Background
Methods
Data sources and literature search strategy
Study selection
Data extraction
Outcomes
Assessment of study quality
Data synthesis and statistical analysis
Results
Search results
Author, year | Study country | Inclusion | No. of children | Group | Transport mode | Outcomes assessed | Overall risk of bias |
---|---|---|---|---|---|---|---|
Aijian 1989 [17] | USA | < 19 years, arrested patients only | 28 | Non-physician, no relaxants | Road | Overall intubation success, overall airway complication, oesophageal intubation, endobronchial intubation | Moderate |
Andrew 2015 [18] | Australia | < 16 years | 16 | Non-physician, with relaxants | Helicopter | Overall and first look success rate, multiple attempts | Low |
Babl 2001 [19] | USA | < 19 years | 15 | Non-physician, no relaxants | Road | Overall intubation success rate | Low |
Baker 2009 [20] | USA | < 18 years | 148 | Non-physician, no relaxants | Road | Overall and first look success rate, overall complication rate | Moderate |
Bankole 2011 [6] | USA | < 13 years, traumatic head injury only | 31 | Non-physician, no relaxants | Helicopter and road | Overall success and airway complication rate, oesophageal intubation, multiple attempts | Low |
Boswell 1995 [21] | USA | < 14 years, unconscious trauma patients transported by helicopter only | 58 | Non-physician, no relaxants | Helicopter | Overall intubation success rate | Moderate |
Brownstein 1996 [22] | USA | < 16 years, successful field intubations only | 355 | Non-physician, with relaxants | Road | Overall complication, oesophageal and endobronchial intubation rate, aspiration rate | Moderate |
Burns 2017 [10] | Australia | < 16 years | 82 | Physician | Helicopter and road | Overall intubation and first look success, overall airway complication, oesophageal and endobronchial intubation, hypoxia, aspiration, multiple attempts | Low |
Burton 2003 [23] | USA | < 13 years | 137 | Non-physician, no relaxants | Road | Overall intubation success rate | Low |
Carlson 2015 [3] | USA | < 18 years | 3049 | Non-physician, no relaxants | Helicopter and road | Overall intubation success rate | Moderate |
Demaret 2016 [24] | Belgium | < 16 years | 353 | Physician | Road | Overall intubation and first look success | Low |
Dyson 2017 [25] | Australia | < 15 years | 434 | Non-physician, with relaxants | Road | Overall intubation and first look success | Low |
Ehrlich 2004 [26] | USA | < 19 years, trauma only | 59 | Non-physician, with relaxants | Helicopter and road | First look success, overall airway complication, oesophageal and endobronchial intubation, aspiration rate | Moderate |
Eich 2009 [1] | Germany | < 14 years | 82, 58 reported in detail | Physician | Helicopter and road | Overall intubation and first look success, overall airway complication, oesophageal and endobronchial intubation, multiple attempts | Moderate |
Garner 2019 [7] | Australia | < 16 years | (a) 7, (b) 61 | (a) Non-physician, no relaxants; (b) physician | (a) Road, (b) helicopter | Overall intubation and first look success, overall airway complication, oesophageal and endobronchial intubation, hypoxia, aspiration rate, multiple attempts | Low |
Garza 2005 [5] | USA | < 16 years, arrested patients only | 86 | Non-physician, no relaxants | Road | Overall intubation success rate | Moderate |
Gausche 2000 [27] | USA | < 12 years | 324 | Non-physician, no relaxants | Road | Overall intubation success rate, overall airway complication, oesophageal and endobronchial intubation rate | Low |
Gerritse 2010 [8] | Netherlands | < 16 years | (a) 86, (b) 214 | (a) Non-physician, no relaxants; (b) physician | (a) Helicopter, (b) road | Overall intubation success, overall airway complication, oesophageal intubation rate | Low |
Hansen 2015 [28] | USA | < 18 years | (a) 2444, (b) 408 | (a) Non-physician, no relaxants; (b) non-physician, with relaxants | Helicopter and road | Overall intubation success, oesophageal intubation rate | Moderate |
Hansen 2018 [29] | USA | < 18 years, transported cardiac arrests only | 35 | Non-physician, no relaxants | Road | Overall intubation success, multiple attempt rate | Low |
Harrison 2004 [30] | USA | < 13 years | 143 | Non-physician, with relaxants | Helicopter and road | Overall intubation and first look success, oesophageal intubation, hypoxia, multiple attempts | Moderate |
Heschl 2018 [31] | Australia | < 15 years | 87 | Non-physician, with relaxants | Helicopter | Overall intubation and first look success, oesophageal intubation, multiple attempts | Moderate |
Jarvis 2019 [32] | USA | < 15 years | (a) 406, (b) 49 | (a) Non-physician, no relaxants; (b) non-physician, with relaxants | Helicopter and road | First look success | Moderate |
Kumar 1997 [33] | USA | < 16 years, arrested patients only | 39 | Non-physician, no relaxants | Road | Overall intubation success rate | Moderate |
Lavery 1992 [34] | USA | < 19 years, trauma only | 14 | Non-physician, no relaxants | Road | Overall intubation success rate | Moderate |
Losek 1989 [35] | USA | < 19 years | 63 | Non-physician, no relaxants | Road | Overall intubation and first look success, multiple attempts | Low |
Losek 1994 [36] | USA | < 19 years | 193 | Non-physician, no relaxants | Road | Overall intubation success rate | Low |
Martinon 2011 [37] | France | 2–15 years, unintentional traumatic brain injury only | (a) 188, (b) 108 | (a) Physician before guideline; (b) physician after guidelines | Road | Overall success rate, overall airway complication rates, hypoxia | Moderate |
Moors 2018 [38] | Netherlands | < 17 years | (a) 79, (b) 103 | (a) Non-physician, no relaxants; (b) physician | (a) Road, (b) helicopter | Overall intubation success, oesophageal and endobronchial intubation | Low |
Nakayama 1990 [39] | USA | Trauma admissions to a paediatric trauma centre | 14 | Non-physician, no relaxants | Road | Overall intubation success, overall airway complication rate, oesophageal and endobronchial intubation rates | Moderate |
Nevin 2014 [40] | UK | < 16 years, trauma only | 315 | Physician | Helicopter and road | Overall intubation success, oesophageal intubation rate, multiple attempts | Low |
Paul 1999 [41] | USA | < 13 years, trauma only | 6 | Paramedic | Road | Overall intubation success rate | Moderate |
Pointer 1989 [42] | USA | < 15 years | 36 | Non-physician, no relaxants | Road | Overall intubation and first look success, overall airway complication, oesophageal and endobronchial intubation, multiple attempts | Low |
Prekker 2016 [43] | USA | < 13 years | 299 | Non-physician, with relaxants | Road | Overall intubation and first look success, overall airway complication, oesophageal and endobronchial intubation, aspiration rate, multiple attempts | Low |
Schmidt 2016 [9] | Switzerland | < 17 years | 215 | Physician | Helicopter | Overall intubation and first look success, oesophageal intubation | Low |
Simons 2017 [44] | Finland | < 16 years | 34 | Physician | Helicopter and road | Oesophageal and endobronchial intubation rate, aspiration rate | Moderate |
Sing 1996 [45] | USA | < 18 years, relaxant assisted cases only | 40 | Non-physician, with relaxants | Helicopter | Overall intubation and first look success, overall airway complication, oesophageal and endobronchial intubation, hypoxia, aspiration rate | Low |
Tarpgaard 2015 [46] | Denmark | < 16 years | 25 | Physician | Helicopter and road | Overall intubation and first look success, overall airway complication, oesophageal intubation, hypoxia, aspiration rate | Low |
Tollefsen 2013 [47] | USA | < 15 years | 260 | Non-physician, with relaxants | Helicopter | Overall intubation and first look success, oesophageal intubation, multiple attempts | Low |
Vilke 2002 [48] | USA | < 15 years | 324 | Non-physician, no relaxants | Helicopter and road | Overall intubation success, and oesophageal intubation | Low |
Quality assessment
Overall intubation and first-pass success rates
Adverse events
Outcome (total no. of studies) | Intubator group (total no. of children) | Pooled prevalence (%, 95% CI) | Intra-group heterogeneity (I2, P value) | Inter-group heterogeneity (P value) |
---|---|---|---|---|
Overall airway complications (16) | Non-physician without relaxants (536) | 39 (28–51) | 82.0%, P < 0.001 | P < 0.001 |
Non-physician with relaxants (667) | 30 (23–38) | 71.5%, P = 0.01 | ||
Physician with relaxants (772) | 10 (3–22) | 94.4%, P < 0.001 | ||
Oesophageal intubations (23) | Non-physician without relaxants (3136) | 4 (0–10) | 92.3%, P < 0.001 | P < 0.001 |
Non-physician with relaxants (1563) | 0 (0–1) | 58.1%, P = 0.02 | ||
Physician with relaxants (815) | 0 (0–0) | 0%, P = 0.98 | ||
Endobronchial intubations (13) | Non-physician without relaxants (311) | 11 (6–17) | 35.8%, P = 0.17 | P = 0.15 |
Non-physician with relaxants (610) | 10 (4–19) | 85.8%, P < 0.001 | ||
Physician with relaxants (260) | 3 (0–11) | 85.1%, P < 0.001 | ||
Pooled (1181) | 7 (3–12) | 86.2%, P < 0.001 | ||
Hypoxia (6) | Non-physician with relaxants (183) | 0 (0–1) | NR | P < 0.001 |
Physician with relaxants (468) | 7 (3–11) | 94.4%, P < 0.001 | ||
Aspiration (8) | Non-physician with relaxants (587) | 12 (4–23) | 90.6%, P < 0.001 | P < 0.001 |
Physician with relaxants (206) | 0 (0–2) | 0%, P = 0.47 | ||
≥ 3 intubation attempts (13) | Non-physician without relaxants (96) | 16 (6–28) | NR | P < 0.001 |
Non-physician with relaxants (816) | 6 (3–10) | 69.7%, P = 0.01 | ||
Physician with relaxants (544) | 1 (0–4) | 75.6%, P = 0.01 |
Outcomes by clinical population
Outcome | Patient population | Intubator group (total no. of studies, total no. of participants) | Pooled prevalence (%, 95% CI) | Intra-group heterogeneity (I2, P value) | Inter-group heterogeneity (P value) |
---|---|---|---|---|---|
Overall success | Mixed | Non-physician without relaxants (12, 6826) | 76 (71–80) | 90.0%, P < 0.001 | P < 0.001 |
Mixed | Non-physician with relaxants (6, 1160) | 96 (94–98) | 38.5%, P = 0.15 | ||
Mixed | Physician with relaxants (7, 1033) | 99 (95–100) | 86.1%, P < 0.001 | ||
Trauma | Non-physician without relaxants (4, 92) | 71 (50–89) | 65.4%, P = 0.03 | P < 0.001 | |
Trauma | Physician with relaxants (1, 315) | 100 (98–100) | NR | ||
Head injury | Non-physician without relaxants (1, 31) | 71 (53–84) | NR | P < 0.001 | |
Head injury | Non-physician with relaxants (1, 87) | 99 (94–100) | NR | ||
Head injury | Physician with relaxants (1, 108) | 100 (97–100) | NR | ||
Arrested | Non-physician without relaxants (4, 232) | 57 (49–64) | 22.5%, P = 0.28 | P < 0.001 | |
Arrested | Non-physician with relaxants (2, 469) | 90 (87–93) | NR | ||
Arrested | Physician with relaxants (1, 103) | 100 (96–100) | NR | ||
First-pass success | Mixed | Non-physician without relaxants (4, 577) | 55 (48–63) | 45.4%, P = 0.14 | P < 0.001 |
Mixed | Non-physician with relaxants (6, 801) | 73 (67–79) | 63.3%, P = 0.02 | ||
Mixed | Physician with relaxants (6, 794) | 91 (86–95) | 69.3%, P = 0.01 | ||
Trauma | Non-physician with relaxants (1, 59) | 66 (53–77) | NR | NA | |
Head injury | Non-physician with relaxants (1, 87) | 93 (86–97) | NR | NA | |
Arrested | Non-physician with relaxants (1, 434) | 70 (66–74) | NR | NA | |
Overall complications | Mixed | Non-physician without relaxants (5, 463) | 32 (20–45) | 83.7%, P < 0.001 | P = 0.01 |
Mixed | Non-physician with relaxants (3, 608) | 31 (22–40) | NR | ||
Mixed | Physician with relaxants (5, 476) | 8 (1–21) | 92.8%, P < 0.001 | ||
Trauma | Non-physician without relaxants (1, 14) | 43 (21–67) | NR | P = 0.26 | |
Trauma | Non-physician with relaxants (1, 59) | 27 (17–40) | NR | ||
Trauma | Pooled (2, 73) | 30 (19–41) | NR | ||
Head injury | Non-physician without relaxants (1, 31) | 68 (50–81) | NR | P < 0.001 | |
Head injury | Physician with relaxants (2, 296)* | 18 (14–23) | NR | ||
Arrested | Non-physician without relaxants (1, 28) | 46 (30–64) | NR | NA |