Endotracheal intubation during chest compressions in the pediatric simulation setting: a systematic review and meta-analysis

Endotracheal intubation (ETI) in the pediatric setting is a complex skill and performing ETI during pediatric cardiopulmonary resuscitation is even more challenging. Simulation studies have investigated the performances of several devices for ETI. We undertook a systematic review and meta-analysis to evaluate the performances of devices for ETI during simulated pediatric on-going chest compressions. Devices were divided in four groups: direct laryngoscopy (DL) with Macintosh or Miller blade, or videolaryngoscopy with screen-on-device (VLS-SoD) or with distant monitor (VLS-DM). Primary outcomes were overall success rate (SR) and time-to-intubation (TTI). Results are expressed as Risk Ratio (RR) or Mean Difference (MD) with 95% confidence interval. We included 12 studies comparing at least two devices. The SR was greater for VLS as compared to DL-Miller (RR: 0.83 (0.78; 0.89), p < 0.00001) or DL-Macintosh (RR: 0.81 (0.77; 0.85), p < 0.00001). Subgroup analyses confirmed that both types of VLS were superior to DL-Miller (VLS-DM: p = 0.03; VLS-SoD: p < 0.00001) or DL-Macintosh (both VLSs: p < 0.00001). As compared with VLS, TTI was longer with both DL blades: Miller (MD: 8.26 seconds (5.30; 11.21), p < 0.00001) or Macintosh blade (MD: 7.63 seconds (4.14; 11.12), p < 0.00001). In the subgroup analyses, VLS-SoD was superior to DL-Miller or DL-Macintosh (both p < 0.00001), while VLS-DM was superior to DL-Macintosh (p < 0.00001), possibly not to DL-Miller (p = 0.06). Under simulated conditions of ongoing pediatric resuscitation, use of VLS guarantees higher overall SR and shorter TTI as compared to DL performed with Miller or Macintosh blade. Among VLSs, those with screen-on-device may have better performances that those with distant monitor.