Discussion
REGRESSION, CARDIAC ARREST
In our randomized manikin study, we were able to show that during ongoing chest compressions a higher FPS rate can be achieved and that the time until successful intubation is significantly shorter with VL compared to DL.To improve the chances of a favourable neurological outcome for patients after cardiac arrest, every effort has to be made not only to achieve the highest possible FPS [According to our results, VL for airway management during CPR allows tracheal intubation with an excellent FPS even during uninterrupted chest compressions and performs significantly better than DL. The practicability and superiority of the VL—even with difficult airway anatomy, in emergency situations as well as complex preclinical situations—have been shown in several studies [Our regression analysis did not find an effect of either profession (physician, nurse) nor working experience in anaesthesia as a significant predictor of FPS. This result is interesting in that it could be postulated that users with many years of experience might be able to intubate more safely using DL. This could be assumed since these participants were regularly intubating patients using DL long before the introduction of VL. In addition to the proven advantage of VL for inexperienced users, it does not seem to be inferior for experienced practitioners either. Therefore, VL may provide further benefits in the prehospital setting, and—according to the finding of two recent studies—especially for providers with little experience in tracheal intubation [Although VL is becoming increasingly widespread it cannot be assumed that this technology is available everywhere. Nonetheless, for example, in German HEMS and the Swiss Air-Rescue (REGA) VL is used as the first-line device [Our study has clear limitations. Firstly, one issue is the use of a manikin that can only partially depict anatomical conditions. However, the benefit of using manikins is that we were able to establish standardized airway conditions for each participant. Secondly, due to the fact that the subjects were only present for one day, a cross-over design was not possible. In the setting of a cross-over design, the two intubations would have taken place within a short period of time and we then would expect a significant bias due to the short-term experience and training effect. This would not fulfil our goal of conducting a pragmatic trial simulating the setting of prehospital emergency care medicine where personnel are regularly confronted with unfamiliar situations for tracheal intubation. Thirdly, as this study was designed as a pragmatic pilot study, we could not complete a power analysis given the fixed population size. In this context, the small sample group must also be noted, despite the proven effect size. Fourthly, the clinical relevance of the absolute difference of 2.5 seconds in TTI can be questioned. For this reason, we chose FPS as the primary endpoint, which seems to be outcome relevant in CPR [