Comparison of six different intubation aids for use while wearing CBRN-PPE: A manikin study

INTRODUCTION: Respiratory failure following chemical exposure can be fatal and although supraglottic airway devices have been evaluated for use in the management of CBRN casualties' intubation remains the gold standard airway.
METHODS: This is a randomised cross-over study involving 66 paramedic students utilising the following intubating aids bougie, stylet, McCoy laryngoscope, Airtraq™, intubating laryngeal mask (ILMA) and standard intubation. Each participant performed intubation with each device while wearing standard uniform and CBRN-PPE.
RESULTS: While wearing standard uniform all intubation aids, except the Airtraq™, resulted in at least a 90% successful intubation rate by 60s. The use of CBRN-PPE led to significantly longer intubation times (ranging from 14.3 to 20.7s) depending on intubation aid used (p < 0.001) with a 90% successful intubation rate not being achieved by all devices even by 150 s. While wearing CBRN-PPE standard intubation and intubation with a stylet were the fastest whereas the ILMA was deemed the easiest to use with the highest success rate. A marked deterioration in the number of intubation attempts completed within 30 s was also noted with standard intubation deteriorating by 82%, stylet deteriorating by 96% and the McCoy by 100%. The deterioration in intubation success at 60 s was less marked.
Conclusion:
In this manikin-based study all intubation aids evaluated while wearing CBRN-PPE were adversely affected by the loss of dexterity associated with wearing Butyl gloves. Standard intubation and intubation utilising a stylet resulted in the fastest intubation times; whereas the ILMA offers the highest intubation success rate and was deemed to be the easiest intubating aid to use. An important consideration with regards future research is the impact of a learning curve with regards to different intubation aids and whether preassembling all the intubation aids prior to the intubation attempt may improve intubation speed. The impact of intubator familiarity with regards to individual intubation aids is also an important consideration but established intubation aids like the Bougie are more difficult to use when dexterity is reduced due to CBRN-PPE.