title: Does position of the patient adversely affect successful intubation whilst wearing CBRN-PPE?
abstract: BACKGROUND
  Following a CBRN incident attending medical personnel will be required to instigate life saving airway interventions whilst wearing CBRN-PPE. CBRN-PPE is known to adversely affect fine motor skill but little is known about whether the position of the patient compounds this problem.
  
  
  METHODS
  Seventy-five clinicians were recruited and performed intubation and insertion of a LMA in to a manikin whilst wearing CBRN-PPE. Both skills were completed twice with the manikin positioned on a bench and once on the floor. Following completion of the study 25 participants (a minimum of 2 participants from each professional group) were interviewed to ascertain their experiences. The recruitment of a non-homogenous group allowed for subgroup analysis with regards the potential impact of professional background on skill performance.
  
  
  RESULTS
  9.33% first attempts at intubation at waist height ended in failure but this reduced to 4% on the second attempt. This improvement was reversed with the manikin on the floor where the failure rate was 26.67%. Intubation on the floor took significantly longer to perform, being 45.9 s slower than the first attempt at intubation in the optimal position [95% CI (30.7 s, 61.1 s); p<0.001] and 62.4 s longer than the second [95% CI (48.4 s, 76.3 s); p<0.001]. LMA insertion was successful at all attempts, regardless of the manikins position. LMA placement on the floor was no slower than the second attempt at waist height (p=0.231) and faster than the first attempt at waist height (by 4.8 s [95% CI (3.4 s, 6.1 s); p<0.001]). Anaesthetists were consistently the fastest at performing all airway skills regardless of the position of the manikin but previous exposure to wearing CBRN-PPE had no statistically significant impact on skill performance. All 25 clinicians interviewed had difficulty in viewing the larynx with the manikin positioned on the floor regardless of being an experienced 'on floor' intubator with the movement of the CBRN-PPE hood being the principle reason. This is in contrast to only three participants noting issues with vision whilst standing-up.
  
  
  CONCLUSIONS
  the position of the patient is likely to be an independent factor when choosing to either intubate or insert a LMA whilst wearing the current NHS CBRN-PPE.
authors.affiliation: Department of EMC&R, Durban University of Technology Durban, KwaZulu Natal, South Africa. Castle.nicholas@gmail.com
authors.forename: Nicholas
authors.initials: N
authors.lastname: Castle
authors.forename: Robert
authors.initials: R
authors.lastname: Owen
authors.forename: Simon
authors.initials: S
authors.lastname: Clarke
authors.forename: Mark
authors.initials: M
authors.lastname: Hann
authors.forename: David
authors.initials: D
authors.lastname: Reeves
authors.forename: Ian
authors.initials: I
authors.lastname: Gurney
mesh_terms: D001049:Apnea / Q000628:therapy; D055885:Biohazard Release; D055884:Chemical Hazard Release; D006801:Humans; D007407:Interviews as Topic; D007442:Intubation, Intratracheal / Q000379:methods*; D017214:Laryngeal Masks; D008348:Manikins; D056888:Patient Positioning / Q000009:adverse effects*; D011482:Protective Devices; D018788:Radioactive Hazard Release