Comparison of Coopdech®, CoPilot®, Intubrite®, and Macintosh laryngoscopes for tracheal intubation during pediatric cardiopulmonary resuscitation: a randomized, controlled crossover simulation trial

The main cause of sudden cardiac arrest in children is respiratory failure and not heart disease as is the case with adults [1, 11, 14, 23]. The 2010 European Resuscitation Council (ERC) and American Heart Association (AHA) resuscitation guidelines emphasize the importance of minimizing interruptions to chest compression during cardiopulmonary resuscitation (CPR) [4, 17, 23]. These guidelines also suggest that the intubator should be able to secure the airway without interrupting chest compression. However, direct laryngoscopy and tracheal intubation during emergencies remain a challenge to medical practitioners who do not have clinical experience with the techniques or who are expected to perform intubation in difficult situations.

In the present study conducted under simulated resuscitation, intubation efficiency with Macintosh was 80.4 % and 89.7 % with Intubrite®. The higher efficiency of Intubrite® may be due to the different profiles of its handle and better lighting placement on the laryngoscope blade. The effectiveness of direct intubation on children using a laryngoscope with Macintosh or Miller blades performed by paramedics in out-of-hospital conditions is varied and ranges from 63.4 to 77 % in the study by Gerritse et al. [7, 8], 79.8 % in the study by Tollefsen et al. [19], and 82 % in the study by Vilke et al. [20]. Research indicates that low first attempt efficiency of intubation of children does not apply only to intubation performed by paramedics and activities under prehospital care. The study performed in 13 emergency departments by Choi et al. indicates that the first intubation attempt effectiveness with laryngoscope with Macintosh or Miller blades, for doctors with a specialization in emergency medicine, was 74.4 and 50 % for people with other specialties [3]. The poor efficiency of the first intubation attempts performed by paramedics and emergency physicians is also indicated in a study by Ehrlich et al. [5], in which the first intubation attempt effectiveness was 45 %, when performed by paramedics and 67 % [5] for doctors with emergency medicine specialization outside trauma centers. Eich et al. also showed in their study that intubation effectiveness increases with the age of the child. In prospective studies examining prehospital intubation of children by doctors with a specialization in the field of emergency medicine, the first intubation attempt effectiveness through the mouth was varied and was 53.9 % for infants, 68.2 % for children under 5 years of age, and 95.7 for children aged 6–14 years [6].

Alternative methods of airway management may be useful, especially for those who do not have regular exposure to situations in which airway management skills are required. In these situations, it is vital that an effective airway can be obtained quickly and without extensive prior training using the airway device. The authors of several studies indicate the higher efficiency of video laryngoscopes on direct laryngoscopy child intubation [9, 18, 21, 22].

The main findings of the study are that video laryngoscopes (Coopdech® and CoPilot®) may provide benefits regarding time to final placement compared to direct laryngoscopy. There is no significant difference in time to being operational in the case of those laryngoscopes. The first intubation attempt effectiveness using Coopdech® and CoPilot® in our study was 100 % for both devices. Average intubation time was shorter when using Coopdech® (21.6 ± 6.2 s) than using CoPilot® (25.6 ± 7.4 s.).

This study is the first study showing intubation effectiveness on manikins resembling a six-year-old child using the CoPilot® and Coopdech® video laryngoscopes. Saito et al. evaluated the intubation effectiveness of Coopdech® VLP-100 under simulated difficult airways. He found vocal cord visibility and intubation efficiency to be better with the Coopdech® than with the Macintosh laryngoscope [15].

Video laryngoscopes are supposed to help during intubation. As demonstrated in the study, the effectiveness of pediatric intubation while using the Coopdech® and CoPilot® laryngoscopes was 100 %. These devices offered the most effective “method for pediatric intubation during resuscitation” out of all the tested ETI devices. Analysis showed that according to the researched paramedics, video laryngoscopes provided a better view of the larynx area.

This study has a number of significant limitations. Firstly, it is a manikin study and does not involve real patients, and a recognized problem with manikin studies is that the times required to perform airway interventions are generally quicker than in patients. However, according to the International Liaison Committee on Resuscitation (ILCOR), randomized clinical trials for cases of cardiac arrest are unethical and cannot determine the expected benefits of CPR [12]. In both video laryngoscope and optical laryngoscope (e.g., AirTraq), reduce hampering their use may be the presence of fluids (including blood) in the oral cavity which reduces or completely prevents the visibility of the glottis. The strengths of this study include the use of a highly advanced patient simulator for performing pediatric advanced life support and the randomized crossover procedure.