive regurgitation, a randomized crossover simulation trial

Espen Fevang, Karin Haaland, Jo Røislien, Conrad Arnfinn Bjørshol, Espen Fevang, Karin Haaland, Jo Røislien, Conrad Arnfinn Bjørshol

Abstract

Background: Endotracheal intubation of patients with massive regurgitation represents a challenge in emergency airway management. Gastric contents tend to block suction catheters, and few treatment alternatives exist. Based on a technique that was successfully applied in our district, we wanted to examine if endotracheal intubation would be easier and quicker to perform when the patient is turned over to a semiprone position, as compared to the supine position.

Methods: In a randomized crossover simulation trial, a child manikin with on-going regurgitation was intubated both in the supine and semiprone positions. Endpoints were experienced difficulty with the procedure and time to intubation, as well as visually confirmed intubation and first-pass success rate.

Results: Intubation in the semiprone position was significantly easier and faster compared to the supine position; the median experienced difficulty on a visual analogue scale was 27 and 65, respectively (p = 0.004), and the median time to intubation was 26 and 45 s, respectively (p = 0.001). There were no significant differences in frequency of visually confirmed intubation (16 and 18, p = 0.490) of first-pass success rate (17 and 18, p = 1.000).

Conclusion: In this experiment, endotracheal intubation during massive regurgitation with the patient in the semiprone position was significantly easier and quicker to perform than in the supine position. Endotracheal intubation in the semiprone position can provide a quick rescue method in situations where airway management is hindered by massive regurgitation, and it represents a possible supplement to current airway management training.

Keywords: Airway management; Emergency medical services; Intubation, Intratracheal.

Conflict of interest statement

Ethics approval and consent to participate

This is a simulation study that does not record personal or patient data; hence, approval by the Regional Ethical Committee was not required. Regarding the participants in the simulation experiment, ethical approval was given by the research department and Institutional Review Board at Stavanger University Hospital and informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

JR, KH and EF declare that they have no competing interests. CAB is employed by the Regional Competence Centre for Acute Medicine in Western Norway (RAKOS) with financial support from the Norwegian Directorate of Health. He has participated in Global Resuscitation Alliance meetings sponsored by the Laerdal Foundation for Acute Medicine, TrygFonden and EMS2017. CAB is also a deputy member of the Norwegian Resuscitation Council and has been a member of the Educational Committee of the Scandinavian Society of Anaesthesiology and Intensive Care.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Laryngoscopy in the semiprone position
Fig. 2
Fig. 2
Laryngeal view during laryngoscopy in the semiprone position. The position allows for constant drainage from the oral orifice throughout the procedure
Fig. 3
Fig. 3
Experienced difficulty of intubation with the manikin in the two different positions, measured on a Visual Analogue Scale (VAS)
Fig. 4
Fig. 4
Time to intubation (seconds)

References

    1. Sunde GA, Heltne JK, Lockey D, Burns B, Sandberg M, Fredriksen K, Hufthammer KO, Soti A, Lyon R, Jantti H, et al. Airway management by physician-staffed helicopter emergency medical services - a prospective, multicentre, observational study of 2,327 patients. Scand J Trauma Resusc Emerg Med. 2015;23:57.
    1. Cook T, Behringer EC, Benger J. Airway management outside the operating room: hazardous and incompletely studied. Curr Opin Anaesthesiol. 2012;25(4):461–469. doi: 10.1097/ACO.0b013e32835528b1.
    1. Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med. 2014;42(6):1372–1378. doi: 10.1097/CCM.0000000000000213.
    1. Helm M, Hossfeld B, Schafer S, Hoitz J, Lampl L. Factors influencing emergency intubation in the pre-hospital setting--a multicentre study in the German helicopter emergency medical service. Br J Anaesth. 2006;96(1):67–71. doi: 10.1093/bja/aei275.
    1. Malik MA, Subramaniam R, Maharaj CH, Harte BH, Laffey JG. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth. 2009;103(5):761–768. doi: 10.1093/bja/aep266.
    1. Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. Cochrane Database Syst Rev. 2016;11:CD011136.
    1. Karlik J, Aziz M. Recent trends in airway management. F1000Research. 2017;6:159. doi: 10.12688/f1000research.10311.1.
    1. Kozak RJ, Ginther BE, Bean WS. Difficulties with portable suction equipment used for prehospital advanced airway procedures. Prehosp Emerg Care. 1997;1(2):91–95. doi: 10.1080/10903129708958795.
    1. Kornhall DK, Almqvist S, Dolven T, Ytrebo LM. Intentional oesophageal intubation for managing regurgitation during endotracheal intubation. Anaesth Intensive Care. 2015;43(3):412–414.
    1. Sorour K, Donovan L. Intentional esophageal intubation to improve visualization during emergent endotracheal intubation in the context of massive vomiting: a case report. J Clin Anesth. 2015;27(2):168–169. doi: 10.1016/j.jclinane.2014.07.004.
    1. Klauser R, Roggla G, Pidlich J, Leithner C, Frass M. Massive upper airway bleeding after thrombolytic therapy: successful airway management with the Combitube. Ann Emerg Med. 1992;21(4):431–433. doi: 10.1016/S0196-0644(05)82666-6.
    1. Nathanson MH, Gajraj NM, Newson CD. Tracheal intubation in a manikin: comparison of supine and left lateral positions. Br J Anaesth. 1994;73(5):690–691. doi: 10.1093/bja/73.5.690.
    1. Van Zundert TC, Van Zundert AA. Tracheal intubation of patients in non-standard positions requires training. Minerva Anestesiol. 2013;79(6):679–682.
    1. McCaul CL, Harney D, Ryan M, Moran C, Kavanagh BP, Boylan JF. Airway management in the lateral position: a randomized controlled trial. Anesth Analg. 2005;101(4):1221–1225. doi: 10.1213/.
    1. Baer K, Nystrom B. Routine intubation in the prone position. Ups J Med Sci. 2012;117(4):411–414. doi: 10.3109/03009734.2012.686125.
    1. Atkinson GR RS. NJH Davies Lee's synopsis of Anaesthesia. 11. Oxford: Butterworth-Heinemann; 1993.
    1. Gift AG. Visual analogue scales: measurement of subjective phenomena. Nurs Res. 1989;38(5):286–8. doi: 10.1097/00006199-198909000-00006.
    1. Geoffrey C. Urbaniak SP. Research Randomizer (Version 4.0). 2015. . Accessed 9 Sept 2016.
    1. Wang HE, Simeone SJ, Weaver MD, Callaway CW. Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Ann Emerg Med. 2009;54(5):645–652. doi: 10.1016/j.annemergmed.2009.05.024.
    1. Callaway CW, Soar J, Aibiki M, Bottiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, et al. Part 4: advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2015;132(16 Suppl 1):S84–145. doi: 10.1161/CIR.0000000000000273.
    1. Soar J, Nolan JP, Bottiger BW, Perkins GD, Lott C, Carli P, Pellis T, Sandroni C, Skrifvars MB, Smith GB, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation. 2015;95:100–147. doi: 10.1016/j.resuscitation.2015.07.016.
    1. Kern KB, Hilwig RW, Berg RA, Sanders AB, Ewy GA. Importance of continuous chest compressions during cardiopulmonary resuscitation: improved outcome during a simulated single lay-rescuer scenario. Circulation. 2002;105(5):645–649. doi: 10.1161/hc0502.102963.
    1. Virkkunen I, Ryynanen S, Kujala S, Vuori A, Piilonen A, Kaaria JP, Kahara V, Pettila V, Yli-Hankala A, Silfvast T. Incidence of regurgitation and pulmonary aspiration of gastric contents in survivors from out-of-hospital cardiac arrest. Acta Anaesthesiol Scand. 2007;51(2):202–205. doi: 10.1111/j.1399-6576.2006.01229.x.
    1. Pepe PE, Roppolo LP, Fowler RL. Prehospital endotracheal intubation: elemental or detrimental? Crit Care. 2015;19:121. doi: 10.1186/s13054-015-0808-x.
    1. Bernhard M, Benger JR. Airway management during cardiopulmonary resuscitation. Curr Opin Crit Care. 2015;21(3):183–187. doi: 10.1097/MCC.0000000000000201.
    1. Lecky F, Bryden D, Little R, Tong N, Moulton C. Emergency intubation for acutely ill and injured patients. Cochrane Database Syst Rev. 2008;2:CD001429.
    1. Abraham M, Wadhawan M, Gupta V, Singh AK. Cardiopulmonary resuscitation in the lateral position: is it feasible during pediatric intracranial surgery? Anesthesiology. 2009;110(5):1185–1186. doi: 10.1097/ALN.0b013e31819f7b2b.
    1. Hazinski MF, Nolan JP, Aickin R, Bhanji F, Billi JE, Callaway CW, Castren M, de Caen AR, Ferrer JM, Finn JC, et al. Part 1: executive summary: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2015;132(16 Suppl 1):S2–39. doi: 10.1161/CIR.0000000000000270.
    1. de Caen AR, Maconochie IK, Aickin R, Atkins DL, Biarent D, Guerguerian AM, Kleinman ME, Kloeck DA, Meaney PA, Nadkarni VM, et al. Part 6: pediatric basic life support and pediatric advanced life support: 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2015;132(16 Suppl 1):S177–S203. doi: 10.1161/CIR.0000000000000275.
    1. Maconochie IK, Bingham R, Eich C, Lopez-Herce J, Rodriguez-Nunez A, Rajka T, Van de Voorde P, Zideman DA, Biarent D. European Resuscitation Council Guidelines for Resuscitation 2015: Section 6. Paediatric life support. Resuscitation. 2015;95:223–248. doi: 10.1016/j.resuscitation.2015.07.028.
    1. Gruber C, Nabecker S, Wohlfarth P, Ruetzler A, Roth D, Kimberger O, Fischer H, Frass M, Ruetzler K. Evaluation of airway management associated hands-off time during cardiopulmonary resuscitation: a randomised manikin follow-up study. Scand J Trauma Resusc Emerg Med. 2013;21:10. doi: 10.1186/1757-7241-21-10.
    1. Fattah S, Ekas GR, Hyldmo PK, Wisborg T. The lateral trauma position: what do we know about it and how do we use it? A cross-sectional survey of all Norwegian emergency medical services. Scand J Trauma Resusc Emerg Med. 2011;19:45. doi: 10.1186/1757-7241-19-45.

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