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Cited by 126Airway Management and Intubation TechniquesTracheal and airway disordersRespiratory Support and Mechanisms

Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials

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Suppan, L., Tramèr, M.R., Niquille, M., Grosgurin, O., Marti, C.·2016·British Journal of Anaesthesia
DOI 10.1093/bja/aev205PMC PMC4681615
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Abstract

BACKGROUND: Immobilization of the cervical spine worsens tracheal intubation conditions. Various intubation devices have been tested in this setting. Their relative usefulness remains unclear. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials comparing any intubation device with the Macintosh laryngoscope in human subjects with cervical spine immobilization. The primary outcome was the risk of tracheal intubation failure at the first attempt. Secondary outcomes were quality of glottis visualization, time until successful intubation, and risk of oropharyngeal complications. RESULTS: Twenty-four trials (1866 patients) met inclusion criteria. With alternative intubation devices, the risk of intubation failure was lower compared with Macintosh laryngoscopy [risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35-0.80]. Meta-analyses could be performed for five intubation devices (Airtraq, Airwayscope, C-Mac, Glidescope, and McGrath). The Airtraq was associated with a statistically significant reduction of the risk of intubation failure at the first attempt (RR 0.14; 95% CI 0.06-0.33), a higher rate of Cormack-Lehane grade 1 (RR 2.98; 95% CI 1.94-4.56), a reduction of time until successful intubation (weighted mean difference -10.1 s; 95% CI -3.2 to -17.0), and a reduction of oropharyngeal complications (RR 0.24; 95% CI 0.06-0.93). Other devices were associated with improved glottis visualization but no statistically significant differences in intubation failure or time to intubation compared with conventional laryngoscopy. CONCLUSIONS: In situations where the spine is immobilized, the Airtraq device reduces the risk of intubation failure. There is a lack of evidence for the usefulness of other intubation devices.

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  • Indirect hyperangulated video laryngoscopy (VL) consistently provides an improved glottic view.

    “indirect hyperangulated video laryngoscopy (VL) consistently provides an improved glottic view”

    From Airway Management in Trauma (2018) · cites this paper as [45]

    The Results (Cormack–Lehane grade; page not provided) report significantly better glottic views than Macintosh laryngoscopy for each of five evaluated devices. The claim omits the study's restriction to adults with cervical spine immobilization and describes the devices collectively as indirect hyperangulated VL, a category the reported result does not establish for all five. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • C-spine immobilization consistently impairs the glottic view with DL.

    “c-spine immobilization consistently impairs the glottic view with DL”

    From Airway Management in Trauma (2018) · cites this paper as [45]

    The paper's background says cervical spine immobilization may disrupt airway alignment and jeopardize glottic visualization during direct laryngoscopy. Its Results (Cormack–Lehane grade; page unavailable) also report poorer glottic views with Macintosh laryngoscopy than with alternative devices in immobilized patients. Neither passage establishes that immobilization consistently impairs the view compared with no immobilization, so “consistently” overstates the evidence. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • A recent meta-analysis by Suppan and colleagues reported more failed intubations for DL compared with several alternative intubating devices in patients with c-spine immobilization.

    “A recent meta-analysis by Suppan and colleagues 45 reported more failed intubations for DL compared with several alternative intubating devices in patients with c-spine immobilization.”

    From Airway Management in Trauma (2018) · cites this paper as [45]

    The Results (‘Intubation failure at first attempt’; page not provided) report more first-attempt failures with Macintosh laryngoscopy than with alternative devices pooled. But among the five devices analysed individually, only Airtraq significantly reduced failures; the other four did not show a significant difference. The claim overstates the device-specific finding by implying that several alternatives each had fewer failures. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • There was no statistically significant difference in first-attempt success between the more commonly used VL devices (GlideScope, C-MAC) and DL.

    “there was no statistically significant difference in first-attempt success between the more commonly used VL devices (GlideScope, C-MAC) and DL. 45”

    From Airway Management in Trauma (2018) · cites this paper as [45]

  • Literature comparing intubation devices in c-spine immobilized patients has yielded inconsistent findings, and no consensus as to the optimal approach.

    “Literature comparing intubation devices in c-spine immobilized patients has yielded inconsistent findings, and no consensus as to the optimal approach.38,44,45,48,49”

    From Airway Management in Trauma (2018) · cites this paper as [45]

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Cited by

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Authors
Suppan, L., Tramèr, M. R., Niquille, M., Grosgurin, O., & Marti, C.
Affiliations
  • University Hospital of Geneva (CH)
  • University of Geneva (CH)
Corresponding author
Suppan, L.
ORCID
Venue
British Journal of Anaesthesia
Publisher
Elsevier BV
Published
2016-01
Volume
116
Issue
1
Pages
27-36
ISSN
0007-0912 (ISSN-L)
DOI
10.1093/bja/aev205
PMC
PMC4681615
OpenAlex
W2198408822
Cited by
126
References
1
Citations by year
2026: 4 · 2025: 9 · 2024: 9 · 2023: 6 · 2022: 10 · 2021: 13 · 2020: 17 · 2019: 8 · 2018: 10 · 2017: 25 · 2016: 11 · 2015: 3 · 2014: 1
FWCI
3.22
Type
journal article
Language
en
Open access
Licence
Locations
  • British Journal of Anaesthesia (publishedVersion, cc-by-nc)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Archive ouverte UNIGE (University of Geneva) (publishedVersion, other-oa)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
Topics
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Airway Management and Intubation Techniques
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Tracheal and airway disorders
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory Support and Mechanisms
Keywords
difficult intubation, cervical spine immobilization, Macintosh laryngoscope, Airtraq, video laryngoscopy, failed intubation, glottis visualization, Cormack-Lehane grade, intubation time, C-MAC
MeSH terms
Cervical Vertebrae, Equipment Design, Humans, Immobilization, Intubation, Intratracheal, Laryngoscopy, Randomized Controlled Trials as Topic, Laryngoscopes

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