Effect of real-time carbon dioxide sensing stylet-assisted endotracheal intubation: A case-crossover manikin simulation study

• Published in: The American journal of emergency medicine Vol. 95; pp. 124 - 128
• Main Authors: Kim, Yoonjic, Joo, Yoon Ha, Kim, Ki Hong, Choi, Dong Hyun, Kang, Hyun Jeong, Hong, Ki Jeong, Song, Kyoung Jun, Shin, Sang Do
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.09.2025; Elsevier Limited
• Subjects: Capnography; Capnography - methods; Carbon dioxide; Carbon Dioxide - analysis; Cardiopulmonary resuscitation; Cardiopulmonary Resuscitation - methods; Copper; CPR; Cross-Over Studies; Crossover study; Emergency; Emergency medical technician; Emergency procedures; Endotracheal intubation; Esophagus; Female; Gases; Humans; Immobilization; Intubation; Intubation, Intratracheal - instrumentation; Intubation, Intratracheal - methods; Laryngoscopy; Male; Manikins; Physiology; Questionnaires; Respiratory therapy; Respiratory tract; Sensors; Silicones; Simulation; Statistical analysis; Success; Usability; United States > US; Respiratory therapy; Emergency medical technician; Capnography; Crossover study; Endotracheal intubation
• ISSN: 0735-6757; 1532-8171; 1532-8171
• DOI: 10.1016/j.ajem.2025.05.047

Endotracheal intubation is an important emergency procedure, especially in critical care settings. Capnography-guided intubation (CGI) is a technology that may enhance procedural efficiency. This study aimed to compare the effectiveness of CGI with conventional intubation (CI) using a manikin simulation. A case-crossover manikin simulation study was conducted with three clinical scenarios: normal airway, cervical immobilization, and cardiopulmonary resuscitation. A CO2-exhalation simulation manikin was developed for this purpose. Participants were randomly assigned to perform CGI or CI first, followed by the alternative method. The primary outcome was the first-attempt success rate, and the secondary outcome was the procedure time of intubation. A linear mixed-effects model with a random effect for each subject was applied. A total of 40 participants were enrolled, and 20 in each study group. The first-attempt success rate was higher with CGI than CI across all clinical situations, with statistically significant differences in the normal airway and cervical immobilization settings. Specifically, for the normal airway, the success rate was 40 (100.0 %) for CGI vs. 33 (82.5 %) for CI [abs diff: 17.5 %, 95 % CI: 5.7 %–29.3 %]; for cervical immobilization, 39 (97.5 %) vs. 32 (80.0 %) [abs diff: 17.5 %, 95 % CI: 4.2 %–30.8 %]; and for cardiopulmonary resuscitation, 40 (100.0 %) vs. 38 (95.0 %) [abs diff: 5.0 %, 95 % CI: −1.8 %-11.8 %]. The intubation time was shorter with CGI in the normal airway and cervical immobilization scenarios. The median [interquartile range (IQR)] time for normal airway was 23.5 (19.2–28.4) sec for CGI vs. 31.6 (22.2–59.7) sec for CI, and for cervical immobilization, 24.4 (20.4–30.8) sec for CGI vs. 28.6 (22.6–56.9) sec for CI. In cardiopulmonary resuscitation, the median [IQR] was 23.1 (19.6–31.4) sec for CGI vs. 25.1 (18.6–32.4) sec for CI. In the manikin-based randomized crossover simulation, CGI achieved a higher first-attempt success rate and shorter intubation time than CI in the normal airway and cervical immobilization scenarios.