Evaluation of five static or dynamic tracheal tube introducers during standard and difficult intubations with C-MAC® D-blade videolaryngoscopy in a manikin*

Abstract

Introduction: Tracheal tube introducers facilitate tracheal intubation and include stylets and static/dynamic bougies. There is uncertainty over the most efficacious introducer with hyperangulated videolaryngoscopy. Methods: We evaluated five introducers. Thirty anaesthetists intubated a manikin 10 times with a reusable C-MAC® D-blade videolaryngoscope using five introducers in two airway setups. Airway setup was allocated randomly to standard or difficult tracheal intubation and the order of use of five introducers: two stylets (C-MAC Stylet; Universal Stylet Bougie™); two dynamic bougies (Total Control Introducer™; Steerable Tracheal Intubation Guide™); and a static bougie (Portex® Bougie). The primary outcome was first-attempt tracheal intubation success. Secondary outcomes were tracheal intubation within 120 seconds; time to tracheal intubation; and operator-rated ease of tracheal intubation, railroading and force required. Results: With the standard tracheal intubation setup, first-attempt tracheal intubation success rates (95%CI) were: C-MAC Stylet 100% (100–100%); Universal Stylet Bougie 93% (84–100%); Total Control Introducer 90% (79–100%); Steerable Tracheal Intubation Guide 80% (65–95%); and Portex bougie 57% (37–76%). With the difficult tracheal intubation setup, first-attempt tracheal intubation success rates (95%CI) were: C-MAC Stylet 93% (84–100%); Total Control Introducer 87% (74–99%); Universal Stylet Bougie 73% (56–90%); Steerable Tracheal Intubation Guide 60% (41–79%); and Portex bougie 33% (15–51%). The C-MAC Stylet was best and the static bougie worst across all outcomes, with differences greater when tracheal intubation was designed to be difficult. In pairwise comparisons of tracheal intubation first-attempt success in the difficult airway, the C-MAC Stylet, Universal Stylet Bougie and Total Control Introducer were statistically significantly better than the Portex Bougie; the C-MAC stylet was also statistically significantly better than the Steerable Tracheal Intubation Guide. Discussion: Among introducers for hyperangulated videolaryngoscopy, stylets were most efficacious and a static bougie least. Differences in performance increased when tracheal intubation was difficult.