Cervical spine movements during laryngoscopy and orotracheal intubation: a systematic review and meta-analysis.

BACKGROUND: Airway management is challenging in trauma patients because of the fear of worsening cervical spinal cord damage. Video-integrated and optic-integrated devices and intubation laryngeal mask airways have been proposed as alternatives to direct laryngoscopy with the Macintosh laryngoscope (MAC). We performed a meta-analysis to clarify which devices cause less cervical movement during airway management. METHODS: We searched MEDLINE, Cochrane Central, Embase and LILACS from inception to January 2022. We selected randomised controlled trials comparing alternative devices with the MAC for cervical movement from C0 to C5 in adult patients, evaluated by radiological examination. Additionally, cervical spine immobilisation (CSI) techniques were evaluated. We used the Cochrane Risk of Bias Tool to evaluate the risk of bias, and the principles of the Grading of Recommendations, Assessment, Development, and Evaluations system to assess the quality of the body of evidence. RESULTS: Twenty-one studies (530 patients) were included. Alternative devices caused statistically significantly less cervical movement than MAC during laryngoscopy with mean differences of -3.43 (95% CI -4.93 to -1.92) at C0-C1, -3.19 (-4.04 to -2.35) at C1-C2, -1.35 (-2.19 to -0.51) at C2-C3, and -2.61 (-3.62 to -1.60) at C3-C4; and during intubation: -3.60 (-5.08 to -2.12) at C0-C1, -2.38 (-3.17 to -1.58) at C1-C2, -1.20 (-2.09 to -0.31) at C2-C3. The Airtraq and the Intubation Laryngeal Mask Airway caused statistically significant less movement than MAC restricted to some cervical segments, as well as CSI. Heterogeneity was low to moderate in most results. The quality of the body of evidence was 'low' and 'very low'. CONCLUSIONS: Compared with the MAC, alternative devices caused less movement during laryngoscopy (C0-C4) and intubation (C0-C3). Due to the high risk of bias and the very low grade of evidence of the studies, further research is necessary to clarify the benefit of each device and to determine the efficacy of cervical immobilisation during airway management.

Using the Cusum curve to evaluate the training of orotracheal intubation with the Truview EVO2 laryngoscope.

BACKGROUND AND OBJECTIVES: Learning curves have proved to be useful tools to monitor the performance of a worker on a new assignment. Those curves have been used to evaluate several medical procedures. The objective of this study was to evaluate the learning of orotracheal intubation (OTI) with the Truview EVO2 laryngoscope with the CUSUM learning curve. METHODS: Four trainees underwent OTI training with the Truview EVO2 laryngoscope in a mannequin. They received orientation on the successful and failure criteria of OTI and alternated during the attempts, for a total of 300 OTI for each one. Four learning curves were plotted using the CUSUM cumulative addition method. RESULTS: It was calculated that the 105 OTIs were necessary to achieve proficiency. The four trainees crossed the line of acceptable failure rate of 5% before completing 105 OTIs; the first trainee reached proficiency after 42 OTIs, the second and third after 56 OTIs, and the fourth after 97 OTIs, and from then on their performance remained constant. Differences in the success rate between residents and experienced anesthesiologists were not observed. CONCLUSIONS: The CUSUM learning curve is a useful instrument to demonstrate objectively the ability when performing a new task. Laryngoscopy with the Truview EVO2 in a mannequin proved to be an easy procedure for physicians with prior experience in OTI; however, one should be cautious when transposing those results to clinical practice.

Aplicação da curva CUSUM para avaliar o treinamento da intubação orotraqueal com o laringoscópio Truview EVO2® / Using the Cusum curve to evaluate the training of orotracheal intubation with the Truview EVO2® laryngoscope / Aplicación de la curva CUSUM para evaluar el entrenamiento de la intubación orotraqueal con el laringoscopio Truview Evo2®

JUSTIFICATIVA E OBJETIVOS: As curvas de aprendizado têm se mostrado ferramentas úteis no monitoramento do desempenho de um trabalhador submetido a uma nova tarefa. Essas curvas vêm sendo utilizadas na avaliação de vários procedimentos na prática médica. O objetivo desta pesquisa foi avaliar o aprendizado da intubação orotraqueal (IOT) com o laringoscópio Truview EVO2® através da curva de aprendizado CUSUM. MÉTODO: Quatro aprendizes realizaram o treinamento da IOT com o laringoscópio Truview EVO2® em manequim. Eles foram orientados quanto aos critérios de sucesso e falha na IOT e alternaram-se nas tentativas, num total de 300 IOT para cada um deles. Quatro curvas de aprendizado foram construídas a partir do método da soma cumulativa CUSUM. RESULTADOS: O número calculado para adquirir proficiência na tarefa foi de 105 IOT. Os quatro aprendizes cruzaram a linha de taxa de falha aceitável de 5% antes de completar 105 IOT: o primeiro aprendiz alcançou a faixa de proficiência após 42 IOT, o segundo e o terceiro aprendizes, após 56 IOT, e o quarto aprendiz, após 97 IOT, mantendo-se constantes em seus desempenhos a partir de então. Não houve diferença na taxa de sucesso entre residentes e anestesiologistas experientes. CONCLUSÕES: A curva de aprendizado CUSUM é um instrumento útil para demonstração objetiva de habilidade na execução de uma nova tarefa. A laringoscopia com o Truview EVO2® em manequim demonstrou ser um procedimento fácil para médicos com experiência prévia em IOT, porém, a transposição dos resultados para a prática clínica deve ser cautelosa.

BACKGROUND AND OBJECTIVES: Learning curves have proved to be useful tools to monitor the performance of a worker on a new assignment. Those curves have been used to evaluate several medical procedures. The objective of this study was to evaluate the learning of orotracheal intubation (OTI) with the Truview EVO2® laryngoscope with the CUSUM learning curve. METHODS: Four trainees underwent OTI training with the Truview EVO2® laryngoscope in a mannequin. They received orientation on the successful and failure criteria of OTI and alternated during the attempts, for a total of 300 OTI for each one. Four learning curves were plotted using the CUSUM cumulative addition method. RESULTS: It was calculated that the 105 OTIs were necessary to achieve proficiency. The four trainees crossed the line of acceptable failure rate of 5% before completing 105 OTIs; the first trainee reached proficiency after 42 OTIs, the second and third after 56 OTIs, and the fourth after 97 OTIs, and from then on their performance remained constant. Differences in the success rate between residents and experienced anesthesiologists were not observed. CONCLUSIONS: The CUSUM learning curve is a useful instrument to demonstrate objectively the ability when performing a new task. Laryngoscopy with the Truview EVO2® in a mannequin proved to be an easy procedure for physicians with prior experience in OTI; however, one should be cautious when transposing those results to clinical practice.

JUSTIFICATIVA Y OBJETIVOS: Las curvas de aprendizaje han sido herramientas útiles en el monitoreo del desempeño de un trabajador sometido a una nueva tarea. Esas curvas han venido siendo utilizadas en la evaluación de varios procedimientos en la práctica médica. El objetivo de esta investigación, fue evaluar el aprendizaje de la intubación orotraqueal (IOT) con el Laringoscopio Truview Evo2® a través de la curva de aprendizaje CUSUM. MÉTODO: Cuatro aprendices realizaron el entrenamiento de la IOT con el Laringoscopio Truview Evo2® en un maniquí. Se les orientó en cuanto a los criterios de éxito y falla en la IOT y se intercambiaban los intentos, en un total de 300 IOT para cada uno de ellos. Cuatro curvas de aprendizaje fueron construidas a partir del método de la suma acumulativa CUSUM. RESULTADOS: El número calculado para adquirir el desempeño en la tarea fue de 105 IOT. Los cuatro aprendices cruzaron la línea de rango de falla aceptable de un 5% antes de completar 105 IOT: el primer aprendiz alcanzó el rango de desempeño después del 42 IOT, el segundo y el tercer aprendiz después de 56 IOT, y el cuarto aprendiz, después de 97 IOT, manteniéndose constantes en sus desempeños a partir de ese momento. No se registró diferencias en la tasa de éxito entre residentes y anestesiólogos expertos. CONCLUSIONES: La curva de aprendizaje CUSUM es un instrumento útil para la demostración objetiva de la habilidad en la ejecución de una nueva tarea. La laringoscopia con el TruviewEvo2® en un maniquí, demostró ser un procedimiento fácil para médicos con experiencia previa en IOT, sin embargo, al llevar los resultados a la práctica clínica, eso deberá hacerse con cautela.