Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis
Intubação traqueal usando equipamento de proteção individual em estudos de simulação: uma revisão sistemática e metanálise com análise sequencial de ensaios
Filippo Sanfilippo, Stefano Tigano, Valeria La Rosa, Alberto Morgana, Paolo Murabito, Francesco Oliveri, Federico Longhini, Marinella Astuto
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
Resumo
Introdução: A intubação traqueal em pacientes com doença por coronavírus-19 é um procedimento de alto risco que deve ser realizado com equipamento de proteção individual (EPI). A influência do EPI no desempenho do operador durante a intubação traqueal permanece incerta. Métodos: Realizamos uma revisão sistemática e meta-análise de estudos de simulação para avaliar a influência do uso de EPI em comparação ao uniforme padrão em relação ao tempo de intubação (TI) e taxa de sucesso. As análises de subgrupo foram realizadas de acordo com o dispositivo usado e a experiência do operador. Resultados: O ITT foi prolongado com o uso de EPI (oito estudos): Diferença Média Padrão (DMP) -0,54, Intervalo de Confiança de 95% [-0,75, -0,34], p < 0,0001. As análises de subgrupos de acordo com o dispositivo utilizado mostraram achados semelhantes (laringoscopia direta, DMP -0,63 [-0,88, -0,38], p < 0,0001; videolaringoscopia, DMP -0,39 [-0,75, -0,02], p = 0,04). Considerando a experiência do operador, os não anestesiologistas apresentaram TI prolongado (DMP -0,75 [-0,98, -0,52], p < 0,0001), enquanto a análise dos anestesiologistas não mostrou diferenças significativas (DMP -0,25 [-0,51, 0,01], p = 0,06). A taxa de sucesso da intubação traqueal não foi influenciada pelo EPI: Proporção de Risco (PR) 1,02 [1,00, 1,04]; p = 0,12). As análises de subgrupo de acordo com o dispositivo demonstraram resultados semelhantes (laringoscopia direta, RR 1,03 [0,99, 1,07], p = 0,15, videolaringoscopia, PR 1,01 [0,98, 1,04], p = 0,52). O uso de EPI teve uma tendência de influência negativa na taxa de sucesso em não anestesiologistas (RR 1,05 [1,00, 1,10], p = 0,05), mas não em anestesiologistas (RR 1,00 [0,98, 1,03], p = 0,84). Análises de ensaios sequenciais para TI e taxa de sucesso indicaram robustez de ambos os resultados.
Palavras-chave
References
1 Center for Systems Science and Engineering at Johns Hopkins University. COVID-19 Map. Available from: https://coronavirus.jhu.edu/map.html. [Accessed 17 Jan 2021].
2 W.J. Guan, Z.Y. Ni, Y. Hu, et al. Clinical characteristics of coronavirus disease 2019 in China N Engl J Med, 382 (2020), pp. 1708-1720
3 M. Loeb, A. McGeer, B. Henry, et al. SARS among critical care nurses, Toronto Emerg Infect Dis, 10 (2004), pp. 251-255
4 K. Tran, K. Cimon, M. Severn, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review PloS one, 7 (2012), Article e35797
5 W. Yao, T. Wang, B. Jiang, et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations Br J Anaesth, 125 (2020), pp. e28-e37
6 T.M. Cook, K. El-Boghdadly, B. McGuire, et al. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists Anaesthesia, 75 (2020), pp. 785-799
7 B.A. Orser Recommendations for endotracheal intubation of COVID-19 patients Anesth Analg, 130 (2020), pp. 1109-1110
8 K.M. Caputo, R. Byrick, M.G. Chapman, et al. Intubation of SARS patients: infection and perspectives of healthcare workers Can J Anaesth, 53 (2006), pp. 122-129
9 J. Schumacher, J. Arlidge, D. Dudley, et al. The impact of respiratory protective equipment on difficult airway management: a randomised, crossover, simulation study Anaesthesia, 75 (2020), pp. 1301-1306
10 A. Garner, H. Laurence, A. Lee Practicality of performing medical procedures in chemical protective ensembles Emerg Med Austral, 16 (2004), pp. 108-113
11 E. Plazikowski, R. Greif, J. Marschall, et al. Emergency airway management in a simulation of highly contagious isolated patients: both isolation strategy and device type matter Infect Control Hosp Epidemiol, 39 (2018), pp. 145-151
12 C.C. Wang, C.H. Chaou, C.Y. Tseng, et al. The effect of personal protective equipment on emergency airway management by emergency physicians: a mannequin study Eur J Emerg Med, 23 (2016), pp. 124-129
13 A. Liberati, D.G. Altman, J. Tetzlaff, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration J Clin Epidemiol, 62 (2009), pp. e1-34
14 Classification of personal protective equipment according to the Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OSHA): https://www.remm.nlm.gov/ppe_classification.htm. [Accessed on 17 September 2020].
15 Classification of personal protective equipment according to the Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OSHA): https://www.osha.gov/laws-regs/mou/1991-02-13. [Accessed on 17 September 2020].
16 F. Sanfilippo, S. Tigano, G.J. Palumbo, et al. Systematic review of simulated airway management whilst wearing personal protective equipment Br J Anaesth, 125 (2020), pp. e301-e305
17 D. Luo, X. Wan, J. Liu, et al. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range Stat Methods Med Res, 27 (2018), pp. 1785-1805
18 X. Wan, W. Wang, J. Liu, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range BMC Med Res Methodol, 14 (2014), p. 135
19 F. Julien-Marsollier, D. Michelet, M. Bellon, et al. Muscle relaxation for tracheal intubation during paediatric anaesthesia: a meta-analysis and trial sequential analysis Eur J Anaesthesiol, 34 (2017), pp. 550-561
20 L.E. Vanlinthout, B. Geniets, J.J. Driessen, et al. Neuromuscular-blocking agents for tracheal intubation in pediatric patients (0-12 years): a systematic review and meta-analysis Paediatr Anaesth, 30 (2020), pp. 401-414
21 A. Afshari, J. Wetterslev When may systematic reviews and meta-analyses be considered reliable? Eur J Anaesthesiol, 32 (2015), pp. 85-87
22 A revised tool to assess risk of bias in randomized trials (RoB 2.0). https://www.bristol.ac.uk/population-health-sciences/centres/cresyda/barr/riskofbias/rob2-0/. [Accessed 27 March 2021].
23 P. Alonso-Coello, A.D. Oxman, J. Moberg, R. Brignardello-Petersen, E.A. Akl, M. Davoli, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: clinical practice guidelines BMJ (Clin Res Ed), 353 (2016), p. i2089
24 J.C. Andrews, H.J. Schünemann, A.D. Oxman, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength J Clin Epidemiol, 66 (2013), pp. 726-735
25 G.H. Guyatt, A.D. Oxman, G.E. Vist, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations BMJ (Clin Res Ed), 336 (2008), pp. 924-926
26 J.B.Jr. Burns, R. Branson, S.L. Barnes, et al. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation Prehosp Disaster Med, 25 (2010), pp. 92-95
27 R. Scott Taylor, M. Pitzer, G. Goldman, et al. Comparison of intubation devices in level C personal protective equipment: a cadaveric study Am J Emerg Med, 36 (2018), pp. 922-925
28 D.H. Shin, P.C. Choi, J.U. Na, et al. Utility of the Pentax-AWS in performing tracheal intubation while wearing chemical, biological, radiation and nuclear personal protective equipment: a randomised crossover trial using a manikin Emerg Med J, 30 (2013), pp. 527-531
29 N. Castle, Y. Pillay, N. Spencer What is the optimal position of an intubator wearing CBRN-PPE when intubating on the floor: a manikin study Resuscitation., 82 (2011), pp. 588-592
30 N. Castle, Y. Pillay, N. Spencer Comparison of six different intubation aids for use while wearing CBRN-PPE: a manikin study Resuscitation, 82 (2011), pp. 1548-1552
31 K.B. Greenland, D. Tsui, P. Goodyear, et al. Personal protection equipment for biological hazards: does it affect tracheal intubation performance? Resuscitation, 74 (2007), pp. 119-126
32 E.F. Andrade, L.J. Pereira, A.P.L. Oliveira, et al. Perceived fear of COVID-19 infection according to sex, age and occupational risk using the Brazilian version of the Fear of COVID-19 Scale Death Stud (2020), pp. 1-10
33 D. McKay, C. Minaya, E.A. Storch Conducting exposure and response prevention treatment for contamination fears during COVID-19: The behavioral immune system impact on clinician approaches to treatment J Anxiety Disord, 74 (2020), Article 102270
34 K. Schebesta, M. Hüpfl, B. Rössler, et al. Degrees of reality: airway anatomy of high-fidelity human patient simulators and airway trainers Anesthesiology, 116 (2012), pp. 1204-1209
35 F. Sanfilippo, S. Tigano, G.J. Palumbo, et al. Importance of inclusion criteria in systematic reviews Br J Anaesth, 125 (2020), pp. E398-9
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