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ObjectivesNeonatal intubation is a difficult skill to learn and teach. If an attempt is unsuccessful, the intubator and instructor often cannot explain why. This study aims to review videolaryngoscopy recordings of unsuccessful intubations and explain the reasons why attempts were not successful.Study designThis is a descriptive study examining videolaryngoscopy recordings obtained from a randomised controlled trial that evaluated if neonatal intubation success rates of inexperienced trainees were superior if they used a videolaryngoscope compared with a laryngoscope. All recorded unsuccessful intubations were included and reviewed independently by two reviewers blinded to study group. Their assessment was correlated with the intubator’s perception as reported in a postintubation questionnaire. The Cormack-Lehane classification system was used for objective assessment of laryngeal view.ResultsRecordings and questionnaires from 45 unsuccessful intubations were included (15 intervention and 30 control). The most common reasons for an unsuccessful attempt were oesophageal intubation and failure to recognise the anatomy. In 36 (80%) of intubations, an intubatable view was achieved but was then either lost, not recognised or there was an apparent inability to correctly direct the endotracheal tube. Suctioning was commonly performed but rarely improved the view.ConclusionsLack of intubation success was most commonly due to failure to recognise midline anatomical structures. Trainees need to be taught to recognise the uvula and epiglottis and use these landmarks to guide intubation. Excessive secretions are rarely a factor in elective and premedicated intubations, and routine suctioning should be discouraged. Better blade design may make it easier to direct the tube through the vocal cords.

Background Direct laryngoscopy (DL) is widely recognized as the most commonly used method for tracheal intubation. However, growing evidence highlights the increasingly prominent role of video laryngoscopy (VL) in the management of difficult airways. This study aimed to determine the most effective medical education method to equip medical students with this critical skill. In addition to evaluating the contributions of an intubation training program utilizing direct laryngoscopy and video laryngoscopy to tracheal intubation success among inexperienced medical students, we also aimed to explore the potential benefits of combining these two techniques. Methods This mannequin-based study included 130 medical students. Before the study began, participants attended a 30-minute theoretical training session. Participants were randomly assigned to start with one of two scenarios. In each scenario, participants were given three attempts to perform intubation using each laryngoscope. The maximum allowable time for each intubation was set at 3 min. Students who successfully intubated within 3 min were recorded as successful, while those who failed to do so were recorded as unsuccessful. Results The study demonstrated that VL provided higher success rates and shorter intubation times, particularly during the first and second attempts. However, it is noteworthy that no significant difference in success rates was observed between VL and DL during the third attempt. Conclusion This study highlights the necessity of integrating both VL and DL methods in intubation training programs. The combination of both approaches allows students to achieve quick initial results while progressively developing proficiency for more complex scenarios over time. Clinical trial number Not applicable.

Background Tracheal intubation is a core skill in airway management for anesthesiologists as well as for other medical professionals involved in advanced airway procedures. Traditionally, tracheal intubation in hospitals has been performed using a Macintosh blade for direct laryngoscopy (DL). However, recent literature increasingly supports the potential benefits of routine video laryngoscopy (VL). The aim of this study was to assess whether primary training in hyperangulated VL improves the first-pass success rate of tracheal intubation among first-year anesthesiology residents, compared to conventional DL training, in the operating room. Methods The JuniorDoc-VL Trial is a randomized, controlled, patient-blinded clinical trial of novice anesthesiology residents trained in DL and VL. Thirty residents will be randomly assigned to either the intervention group (VL group) or the control group (DL group) with a 1:1 allocation. The first-pass-success (FPS) rates (primary endpoint) and complication rates (secondary endpoint) will be compared between groups. Discussion We hypothesize that the primary use of hyperangulated video laryngoscopy (VL) in the experimental group will increase first-pass-success rates among inexperienced residents and reduce complication rates associated with advanced airway management in a mixed patient population. This study may provide an opportunity to develop strategies that allow physicians not routinely involved in anesthesia to effectively learn and maintain their skills in tracheal intubation. Trial registration ClinicalTrials.gov Registry (NCT06360328). Registered on 09.04.2024.

IntroductionNeonatal intubation is a challenging skill to acquire. A randomised controlled trial (RCT) found junior trainees had higher intubation success rates if their supervisor shared their airway view on a videolaryngoscope screen compared with intubations where the supervisor could not see the videolaryngoscope screen. The intubations in the trial were supervised by a group of experienced neonatologists who developed an intubation teaching package that aimed to be informative, consistent and supportive. We surveyed the trainees to assess their experiences of the intubation attempts.MethodsTrainees participating in the RCT completed questionnaires anonymously after each intubation attempt. Questionnaires used 5-point Likert scales and free comment sections. Quantitative analysis was performed using descriptive statistics. In a qualitative analysis, free comments were coded to identify central recurring themes.ResultsTwo hundred and six questionnaires were completed by 36 trainees. The majority reported that the guidance received during intubation was helpful, the postprocedure feedback was educational and their confidence levels were increased. Trainees appreciated a controlled environment and calm, consistent guidance. They found intubations in the delivery room, those involving unstable infants, large audiences and parental presence more stressful. Responses were positive whether the videolaryngoscope screen was visible or covered, emphasising the importance of consistent guidance. Overall, 16% of intubations were reported as intimidating.ConclusionThe shared airway view offered by videolaryngoscopy was well received. In addition, taking measures to control the setting, with standardised guidance and feedback, improved confidence and created a more positive learning experience.

Introduction. Airway management plays an essential role in anaesthesia practice, during both elective and urgent surgery procedures and emergency medicine. Aim. The aim of the study was to compare Macintosh laryngoscope (MAC), McGrath, and TruView PCD in 5 separate airway management scenarios. Methods. This prospective cross-over simulation study involved 93 paramedics. All paramedics performed intubation using direct laryngoscope (MAC), McGrath, and TruView PCD video laryngoscopes. The study was performed in 5 different scenarios: (A) normal airway, (B) tongue oedema, (C) pharyngeal obstruction, (D) cervical collar stabilization with tongue oedema, and (E) cervical collar stabilization with pharyngeal obstruction. Results. In scenario A, the success rate was 99% with MAC, 100% with McGrath, and 94% with PCD. Intubation time was 17 s (IQR: 16–21) for MAC, 18 s (IQR: 16–21) for McGrath, and 27 s (IQR: 23–34) for PCD. In scenario B, the success rate was 61% with MAC, 97% with McGrath, and 97% with PCD (p<0.001). Intubation time was 44 s (IQR: 24–46) for MAC, 22 s (IQR: 20–27) for McGrath, and 39 s (IQR: 30–57) for PCD. In scenario C, the success rate with MAC was 74%, 97% with McGrath, and 72% with PCD (p<0.001). Intubation time was 21 s (IQR: 19–29) for MAC, 18 s (IQR: 18–24.5) for McGrath, and 30 s (IQR: 23–39) for PCD. In scenario D, the success rate with MAC was 32%, 69% with McGrath, and 58% with PCD (p<0.001). Intubation time was 26 s (IQR: 20–29) for MAC, 26 s (IQR: 20–29) for McGrath, and 45 s (IQR: 33–56) for PCD. In scenario E, the success rate with MAC was 32%, but 64% with McGrath and 62% with PCD (p<0.001). Intubation time was 28 s (IQR: 25–39) for MAC, 19 s (IQR: 18–26) for McGrath, and 34 s (IQR: 27–45) for PCD. Conclusions. The McGrath video laryngoscope proved better than Truview PCD and direct intubation with Macintosh laryngoscope in terms of success rate, duration of first intubation attempt, number of intubation attempts, Cormack-Lehane grade, percentage of glottis opening (POGO score), number of optimization manoeuvres, severity of dental compression, and ease of use.

While previous simulation studies demonstrated comparable retention of skills for DL versus VL in normal manikins [4, 5], it is unknown if VL training among physician trainees would lead to ineffective DL use for difficult intubation scenarios. Ethical approval was sought from the National Healthcare Group Domain Specific Review Board (DSRB 2015/00937). Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due as the local approval authority does not permit data sets to be placed publicly but are available from the corresponding author on reasonable request.

Background For both normal and difficult airway management, VL is thought to be more effective. However, VL seems far from being offered as a standard option in both healthcare delivery and educational activities in low-income countries, considering its high costs. Therefore, three-dimensional(3D)printed VLs may be considered an alternative to conventional VLs in low-income countries and other places with limited resources. Our objective was to compare the efficacy of AirAngel 3D-printed VL (3D-PVL) with those of commercially available Storz® VL (SVL) and conventional Macintosh® laryngoscope (MCL) in normal and difficult airway scenarios in the hands of inexperienced users. Methods This is a prospective randomized crossover manikin study that included 126 senior medical students with no experience in intubation. The effectiveness of all three laryngoscopy devices in the hands of inexperienced users was evaluated in terms of intubation time, glottic visualization, ease of use, endotracheal tube placement, and intubation success rate. Between 2020 and 2022, 126 last year medical students participated in the study. Results MCL resulted in significantly longer intubation times than 3D-PVL and SVL in the difficult airway scenario, with no significant difference between 3DPVL and SVL (Wilcoxon test, p  < 0.016; Bonferroni correction MCL: 28.54 s; SVL: 26.68 s; 3DPVL: 26.64 s). Both SVL and 3D-PVL resulted in significantly better Cormack − Lehane grades in both normal and difficult airway scenarios, and thus provided better glottic viewing than MCL, with no significant difference between 3D-PVL and SVL (Wilcoxon test, p  < 0.016; Bonferroni correction, MCL: 1.73; SVL: 1.29; 3DPVL: 1.25). The SVL was the easiest device to use for normal airway scenarios (1: very easy, 5: very difficult), while the MCL was the most difficult (MCL: 2.64; 3DPVL: 1.98; SVL: 1.49). Conversely, no significant difference was found between 3DPVL and other devices in terms of ease of use in difficult airway scenarios and in terms of accurate placement of the endotracheal tube and successful intubation attempts. Conclusion 3D-PVL is a good educational and possible clinical alternative to conventional VL, particularly in places with limited resources, due to its low cost.

We hypothesized that the McGRATH MAC would decrease the time of intubation compared to C-MAC for novices. Thirty-nine medical students who had used the Macintosh blade to intubate a manikin fewer than 3 times were recruited. The participants performed sequential intubations on the manikin in two simulated settings that included a normal airway and a difficult airway (tongue edema). The intubation time, success rate of intubation, Cormack-Lehane grade at laryngoscopy, and difficulty using the device were recorded. Each participant was asked to identify the device that was most useful. The intubation time decreased significantly and by a similar amount to the McGRATH MAC and C-MAC compared to the Macintosh blade ( P < 0.001 and P = 0.017 , resp.). In the difficult airway, the intubation times were similar among the three devices. The McGRATH MAC and C-MAC significantly increased the success rate of intubation, improved the Cormack-Lehane grade, and decreased the difficulty score compared to the Macintosh blade in both airway settings. The majority of participants selected the McGRATH MAC as the most useful device. The McGRATH MAC and C-MAC may offer similar benefits for intubation compared to the Macintosh blade in normal and difficult airway situations.

Objective To determine whether intubation education using the Pentax Airway Scope (AWS) in normal airways is more useful than direct laryngoscopy (Macintosh laryngoscope) in novice personnel. Methods Eleven intern doctors without intubation experience performed 60 sequential intubations with each device on a manikin and 10 sequential intubations in adult patients. The time required for successful intubation, percentage of glottic opening (POGO) score, number of intubation attempts, and number of dental injuries were analyzed for each intubation technique. Results The mean (standard deviation) time required for successful intubation decreased as the number of intubations increased and was significantly shorter with the Pentax AWS than direct laryngoscope [22.6 (7.3) vs. 29.6 (10.0) and 33.0 (8.0) vs. 44.7 (5.6) s, respectively] in both the manikin and clinical studies. The Pentax AWS was also associated with higher POGO scores than the direct laryngoscope [81.7 (8.9) vs. 55.1 (13.2) and 80.9 (9.7) vs. 49.6 (16.5), respectively] and fewer intubation attempts. Fewer dental injuries occurred with the Pentax AWS in the manikin study. Conclusions Novices performed intubation more rapidly and easily with an improved laryngeal view using the Pentax AWS. We suggest that intubation education with video laryngoscopy should be mandatory along with direct laryngoscope training.

With the advancement of chemical, biological and nuclear warfare and the reemergence of infectious diseases, the possibility of intubating in personal protective equipment has become increasingly more real to the emergency physician. Human cadaveric models have been found to simulate real world conditions better than mannequins. The aim of the study was to determine the first pass success rate and average time to successful intubation while wearing Personal Protective Equipment (PPE). Secondarily, subjects were asked to rank their choice of a primary and back up device, as well as the most common encountered barriers using PPE. Emergency medicine residents and pre-hospital providers were enrolled in a double randomized sequence to either intubation with direct laryngoscopy (DL), video laryngoscopy (VL), or the Supraglottic Airway Laryngopharyngeal Tube (SALT) in a cadaveric model while wearing level C PPE or without PPE. First pass success rate was 96% without PPE and 58% while wearing PPE when all devices were considered (p≤0.001). Time to intubation while wearing PPE was 35.0s while no PPE was 22.2s (p=0.012). While wearing PPE both DL and VL were found to allow for a faster intubation as compared to the SALT (23.0s and 18.8s; p=0.002 and p=0.006 respectively). No statistical difference was noted in intubations without PPE. Participants indicated the most common barrier to successful intubation included visibility while wearing hoods (73.7%). Furthermore, 52.6% of participants indicated they would choose DL as the primary method to intubate with if wearing PPE while 47.4% would choose VL. There is a statistically significant difference in first pass success and time to successful intubation while wearing and not wearing PPE in human cadaveric models.