JBI Database of Systematic Reviews & Implementation Reports 2015;13(6) 35-44

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1 Comparison of the force required to perform endotracheal intubation on healthy adult patients utilizing the GlideScope videolaryngoscope and Macintosh laryngoscope: a systematic review protocol Brad Mitsdarffer 1,2 Melanie Browder 1,2 1. School of Nurse Anesthesia, Texas Christian University, Texas, USA 2. Texas Christian University Center for Evidence Based Practice and Research: a Collaborating center of The Joanna Briggs Institute Review question/objective Corresponding author Brad Mitsdarffer B.Mitsdarffer@TCU.edu The objective of this systematic review is to evaluate the characteristics of the force, in Newton (N), required to perform endotracheal intubation utilizing a GlideScope (Verathon Medical, Bothwell, WA, USA) videolaryngoscope or a Macintosh laryngoscope on healthy adult patients. This involves the determination of the quantum of force in Newton (N) required to visualize the epiglottis and perform the orotracheal intubation with either a GlideScope videolaryngoscope or a Macintosh laryngoscope blade. Background Direct laryngoscopy is a technique that facilitates tracheal intubation via the use of a laryngoscope. Success of direct laryngoscopy depends on optimizing the laryngoscopist's line of sight from the teeth to the larynx. The management of anatomic structures, including the tongue and epiglottis, intruding into the line of sight through patient positioning and laryngoscope placement is central to the success of direct laryngoscopy. The force applied to the laryngoscope handle displaces the tongue, the hyoid bone and connected tissues, and directly or indirectly the epiglottis, which is parallel to the line of sight, and reveals the laryngeal inlet to be instrumented. Lifting force exerted on the laryngoscope handle, and subsequently the airway structures, optimizes visualization and intubation, which are pivotal determinants of both successful intubation as well as adverse effects. Factors related to both the patient and the laryngoscopist determine the force applied to the laryngoscope handle to facilitate orotracheal intubation. Patient-related factors may result in non-ideal intubating conditions possibly resulting in increased laryngoscope force being applied. This situation could be predicted by assessment or testing, or may be completely unforeseen. 1 Regardless of the doi: /jbisrir Page 35

2 cause of poor intubating conditions, laryngoscopists who experience difficulty in establishing an airway typically use more force in order to achieve a better view. 2 Furthermore, torque and pressure application during laryngoscopy when compared among experienced laryngoscopists vary significantly, even when performed on the same patient to exclude interpatient variability. Differences in physical traits and experience level between providers also impact on the force that is applied with direct laryngoscopy. 3,4,5 Patient characteristics and the laryngoscopist technique are unique and dynamic. The purpose of this systematic review is to focus specifically on the intubation device used and the best evidence of force application available, while attempting to control for these variables, in order to minimize patient exposure to excessive force during orotracheal intubation and reduce subsequent related adverse events. Interventions prior to intubation are commonly implemented to attenuate the response of the sympathetic nervous system to airway stimulation, such as intravenous lidocaine and/or opioids. However, increases in heart rate and blood pressure may still occur even after drug administration prior to laryngoscopy due to the direct stimulation of the extensively innervated oropharynx by the laryngoscope blade. 6,7 This effect may be exacerbated further when intubation attempts are prolonged, causing an increase in the amount of time the oropharynx is stimulated by the pressure of the laryngoscope. 6-9 A common adverse event related to excessive force during laryngoscopy and intubation is inadvertent damage to teeth, oral cavity, and/or oropharynx. 4,10 Evidence has shown greater force is applied to the teeth and subsequent greater risk of oral trauma with direct laryngoscopy using a Macintosh laryngoscope blade compared to several other video laryngoscopes. 11 Furthermore, patients who may be compromised by hyper-dynamic conditions, such as patients with coronary artery disease of elevated intracranial pressure, are at a higher risk for further injury caused by increases in blood pressure and heart rate with manipulation of the airway during orotracheal. 6,8,12 A scoping search revealed numerous studies comparing GlideScope and Macintosh laryngoscopes. There were no existing systematic reviews comparing the force in Newtons applied by the devices, although studies are available that compare the measurement of the force applied in Newtons by the respective laryngoscopes. The purpose of this systematic review is to synthesize the evidence to identify which laryngoscope, if any, reduces the risk of exposure to excessive laryngoscope force by reducing force generated to achieve intubation, and reducing the duration of oropharyngeal stimulation and intubation. Keywords laryngoscope; videolaryngoscope; pressure; force; Intubation Inclusion criteria Types of participants The target population of this systematic review will be healthy adult patients who provided informed consent for this study and were undergoing elective surgery, with or without rapid sequence intubation. Specifically, patient populations that will be included in this review are adults who are over the age of 18 with a body mass index (BMI) of less than 35 and are of physical status classification 1 or 2 in accordance to the American Society of Anesthesiologist (ASA). These limiters were applied to this review's population of interest to control for the potentially increased laryngoscope handle force doi: /jbisrir Page 36

3 applied by the laryngoscopist under conditions that deviated from normal, hence confounding devicerelated force comparison. Laryngoscopists used must be experienced with both the GlideScope and Macintosh laryngoscopes, as defined by having at least 25 attempts with each device. The techniques utilized for pediatric laryngoscopy as well as airway anatomy axes are not the same as those for adults; as such pediatric patients will not be included. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the force generated by the GlideScope videolaryngoscope and Macintosh laryngoscope blade on the described population as measured in Newtons (N). The force generated by the GlideScope videolaryngoscope and the Macintosh laryngoscope blade will be measured at the tip of each blade by a device allowing data extraction in Newtons. The control group for this systematic review will be patients intubated with a Macintosh laryngoscope and the intervention group will be patients intubated with a GlideScope videolaryngoscope. Types of outcomes This review will consider studies that evaluate the outcome of force (N) applied by the GlideScope videolaryngoscope and the Macintosh laryngoscope blade during the orotracheal intubation process: Force (N) required to intubate the trachea Secondary outcomes that will be examined include: Time in seconds required to intubate, beginning as each respective laryngoscope passes through the subjects teeth and ends at the time the endotracheal tube is at, but not through, the vocal cords. Types of studies This review will consider experimental and epidemiological study designs including randomized controlled trails, non-randomized controlled trials, case control studies, and analytical cross sectional studies for inclusion. Search strategy The search strategy for this review aims to find both published and unpublished studies. A threetiered search strategy will be utilized for this review. First, an initial generalized search of PubMed will be undertaken, followed by an analysis of the text words contained in the title, abstract, and of the index descriptor words in resulted articles. Secondly, all identified keywords and index terms will be undertaken across all included databases, including but not limited to: Embase Nursing@OVID Cochrane Central Register of Controlled Trials CINAHL Web of Science doi: /jbisrir Page 37

4 Clinical Key. After reports meeting inclusion criteria have been identified, the third tier of this search strategy includes reference list and citation analysis of additional studies to be considered for inclusion. During each tier of this review search strategy, all resulting studies will be analyzed and assessed for relevance to the review based on information provided in the title, abstract, and descriptor/mesh terms at a minimum. Studies of questionable inclusion viability based on these initial assessors will be analyzed further as needed to determine inclusion acceptability. A full report will be retrieved for all studies that do meet the inclusion criteria. Studies published in English will be considered for inclusion in this review. Studies published after 2001, the year of invention of the GlideScope, will be considered for inclusion in this review. The search for unpublished studies will include: World Health Organization's International Clinical Trials Registry Platform Search Portal Clinical Trial Information New York Academy of Medicine Gray Literature ProQuest database for theses and dissertations Google Scholar. Initial keywords to be used will be: Videolaryngoscope OR video laryngoscope OR videolaryngoscopy AND laryngoscopy OR laryngoscope OR direct laryngoscopy AND/OR GlideScope AND pressure OR force OR flexiforce Final review of reference lists and selective hand searching will be included in this review. Assessment of methodological quality Studies selected for retrieval will be assessed by the two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI- MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. The quantitative assessment of methodological quality will be based on the research design of the studies. Considering the randomized controlled trial inclusion criteria, studies will then be assessed using the experimental forms from the JBI set of critical appraisal templates. Data extraction Data will be extracted from the selected studies meeting inclusion criteria in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include details about the interventions, populations, study methods, and outcomes of significance in relation to this review question and specific objectives as previously discussed. The data extraction form will be created at the conclusion of the full search for this review. doi: /jbisrir Page 38

5 Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis as appropriate. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analysis based on the study designs included in the review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest The authors have no conflicts of interest to declare. doi: /jbisrir Page 39

6 References 1. Gupta S, Sharma R, Jain D. Airway assessment: predictors of difficult airway. Indian J Anaesth 2005;49(4): McCoy E, Austin B, Mirakhur R, Wong K. A new device for measuring and recording the forces applied during laryngoscopy. Anaesthesia 1995;50(2): Russell T, Lee C, Firat M, Cooper R. A comparison of forces applied to a manikin during laryngoscopy with the GlideScope and Macintosh laryngoscopes. Anaesth Intensive Care 2011;39(6): Hastings R, Hon E, Nghiem C, Wahrenbrock E. Force, torque and stress relaxation with direct laryngoscopy. Anesth Analg 1996;82(3): Hastings R, Hon E, Nghiem C, Wahrenbrock E. Force and torque vary between laryngoscopists and laryngoscope blades. Anesth Analg 1996;82(3): Stoelting R. Circulatory changes during direct laryngoscopy and tracheal intubation: influence of duration of laryngoscopy with or without prior lidocaine. Anesthesiology 1977;47(4): Xue F, Zhang G, Liu K, et al. Comparison of hemodynamic responses to orotracheal intubation with the GlideScope videolaryngoscope and the Macintosh direct laryngoscope. J Clin Anesth 2007;19(4): Pournajafian A, Ghodraty M, Faiz S, Rahimzadeh P, Goodarzynejad H, Dogmehchi E. Comparing GlideScope video laryngoscope and Macintosh laryngoscope regarding hemodynamic responses during orotracheal intubation: A randomized controlled trial. Iran Red Crescent Med J 2014;16(4): Bucx M, van Geel R, Scheck P, Stijnen T. Cardiovascular effects of forces applied during laryngoscopy. The importance of tracheal intubation. Anaesthesia 1992;47(12): Givol N, Gershtansky Y, Halamish-Shani T, Taicher S, Perel A, Segal E. Perianesthetic dental injuries: analysis of incident reports. J Clin Anesth 2004;16(3): Lee R, van Zundert A, Maassen R, Wieringa P. Forces applied to the maxillary incisors by video laryngoscopes and the Macintosh laryngoscope. Acta Anaesthesiol Scand 2012;56(2): Kitamura T, Yamada Y, Chinzei M, Du H, Hanaoka K. Attenuation of haemodynamic responses to tracheal intubation by the styletscope. Br J Anaesth 2001;86(2): Carassiti M, Biselli V, Cecchini S, et al. Force and pressure distribution using Macintosh and GlideScope laryngoscopes in normal airway: An in vivo study. Minerva Anestesiol 2013;79(5): Russell T, Khan S, Elman J, Katznelson R, and Cooper RM. Measurement of forces applied during Macintosh direct laryngoscopy compared with GlideScope videolaryngoscopy. Anaesthesia 2012;67(6): doi: /jbisrir Page 40

7 Appendix I: Appraisal instruments MAStARI appraisal instrument doi: /jbisrir Page 41

8 doi: /jbisrir Page 42

9 Appendix II: Data extraction instruments MAStARI data extraction instrument doi: /jbisrir Page 43

10 doi: /jbisrir Page 44

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