Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Systematic Review

Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis

Intubação traqueal usando equipamento de proteção individual em estudos de simulação: uma revisão sistemática e metanálise com análise sequencial de ensaios

Filippo Sanfilippo, Stefano Tigano, Valeria La Rosa, Alberto Morgana, Paolo Murabito, Francesco Oliveri, Federico Longhini, Marinella Astuto

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Tracheal intubation in patients with coronavirus disease-19 is a high-risk procedure that should be performed with personal protective equipment (PPE). The influence of PPE on operator’s performance during tracheal intubation remains unclear.

We conducted a systematic review and meta-analysis of simulation studies to evaluate the influence of wearing PPE as compared to standard uniform regarding time-to-intubation (TTI) and success rate. Subgroup analyses were conducted according to device used and operator’s experience.

The TTI was prolonged when wearing PPE (eight studies): Standard Mean Difference (SMD) -0.54, 95% Confidence Interval [-0.75, -0.34],p <  0.0001. Subgroup analyses according to device used showed similar findings (direct laryngoscopy, SMD -0.63 [-0.88, -0.38], p < 0.0001; videolaryngoscopy, SMD -0.39 [-0.75, -0.02], p =  0.04). Considering the operator’s experience, non-anesthesiologists had prolonged TTI (SMD -0.75 [-0.98, -0.52], p < 0.0001) while the analysis on anesthesiologists did not show significant differences (SMD -0.25 [-0.51, 0.01], p = 0.06). The success rate of tracheal intubation was not influenced by PPE: Risk Ratio (RR) 1.02 [1.00, 1.04]; p = 0.12). Subgroup analyses according to device demonstrated similar results (direct laryngoscopy, RR 1.03 [0.99, 1.07], p = 0.15, videolaryngoscopy, RR 1.01 [0.98, 1.04], p =  0.52). Wearing PPE had a trend towards negative influence on success rate in non-anesthesiologists (RR 1.05 [1.00, 1.10], p =  0.05), but not in anesthesiologists (RR 1.00 [0.98, 1.03], p =  0.84). Trial-sequential analyses for TTI and success rate indicated robustness of both results.

Under simulated conditions, wearing PPE delays the TTI as compared to dressing standard uniform, with no influence on the success rate. However, certainty of evidence is very low. Performing tracheal intubation with direct laryngoscopy seems influenced to a greater extent as compared to videolaryngoscopy. Similarly, wearing PPE affects more the non-anesthesiologists subgroup as compared to anesthesiologists.


Direct laryngoscopy;  Videolaryngoscopy;  Anesthesiologists;  Paramedics;  Time to intubation;  Success rate


Introdução: A intubação traqueal em pacientes com doença por coronavírus-19 é um procedimento de alto risco que deve ser realizado com equipamento de proteção individual (EPI). A influência do EPI no desempenho do operador durante a intubação traqueal permanece incerta. Métodos: Realizamos uma revisão sistemática e meta-análise de estudos de simulação para avaliar a influência do uso de EPI em comparação ao uniforme padrão em relação ao tempo de intubação (TI) e taxa de sucesso. As análises de subgrupo foram realizadas de acordo com o dispositivo usado e a experiência do operador. Resultados: O ITT foi prolongado com o uso de EPI (oito estudos): Diferença Média Padrão (DMP) -0,54, Intervalo de Confiança de 95% [-0,75, -0,34], p < 0,0001. As análises de subgrupos de acordo com o dispositivo utilizado mostraram achados semelhantes (laringoscopia direta, DMP -0,63 [-0,88, -0,38], p < 0,0001; videolaringoscopia, DMP -0,39 [-0,75, -0,02], p = 0,04). Considerando a experiência do operador, os não anestesiologistas apresentaram TI prolongado (DMP -0,75 [-0,98, -0,52], p < 0,0001), enquanto a análise dos anestesiologistas não mostrou diferenças significativas (DMP -0,25 [-0,51, 0,01], p = 0,06). A taxa de sucesso da intubação traqueal não foi influenciada pelo EPI: Proporção de Risco (PR) 1,02 [1,00, 1,04]; p = 0,12). As análises de subgrupo de acordo com o dispositivo demonstraram resultados semelhantes (laringoscopia direta, RR 1,03 [0,99, 1,07], p = 0,15, videolaringoscopia, PR 1,01 [0,98, 1,04], p = 0,52). O uso de EPI teve uma tendência de influência negativa na taxa de sucesso em não anestesiologistas (RR 1,05 [1,00, 1,10], p = 0,05), mas não em anestesiologistas (RR 1,00 [0,98, 1,03], p = 0,84). Análises de ensaios sequenciais para TI e taxa de sucesso indicaram robustez de ambos os resultados.


Laringoscopia direta; Videolaringoscopia; Anestesiologistas; Paramédicos; Tempo para intubação; Taxa de sucesso


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