[Recommendations of the new S1 guidelines on airway management]. / Empfehlungen zur neuen S1-Leitlinie Atemwegsmanagement.

The German guidelines for airway management aim to optimize the care of patients undergoing anesthesia or intensive care. The preanesthesia evaluation is an important component for detection of anatomical and physiological indications for difficult mask ventilation and intubation. If predictors for a difficult or impossible mask ventilation and/or endotracheal intubation are present the airway should be secured while maintaining spontaneous breathing. In an unexpectedly difficult intubation, attempts to secure the airway should be limited to two with each method used. A video laryngoscope is recommended after an unsuccessful direct laryngoscopy. Therefore, a video laryngoscope should be available at every anesthesiology workspace throughout the hospital. Securing the airway should primarily be performed with a video laryngoscope in critically ill patients and patients at risk of pulmonary aspiration. Experienced personnel should perform or supervise airway management in the intensive care unit.

German guidelines for airway management 2023.

The German airway management guidelines are intended to serve as an orientation and decision-making aid and thus contribute to the optimal care of patients undergoing anesthesiologic- and intensive medical care. As part of the pre-anesthesiologic evaluation, anatomical and physiological indications for difficult mask ventilation and intubation shall be evaluated. This includes the assessment of mouth opening, dental status, mandibular protrusion, cervical spine mobility and existing pathologies. The airway shall be secured while maintaining spontaneous breathing if there are predictors or anamnestic indications of difficult or impossible mask ventilation and/or endotracheal intubation. Various techniques can be used here. If there is an unexpectedly difficult airway, a video laryngoscope is recommended after unsuccessful direct laryngoscopy, consequently a video laryngoscope must be available at every anesthesiology workplace. The airway shall primarily be secured with a video laryngoscope in critically ill- and patients at risk of aspiration. Securing the airway using translaryngeal and transtracheal techniques is the "ultima ratio" in airway management. The performance or supervision of airway management in the intensive care unit is the responsibility of experienced physicians and nursing staff. Appropriate education and regular training are essential. Clear communication and interaction between team members are mandatory before every airway management procedure. Once the airway has been secured, the correct position of the endotracheal tube must be verified using capnography.

Current practice of German anesthesiologists in airway management : Results of a national online survey.

BACKGROUND: There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners. OBJECTIVE: To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps. METHODS: A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices. RESULTS: A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a "cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques. CONCLUSION: Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.

[Manikin-based comparison of the use of different supraglottic airways by laypersons]. / Vergleich der Anwendung verschiedener extraglottischer Atemwegshilfen durch Laien am Phantom.

BACKGROUND: Supraglottic airways (SGA) are an established method of airway management both in prehospital medicine and clinical settings. Endotracheal intubation is the gold standard, but SGA offer advantages in terms of faster application learnability. OBJECTIVES: In the present study it was investigated whether the time until the first sufficient ventilation in the three examined SGAs applied by bystander differed significantly. MATERIALS AND METHODS: A total of 160 visitors to a shopping mall were assigned to one of the three SGA after permutative block randomization. The primary endpoint of the present study was the required placement time until the first sufficient ventilation. RESULTS: Participants managed to place the i­gel laryngeal mask airway (i-gel, Intersurgical Beatmungsprodukte GmbH, Sankt Augustin, Germany) after a median time of 11 s, whereas the median time until the first sufficient ventilation using a classic laryngeal mask airway (LMA; 26 s) or a laryngeal tube (LT; 28 s) was significantly longer. Thus, the time savings when using the i­gel compared to the LT and LMA were each significant (p < 0.001), whereas the times between LT and LMA did not differ significantly (p 0.65). CONCLUSION: The results show that laypersons are able to successfully apply various supraglottic airways to the phantom after a short learning period. The i­gel laryngeal mask could be placed with the highest success rate and speed.

The Orogastric Tube Guide® as a novel strategy for gastric tube insertion: a prospective, randomized controlled clinical trial.

BACKGROUND: Gastric tube insertion, either orally or nasally, is daily practice in anesthesia and intensive care. "Blind" insertion represents the common conventional method and is associated with low first-pass success and frequent complications. This trial aimed to evaluate the novel gastric tube guide as a rigid conduit in regard to insertion success rate, time required and associated complications versus the conventional "blind" insertion method. We hypothesized that the insertion success rate is higher using the Orogastric tube guide. METHODS: This trial was approved by ethics committee prior to patient recruitment. In a randomized order, anesthetists performed oral insertion of a gastric tube either with the Orogastric tube guide (GTG) or by conventional "blind" technique (CONV) in elective surgical patients. Exclusion criteria were defined as age under 18 years, pregnancy, emergency surgery and patients without indication for tracheal intubation and gastric tube insertion. RESULTS: We examined 151 patients (GTG, N.=71; CONV, N.=80). The success rate was higher with the GTG compared to the conventional method (69/71 (97%) vs. 61/80 (76%); P<0.001). The median insertion time was 25 s (IQR 20-39) using the GTG and 31 s (IQR 24-58; P=0.027) with the conventional method. We found no differences with regard to complications between the groups (P=0.54). CONCLUSIONS: Our findings suggest that the use of the GTG facilitates and fastens orogastric tube placement in anesthetized patients and thereby constitutes a benefit in clinical routine.

Red blood cell transfusion in perioperative pediatric anesthesia: a survey of current practice in Germany.

BACKGROUND: Little is known about the current practice of the perioperative transfusion of red blood cells (RBCs) in pediatric patients. This study was performed to evaluate the practice of RBC transfusion in German pediatric anesthesia. STUDY DESIGN AND METHODS: An online survey was conducted among members of the German Society of Anesthesiology and Intensive Care. Participants were asked to indicate the hemoglobin (Hb) thresholds for starting RBC transfusion in six cases of different bleeding situations in pediatric anesthesia. Demographics of participants, general knowledge, and application of transfusion rules and guidelines were assessed. RESULTS: We included 1207 of 1396 returned questionnaires. Of the respondents, 89% were qualified specialists and 68% had experience in anesthesia in children aged less than 6 months. The lowest median Hb transfusion threshold was 6 g/dL in a 16-year-old and the highest was 10 g/dL in a premature neonate. Intraoperative Hb thresholds increased for clinically unstable (median difference to clinically stable children, +1 g/dL; p < 0.001) or neonate and premature children (median difference to older children, +1 and +2 g/dL; p < 0.001). The stated Hb threshold ranges were broad, especially in neonates or premature children (interquartile range, neonates 3, premature children 4 g/dL). Of the participants, only 16% had knowledge of a guideline that includes blood transfusion in children. CONCLUSION: Striking variability exists in practice of perioperative pediatric RBC transfusion. A specialized guideline for perioperative blood transfusion in children could be helpful to define and promote optimal pediatric RBC transfusion strategies.

Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: the randomised multicentre EMMA trial study protocol.

INTRODUCTION: The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients. METHODS AND ANALYSIS: The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications. ETHICS AND DISSEMINATION: The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT 02611986; pre-results.

Orogastric tube insertion using the new gastric tube guide: first experiences from a manikin study.

BACKGROUND: Orogastric tube placement is a common procedure routinely used in clinical anesthesiology and intensive care medicine. Nevertheless high failure rates and severe complications have been reported. We conducted this study to evaluate if the usage of the new gastric tube guide would speed up the placement of orogastric tubes and ease the procedure. METHODS: Thirty one professionals were given a hands-on-training in orogastric tube placement in a simulation manikin without and with the gastric tube guide. Afterwards they performed both methods in randomized order. We recorded the placement time, counted the required attempts and asked the participants to rate their experience with both methods. RESULTS: The median placement time using the gastric tube guide was 14 s compared to 25 s without the device. In addition all participants were able to place the orogastric tube when using the gastric tube guide compared to 26/31 (84%) without it. Furthermore 26/31 (84%) users preferred the gastric tube guide over the standard method. CONCLUSION: Our results show that using the gastric tube guide to place orogastric tubes in a manikin led to a significant shorter placement time and a higher overall success rate.

Evaluation of the optimal cuff volume and cuff pressure of the revised laryngeal tube "LTS-D" in surgical patients.

BACKGROUND: Recent case reports have indicated significant cuff overinflation when using the standard filling volume based on the manufacturer's recommendations in older models of laryngeal tubes. The aim of this study was to determine the minimum cuff pressure needed to perform standardized ventilation without leakage in the new, revised model of the laryngeal tube "LTS-D". METHODS: After ethical approval, LTS-D was placed for ventilation in 60 anesthetized patients. The cuff was inflated to the recommended volume (#3: 60 ml, #4: 80 ml, and #5: 90 ml). After evaluation of the initial cuff pressure (CP), the CP was lowered in 10 cmH2O steps until a minimal cuff pressure of 30 cmH2O was achieved. The absence of an audible leak was required for a step-by-step reduction in the CP. Evacuated cuff volume, success rate, and airway injuries were documented. Data were expressed as medians (interquartile ranges [IQRs]). The comparison of CPs and cuff volumes was performed using the Mann-Whitney test. RESULTS: After initial inflation, the CP ranged from 105 cmH2O [90-120; #5] to 120 cmH2O [110-120; #3]. Lowering the CP to 60 cmH2O resulted in a reduced cuff volume ranging from 47 ml [44-54; #3] to 77 ml [75-82; #5] compared to the initial inflation (p < 0.001). Leakage occurred more frequently when the CP was lowered to 40 cmH2O compared to the initial inflation (44/54 [81%]; p < 0.01). Using a CP between 50 cmH2O and 60 cmH2O, a leakage rate of 3/54 (5%) was observed, compared to a rate of 11/54 (21%) when using a CP lower than 50 cmH2O. The overall success rate was 90%, and airway injury occurred in 7% of patients (4/60). CONCLUSION: We found significant overinflation of the revised LTS-D using the recommended volume for initial cuff inflation. A CP of 60 cmH2O was found to be sufficient for ventilation in the majority of patients evaluated. Checking and adjusting the CP in laryngeal tubes is mandatory to avoid overinflation. TRIAL REGISTRATION: ClinicalTrials.gov NCT02300337 . Registered: 20 November 2014.

LMA Supreme™ and Ambu® AuraGain™ in anesthetized adult patients: a prospective observational study.

BACKGROUND: Second-generation laryngeal masks with gastric access are increasingly used in daily practice and expand the indications for laryngeal masks in the OR. Only limited data exist comparing different types of laryngeal masks. We investigated the second-generation laryngeal masks LMA Supreme™ and Ambu® AuraGain™ in a clinical setting. We hypothesized that the two devices would be comparable in terms of success rate and airway complications. METHODS: After approval from the local ethics committee, data were collected in a prospective trial. Endpoints were success rate, time to insertion and airway morbidity. Anesthesiologists used either the Supreme (Teleflex Medical GmbH) or Gain (Ambu GmbH) laryngeal mask. Patients <18 years and those with a possible risk of regurgitation were excluded. RESULTS: Data from 351 adult patients were documented (Supreme N.=177; Gain N.=174). Success rate for first attempt was 80% (Supreme) and 72% (Gain; P=0.08). Overall success rate was 89% and 92%, respectively (P=0.38). Providers with minimal experience were more successful at first attempt using Supreme (95%), compared to Gain (67%; P=0.01). The median insertion time was shorter in Supreme at 18 s [interquartile range (IQR), 14-25 s] compared to 30 s for Gain [18-41s] (P<0.0001). A higher incidence of airway complications was observed after device removal for Gain (P=0.009). CONCLUSIONS: Supreme was superior to Gain in terms of insertion time and airway morbidity. Novices were more successful at first attempt using Supreme. These differences between supraglottic airway devices might be due to the different shapes and materials of the masks.

Bonfils intubation fibrescope: use in simulation-based intubation training for medical students in comparison to MacIntosh laryngoscope.

BACKGROUND: A variety of instruments are used to perform airway management by tracheal intubation. In this study, we compared the MacIntosh balde (MB) laryngoscope with the Bonfils intubation fibrescope as intubation techniques. The aim of this study was to identify the technique (MB or Bonfils) that would allow students in their last year of medical school to perform tracheal intubation faster and with a higher success probability. Data were collected from 150 participants using an airway simulator ['Laerdal Airway Management Trainer' (Laerdal Medical AS, Stavanger, Norway)]. The participants were randomly assigned to a sequence of techniques to use. Four consecutive intubation 'trials' were performed with each technique. These trials were evaluated for differences in the following categories: the 'time to successful ventilation', 'success probability' within 90 s,'time to visualisation' of the vocal cords (glottis), and 'quality of visualisation' according to the Cormack and Lehane score (C&L, grade 1-4). The primary endpoint was the 'time to successful ventilation'in the fourth and final trial. RESULTS: There was no statistically significant difference in the 'time to successful ventilation' between the two techniques in trial 4 ('time to successful ventilation': median: MB: 16 s, Bonfils: 14 s, p = 0.244). However, the 'success probability' within 90 s was higher when using a Macintosh blade than when using a Bonfils (95 vs. 87%). The glottis could be better visualised when using a Bonfils (C&L score of 1 (best view): MB: 41%, Bonfils: 93%), but visualisation was achieved more rapidly when using a Macintosh blade (median: 'time to visualisation': MB: 6 s, Bonfils: 8 s, p = 0.003). CONCLUSIONS: The time to ventilation using the MacIntosh blade and Bonfils mainly did to differ, however success probabilities and time to visualisation primary favoured the MacIntosh blade as intubation technique, although the Bonfils seem to have a steeper learning curve. The Bonfils is still a promising intubation technique and might be easier to learn as the MB, at least in a manikin.

Airway management techniques in a restricted-access situation: a manikin study.

BACKGROUND: Access to patients can be restricted in emergency situations. A variety of techniques and devices are available for use in patients who require oxygenation in a restricted-access situation. OBJECTIVES: The aim of this study was to investigate whether there is one ventilation technique that is superior to others. MATERIALS AND METHODS: Fifty-four emergency medical services providers including emergency medical technicians, paramedics and physicians were asked to use a bag-valve mask (BVM), a laryngeal mask airway (LMA), and a laryngeal tube (LT) to ventilate a full-scale manikin sitting upright in the driver's seat of a motor vehicle. Access to the manikin was gained through the side window and from the backseat. RESULTS: There were significant differences in time to first successful ventilation between the two approaches for access to the airway. The fastest median time to ventilation was obtained with the BVM (7 and 8 s), followed by the LT (13 and 14 s) and the LMA (15 s for both types of access). Overall success rates were 97.2% for the BVM, 96.3% for the LMA, and 100% for the LT. Most participants needed two attempts for each device. There were no significant differences between participants depending on the level of qualification or professional experience. The BVM was rated the lowest and the LT was rated the highest for ease of use. CONCLUSION: Supraglottic airway devices appear to offer advantages in restricted-access situations.

[Hyperbaric therapy and diving medicine - diving medicine - present state and prospects]. / Hyperbare Therapie und Tauchmedizin - Tauchmedizin: Status quo und Ausblick.

The diving accident (decompression incident, DCI) occurs in the decompression phase of dives. The DCI can either be caused by an arterial gas embolism (AGE) subsequent to a pulmonary barotrauma or by the formation of inert gas bubbles subsequent to a reduction of ambient pressure during the ascent from depth. In contrast to the traditional assumption that decompression incidents only occur if decompression rules are neglected, recent data indicate that a vast amount of diving accidents occur even though divers adhered to the rules. Hence, there is a large inter- and intraindividual variability in the predisposition for diving accidents. Within the past few years, the molecular understanding of the pathophysiology of diving accidents has improved considerably. It is now well accepted that pro-inflammatory and pro-coagulatory mechanisms play a central role. Moreover, microparticles are increasingly discussed in the pathogenesis of diving accidents. These new molecular findings have not yet resulted in new therapeutic approaches. However, new approaches of preconditioning before the dive have been developed which are intended to reduce the risk of diving accidents. The symptoms of a diving accident show a large variability and range. They reach from pruritus over tension in the female breast, marbled skin and pain in the joints to severe neurological disability like paraplegia or hemiplegia. Furthermore, pulmonary symptoms can be a result of a pulmonary gas embolism and/or a tension pneumothorax. Extreme cases can also manifest as generalized, difficult-to-treat seizures, loss of consciousness or even death. The evidence-based therapy of diving accidents consists of an immediate application of 100% inspiratory O2. This can be performed via a demand valve, face mask with reservoir bag or ventilation bag connected to a reservoir bag. Fluid substitution is performed by i. v. infusion of 500-1000ml/h of cristalloids. If consciousness is not impaired, the diver is positioned in a supine position, in case of impaired or absent consciousness in a lateral recovery position. Especially in severe cases of DCI a fast transfer to a qualified hyperbaric center and the earliest possible hyperbaric O2-therapy is essential.

The novel intubating laryngeal tube (iLTS-D) is comparable to the intubating laryngeal mask (Fastrach) - a prospective randomised manikin study.

BACKGROUND: Supraglottic devices are helpful for inexperienced providers who perform ventilation in emergency situations. Most supraglottic devices do not allow secondary tracheal intubation through the device. The novel intubating laryngeal tube (iLTS-D) and the intubating laryngeal mask (Fastrach) are devices that offer supraglottic ventilation and secondary tracheal intubation. METHODS: We evaluated the novel iLTS-D and compared it to the established Fastrach using a manikin-based study. Participants used both devices in a randomised order. The participants conducted four consecutive trials on a manikin. One trial was composed of the following procedures. First, participants ventilated the manikin using either iLTS-D or Fastrach. 'Time to ventilation', success rates and number of attempts were recorded for the supraglottic device. Second, participants intubated the manikin through the previously inserted supraglottic device. 'Time to tracheal ventilation', success rate and tube localisation were recorded. The primary endpoint was the results of the final fourth trial, which mirrored the standardised training of trials 1, 2 and 3. RESULTS: A total of 64 participants were enrolled. All of the participants successfully inserted both devices on their first attempt in trial 4. Fastrach was applied 1 s faster in trial 4 than the iLTS-D (median 'time to ventilation' Fastrach: 13.5 s., iLTS-D: 14.5 s., p = 0.04). All participants successfully intubated through both devices in trial 4. There was no difference in 'time to tracheal ventilation' by tracheal intubation between either device (median 'time to tracheal ventilation': Fastrach: 14.0 s., iLTS-D: 14.0 s., p = 0.16). CONCLUSION: The iLTS-D performed similarly to the ILMA in insertion and intubation times in a manikin setting.

Endotracheal intubation using the C-MAC® video laryngoscope or the Macintosh laryngoscope: a prospective, comparative study in the ICU.

INTRODUCTION: Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC® video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy. METHODS: In a single-center, prospective, comparative before-after study in an anesthetist-lead surgical ICU of a tertiary university hospital, predictors of potentially difficult tracheal intubation, number of intubation attempts, success rate and glottic view were evaluated during a 2-year study period (first year, Macintosh laryngoscopy (ML); second year, C-MAC®). RESULTS: A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC® were assessed. In patients with at least one predictor for difficult intubation, the C-MAC® resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC® (7%, C&L grade 3 and 4) (P < 0.0001). CONCLUSION: Use of the C-MAC® video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations regularly occur.

Comparison of the McGrath® Series 5 and GlideScope® Ranger with the Macintosh laryngoscope by paramedics.

BACKGROUND: Out-of-hospital endotracheal intubation performed by paramedics using the Macintosh blade for direct laryngoscopy is associated with a high incidence of complications. The novel technique of video laryngoscopy has been shown to improve glottic view and intubation success in the operating room. The aim of this study was to compare glottic view, time of intubation and success rate of the McGrath® Series 5 and GlideScope® Ranger video laryngoscopes with the Macintosh laryngoscope by paramedics. METHODS: Thirty paramedics performed six intubations in a randomised order with all three laryngoscopes in an airway simulator with a normal airway. Subsequently, every participant performed one intubation attempt with each device in the same manikin with simulated cervical spine rigidity using a cervical collar. Glottic view, time until visualisation of the glottis and time until first ventilation were evaluated. RESULTS: Time until first ventilation was equivalent after three intubations in the first scenario. In the scenario with decreased cervical motion, the time until first ventilation was longer using the McGrath® compared to the GlideScope® and AMacintosh (p < 0.01). The success rate for endotracheal intubation was similar for all three devices. Glottic view was only improved using the McGrath® device (p < 0.001) compared to using the Macintosh blade. CONCLUSIONS: The learning curve for video laryngoscopy in paramedics was steep in this study. However, these data do not support prehospital use of the McGrath® and GlideScope® devices by paramedics.

Lay basic life support: the current situation in a medium-sized German town.

OBJECTIVE: Basic life support (BLS) by laypersons is essential for surviving sudden cardiac death in the community. The present study investigates BLS skill knowledge of German laypersons in a public community place and examines the effect of the interval between the last BLS course and present skills in cardiopulmonary resuscitation (CPR). METHODS: Participants were randomly recruited at a public place in a medium-sized German town. Volunteers were confronted with a fictitious cardiac arrest situation using a BLS training manikin and were asked to help. Using a standardised evaluation sheet, measures were documented. Participants' demographic data were evaluated after completion of the scenario. RESULTS: None of the participants (n=89; male=42, female=47) followed the current BLS algorithm correctly; independent from the last CPR course was attended. Most steps were performed in random order. 43% (n=38) of participants checked for responsiveness, 65% (n=58) performed chest compressions, and 63% (n=56) delivered rescue breathing. 10% (n=9) of participants were unable to name a national emergency telephone number. Laypersons who attended a BLS course more than 10 years ago showed a significant lack of BLS knowledge and failed more often to deliver chest compressions and rescue breathing. CONCLUSIONS: The present study demonstrates that current CPR guidelines for BLS are not followed by laypersons in a medium-sized town in Germany. These data suggest that CPR refresher courses as well as implication of BLS guidelines in daily life are warranted.

Rigid fibrescope Bonfils: use in simulated difficult airway by novices.

BACKGROUND: The Bonfils intubation fibrescope is a promising alternative device for securing the airway. We examined the success rate of intubation and the ease of use in standardized simulated difficult airway scenarios by physicians. We compared the Bonfils to a classical laryngoscope with Macintosh blade. METHODS: 30 physicians untrained in the use of rigid fibrescopes but experienced in airway management performed endotracheal intubation in an airway manikin (SimMan, Laerdal, Kent, UK) with three different airway conditions. We evaluated the success rate using the Bonfils (Karl Storz, Tuttlingen, Germany) or the Macintosh laryngoscope, the time needed for securing the airway, and subjective rating of both techniques. RESULTS: In normal airway all intubations were successful using laryngoscope (100%) vs. 82% using the Bonfils (p < 0.05). In the scenario "tongue oedema" success rate using the Macintosh laryngoscope was 67% and 83% using the Bonfils. In the scenario "decreased cervical range of motion with jaw trismus", success rate using the Macintosh laryngoscope was 84% vs. 76%. In difficult airway scenarios time until airway was secured did not differ between the two devices. Use of Bonfils was rated "easier" in both difficult airway scenarios. CONCLUSION: The Bonfils can be successfully used by physicians unfamiliar with this technique in an airway manikin. The airway could be secured with at least the same success rate as using a Macintosh laryngoscope in difficult airway scenarios. Use of the Bonfils did not delay intubation in the presence of a difficult airway. These results indicate that intensive special training is advised to use the Bonfils effectively in airway management.