Force Applied During Tracheal Intubation

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Abstract
This study quantitated the force applied during tracheal intubation to determine (a) whether the force differed among novice and experienced intubators, and (b) whether the force required differed when intubating patients' tracheas versus intubating the trachea of a commonly used training mannequin. We studied 27 tracheal intubations performed by 17 experienced (10 prior intubations) intubators. Each intubation was performed with a No. 3 Macintosh blade instrumented with strain gauges to determine force applied in the sagittal plane. The mean force applied was 24.6 ± 2.9 N (mean ± SEM) and the maximum force applied by each intubator was 47.6 ± 3.8 N. There was no difference between groups in the mean force applied (28.8 ± 6.1 N for the novice group vs 22.3 ± 2.7 N for the experienced group, P = 0.27) nor in the maximum force applied (55.1 ± 6.5 N for the novice group vs 43.2 ± 4.7 N for the experienced group, P = 0.08). The only difference was in the impulse (force × duration), which was more for the novice group largely because of the longer average duration of intubation (40 ± 12s vs 19 ± 4s, P = 0.06). Among experienced intubators, we found that applied force correlated with patient weight and Mallampati class. Intubation of the Laerdal Airway Management Trainer required mean forces comparable to those required in patients (26.6 ± 2.5 N vs 22.3 ± 2.9 N), although the maximum force applied during the intubation effort was greater (58.3 ± 4.7 N vs 43.2 ± 4.7 N, P < 0.05). We conclude that force applied during intubation of the trachea is easily quantified but is not clearly different between novice and experienced operators. However, a device such as we used can distinguish excessive or inadequate force. We also suggest that future airway models may need to be modified to reflect the forces actually required in patients.

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