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    1 Comment for this article
    May still be helpful to keep a checklist handy
    Nicolas Cazes, M.D. | Bataillon de marins-pompiers de Marseille
    We read with great interest the article by Turner et al.1 about the value of using a checklist during endotracheal intubation (ETI). First, the authors selected mortality as the primary outcome, which may not be the most judicious choice. On the one hand, it is somewhat unclear (was this 28-day mortality, 1-year mortality, or global hospital mortality when the authors wrote "hospital mortality was used preferentially"?), and on the other hand, it may be difficult to compare across patients with serious pathology. Indeed, patients who benefit from ETI in an emergency context often have organ failure secondary to a pathology, where intubation is not an etiological treatment itself, but only one means among many others (some examples are mechanical ventilation, transfusion, surgery, antibiotic therapy, and dialysis) to treat the primary pathology. Thus, it seems more judicious to us to correlate checklist completion at the time of ETI with the rate of hypoxic events. A hypoxic event is a main element directly correlated with ETI failure with real clinical consequences for the patient2.
    Furthermore, the initial interest in checklists, as used in aeronautics for example, was to make sure not to forget an element before performing a high-risk procedure. When ETI is carried out in a hospital, particularly in an intensive care unit or operating room, there are several staff members close by to help, advise or even replace the person performing the procedure if necessary. In contrast, when ETI is necessary in a pre-hospital setting, conditions are not as conducive for its success. Several individual elements, sometimes combined, make pre-hospital ETI systematically difficult, whether due to the patient's position (such as on the ground, or sitting in a car), the state of the patient at the scene when the emergency medical team arrives (such as being in a state of respiratory distress, being unconscious and having vomited, or having facial trauma), the absence of any immediate outside help, or operating in a hostile environment for military doctors. All of these elements make ETI a particularly high-risk procedure in pre-hospital settings. For these circumstances, a checklist seems warranted. The Lewis study3 cited by the authors shows results along these lines. Thus, before concluding that a checklist is of no interest during ETI, a large-scale comparative study of the procedure in pre-hospital environments should be carried out.

    References :
    1. Turner JS, Bucca AW, Propst SL, et al. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020;3(7):e209278. Published 2020 Jul 1. doi:10.1001/jamanetworkopen.2020.9278.

    2. Mort TC. Complications of emergency tracheal intubation: immediate airway-related consequences: part II. J Intensive Care Med. 2007;22(4):208-215. doi:10.1177/0885066607301359

    3. Lewis CT, Brown J, Inglis AC, Naumann DN, Crombie N. Emergency intubation in trauma in KwaZulu-Natal Province, South Africa. S Afr Med J. 2018;108(8):660-666. Published 2018 Jul 25. doi:10.7196/SAMJ.2018.v108i8.12670
    Original Investigation
    July 2, 2020

    Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
    • 2Now with Department of Emergency Medicine, CoxHealth, Springfield, Missouri
    • 3Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
    JAMA Netw Open. 2020;3(7):e209278. doi:10.1001/jamanetworkopen.2020.9278
    Key Points español 中文 (chinese)

    Question  Is the use of airway checklists associated with improved outcomes in patients undergoing endotracheal intubation?

    Findings  This systematic review and meta-analysis of 11 studies with 3261 patients undergoing endotracheal intubation did not find a difference in mortality or most secondary outcomes associated with checklist use.

    Meaning  The findings suggest that the use of airway checklists during endotracheal intubation is not associated with improved outcomes.


    Importance  Endotracheal intubation of critically ill patients is a high-risk procedure. Checklists have been advocated to improve outcomes.

    Objective  To assess whether the available evidence supports an association of use of airway checklists with improved clinical outcomes in patients undergoing endotracheal intubation.

    Data Sources  For this systematic review and meta-analysis, PubMed (OVID), Embase, Cochrane, CINAHL, and SCOPUS were searched without limitations using the Medical Subject Heading terms and keywords airway; management; airway management; intubation, intratracheal; checklist; and quality improvement to identify studies published between January 1, 1960, and June 1, 2019. A supplementary search of the gray literature was performed, including conference abstracts and clinical trial registries.

    Study Selection  Full-text reviews were performed to determine final eligibility for inclusion. Included studies were randomized clinical trials or observational human studies that compared checklist use with any comparator for endotracheal intubation and assessed 1 of the predefined outcomes.

    Data Extraction and Synthesis  Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for observational studies and Cochrane risk of bias tool for randomized clinical trials. Study results were meta-analyzed using a random-effects model. Reporting of this study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

    Main Outcomes and Measures  The primary outcome was mortality. Secondary outcomes included first-pass success and known complications of endotracheal intubation, including esophageal intubation, hypoxia, hypotension, and cardiac arrest.

    Results  The search identified 1649 unique citations of which 11 (3261 patients) met the inclusion criteria. One randomized clinical trial and 3 observational studies had a low risk of bias. Checklist use was not associated with decreased mortality (5 studies [2095 patients]; relative risk, 0.97; 95% CI, 0.80-1.18; I2 = 0%). Checklist use was associated with a decrease in hypoxic events (8 studies [3010 patients]; relative risk, 0.75; 95% CI, 0.59-0.95; I2 = 33%) but no other secondary outcomes. Studies with a low risk of bias did not demonstrate decreased hypoxia associated with checklist use.

    Conclusions and Relevance  The findings suggest that use of airway checklists is not associated with improved clinical outcomes during and after endotracheal intubation, which may affect practitioners’ decision to use checklists in this setting.