Determination of Optimal Magill Forceps Hand Position and Laryngoscope Type to Remove a Simulated Foreign Body Airway Obstruction.

Abstract

Introduction: Foreign body removal for airway obstruction is an infrequent skill performed by paramedics, and Magill forceps for removal of a foreign body from the airway is reserved for patients with persistent obstruction. Traditional paramedic instruction uses direct laryngoscopy to visualize foreign body removal. Our objective in this study was to evaluate time to removal of an obstruction comparing hand position and hyperangulated video laryngoscopy vs direct laryngoscopy with Magill forceps.

Methods: A foreign body airway obstruction station was included in paramedics' annual competency assessment over a two-year period as a quality improvement project. Paramedics were randomized to remove the foreign body with either direct laryngoscopy or hyperangulated video laryngoscopy with a handheld video laryngoscope. Our primary outcome measure was time from blade insertion to foreign body removal. The paramedics had further training regarding hand position prior to the second year's annual competency assessment. After fitting a mixed-effects statistical model to the data, we included fixed effects of competency assessment year, device used, hand position, and random effect of paramedic. We evaluated the significance of these predictors on the dependent variable of time for removal.

Results: We observed 245 foreign body airway obstruction removals, 77 in year 1 and 168 in year 2. The direct laryngoscopy (n = 123) and hyperangulated video laryngoscopy (n = 122) groups were nearly equal. During year 1, hand position was noted to be an important factor for removal time, as paramedics were seen to use different hand positions. Recording of hand position began during year 1, which excluded 95 earlier observations from year 1. Competency training year was not a significant factor for time to removal. However, direct laryngoscopy was faster at 14.9 seconds [sec], (95% CI 12.9-17.1) than hyperangulated video laryngoscopy at 19.2 sec [16.9-22]; P < .001. Of the four possible hand positions, forceps grasped by the right thumb and either middle or fourth finger, with the hand in a handshake position, and with the forceps superior to the hand was associated with the shortest time to foreign body removal. This optimal hand position was significantly better than the other grasping methods, with a mean of 11.2 sec (95% CI, 10.2-12.4) vs underhand method, 17.5 sec (14.7-21); overhand method, 15.1 sec (10.7-21.2); and multiple positions (27.5 sec, 22-34.5); P < .001).

Conclusion: We found that hand positioning for Magill forceps significantly affected time to foreign body removal. In addition, direct laryngoscopy outperformed hyperangulated video laryngoscopy. Given these findings, training on removal of foreign body airway obstruction with Magill forceps should emphasize optimal hand positioning. Paramedics may also consider the use of direct laryngoscopy over hyperangulated video laryngoscopy in removal of these obstructions. Further research is required to validate these findings.