Cochrane Database of Systematic Reviews Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents (Review) Lundstrøm LH, Duez CHV, Nørskov AK, Rosenstock CV, Thomsen JL, Møller AM, Strande S, Wetterslev J Lundstrøm LH, Duez CHV, Nørskov AK, Rosenstock CV, Thomsen JL, Møller AM, Strande S, Wetterslev J. Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents. Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD009237. DOI: 10.1002/14651858.CD009237.pub2. www.cochranelibrary.com Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents (Review) Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . ..... 4 BACKGROUND .................................... 7 OBJECTIVES ..................................... 8 METHODS ...................................... 8 RESULTS....................................... 12 Figure1. ..................................... 13 Figure2. ..................................... 15 Figure3. ..................................... 17 Figure4. ..................................... 18 Figure5. ..................................... 21 Figure6. ..................................... 22 DISCUSSION ..................................... 23 AUTHORS’CONCLUSIONS . 26 ACKNOWLEDGEMENTS . 26 REFERENCES ..................................... 27 CHARACTERISTICSOFSTUDIES . 32 DATAANDANALYSES. 90 Analysis 1.1. Comparison 1 Avoidance vs use of NMBA, Outcome 1 Difficult tracheal intubation: low risk of bias vs high oruncertainriskofbias. 92 Analysis 1.2. Comparison 1 Avoidance vs use of NMBA, Outcome 2 Difficult tracheal intubation: depolarizing vs non- depolarizingNMBA. 94 Analysis 1.3. Comparison 1 Avoidance vs use of NMBA, Outcome 3 Difficult tracheal intubation: remifentanil vs no remifentanil. .................................. 96 Analysis 1.4. Comparison 1 Avoidance vs use of NMBA, Outcome 4 Difficult tracheal intubation: alfentanil vs no alfentanil. ................................... 98 Analysis 1.5. Comparison 1 Avoidance vs use of NMBA, Outcome 5 Difficult tracheal intubation: local anaesthesia vs no localanaesthesia.. 100 Analysis 1.6. Comparison 1 Avoidance vs use of NMBA, Outcome 6 Difficult tracheal intubation: excluded anticipated DTI vs included anticipated DTI. 102 Analysis 1.7. Comparison 1 Avoidance vs use of NMBA, Outcome 7 Difficult tracheal intubation: “best-case scenario”. 104 Analysis 1.8. Comparison 1 Avoidance vs use of NMBA, Outcome 8 Difficult tracheal intubation excluding dose-finding studies..................................... 106 Analysis 1.9. Comparison 1 Avoidance vs use of NMBA, Outcome 9 Difficult tracheal intubation: funding from pharmaceuticalindustry. 107 Analysis 1.10. Comparison 1 Avoidance vs use of NMBA, Outcome 10 One or more events of upper airway discomfort or injury: low risk of bias vs high or uncertain risk of bias. ............... 109 Analysis 1.11. Comparison 1 Avoidance vs use of NMBA, Outcome 11 One or more events of upper airway discomfort or injury: depolarizing vs non-depolarizing NMBA. ............ 110 Analysis 1.12. Comparison 1 Avoidance vs use of NMBA, Outcome 12 One or more events of upper airway discomfort or injury: remifentanil vs no remifentanil. .......... 111 Analysis 1.13. Comparison 1 Avoidance vs use of NMBA, Outcome 13 One or more events of upper airway discomfort or injury: alfentanil vs no alfentanil. ........ 112 Analysis 1.14. Comparison 1 Avoidance vs use of NMBA, Outcome 14 One or more events of upper airway discomfort or injury: excluded anticipated DTI vs included anticipated DTI. ................ 113 Analysis 1.15. Comparison 1 Avoidance vs use of NMBA, Outcome 15 Difficult laryngoscopy: low risk of bias vs high or uncertainriskofbias. 114 ADDITIONALTABLES. 114 APPENDICES ..................................... 130 Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in i adults and adolescents (Review) Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. CONTRIBUTIONSOFAUTHORS . 140 DECLARATIONSOFINTEREST . 141 DIFFERENCES BETWEEN PROTOCOL AND REVIEW . .... 141 Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in ii adults and adolescents (Review) Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. [Intervention Review] Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents Lars H Lundstrøm1, Christophe HV Duez2, Anders K Nørskov1, Charlotte V Rosenstock1, Jakob L Thomsen3, Ann Merete Møller 4, Søren Strande5, Jørn Wetterslev6 1Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, Denmark. 2Research Center for Emergency Medicine, Univer- sity of Aarhus, Aarhus, Denmark. 3Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark. 4The Cochrane Anaesthesia, Critical and Emergency Care Group, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark. 5Department of Anaesthesiology and Intensive Care, Gentofte Hospital, Copenhagen, Denmark. 6Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Contact address: Lars H Lundstrøm, Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, 3400, Denmark. [email protected]. Editorial group: Cochrane Anaesthesia, Critical and Emergency Care Group. Publication status and date: New, published in Issue 5, 2017. Citation: Lundstrøm LH, Duez CHV, Nørskov AK, Rosenstock CV, Thomsen JL, Møller AM, Strande S, Wetterslev J. Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents. Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD009237. DOI: 10.1002/14651858.CD009237.pub2. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background Tracheal intubation during induction of general anaesthesia is a vital procedure performed to secure a patient’s airway. Several studies have identified difficult tracheal intubation (DTI) or failed tracheal intubation as one of the major contributors to anaesthesia-related mortality and morbidity. Use of neuromuscular blocking agents (NMBA) to facilitate tracheal intubation is a widely accepted practice. However, because of adverse effects, NMBA may be undesirable. Cohort studies have indicated that avoiding NMBA is an independent risk factor for difficult and failed tracheal intubation. However, no systematic review of randomized trials has evaluated conditions for tracheal intubation, possible adverse effects, and postoperative discomfort. Objectives To evaluate the effects of avoiding neuromuscular blocking agents (NMBA) versus using NMBA on difficult tracheal intubation (DTI) for adults and adolescents allocated to tracheal intubation with direct laryngoscopy. To look at various outcomes, conduct subgroup and sensitivity analyses, examine the role of bias, and apply trial sequential analysis (TSA) to examine the level of available evidence for this intervention. Search methods We searched CENTRAL, MEDLINE, Embase, BIOSIS, International Web of Science, LILACS, advanced Google, CINAHL, and the following trial registries: Current Controlled Trials; ClinicalTrials.gov; and www.centerwatch.com, up to January 2017. We checked the reference lists of included trials and reviews to look for unidentified trials. Selection criteria We included randomized controlled trials (RCTs) that compared the effects of avoiding versus using NMBA in participants 14 years of age or older. Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in 1 adults and adolescents (Review) Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Data collection and analysis Two review authors extracted data independently. We conducted random-effects and fixed-effect meta-analyses and calculated risk ratios (RRs) and their 95% confidence intervals (CIs). We used published data and data obtained by contacting trial authors. To minimize the risk of systematic error, we assessed the risk of bias of included trials. To reduce the risk of random errors caused by sparse data and repetitive updating of cumulative meta-analyses, we applied TSA. Main results We identified 34 RCTs with 3565 participants that met our inclusion criteria. All trials reported on conditions for tracheal intubation; seven trials with 846 participants described ‘events of upper airway discomfort or injury’, and 13 trials with 1308 participants reported on direct laryngoscopy. All trials used a parallel design. We identified 18 dose-finding studies that included more interventions or control groups or both. All trials except three included only American Society of Anesthesiologists (ASA) class I and II participants, 25 trials excluded participants