Resuscitation 89 (2015) A7–A9
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Videolaryngoscopy at cardiac arrest – The need to move from video-games to video-science
This issue of the journal includes two studies examining the use of videolaryngoscopy (VL) during cardiac arrest.1,2 VL is increasingly being used both inside and outside the operating room.3,4 Tracheal intubation (TI) in critically ill patients is acknowledged to be challenging, is more likely to fail than in the operating room, is associated with serious complications and yet is often performed by inexperienced operators.5–8 Similar issues arise during airway management at cardiac arrest.9 The optimal method of managing the airway during cardiac arrest remains uncertain. Speed and reliability of airway management are critical during cardiopulmonary resuscitation (CPR) because of their impact on cardiac compressions10 – and TI has been shown to potentially have a negative impact on the quality of CPR.10 Recent guidelines have encouraged the use of supraglottic airway devices and deemphasised TI during CPR, particularly for those inexperienced in the technique.9 However most of the literature underpinning these recommendations pre-dates the availability of VL. Videolaryngoscopy is designed to improve the view of the glottis and facilitate intubation as the reliance on aligning the oral–pharyngeal–tracheal axis with the operator’s line of vision is removed. There is some evidence that learning intubation with VL is easier than with conventional direct laryngoscopy (DL).10,11 This is important in the context of airway management at cardiac arrest as VL has the potential to make TI easier during CPR, especially for inexperienced airway operators and so to minimise any interruption to chest compressions. The two studies in this edition of the journal examine aspects of success, speed and learning with VL during CPR. In the first study, Lee and colleagues compare the efficiency, safety and clinical outcomes of TI using either VL or DL during inhospital CPR.1 Intubators were permitted to choose either VL or DL and if they chose VL they could then select either a Glidescope (Verathon, Bothell, WA, USA) or a Pentax-Airway Scope (Pentax Medical, Hamburg, Germany). Both device blades are more curved than a standard Macintosh laryngoscope blade, taking the larynx out of the line of sight. The Airtraq has a conduit to deliver the tracheal tube to the centre of the camera’s field of view while the Glidescope has no conduit and use of a preformed stylet is recommended. Tracheal intubation success rates were analysed according to the type of laryngoscope used (VL vs DL), the operator’s airway experience and whether the airway was predicted to be difficult. In a study of 229 patients VL was used in 53% and DL in 47%. Experienced operators more frequently chose VL (64%) as their preferred technique compared to less experienced practitioners (41%). http://dx.doi.org/10.1016/j.resuscitation.2015.01.016 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
A significantly higher first attempt tracheal intubation success rate was seen with VL compared to DL (72% vs 53%; p = 0.003). No significant difference was observed in time to intubate (VL 2.1 ± 3.2 min, DL 2.5 ± 2.4 min). An experienced operator, VL, and the lack of a difficult airway were independently associated with successful first attempt TI but none of these factors, nor successful first attempt intubation, affected patient outcome (return of spontaneous circulation (ROSC), discharge alive, mortality at 24 h or 28 days). The study has significant limitations (non-randomised nature; arbitrary definitions of intubation experience and intubation difficulty; failure to analyse whether first attempt tracheal intubation success rate was affected by type of VL) but as the first examination of VL in this setting it is an important study. The overall first attempt tracheal intubation success rates are rather low overall and it is uncertain whether this can be explained by the characteristics of patients in cardiac arrest or the unpredictable nature of airway management during CPR. In the second study, Park examines inexperienced airway operators (first year emergency physicians) and explores the success, speed and complications of TI using VL during CPR, compared to a historical group using DL.2 All operators underwent manikinbased training and were observed intubating patients not in cardiac arrest using their allocated laryngoscopy technique before studying patients. In total 305 patients in cardiac arrest were recruited. Compared to DL the VL group had a significantly higher first attempt success rate (92% vs 56%, p = 0.001) and completed intubation more quickly (37 vs 62 s, p = 0.001). Importantly, the rate of oesophageal intubation was markedly lower in the VL group (VL 0 vs DL 18%) and performance in the VL group, but did not in the DL group, improved over time (3 month episodes). Finally, interruption of cardiac compression was both very short and shorter in the VL group compared with the DL group (0 vs 7 s, p < 0.001). While VL is increasing in penetration and popularity, the scientific evidence supporting this is perhaps lagging behind. Importantly, airway management is context specific and the impact of novel equipment is unlikely to be identical in all settings. In the operating room environment many studies have shown improved laryngeal view but few have shown easier intubation and most studies have not examined difficult patients.13 Although VL has increasingly been shown to improve intubation success when DL fails,14 commentators have questioned the genuine benefit of VL,15 while others have emphasised the importance of training and experience.14 In the hands of inexperienced operators in critical
A8
Editorial / Resuscitation 89 (2015) A7–A9
care, VL improved laryngeal view but did not improve speed or success rate of TI.16 Of note, in the setting of trauma a recent RCT of VL vs DL reported that VL took significantly longer and had no impact on intubation success or overall mortality. Further, in a subset of this study with severe head injury VL was associated with slower intubation, more hypoxaemia and worsened outcome.17 We must therefore not assume benefit from use of new technology and should examine its actual benefits (or harms) before adoption. Intubation at cardiac arrest has its own set of challenges: it is often performed in sub-optimal sites and conditions, often without neuromuscular blockade, sometimes by inexperienced operators, pre-oxygenation may be difficult and there is a high risk of regurgitation/aspiration. Speed of airway management is uniquely important as it usually involves a period of interruption of chest compressions. Of note, Park has reported in this journal a series of 71 successful intubations with VL without interruption of CPR.18 In a cohort in which all physicians were briefly trained in VL, speed and success did not vary with prior airway experience. With these considerations in mind, the potential benefits of VL at cardiac arrest include the following: • Improved laryngeal view and improved success rates for all intubations by inexperienced intubators (some evidence1,2 but more required). • Improved success rates when intubation is difficult or DL fails for experienced users (no evidence). • Improved CPR continuity through reduced intubation time for inexperienced operators (some evidence but more required2 ) and intubation during on-going CPR for experienced and inexperienced intubators (some evidence18 but more required). • Reduced (undetected) oesophageal intubation (some evidence2 but more required). • Improved teamwork (no robust evidence). This latter point is perhaps worth considering further. Videolaryngoscopy enables colleagues to observe the progress of intubation and to co-confirm success. The intubating assistant may assist intubation in a far more engaged manner and can readily observe difficulty and the effects of attempts to overcome this.19 Videolaryngoscopy has the potential to improve teamwork, communication and situational awareness. In the authors view these non-technical benefits are likely of equal benefit to the technical ones. The articles by Lee and Park have each identified the importance of experience and training in achieving successful airway management during cardiac arrest/CPR. Other studies equally emphasise the benefits for training and importance of experience in VL.11,12,15 Videolaryngoscopy facilitates training with close supervision, offering immediate feedback on intubation practice in a manner that cannot be achieved with DL. Importantly, different videolaryngoscopes require different techniques (‘tricks and tips’) so training and experience with the specific device in use is critical. So what does the current evidence base tell us about the role of VL during CPR? As described above, VL may improve laryngeal view, speed of intubation for inexperienced intubators, and has the potential to be performed during ongoing CPR thus improving compression times. However, despite some supporting evidence from manikin studies,20 there is no evidence of an improvement in clinically important patient outcomes. The potential for reducing the oesophageal intubation rate is potentially important – though widespread use of capnography should already ensure that all oesophageal intubations are promptly recognised. Although the two studies reported here included relatively few subjects, and their conclusions are limited by study design, the authors are to be congratulated in providing original clinical research on the
reliability of intubation with VL during CPR, and investigating its effect on CPR quality and on overall clinical outcome. Such research is not easy – but more is needed. In the authors’ view there is insufficient evidence to support a change from primary airway management with a supraglottic airway in the hands of inexperienced operators. Future studies of the use of VL at cardiac arrest should ensure participants are suitably trained in the devices they use and should be powered to detect clinically important outcomes such as total airway time, interruption of compression and ultimately ROSC and mortality. It is unlikely that all videolaryngoscopes perform equally and in time it will be important to identify both high and poor performers through direct comparisons. Ultimately VL might provide the ability to reliably and quickly establish the airway at cardiac arrest with the security of a cuffed tracheal tube without need to stop chest compression – but only time and research will tell us if this is the case. While technology often improves technical (and non-technical) performance this cannot be assumed. Videolaryngoscopy at cardiac arrest and in the hands of inexperienced and experienced operators has considerable potential and appeal – it is important that the science advances before the appeal of the devices leads to adoption without evidence.
Conflict of interest statement JA – no conflicts reported. TMC and his department have received free, at cost or on loan airway equipment from various airway manufacturers for evaluation or research. He and his family have no relevant financial conflicts.
References 1. Lee DH, Han M, An JY, et al. Video laryngoscope versus direct laryngoscope for endotracheal intubation during in-hospital cardiopulmonary resuscitation. Resuscitation 2015;89:195–9. 2. Park SO, Kim JW, Na JH, et al. Video laryngoscopy improves the first-attempt success in endotracheal intubation during cardiopulmonary resuscitation among novice physicians. Resuscitation 2015;89:188–94. 3. Mosier JM, Whitmore SP, Bloom JW, et al. Videolaryngoscopy improve intubation success and reduces oesophageal intubations compared to direct laryngoscopy in the medical intensive care unit. Crit Care 2013;17:R237. http:// ccforum.com/content/pdf/cc13061.pdf (accessed 05.01.15). 4. Brown CA, Bair AE, Pallin DJ, Laurin EG, Walls RM, National Emergency Airway Registry (NEAR) Investigators. Improved glottis exposure with the Video Macintosh Laryngoscope in adult emergency department tracheal intubations. Ann Emerg Med 2010;56:83–8. 5. Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34:1835–42. 6. Hasegawa K, Hagiwara Y, Chiba T, et al. Emergency airway management in Japan: interim analysis of a multicenter prospective observational study. Resuscitation 2012;83:428–33. 7. Martin LD, Mhyre JM, Shanks AM, et al. 3423 Emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology 2011;114:42–8. 8. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society Part 2 Intensive Care and Emergency Department. Br J Anaesth 2011;106:632–42. 9. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010;81:1219–76. 10. Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with outof-hospital cardiac arrest. JAMA 2013;309:257–66. 11. Low D, Healy D, Rasburn N. The use of the BERCI DCI Video Laryngoscope for teaching novices direct laryngoscopy and tracheal intubation. Anaesthesia 2008;63:195–201. 12. Bernhard M, Mohr S, Weigand MA, Martin E, Walther A. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand 2012;56:164–71. 13. Mihai R, Blair E, Kay H, Cook TM. A quantitative review and meta-analysis of performance of non-standard laryngoscopes and rigid fibreoptic intubation aids. Anaesthesia 2008;63:745–60.
Editorial / Resuscitation 89 (2015) A7–A9 14. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011;66(Suppl. 2):57–64. 15. Asai T. Videolaryngoscopes: do they truly have roles in difficult airways? Anesthesiology 2012;116:515–7. 16. Griesdale DE, Chau A, Isac G, et al. Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial for the Canadian Critical Care Trials Group. Can J Anaesth 2012;59:1032–9. 17. Yeatts DJ, Dutton RP, Hu PF, et al. Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. J Trauma Acute Care Surg 2013;75:212–9. 18. Park SO, Baek KJ, Hong DY, Kim SC, Lee KR. Feasibility of the videolaryngoscope (GlideScope(R)) for endotracheal intubation during uninterrupted chest compressions in actual advanced life support: a clinical observational study in an urban emergency department. Resuscitation 2013;84: 1233–7. 19. Kelly FE, Cook TM. Randomised controlled trials of videolaryngoscopy vs direct laryngoscopy on intensive care are needed. Intensive Care Med 2014, http://dx.doi.org/10.1007/s00134-014-3262-3. Published online March 19 [http://link.springer.com/article/10.1007/s00134-01403262-3262-3/fulltext. html].
A9
20. Han SK, Shin DH, Choi PC. Utility of the Pentax-AWS without interruption of chest compression: comparison of the Macintosh laryngoscope with the PentaxAWS in manikin model. Resuscitation 2010;81:69–73.
J. Astin Registrar, Royal United Hospitals, Bath, UK T.M. Cook ∗ Consultant, Royal United Hospitals, Bath, UK ∗ Corresponding author at: Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Combe Park, Bath BA1 3NG, UK. E-mail address: [email protected] (T.M. Cook)
19 January 2015
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Videolaryngoscopy at cardiac arrest – The need to move from video-games to video-science
This issue of the journal includes two studies examining the use of videolaryngoscopy (VL) during cardiac arrest.1,2 VL is increasingly being used both inside and outside the operating room.3,4 Tracheal intubation (TI) in critically ill patients is acknowledged to be challenging, is more likely to fail than in the operating room, is associated with serious complications and yet is often performed by inexperienced operators.5–8 Similar issues arise during airway management at cardiac arrest.9 The optimal method of managing the airway during cardiac arrest remains uncertain. Speed and reliability of airway management are critical during cardiopulmonary resuscitation (CPR) because of their impact on cardiac compressions10 – and TI has been shown to potentially have a negative impact on the quality of CPR.10 Recent guidelines have encouraged the use of supraglottic airway devices and deemphasised TI during CPR, particularly for those inexperienced in the technique.9 However most of the literature underpinning these recommendations pre-dates the availability of VL. Videolaryngoscopy is designed to improve the view of the glottis and facilitate intubation as the reliance on aligning the oral–pharyngeal–tracheal axis with the operator’s line of vision is removed. There is some evidence that learning intubation with VL is easier than with conventional direct laryngoscopy (DL).10,11 This is important in the context of airway management at cardiac arrest as VL has the potential to make TI easier during CPR, especially for inexperienced airway operators and so to minimise any interruption to chest compressions. The two studies in this edition of the journal examine aspects of success, speed and learning with VL during CPR. In the first study, Lee and colleagues compare the efficiency, safety and clinical outcomes of TI using either VL or DL during inhospital CPR.1 Intubators were permitted to choose either VL or DL and if they chose VL they could then select either a Glidescope (Verathon, Bothell, WA, USA) or a Pentax-Airway Scope (Pentax Medical, Hamburg, Germany). Both device blades are more curved than a standard Macintosh laryngoscope blade, taking the larynx out of the line of sight. The Airtraq has a conduit to deliver the tracheal tube to the centre of the camera’s field of view while the Glidescope has no conduit and use of a preformed stylet is recommended. Tracheal intubation success rates were analysed according to the type of laryngoscope used (VL vs DL), the operator’s airway experience and whether the airway was predicted to be difficult. In a study of 229 patients VL was used in 53% and DL in 47%. Experienced operators more frequently chose VL (64%) as their preferred technique compared to less experienced practitioners (41%). http://dx.doi.org/10.1016/j.resuscitation.2015.01.016 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
A significantly higher first attempt tracheal intubation success rate was seen with VL compared to DL (72% vs 53%; p = 0.003). No significant difference was observed in time to intubate (VL 2.1 ± 3.2 min, DL 2.5 ± 2.4 min). An experienced operator, VL, and the lack of a difficult airway were independently associated with successful first attempt TI but none of these factors, nor successful first attempt intubation, affected patient outcome (return of spontaneous circulation (ROSC), discharge alive, mortality at 24 h or 28 days). The study has significant limitations (non-randomised nature; arbitrary definitions of intubation experience and intubation difficulty; failure to analyse whether first attempt tracheal intubation success rate was affected by type of VL) but as the first examination of VL in this setting it is an important study. The overall first attempt tracheal intubation success rates are rather low overall and it is uncertain whether this can be explained by the characteristics of patients in cardiac arrest or the unpredictable nature of airway management during CPR. In the second study, Park examines inexperienced airway operators (first year emergency physicians) and explores the success, speed and complications of TI using VL during CPR, compared to a historical group using DL.2 All operators underwent manikinbased training and were observed intubating patients not in cardiac arrest using their allocated laryngoscopy technique before studying patients. In total 305 patients in cardiac arrest were recruited. Compared to DL the VL group had a significantly higher first attempt success rate (92% vs 56%, p = 0.001) and completed intubation more quickly (37 vs 62 s, p = 0.001). Importantly, the rate of oesophageal intubation was markedly lower in the VL group (VL 0 vs DL 18%) and performance in the VL group, but did not in the DL group, improved over time (3 month episodes). Finally, interruption of cardiac compression was both very short and shorter in the VL group compared with the DL group (0 vs 7 s, p < 0.001). While VL is increasing in penetration and popularity, the scientific evidence supporting this is perhaps lagging behind. Importantly, airway management is context specific and the impact of novel equipment is unlikely to be identical in all settings. In the operating room environment many studies have shown improved laryngeal view but few have shown easier intubation and most studies have not examined difficult patients.13 Although VL has increasingly been shown to improve intubation success when DL fails,14 commentators have questioned the genuine benefit of VL,15 while others have emphasised the importance of training and experience.14 In the hands of inexperienced operators in critical
A8
Editorial / Resuscitation 89 (2015) A7–A9
care, VL improved laryngeal view but did not improve speed or success rate of TI.16 Of note, in the setting of trauma a recent RCT of VL vs DL reported that VL took significantly longer and had no impact on intubation success or overall mortality. Further, in a subset of this study with severe head injury VL was associated with slower intubation, more hypoxaemia and worsened outcome.17 We must therefore not assume benefit from use of new technology and should examine its actual benefits (or harms) before adoption. Intubation at cardiac arrest has its own set of challenges: it is often performed in sub-optimal sites and conditions, often without neuromuscular blockade, sometimes by inexperienced operators, pre-oxygenation may be difficult and there is a high risk of regurgitation/aspiration. Speed of airway management is uniquely important as it usually involves a period of interruption of chest compressions. Of note, Park has reported in this journal a series of 71 successful intubations with VL without interruption of CPR.18 In a cohort in which all physicians were briefly trained in VL, speed and success did not vary with prior airway experience. With these considerations in mind, the potential benefits of VL at cardiac arrest include the following: • Improved laryngeal view and improved success rates for all intubations by inexperienced intubators (some evidence1,2 but more required). • Improved success rates when intubation is difficult or DL fails for experienced users (no evidence). • Improved CPR continuity through reduced intubation time for inexperienced operators (some evidence but more required2 ) and intubation during on-going CPR for experienced and inexperienced intubators (some evidence18 but more required). • Reduced (undetected) oesophageal intubation (some evidence2 but more required). • Improved teamwork (no robust evidence). This latter point is perhaps worth considering further. Videolaryngoscopy enables colleagues to observe the progress of intubation and to co-confirm success. The intubating assistant may assist intubation in a far more engaged manner and can readily observe difficulty and the effects of attempts to overcome this.19 Videolaryngoscopy has the potential to improve teamwork, communication and situational awareness. In the authors view these non-technical benefits are likely of equal benefit to the technical ones. The articles by Lee and Park have each identified the importance of experience and training in achieving successful airway management during cardiac arrest/CPR. Other studies equally emphasise the benefits for training and importance of experience in VL.11,12,15 Videolaryngoscopy facilitates training with close supervision, offering immediate feedback on intubation practice in a manner that cannot be achieved with DL. Importantly, different videolaryngoscopes require different techniques (‘tricks and tips’) so training and experience with the specific device in use is critical. So what does the current evidence base tell us about the role of VL during CPR? As described above, VL may improve laryngeal view, speed of intubation for inexperienced intubators, and has the potential to be performed during ongoing CPR thus improving compression times. However, despite some supporting evidence from manikin studies,20 there is no evidence of an improvement in clinically important patient outcomes. The potential for reducing the oesophageal intubation rate is potentially important – though widespread use of capnography should already ensure that all oesophageal intubations are promptly recognised. Although the two studies reported here included relatively few subjects, and their conclusions are limited by study design, the authors are to be congratulated in providing original clinical research on the
reliability of intubation with VL during CPR, and investigating its effect on CPR quality and on overall clinical outcome. Such research is not easy – but more is needed. In the authors’ view there is insufficient evidence to support a change from primary airway management with a supraglottic airway in the hands of inexperienced operators. Future studies of the use of VL at cardiac arrest should ensure participants are suitably trained in the devices they use and should be powered to detect clinically important outcomes such as total airway time, interruption of compression and ultimately ROSC and mortality. It is unlikely that all videolaryngoscopes perform equally and in time it will be important to identify both high and poor performers through direct comparisons. Ultimately VL might provide the ability to reliably and quickly establish the airway at cardiac arrest with the security of a cuffed tracheal tube without need to stop chest compression – but only time and research will tell us if this is the case. While technology often improves technical (and non-technical) performance this cannot be assumed. Videolaryngoscopy at cardiac arrest and in the hands of inexperienced and experienced operators has considerable potential and appeal – it is important that the science advances before the appeal of the devices leads to adoption without evidence.
Conflict of interest statement JA – no conflicts reported. TMC and his department have received free, at cost or on loan airway equipment from various airway manufacturers for evaluation or research. He and his family have no relevant financial conflicts.
References 1. Lee DH, Han M, An JY, et al. Video laryngoscope versus direct laryngoscope for endotracheal intubation during in-hospital cardiopulmonary resuscitation. Resuscitation 2015;89:195–9. 2. Park SO, Kim JW, Na JH, et al. Video laryngoscopy improves the first-attempt success in endotracheal intubation during cardiopulmonary resuscitation among novice physicians. Resuscitation 2015;89:188–94. 3. Mosier JM, Whitmore SP, Bloom JW, et al. Videolaryngoscopy improve intubation success and reduces oesophageal intubations compared to direct laryngoscopy in the medical intensive care unit. Crit Care 2013;17:R237. http:// ccforum.com/content/pdf/cc13061.pdf (accessed 05.01.15). 4. Brown CA, Bair AE, Pallin DJ, Laurin EG, Walls RM, National Emergency Airway Registry (NEAR) Investigators. Improved glottis exposure with the Video Macintosh Laryngoscope in adult emergency department tracheal intubations. Ann Emerg Med 2010;56:83–8. 5. Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34:1835–42. 6. Hasegawa K, Hagiwara Y, Chiba T, et al. Emergency airway management in Japan: interim analysis of a multicenter prospective observational study. Resuscitation 2012;83:428–33. 7. Martin LD, Mhyre JM, Shanks AM, et al. 3423 Emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology 2011;114:42–8. 8. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society Part 2 Intensive Care and Emergency Department. Br J Anaesth 2011;106:632–42. 9. Nolan JP, Soar J, Zideman DA, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010;81:1219–76. 10. Hasegawa K, Hiraide A, Chang Y, Brown DF. Association of prehospital advanced airway management with neurologic outcome and survival in patients with outof-hospital cardiac arrest. JAMA 2013;309:257–66. 11. Low D, Healy D, Rasburn N. The use of the BERCI DCI Video Laryngoscope for teaching novices direct laryngoscopy and tracheal intubation. Anaesthesia 2008;63:195–201. 12. Bernhard M, Mohr S, Weigand MA, Martin E, Walther A. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand 2012;56:164–71. 13. Mihai R, Blair E, Kay H, Cook TM. A quantitative review and meta-analysis of performance of non-standard laryngoscopes and rigid fibreoptic intubation aids. Anaesthesia 2008;63:745–60.
Editorial / Resuscitation 89 (2015) A7–A9 14. Behringer EC, Kristensen MS. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia 2011;66(Suppl. 2):57–64. 15. Asai T. Videolaryngoscopes: do they truly have roles in difficult airways? Anesthesiology 2012;116:515–7. 16. Griesdale DE, Chau A, Isac G, et al. Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial for the Canadian Critical Care Trials Group. Can J Anaesth 2012;59:1032–9. 17. Yeatts DJ, Dutton RP, Hu PF, et al. Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. J Trauma Acute Care Surg 2013;75:212–9. 18. Park SO, Baek KJ, Hong DY, Kim SC, Lee KR. Feasibility of the videolaryngoscope (GlideScope(R)) for endotracheal intubation during uninterrupted chest compressions in actual advanced life support: a clinical observational study in an urban emergency department. Resuscitation 2013;84: 1233–7. 19. Kelly FE, Cook TM. Randomised controlled trials of videolaryngoscopy vs direct laryngoscopy on intensive care are needed. Intensive Care Med 2014, http://dx.doi.org/10.1007/s00134-014-3262-3. Published online March 19 [http://link.springer.com/article/10.1007/s00134-01403262-3262-3/fulltext. html].
A9
20. Han SK, Shin DH, Choi PC. Utility of the Pentax-AWS without interruption of chest compression: comparison of the Macintosh laryngoscope with the PentaxAWS in manikin model. Resuscitation 2010;81:69–73.
J. Astin Registrar, Royal United Hospitals, Bath, UK T.M. Cook ∗ Consultant, Royal United Hospitals, Bath, UK ∗ Corresponding author at: Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital, Combe Park, Bath BA1 3NG, UK. E-mail address: [email protected] (T.M. Cook)
19 January 2015
