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Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study.

成人急诊科气管插管中视频喉镜与增强直接喉镜的比较: 国家紧急气道登记 (NEAR) 研究。

  • 影响因子:2.38
  • DOI:10.1111/acem.13851
  • 作者列表:"Brown CA 3rd","Kaji AH","Fantegrossi A","Carlson JN","April MD","Kilgo RW","Walls RM","National Emergency Airway Registry (NEAR) Investigators.
  • 发表时间:2020-01-20
Abstract

OBJECTIVE:The objective was to compare first-attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (A-DL) with unaided video laryngoscopy (VL) in adult emergency department (ED) intubations. METHODS:This study was a secondary analysis of a multicenter prospective observational database of ED intubations from the National Emergency Airway Registry (NEAR). We compared all VL procedures to seven exploratory permutations of A-DL using multivariable regression models. We further stratified by blade shape into hyperangulated VL (HA-VL) and standard-geometry VL (SG-VL). We report differences in first-attempt intubation success and peri-intubation adverse events with cluster-adjusted odds ratios (ORs) with 95% confidence intervals (CIs). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and OR with 95% CI. RESULTS:We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either A-DL or unaided VL on first attempt. A-DL was used first in 3,936 (56.7%, 95% CI = 46.9 to 66.5) versus unaided VL in 3,002 (43.3%, 95% CI = 33.5 to 53.1). Of the A-DL first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (ELM), and 365 (9.3%) used a bougie. Rapid sequence intubation (RSI) was the most common method used in 5,602 (80.8%, 95% CI = 77.0 to 84.5) cases. First-attempt success was significantly higher with all VL (90.9%, 95% CI = 88.7 to 93.1) versus all A-DL (81.1%, 95% CI = 78.7 to 83.5) despite the VL group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry-recorded difficult airway predictors revealed first-attempt success was higher with all unaided VL compared with any A-DL (adjusted OR [AOR] = 2.8, 95% CI = 2.4 to 3.3), DL with bougie (AOR = 2.7, 95% CI = 2.1 to 3.5), DL with ELM (AOR = 1.8, 95% CI = 1.5 to 2.2), DL with ramped positioning (AOR = 2.8, 95% CI = 2.3 to 3.3), or DL with ELM plus bougie (AOR = 2.8, 95% CI = 2.3 to 3.3). Subgroup analyses of HA-VL and SG-VL compared with any A-DL yielded similar results (AOR = 3.2, 95% CI = 2.6 to 3.0; and AOR = 2.4, 95% CI = 1.9 to 3.0, respectively). The propensity score-adjusted odds for first-attempt success with VL was also 2.8 (95% CI = 2.4 to 3.3). Fewer esophageal intubations were observed in the VL cohort (0.4% vs. 1.3%, AOR = 0.2, 95% CI = 0.1 to 0.5). CONCLUSIONS:Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first-attempt success than does DL that is augmented by use of a bougie, ELM, ramping, or combinations thereof.

摘要

目的: 本研究的目的是比较直接喉镜检查 (喉部操作增强) 、倾斜患者定位和探条 (a-DL) 的首次插管成功率。在成人急诊科 (ED) 插管中使用非辅助视频喉镜 (VL)。 方法: 本研究是对来自国家紧急气道登记处 (NEAR) 的多中心前瞻性观察性 ED 插管数据库的二次分析。我们使用多变量回归模型将所有 VL 程序与 A-DL 的 7 个探索性排列进行了比较。我们通过叶片形状进一步分层为高角 VL (HA-VL) 和标准几何 VL (SG-VL)。我们报告了首次插管成功和围插管期不良事件与 95% 置信区间 (CIs) 的集群调整比值比 (ORs) 的差异。我们使用描述性统计和 OR (95% CI) 报告了患者特征、困难气道属性和插管方法的单变量比较。 结果: 我们分析了从 2016年1月1日到 2017年12月31日进行的 11,714 次插管。在这些遭遇中,6,938 在首次尝试时接受了 A-DL 或非辅助 VL 的经口气管插管。首先使用 A-DL 的比例为 3,936 (56.7%,95% CI = 46.9 ~ 66.5),而非辅助 VL 的比例为 3,002 (43.3%,95% CI = 33.5 ~ 53.1)。在 A-DL 首次插管中,1,787 例 (45.4%) 采用单独倾斜定位,1,472 例 (37.4%) 采用喉外操作 (ELM),365 例 (9.3%) 采用探条。快速序列插管 (RSI) 是 5,602 (80.8%,95% CI = 77.0 ~ 84.5) 病例最常用的方法。所有 VL (90.9%,95% CI = 88.7 ~ 93.1) 的首次尝试成功率显著高于所有 A-DL (81.1%,95% CI = 78.7 ~ 83.5) 尽管 VL 组有更多的患者张口减少,颈部不动,最初印象是气道困难。多变量回归分析控制适应症、方法、操作员专业和培训年份,中心聚类, 所有登记记录的困难气道预测因子显示,与任何 A-DL 相比,所有非辅助 VL 的首次尝试成功率更高 (校正 OR [AOR] = 2.8, 95% CI = 2.4 至 3.3),DL 伴 bougie(AOR = 2.7,95% CI = 2.1 ~ 3.5),DL 伴 ELM (AOR = 1.8,95% CI = 1.5 ~ 2.2),DL 伴 ramped 定位 (AOR = 2.8, 95% CI = 2.3 ~ 3.3),or DL 伴 ELM 加 bougie (AOR = 2.8,95% CI = 2.3 ~ 3.3)。与任何 A-DL 相比,HA-VL 和 SG-VL 的亚组分析得出相似的结果 (AOR = 3.2,95% CI = 2.6 ~ 3.0; AOR = 2.4, 95% CI 分别为 1.9 ~ 3.0)。倾向评分调整后的 VL 首次尝试成功的几率也为 2.8 (95% CI = 2.4 ~ 3.3)。在 VL 队列中观察到较少的食管插管 (0.4% vs.1.3%,AOR = 0.2,95% CI = 0.1 ~ 0.5)。 结论: 在没有任何增强操作、装置或技术的情况下使用视频喉镜比使用探条、 ELM 、 ramp 增强的 DL 首次尝试成功率更高, 或其组合。

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来源期刊:Bioscience reports
DOI:10.1042/BSR20192435
作者列表:["Yu H","Luo J","Ni Y","Hu Y","Liu D","Wang M","Liang B","Liang Z"]

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