Background: Passage of an endotracheal tube (ETT) into the trachea is an essential portion of airway management. Four different methods aid ETT are frequently advocated: a ‘naked’ ETT without adjuncts, a preformed stylet inside an ETT, a bougie followed by a railroaded ETT, and an ETT with preloaded bougie. There is currently minimal evidence to support which method is best for first pass success rate (FPS). We aimed to demonstrate which method has the highest FPS and shortest time to endotracheal intubations (ETI).
Methods: This is a cross-sectional, prospective, cross-over manikin study design. Participants performed timed ETI on “easy” and “difficult” airway models.
The primary outcome was defined as FPS. The secondary outcomes include time taken for ETI and participants’ preferred technique. ETI times were measured from commencement of laryngoscopy until first ventilation. Pre- and post-tests surveys recorded participant experience and perceptions of the four methods.
Results: Data was collected on a 111 participants (888 ETI attempts). Of these participants, 54 worked in anesthesia, 33 in emergency medicine, and 24 in out-of-hospital environments. In the “difficult” airway, FPS was 32% using the naked ETT. Stylet, railroaded bougie, and preloaded bougie had 96%, 78% and 91% respectively. Mean time to ETI was faster in the stylet technique (25 seconds) with the railroaded bougie technique being the slowest (42 seconds).
79% of participants stated that they would change their practice. A significant increase in preference of 38% towards the preloaded bougie.
Conclusions: The continued use of a naked ETT for ETI in the difficult airway is not recommended. ETI was most rapid using a stylet or preloaded bougie. This study shows that ETI with adjuncts such as a stylet or a bougie is both superior in achieving FPS and faster in a difficult airway model.
Counties Manukau Health