title: A mannequin study of intubation with the AP advance and GlideScope Ranger videolaryngoscopes and the Macintosh laryngoscope.
abstract: BACKGROUND
  The AP Advance (APA) is a videolaryngoscope with interchangeable blades: intubators can choose standard Macintosh blades or a difficult-airway blade with increased curvature and a channel to guide the tube to the larynx. The APA may therefore be comparably effective in both normal and difficult airways. We tested the hypotheses that intubation with the APA is no slower than Macintosh laryngoscopy for normal mannequin airways, and that it is no slower than videolaryngoscopy using a GlideScope Ranger in difficult mannequin airways.
  
  
  METHODS
  Medical professionals whose roles potentially include tracheal intubation were trained with each device. Participants intubated simulated (Laerdal SimMan) normal and difficult airways with the APA, GlideScope, and a conventional Macintosh blade. Speed of intubation was compared using Cox proportional hazards regression, with a hazard ratio >0.8 considered noninferior. We also compared laryngeal visualization, failures, and participant preferences.
  
  
  RESULTS
  Unadjusted intubation times in the normal airway with the APA and Macintosh were virtually identical (median, 22 vs 23 seconds); after adjustment for effects of experience, order, and period, the hazard ratio (95% confidence interval) comparing APA with Macintosh laryngoscopy was 0.87 (0.65, 1.17), which was not significantly more than our predefined noninferiority boundary of 0.8 (P = 0.26). Intubation with the APA was faster than with the GlideScope in difficult airways (hazard ratio = 7.6 [5.0, 11.3], P < 0.001; median, 20 vs 59 seconds). All participants intubated the difficult airway mannequin with the APA, whereas 33% and 37% failed with the GlideScope and Macintosh, respectively. In the difficult airway, 99% of participants achieved a Cormack and Lehane grade I to II view with the APA, versus 85% and 33% with the GlideScope and Macintosh, respectively. When asked to choose 1 device overall, 82% chose the APA.
  
  
  CONCLUSIONS
  Intubation times were similar with the APA and Macintosh laryngoscopes in mannequins with normal airways. However, intubation with the APA was significantly faster than with the GlideScope in the difficult mannequin simulation.
authors: Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA. jackhodd@gmail.com
authors: Jack A R
authors: JA
authors: Hodd
authors: D John
authors: DJ
authors: Doyle
authors: Shipra
authors: S
authors: Gupta
authors: Jarrod E
authors: JE
authors: Dalton
authors: Juan P
authors: JP
authors: Cata
authors: Edward J
authors: EJ
authors: Brewer
authors: Monyulona
authors: M
authors: James
authors: Daniel I
authors: DI
authors: Sessler
mesh_terms: D002983:Clinical Competence; D018592:Cross-Over Studies; D004867:Equipment Design; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000295:instrumentation*; D020704:Laryngoscopes / Q000009:adverse effects; D007828:Laryngoscopy / Q000009:adverse effects / Q000295:instrumentation*; D016015:Logistic Models; D008348:Manikins; D016017:Odds Ratio; D009820:Ohio; D016016:Proportional Hazards Models; D013647:Task Performance and Analysis; D013997:Time Factors; D014741:Video Recording