A Comparison of Three Maneuvers and Their Effect on Laryngoscopic View, Time to Intubate, and Intubation Outcome by Novice Intubators in a Simulated Airway

Aim: The goal of this study was to compare the relative effectiveness of three adjunctive maneuvers - head elevation (HE), forward laryngoscope traction (FT), and external laryngeal manipulation (ELM) - on laryngoscopic view, intubation time, and intubation success performed by a sample of novice intubators using a simulated airway. Methods: Twenty-two second year university paramedic students were required to perform laryngoscopy and intubation on a simulator four times on two separate days. The first day involved intubation using no adjunctive maneuvers (control) plus HE, FT, and ELM in random order in a normal simulated airway. A similar approach was used on the second day, but the simulator was configured to have a difficult airway. Percentage of glottic opening (POGO) scores, intubation time, and intubation success were measured for all intubation attempts. Results: Head elevation was found to be the most effective adjunctive maneuver in the normal airway, increasing the mean POGO score from control by 27% (P = .002), while ELM was most effective in the difficult airway, increasing the mean POGO score by 21% (P = .009) and the proportion of successful intubations by 41% (P< .001). All maneuvers decreased intubation time in the normal and difficult airway and were associated with significant differences in intubation success compared to control in the difficult airway. Conclusions: This study identified HE as the most effective maneuver for improving laryngoscopic view in a normal airway and ELMas the most effective in a difficult airway in a group of novice intubators.