Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents

Lars H Lundstrøm; Christophe HV Duez; Anders K Nørskov; Charlotte V Rosenstock; Jakob L Thomsen; Ann Merete Møller; Søren Strande; Jørn Wetterslev

doi:10.1002/14651858.CD009237.pub2

Cochrane Database of Systematic Reviews

Evitación versus uso de agentes bloqueadores neuromusculares para mejorar las condiciones durante la intubación traqueal o la laringoscopia directa en adultos y adolescentes

Información

DOI:

https://doi.org/10.1002/14651858.CD009237.pub2 Copiar DOI

Base de datos:

Cochrane Database of Systematic Reviews

Versión publicada:

17 mayo 2017see what's new

Tipo:

Intervention

Etapa:

Review

Grupo Editorial Cochrane:

Grupo Cochrane de Anestesia

Copyright:

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Cifras del artículo

Altmetric:

Citado por:

Citado 0 veces por enlace Crossref Cited-by

Contraer

Autores

Lars H Lundstrøm

Correspondencia a: Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, Denmark

[email protected]
Christophe HV Duez

Research Center for Emergency Medicine, University of Aarhus, Aarhus, Denmark
Anders K Nørskov

Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, Denmark
Charlotte V Rosenstock

Department of Anaesthesiology, Nordsjællands Hospital, Hillerød, Denmark
Jakob L Thomsen

Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark
Ann Merete Møller

The Cochrane Anaesthesia, Critical and Emergency Care Group, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
Søren Strande

Department of Anaesthesiology and Intensive Care, Gentofte Hospital, Copenhagen, Denmark
Jørn Wetterslev

Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

Contributions of authors

Conceiving of the review: LHL, SS, AMM, JW.

Designing the review: LHL, JW, AMM, SS.

Co‐ordinating the review: LHL.

Undertaking manual searches: LHL.

Screening search results: LHL, CD, AN.

Organizing retrieval of papers: LHL, CD, AN.

Screening retrieved papers against inclusion criteria: LHL, CD, AN, CVR, JT.

Appraising the quality of papers: LHL, CD, AN, CVR, JT.

Abstracting data from papers: LHL, CD, AN, CVR, JT.

Writing to authors of papers for additional information: LHL.

Providing additional data about papers: LHL.

Obtaining and screening data on unpublished studies: LHL, AN.

Managing data for the review: LHL, CD, AN.

Entering data into Review Manager (RevMan 5.3): LHL, AN.

Analysing RevMan statistical data: LHL, JW.

Performing other statistical analysis not using RevMan: LHL, JW.

Performing double entry of data: data entered by person one: LHL; data entered by person two: AN.

Interpreting data: LHL, AMM, JW.

Making statistical inferences: LHL, JW.

Writing the review: LHL, CD, AN, CR, JT, SS, AMM, JW.

Securing funding for the review: Copenhagen Trial Unit, Rigshospitalet, Copenhagen, Denmark, and Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark.

Serving as guarantor for the review (one review author): LHL.

Taking responsibility for reading and checking the review before submission: LHL.

Declarations of interest

LHL, AMM, CR, and JW were co‐authors of an observational study entitled "Avoidance of neuromuscular blocking agents may increase the risk of difficult tracheal intubation: a cohort study of 103,812 consecutive adult patients recorded in the Danish Anaesthesia Database" (Lundstrom 2009a).

JW is a member of the task force in the Copenhagen Trial Unit, which develops theory, software, and manuals for trial sequential analysis (TSA).

AMM is a Co‐ordinating Editor for the Cochrane Anaesthesia, Critical and Emergency Care Group.

JT received grants for two studies in 2016 through the Merck Investigator Studies Program. The aims of the two studies were (1) to assess the use of neuromuscular monitoring and the incidence of residual neuromuscular blockade in six Danish anaesthesia departments, and (2) to assess the effect of an e‐learning course in neuromuscular monitoring.

Acknowledgements

We would like to thank Karen Hovhannisyan and Janne Vendt (former and present Cochrane Anaesthesia, Critical and Emergency Care Group Trial Information specialists, respectively) for their valuable help with phrasing of the search strategies.

We would like to thank Andrew Smith (Content Editor); Jing Xie (Statistical Editor); Emmanuel Boselli and Thomas Mencke (Peer Reviewers); and Brian Stafford (Consumer Referee) for help and editorial advice provided during preparation of this systematic review. We would like to thank Julie Wetterslev (cand. scient. soc.) for assistance with Spanish translation.

We would like to thank Andy Smith (Content Editor); Marialena Trivella (Statistical Editor); Rodrigo Cavallazzi, Shahla Siddiqui, and Fred Cheney (Peer Reviewers), and Tracey Lloyd (representative of the ACE consumer panel) for help and editorial advice provided during preparation of the protocol (Lundstrøm 2011a).

Version history

Published

Title

Stage

Authors

Version

2017 May 17

Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents

Review

Lars H Lundstrøm, Christophe HV Duez, Anders K Nørskov, Charlotte V Rosenstock, Jakob L Thomsen, Ann Merete Møller, Søren Strande, Jørn Wetterslev

https://doi.org/10.1002/14651858.CD009237.pub2

2011 Jul 06

Use versus avoidance of neuromuscular blocking agent for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents

Protocol

Lars H Lundstrøm, Søren Strande, Ann Merete Møller, Jørn Wetterslev

https://doi.org/10.1002/14651858.CD009237

Differences between protocol and review

We made the following changes to the protocol (Lundstrøm 2011a).

1. Christophe HV Duez, Anders K Nørskov, Charlotte V Rosenstock, and Jakob L Thomsen joined as review authors after publication of the protocol.

2. We considered avoiding NMBA as the intervention, thus we changed the title from "Use versus avoidance of neuromuscular blocking agent for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents" to "Avoidance versus use of neuromuscular blocking agent for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents".

3. We did not consider stopping early for benefit, harm, or futility on inadequate stopping rules (or no reporting of sample size at all), as risk of bias in the accomplished review was high. In the protocol, we considered this a risk of bias component, but after the 11th Cochrane Symposium in Keystone, Colorado, early stopping was changed from constituting a bias risk to constituting increased risk of random error.

4. We did not consider baseline imbalance or lack of reporting of baseline characteristics as introducing high risk of bias. After the 11th Cochrane Symposium in Keystone, Colorado, baseline imbalance or lack of reporting of baseline characteristics changed from constituting a bias risk to constituting increased risk of random error.

5. We did not report on 'other bias' as suggested in the protocol.

6. In our protocol, we stated, "We will exclude trials using quasi‐randomization and observational studies with regard to benefits, but not harms". In the review, we stated, "We excluded trials using quasi‐randomization as well as observational studies". Thus we did not identify any quasi‐randomized trials and did not include any observational studies examining harms.

7. Under 'Data extraction and management' in the protocol, we stated, "We will include each pair‐wise comparison separately but with shared intervention groups divided out approximately evenly among the comparisons. For example if multiple intervention groups share a common control group the number of patients and the number of events of the control group will be divided equally, thereby the number of subgroups of the control group will match the number of intervention groups (Higgins 2011)" and "We will combine all relevant experimental intervention groups of the trials into a single intervention group, and combined all relevant control intervention groups into a single control group" (Higgins 2011). However, during the review process, we decided to perform only the latter (recommended) method when handling studies with multiple intervention or control groups. Thus, in the review, we have stated the following: "Some trials randomized participants to multiple intervention and/or control groups (more than two groups, as in dose‐finding studies)". In the review, we combined all relevant experimental intervention groups from trials into a single intervention group, and we combined all relevant control intervention groups into a single control group, as recommended (Higgins 2011).

8. As conditions for tracheal intubation were not reported as a continuous outcome in any of the included trials, we did not calculate risk differences or mean differences with 95% confidence intervals.

9. We added two explorative outcomes: (1) a best‐case scenario, whereby dose‐finding studies were represented only by control and intervention groups with the lowest prevalence of difficult intubation; and (2) exclusion of dose‐finding studies.

10. We did not explore selective outcome reporting by comparing publications with their protocols, if the latter were available.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adolescent; Adult; Humans;

PICO

Population

Intervention

Comparison

Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Figure 1

Study flow diagram.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 3

Funnel plot of comparison: 1 Avoidance vs use of NMBA, outcome: 1.1 Difficult tracheal intubation: low risk of bias vs high or uncertain risk of bias.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 4

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 5

Ir a la figura de la revisiónAbrir en una pestaña nueva

Figure 6

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.1

Comparison 1 Avoidance vs use of NMBA, Outcome 1 Difficult tracheal intubation: low risk of bias vs high or uncertain risk of bias.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.2

Comparison 1 Avoidance vs use of NMBA, Outcome 2 Difficult tracheal intubation: depolarizing vs non‐depolarizing NMBA.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.3

Comparison 1 Avoidance vs use of NMBA, Outcome 3 Difficult tracheal intubation: remifentanil vs no remifentanil.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.4

Comparison 1 Avoidance vs use of NMBA, Outcome 4 Difficult tracheal intubation: alfentanil vs no alfentanil.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.5

Comparison 1 Avoidance vs use of NMBA, Outcome 5 Difficult tracheal intubation: local anaesthesia vs no local anaesthesia.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.6

Comparison 1 Avoidance vs use of NMBA, Outcome 6 Difficult tracheal intubation: excluded anticipated DTI vs included anticipated DTI.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.7

Comparison 1 Avoidance vs use of NMBA, Outcome 7 Difficult tracheal intubation: "best‐case scenario".

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.8

Comparison 1 Avoidance vs use of NMBA, Outcome 8 Difficult tracheal intubation excluding dose‐finding studies.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.9

Comparison 1 Avoidance vs use of NMBA, Outcome 9 Difficult tracheal intubation: funding from pharmaceutical industry.

Ir a la figura de la revisiónAbrir en una pestaña nueva

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.

Ir a la figura de la revisiónAbrir en una pestaña nueva

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.

Ir a la figura de la revisiónAbrir en una pestaña nueva

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.

Ir a la figura de la revisiónAbrir en una pestaña nueva

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.

Ir a la figura de la revisiónAbrir en una pestaña nueva

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.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Analysis 1.15

Comparison 1 Avoidance vs use of NMBA, Outcome 15 Difficult laryngoscopy: low risk of bias vs high or uncertain risk of bias.

Ir a la figura de la revisiónAbrir en una pestaña nueva

Summary of findings for the main comparison. Summary of findings table: primary and secondary outcomes

Avoidance vs use of neuromuscular blocking agent for improving conditions during tracheal intubation in adults and adolescents
Patient or population: improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents Setting: people undergoing various surgical procedures in hospital departments. Most trials were conducted in high‐income countries, and most participants were undergoing elective surgery. Participants of both genders were included; most were ASA class I or II, were non‐obese, and had no expected airway management difficulties Intervention: avoidance of NMBA Comparison: use of NMBA
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI) of avoidance vs use of NMBA	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk Risk with use of NMBA	Corresponding risk Risk with avoidance of NMBA
Primary outcomes
Difficult tracheal intubation: low risk of bias trials	Study population		RR 13.27 (8.19 to 21.49)	508 (4 studies)	⊕⊕⊕⊝ Moderate^a	TSA shows that the required information size of 8195 for a 20% RRR has not been achieved, but the trial sequential monitoring boundary has been crossed and the TSA‐adjusted CI for the RR is 1.85 to 95.04
	47 per 1000	620 per 1000 (383 to 1000)
Difficult tracheal intubation: all trials	Study population		RR 5.00 (3.49 to 7.15)	3565 (34 studies)	⊕⊕⊝⊝ Low^b	TSA shows that the required information size of 44,661 for a 20% RRR has not been achieved, but the trial sequential monitoring boundary has been crossed and the TSA‐adjusted CI for the RR is 1.20 to 20.77.
	81 per 1000	406 per 1000 (284 to 597)
One or more events of upper airway discomfort or injury: low risk of bias trials	Study population		RR 2.74 (1.21 to 6.21)	73 (1 study)	See comments	Because only 1 low risk of bias trial was identified, no quality of evidence assessment was performed
	162 per 1000	444 per 1000 (196 to 1000)
One or more events of upper airway discomfort or injury: all trials	Study population		RR 1.37 (1.09 to 1.74)	846 (7 studies)	⊕⊕⊕⊝ Moderate^c	TSA shows that the required information size of 1981 for a 20% RRR has not been achieved, but the trial sequential monitoring boundary has been crossed and the TSA‐adjusted CI for the RR is 1.00 to 1.86.
	273 per 1000	374 per 1000 (298 to 475)
Mortality	Not estimated	Not estimated	Not estimated	0 (34 studies)	Not estimated
Secondary outcomes
Difficult laryngoscopy: low risk of bias trials	Study population		RR 4.00 (0.47 to 34.20)	78 (1 study)	See comments	Because only 1 low risk of bias trial was identified, no quality of evidence assessment was performed
	26 per 1000	103 per 1000 (12 to 877)
Difficult laryngoscopy: all trials	Study population		RR 2.54 (1.53 to 4.21)	1308 (13 studies)	⊕⊕⊝⊝ Low^d	TSA shows that the required information size of 22,911 for a 20% RRR was not achieved, and in no trials were sequential monitoring boundaries crossed. The TSA‐adjusted CI for the RR is 0.27 to 21.75.
	33 per 1000	85 per 1000 (51 to 141)
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI = confidence interval; RR = risk ratio
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aDowngraded one level because of indirectness ^bDowngraded two levels because of indirectness, heterogeneity, and high or uncertain risk of bias ^cDowngraded one level because of high or uncertain risk of bias ^dDowngraded two levels because of imprecision and high or uncertain risk of bias

Summary of findings for the main comparison. Summary of findings table: primary and secondary outcomes

Ir a la tabla de la revisión

Table 1. Baseline

Study ID	NMBA	Country	Language	Randomized	Sex	Age, years	Weight, kg	BMI	ASA class included	Expected difficult airway excluded	Overweight excluded
Alexander 1999	C1: suxamethonium 1 mg/kg	UK	English	60	C: 12F/8M I1: 11F/9M I2: 11F/9M	C: 41.7 (17.4) I1: 40.3 (10.6) I2: 44.2 (15.0)	C: 76.3 (15.0) I1: 75.5 (15.1) I2: 76.6 (16.8)	ns	I‐II	yes
Barclay 1997	C1: rocuronium 0.1 mg/kg C2: rocuronium 0.13 mg/kg	UK	English	60	ns	C1: 30 C2: 29 I1: 27	C1: 74 C2: 72 I1: 64	ns	ns	yes	yes
Beck 1993	C1: suxamethonium 1 mg/kg	USA	English	64	C1: 22F/11M I1: 21F/10M	C1: 34 (11) I1: 35 (11)	C1: 69 (14) I1: 65 (13)		I‐II
Bouvet 2008	C1: cisatracurium 0.15 mg/kg	France	English	130	C1: 65F I1: 65F	C1: 41.5 (12.9) I1: 40.7 (15.2)	ns	C1: 24.6 (5.4) I1: 23.0 (3.5)	I‐II	yes
Combes 2007	C1: rocuronium 0.6 mg/kg	France	English	300	C1: 73F/77M I1: 69F/81M	C1: 41 (18‐70) I1: 43 (18‐66)	C1: 73 (13) I1: 70 (13)	ns	I‐II	yes	yes
Dominici 1990	C1: suxamethonium 1.5 mg/kg	France	French	60	C1: 9F/21M I1: 9F/21M	C1: 48.4 (3.4) I1: 50.1 (2.9)	C1: 62.8 (2.5) I1: 61.6 (2.1)	ns	I‐III
González Obregón 2010	C1: rocuronium 0.6 mg/kg	Columbia	Spanish	100	C1: 33F/17M I1: 33F/17M	C1: 34.7 (11.0) I1: 32.8 (12.3)	ns	ns	I‐II	yes
Gulhas 2013	C1: succinylcholine 1 mg/kg	Turkey	English	80	C1: 19F/21M I1: 22F/18M	C1: 49.6 (8.4) I1: 47.9 (8.7)	C1: 77.3 (13.1) I1: 73.2 (14.4)	ns	I‐II
Hanna 2010	C1: rocuronium 0.06 mg/kg + succinylcholine 1.5 mg/kg	USA	English	50	C1: 15F/9M I1: 5F/18M	C1: 39.0 (13.3) I1: 43.0 (14.5)	C1: 75.0 (15.0) I1: 81.0 (13.0)	C1: 25.9 (4.6) I1: 26.5 (2.9)	I‐II	yes
Harsten 1997	C1: suxamethonium 1 mg/kg	Sweden	English	80	C1: 26F/13M I1: 23F/14M	C1: 41.8 (13) I1: 39.5 (14)	ns	ns	I‐II
Iamaroon 2001	C1: suxamethonium 1.5 mg/kg	Thailand	English	120	C1: 54F/6M I1: 54F/6M	C1: 40.6 (9.1) I1: 39.7 (9.2)	C1: 55.8 (10.8) I1: 55.1 (9.1)	ns	I‐II	yes	yes
Isesele 2012	C1: suxamethonium 1.5 mg/kg	Nigeria	English	96	C1: 12F/32M I1: 21F/23M	C1: 30.8 (9.0) I1: 32.6 (8.0)	C1. 69.0 (7.4) I1: 68.3 (6.6)		I‐II	yes
Jiao 2014	C1: suxamethonium 0.6 mg/kg	China	English	55	C1: 27F/0M I1: 28F/0M	C1: 38.4 (10.9) I2: 36.3 (9.9)	C1: 58.1 (7.0) I2: 58.2 (7.9)	ns	I‐II		yes
Kahwaji 1997	C1: ORG 9487 (rapacuronium) 0.5 mg/kg C2: ORG 9487 (rapacuronium) 1.0 mg/kg C3: ORG 9487 (rapacuronium) 1.5 mg/kg C4: ORG 9487 (rapacuronium) 2.0 mg/kg C5: ORG 9487 (rapacuronium) 2.5 mg/kg	USA	English	181	C1: 20F/10M C2: 18F/9M C3: 17F/15M C4: 15F/13M C5: 22F/9M I1: 19F/11M	C1: 51.3 C2: 49.6 C3: 52.0 C4: 50.6 C5: 50.2 I1: 52.6	C1: 67.3 C2: 70.5 C3: 68.6 C4: 71.3 C5: 75.9 I1: 69.7	ns	I‐III	yes
Kirkegaard‐Nielsen 1999	C1: rocuronium 0.4 mg/kg C2: rocuronium 0.8 mg/kg C3: rocuronium 1.2 mg/kg	USA	English	80	C1: 2F/18M C2: 6F/14M C3: 10F/10M I1: 5F/15M	C1: 39.7 (7.5) C2: 39.5 (14.3) C3: 39.2 (10.5) I1: 39.3 (11.8)	C1: 75.0 (16.9) C2: 78.6 (15.8) C3: 67.4 (14.8) I1: 73.4 (16.6)	ns	I‐II		yes
Kopman 2001	C1: rapacuronium 1.0 mg/kg C2: rapacuronium 1.2 mg/kg C3: rocuronium 0.50 mg/kg	USA	English	100	ns	range: 18‐65	ns	range: 17.5‐27.5	I‐II		yes
Lieutaud 2003	C1: atracurium 0.5 mg/kg C2: atracurium 0.5 mg/kg C3: atracurium 0.5 mg/kg	France	English	170	C1: 3F/42M C2: 7F/41M C3: 8F/39M I1: 2F/18M	C1: 52.9 (11.8) C2: 51.3 (12.6) C3: 56.3 (11.9) I1: 50.4 (10.7)	ns	C1: 23.7 (3.2) C2: 23.1 (3.2) C3: 23.6 (3.4) I1: 23.3 (3.9)	I‐II	yes
Lowry 1999	C1: rocuronium 0.3 mg/kg C2: rocuronium 0.45 mg/kg C3: rocuronium 0.6 mg/kg C4: rocuronium 0.3 mg/kg C5: rocuronium 0.45 mg/kg C6: rocuronium 0.6 mg/kg	UK	English	140	C1: 4F/16M C2: 7F/13M C3: 12F/8M C4: 9F/11M C5: 9F/11M C6: 4F/16M I1: 2F/8M I2: 4F/6M	C1: 29 (11) C2: 40 (14) C3: 36 (12) C4: 33 (12) C5: 30 (12) C6: 33 (13) I1: 29 (11) I2: 30 (9)	C1: 77(16) C2: 75 (14) C3: 69 (14) C4: 72 (12) C5: 73 (14) C6: 74 (14) I1: 72 (12) I2: 73 (15)	ns	I‐II	yes	yes
McNeil 2000	C1: succinylcholine 1 mg/kg	UK	English	60	ns	C1: 44 (15) I1: 39 (11) I2: 40 (13)	C1: 75 (10) I1: 76 (15) I2: 71 (12)	ns	I‐II	yes	yes
Mencke 2003	C1: atracurium 0.5 mg/kg	Germany	English	80	C1: 19F/18M I1: 18F/18M	C1: 47.2 (13.2) I1: 47.7 (14.3)	C1: 77.7 (16) I1: 74.2 (15)		I‐II	yes	yes
Mencke 2014	I1: rocuronium 0.45 mg·kg^‐1	Germany	English	83	C1: 16F/24M I1: 16F/23M	C1: 50 (16) I1: 48 (17)	C1: 83.8 (16) I1: 79.6 (15)	C1: 28.2 (4.3) I1: 26.5 (3.7)	I‐III	yes	yes
Naguib 2003	C1: succinylcholine 0.3 mg/kg C2: succinylcholine 0.5 mg/kg C3: succinylcholine 1.0 mg/kg	Saudi Arabia	English	200	C1: 25F/25M C2: 23F/27M C3: 28F/22M I1: 23F/27M	C1: 30.9 (28‐34) C2: 30.5 (27‐34) C3: 30.0(28‐32) I1: 29.5 (27‐32)	C1: 66.6 (64‐70) C2: 67.4 (64‐71) C3: 67.8 (65‐71) I1: 67.4 (64‐71)	ns	I	yes
Naguib 2006	C1: succinylcholine 0.3 mg/kg C2: succinylcholine 0.5 mg/kg C3: succinylcholine 1.0 mg/kg C4: succinylcholine 1.5 mg/kg C5: succinylcholine 2.0 mg/kg	Saudi Arabia	English	180	C1: 17F13M C2: 19F/11M C3: 13F/17M C4: 14F/16M C5: 18F/12M I1: 19F/11M	C1: 33.5 (8.7) C2: 29.7 (8.8) C3: 28.3 (7.9) C4: 31.5 (9.6) C5: 33.8 (14.8) I1: 20.1 (8.8)	C1: 67.8 (10.3) C2: 67.3 (10.8) C3: 71.1 (14.2) C4: 72.9 (12.5) C5: 70.9 (14.5) I1: 67.4 (10.7)	C1: 25.6 (2.8) C2: 25.6 (3.2) C3: 25.9 (3.9) C4: 26.2 (3.2) C5: 25.7 (3.9) I1: 25.7 (3.4)	I	yes
Nimmo 1995	C1: suxamethonium 0.25 mg/kg C2: suxamethonium 0.5 mg/kg	USA	English	60	C1: 12F/8M C2: 12F/8M I1: 14F/6M	C1: 28.6 (17‐55) C2: 29.0 (16‐53) I1: 27.0 (18‐53)	C1: 66.2 (13.6) C2: 64.4 (11.2) I1: 68.1 (13.6)	ns	I‐II
Pang 2014	C1: cisatracurium 0.1 mg/kg	China	English	40	C1: 14F/6M I1: 9F/11M	C1: 45.2 (7.4) I1: 43.3 (6.7)	C1: 63.8 (9.5) I1: 64.6 (7.9)	C1: 23.7 (2.8) I1: 23.3 (3.1)	I‐II	yes	yes
Pino 1998	C1: mivacurium 0.25 mg/kg C2: rocuronium 0.45 mg/kg C3: rocuronium 0.6 mg/kg C4: rocuronium 0.9 mg/kg C5: rocuronium 1.2 mg/kg	USA	English	100	ns	ns	ns	ns	I‐II	yes	yes
Rousseau 1995	C1: vecuronium 0.08 mg/kg	France	French	152	ns	C1: 23 (5) I1: 25 (8)	C1: 71 (10) I1: 71 (11)	ns	I	yes
Scheller 1992	C1: d‐tubocurarine 3 mg and succinylcholine 1 mg/kg	USA	English	75	C1: 8F/7M I1: 10F/5M I2: 11F/4M I3: 13F/2M I4: 10F/5M	C1: 37 (10) I1: 33 (9) I2: 30 (10) I3: 35 (11) I4: 36 (16)	C1: 77 (20) I1: 65 (11) I2: 66 (15) I3: 66 (12) I4: 68 (16)	ns	I	yes
Schlaich 2000	C1: rocuronium 0.6 mg/kg C2: rocuronium 0.45 mg/kg C3: rocuronium 0.3 mg/kg	Germany	English	120	C1: 13F/17M C2: 13F/17M C3: 14F/16M I1: 14F/16M	C1: 37 (11) C2: 35 (11) C3: 36 (12) I1: 37 (11)	C1: 72 (14) C2: 75 (13) C3: 75 (12) I1: 70 (14)	ns	I‐II	yes
Sivalingam 2001	C1: suxamethonium 1 mg/kg	New Zealand	English	100	C1: 7F/18M I1: 9F/16M I2: 8F/17M I3: 10F/15M	C1: 34.3 (14.0) I1: 36.8 (12.6) I2: 29.6 (9.7) I3: 37.7 (12)	C1: 66 (10) I1: 62 (11) I2: 63 (15) I3: 61 (11)	ns	I‐II	yes
Stevens 1997	C1: d‐tubocurarine 3 mg and succinylcholine 1 mg/kg	USA	English	140	C1: 12F/8M I1: 12F/8M I2: 15F/5M I3: 17F/3M I4: 17F/3M I5: 15F/5M I6: 14F/6M	C1: 35 (9) I1: 38 (12) I2: 34 (11) I3: 37 (10) I4: 34 (9) I5: 33 (11) I6: 37 (14)	C1: 70 (8) I1: 72 (17) I2: 70 (14) I3: 72 (10) I4: 72 (13) I5: 72 (18) I6: 70 (13)	ns	I‐II	yes	yes
Striebel 1995	C1: vecuronium 1 mg + succinylcholine 1 mg/kg C2: vecuronium 1 mg + succinylcholine 1 mg/kg	Germany	German	100	C1: 25F C2: 25F I1: 25F I2: 25F	C1: 47.8 (11.7) C2: 43.8 (9.5) I1: 46.5 (12.7) I2: 46.0 (12.4)	C1: 62.6 (9.4) C2: 68.2 (14) I1: 64.9 (10.1) I2: 70.8 (14.6)	ns	I‐II
Wong 1996	C1: succinylcholine 1 mg/kg	Malaysia	English	120	C1: 16F/14M I1: 13F/17M I2: 18F/12M I3: 12F/17M	C1: 35.7 (16) I1: 35.5 (12) I2: 35.4 (13) I3: 35.7 (11)	C1: 60.2 (8.9) I1: 66.0 (13.1) I2: 63.4 (12.9) I3: 60.1 (10.8)	ns	I‐II	yes
Yazdi 2016	C1: atracurium 0.5 mg/kg	Iran	English	66	69.7% M	31.6 (13)	ns	ns	I‐II	yes
ns = not specified; The values in parentheses are standard deviation or range

Table 1. Baseline

Ir a la tabla de la revisión

Table 2. Intervention

Study ID	NMBA	Randomized/ Analysed	Hypnotic	Opioid	Local anaesthetic	Difficult intubation events/ total	Difficult laryngos‐ copy events/ total	Upper airway discomfort or injury events/total
Alexander 1999	C1: suxamethonium 1 mg/kg	60/60	C1: propofol 2 mg/kg I1: propofol 2 mg/kg I2: propofol 2 mg/kg	C1: none I1: alfentanil 50 μg/kg I2: remifentanil 2 μg/kg	None	C1: 0/20 I1: 3/20 I2: 13/20	ns	ns
Barclay 1997	C1: rocuronium 0.1 mg/kg C2: rocuronium 0.3 mg/kg	60/60	C1: propofol 2.5 mg/kg C2: propofol 2.5 mg/kg I1: propofol 2.5 mg/kg	C1: alfentanil 10 μg/kg C2: alfentanil 10 μg/kg I1: alfentanil 10 μg/kg	Lidocaine 10 mg IV	C1: 14/20 C2: 2/20 I1: 19/20	ns	ns
Beck 1993	C1: suxamethonium 1 mg/kg	64/64	C1: thiopenthal 5 mg/kg I1: propofol 2 mg/mL	C1: none I1: alfentanil 50 μg/kg	None	C1: 0/33 I1: 1/31	C1: 0/33 I1: 1/31	ns
Bouvet 2008	C1: cisatracurium 0.15 mg/kg	130/129	C1: propofol 2.5 mg/kg I1: propofol 2.5 mg/kg	C1: remifentanil 2 μg/kg I1: remifentanil 2 μg/kg	None	C1: 0/64 I1: 3/65	C1: 1/64 I1: 1/65	C1: 17/64 I1: 14/65
Combes 2007	C1: rocuronium 0.6 mg/kg	300/300	C1: propofol 2.5 mg/kg I1: propofol 2.5 mg/kg	C1: alfentanil 15 µg/kg I1: alfentanil 40 µg/kg	None	C1: 1/150 I1: 18/150	C1: 5/150 I1: 18/150	C1: 64/150 I1: 86/150
Dominici 1990	C1: suxamethonium 1.5 mg/kg	60	C1: propofol 3 mg/mL I1: propofol 3 mg/mL	C1: alfentanil 7‐10 µg/kg I1: alfentanil 7‐10 µg/kg	Lidocaine (2%): IV + topical Lidocaine 5%	C1: 10/30 I1: 11/30	C1: 5/30 I1: 15/30	ns
González Obregón 2010	C1: rocuronium 0.6 mg/kg	100/100	C1: propofol 1‐2 mg/kg I1: Sevoflurane 3% + propofol 2 mg/kg	C1: remifentanil 1‐2 μg/kg in 1 min + 0.15 µ/kg/min in1 min I1: remifentanil 0.6 µ/kg/min for 5 min	None	C1: 4/50 I1: 1/50	C1: 4/50 I1: 1/50	C1: 0/50 I1: 0/50
Gulhas 2013	C1: succinylcholine 1 mg/kg	80/80	C1: propofol 2 mg/kg I1: propofol 2 mg/kg	C1: remifentanil 1 μg/kg I1: remifentanil 4 μg/kg	None	C1: 5/40 I1: 0/40	ns	C1: 2/40 I1: 4/40
Hanna 2010	C1: rocuronium 0.06 mg/kg + succinylcholine 1.5 mg/kg	50/47	C1: propofol 2 mg/kg I1: propofol 2 mg/kg	C1: none I1: remifentanil 4 μg/kg	Lidocaine 0.5 mg/kg IV	C1: 2/24 I1: 3/23	ns	ns
Harsten 1997	C1: suxamethonium 1 mg/kg	80/79	C1: thiopental 5 mg/kg I1: propofol 2.5 mg/kg	C1: alfentanil 10 μg/kg I1: alfentanil 10 μg/kg	None	C1: 0/40 I1: 6/39	C1: 0/40 I1: 2/39	ns
Iamaroon 2001	C1: suxamentonium 1.5 mg/kg	120/120	C1: thiopenthal 5 mg/kg + (N₂O) I1: sevoflurane 8%	C1: fentanyl 1.5 μg/kg I1: fentanyl 1.5 μg/kg	None	C1: 0/60 I1: 4/60	ns	ns
Isesele 2012	C1: suxamethonium 1.5 mg/kg	96/88	C1: propofol 2.0 mg/kg I1: propofol 2.0 mg/kg	None	C1: none I1: lidocaine IV 1.5 mg/kg	C1: 0/44 I1: 18/44	ns	ns
Jiao 2014	C1: suxamethonium 0.6 mg/kg	55/55	C1: propofol 2 mg/kg I1: propofol 2 mg/kg	C1: remifentanil 1 μg/kg I1: remifentanil 1.5 μg/kg	None	C1: 1/27 I2: 13/28	ns	ns
Kahwaji 1997	C1: ORG 9487 (rapacuronium) 0.5 mg/kg C2: ORG 9487 (rapacuronium) 1.0 mg/kg C3: ORG 9487 (rapacuronium) 1.5 mg/kg C4: ORG 9487 (rapacuronium) 2.0 mg/kg C5: ORG 9487 (rapacuronium) 2.5 mg/kg	181/176	C1: thiopental 3‐6 mg/kg C2: thiopental 3‐6 mg/kg C3: thiopental 3‐6 mg/kg C4: thiopental 3‐6 mg/kg C5: thiopental 3‐6 mg/kg I1: thiopental 3‐6 mg/kg	C1: fentanyl 0.5‐3 μm/kg C2: fentanyl 0.5‐3 μm/kg C3: fentanyl 0.5‐3 μm/kg C4: fentanyl 0.5‐3 μm/kg C5: fentanyl 0.5‐3 μm/kg I1: fentanyl 0.5‐3 μm/kg	None	C1: 9/30 C2: 6/27 C3: 1/32 C4: 0/28 C5: 1/29 I1: 18/30	ns	ns
Kirkegaard‐Nielsen 1999	C1: rocuronium 0.4 mg/kg C2: rocuronium 0.8 mg/kg C3: rocuronium 1.2 mg/kg	80/80	C1: propofol 2 mg/kg C2: propofol 2 mg/kg C3: propofol 2 mg/kg I1: propofol 2 mg/kg	C1: fentanyl 2 μm/kg C2: fentanyl 2 μm/kg C3: fentanyl 2 μm/kg I1: fentanyl 2 μm/kg	None	C1: 9/20 C2: 2/20 C3: 1/20 I1: 13/20	ns	ns
Kopman 2001	C1: rapacuronium 1.0 mg/kg C2: rapacuronium 1.2 mg/kg C3: rocuronium 0.50 mg/kg	100/100	C1: propofol 2.0 mg/kg IV C2: propofol 2.0 mg/kg IV C3: propofol 2.0 mg/kg IV I1: propofol 2.0 mg/kg IV	C1: alfentanil 12.5 μg/kg C2: alfentanil 12.5 μg/kg C3: alfentanil 12.5 μg/kg I1: alfentanil 12.5 μg/kg	None	C1: 2/30 C2: 0/30 C3: 0/30 I1: 7/10
Lieutaud 2003	C1: atracurium 0.5 mg/kg C2: atracurium 0.5 mg/kg C3: atracurium 0.5 mg/kg	170/160	C1: propofol 1.5 mg/kg C2: propofol 2.0 mg/kg C3: propofol 2.5 mg/kg I1: propofol 2.5 mg/kg	C1: fentanyl 3 μm/kg C2: fentanyl 3 μm/kg C3: fentanyl 3 μm/kg I1: fentanyl 3 μm/kg	None	C1: 7/47 C2: 1/48 C3: 2/45 I1: 13/20	ns	ns
Lowry 1999	C1: rocuronium 0.3 mg/kg C2: rocuronium 0.45 mg/kg C3: rocuronium 0.6 mg/kg C4: rocuronium 0.3 mg/kg C5: rocuronium 0.45 mg/kg C6: rocuronium 0.6 mg/kg	140/140	C1: propofol 2‐3 mg/kg C2: propofol 2‐3 mg/kg C3: propofol 2‐3 mg/kg C4: sevoflurane 8% C5: sevoflurane 8% C6: sevoflurane 8% I1: propofol 2‐3 mg/kg I2: sevoflurane 8%	C1: fentanyl 1 μm/kg C2: fentanyl 1 μm/kg C3: fentanyl 1 μm/kg C4: fentanyl 1 μm/kg C5: fentanyl 1 μm/kg C6: fentanyl 1 μm/kg I1: fentanyl 1 μm/kg I2: fentanyl 1 μm/kg	None	C1: 11/20 C2: 4/20 C3: 2/20 C4:14/20 C5: 9/20 C6: 2/20 I1:10/10 I2: 9/10	ns	ns
McNeil 2000	C1: succinylcholine 1 mg/kg	60/60	C1: propofol 2 mg/kg I1: propofol 2 mg/kg I2: propofol 2 mg/kg	C1: none I1: remifentanil 2 μg/kg I2: remifentanil 4 μg/kg	None	C1: 0/17 I1: 2/23 I2: 2/20	C1: 0/17 I1: 0/23 I2: 0/20	ns
Mencke 2003	C1: atracurium 0.5 mg/kg	80/73	C1: propofol 2.5‐3 mg/kg I1: propofol 2.5‐3 mg/kg	C1: fentanyl 2‐3 μg/kg I1: fentanyl 2‐3 μg/kg	None	C1: 2/37 I1: 12/36	C1: 1/39 I1: 4/39	C1: 6/37 I1: 16/36
Mencke 2014	C1: rocuronium 0.45 mg·kg/kg	83/83	C1: propofol 1.5 mg·kg^‐1 + sevoflurane 3.0‐3.5 Vol%,8 l·min^‐1 in 2‐3 minutes I1: propofol 1.5 mg/kg	C1: remifentanil 0.30 μg/kg/min for 3 minutes I1: remifentanil 0.30 μg/kg/min for 3 minutes	None	C1: 1/40 I1: 11/43	C1: 0/40 I1: 2/43	C1: 12/33 I1: 17/31
Naguib 2003	C1: succinylcholine 0.3 mg/kg C2: succinylcholine 0.5 mg/kg C3: succinylcholine 1.0 mg/kg	200/200	C1: propofol 2 mg/kg C2: propofol 2 mg/kg C3: propofol 2 mg/kg I1: propofol 2 mg/kg	C1: fentanyl 2 μg/kg C2: fentanyl 2 μg/kg C3: fentanyl 2 μg/kg I1: fentanyl 2 μg/kg	None	C1: 4/50 C2: 3/50 C3: 1/50 I1: 15/50	ns	ns
Naguib 2006	C1: succinylcholine 0.3 mg/kg C2: succinylcholine 0.5 mg/kg C3: succinylcholine 1.0 mg/kg C4: succinylcholine 1.5 mg/kg C5: succinylcholine 2.0 mg/kg	180/180	C1: propofol 2 mg/kg C2: propofol 2 mg/kg C3: propofol 2 mg/kg C4: propofol 2 mg/kg C5: propofol 2 mg/kg I1: propofol 2 mg/kg	C1: fentanyl 2 μm/kg C2: fentanyl 2 μm/kg C3: fentanyl 2 μm/kg C4: fentanyl 2 μm/kg C5: fentanyl 2 μm/kg I1: fentanyl 2 μm/kg	None	C1: 2/30 C2: 2/30 C3: 1/30 C4: 1/30 C5: 0/30 I1: 21/30	ns	ns
Nimmo 1995	C1: suxamethonium 0.25 mg/kg C2: suxamethonium 0.5 mg/kg	60/60	C1: propofol 2.5 mg/kg C2: propofol 2.5 mg/kg I1: Propofol 2.5 mg/kg	C1: alfentanil 15 μg/kg C2: alfentanil 15 μg/kg I1: alfentanil 15 μg/kg	None	C1: 0/20 C2: 1/20 I1: 9/20	ns	ns
Pang 2014	C1: cisatracurium 0.1 mg/kg	20/20	C1: propofol target control I1: propofol target control	C1: remifentanil target control I1: remifentanil target control	C1: tetracaine 10 mg/mL I1: tetracaine 10 mg/mL	C1: 0/20 I1: 0/20	C1: 0/20 I1: 0/20	ns
Pino 1998	C1: mivacurium 0.25 mg/kg C2: rocuronium 0.45 mg/kg C3: rocuronium 0.6 mg/kg C4: rocuronium 0.9 mg/kg C5: rocuronium 1.2 mg/kg	100/98	C1: propofol 2 mg/kg C2: propofol 2 mg/kg C3: propofol 2 mg/kg C4: propofol 2 mg/kg C5: propofol 2 mg/kg I1: propofol 2 mg/kg	C1: fentanyl 2 μm/kg C2: fentanyl 2 μm/kg C3: fentanyl 2 μm/kg C4: fentanyl 2 μm/kg C5: fentanyl 2 μm/kg I1: fentanyl 2 μm/kg	None	C1: 2/30 IC2: 9/15 C3: 4/14 C4: 1/14 C5: 0/15 I1: 10/10	ns	ns
Rousseau 1995	C1: vecuronium 0.08 mg/kg	152/152	C1: propofol 2.5 mg/kg I1: propofol 2.5 mg/kg	C1: alfentanil 0.03 mg/kg I1: alfentanil 0.03 mg/kg	C1: none I1: lidocaine 1.5 mg/kg	C1: 2/77 I1: 4/75	ns	ns
Scheller 1992	C1: d‐tubocurarine 3 mg and succinylcholine 1 mg/kg	75/75	C1: thiamylal 4 mg/kg I1: propofol 2 mg/kg I2: propofol 2 mg/kg I3: propofol 2 mg/kg I4: propofol 2 mg/kg	C1: none I1: alfentanil 30 µg/kg I2: alfentanil 40 µg/kg I3: alfentanil 50 µg/kg I4: alfentanil 60 µg/kg	None	C1: 0/15 I1: 1/15 I2: 1/15 I3: 1/15 I4: 1/15	C1: 0/15 I1: 1/15 I2: 1/15 I3: 1/15 I4: 1/15	ns
Schlaich 2000	C1: rocuronium 0.6 mg/kg C2: rocuronium 0.45 mg/kg C3: rocuronium 0.3 mg/kg	120/120	C1: propofol 2‐2.5 mg/kg C2: propofol 2‐2.5 mg/kg C3: propofol 2‐2.5 mg/kg I1: propofol 2‐2.5 mg/kg	C1: remifentanil 0.5 µg/kg/min C2: remifentanil 0.5 µg/kg/min IC3: remifentanil 0.5 µg/kg/min I1: remifentanil 0.5 µg/kg/min	None	C1: 0/30 C2: 1/30 C3: 0/30 I1: 12/30	ns	ns
Sivalingam 2001	C1: suxamethonium 1 mg/kg	100/100	C1: Sevoflu 7% + N₂O60% I1: Sevoflu 7% + N₂O60% I2: Sevoflu 7% + N₂O60% I3: Sevoflu 7% + N₂O60%	C1: alfentanil 10 µg/kg I1: alfentanil 20 µg/kg I2: alfentanil 25 µg/kg I3: alfentanil 30 µg/kg	None	C1: 1/25 I1: 4/25 I2: 5/25 I3: 2/25	ns	C1: 8/25 I1: 12/25 I2: 13/25 I3: 9/25
Stevens 1997	C1: d‐tubocurarine 3 mg and succinylcholine 1 mg/kg	140/140	C1: thiopental 4 mg/kg I1: etomidate 0.3 mg/kg I2: etomidate 0.3 mg/kg I3: propofol 2 mg/kg I4: propofol 2 mg/kg I5: thiopental 4 mg/kg I6: thiopental 4 mg/kg	C1: none I1: alfentanil 40 µg/kg I2: alfentanil 40 µg/kg I3: alfentanil 40 µg/kg I4: alfentanil 40 µg/kg I5: alfentanil 40 µg/kg I6: alfentanil 40 µg/kg	C1: none I1: none I2: lidocaine 1 mg/kg I3: none I4: lidocaine 1 mg/kg I5: none I6: lidocaine1 mg/kg	C1: 1/20 I1: 3/20 I2: 1/20 I3: 3/20 I4: 2/20 I5: 8/20 I6: 3/20	C1: 0/20 I1: 0/20 I2: 0/20 I3: 0/20 I4: 0/20 I5: 0/20 I6: 0/20	ns
Striebel 1995	C1: vecuronium 1 mg + succinylcholine 1 mg/kg C2: vecuronium 1 mg + succinylcholine 1 mg/kg	100/100	C1: thiopental 5.5 mg/kg C2: propofol 2.2 mg/kg I1: propofol 2.4 mg/kg I2: propofol 2.2 mg/kg	C1: fentanyl 0.1 mg C2: fentanyl 0.1 mg I1: fentanyl 0.1 mg I2: fentanyl 0.2 mg	2 mL lidocaine 1% IV	C1: 1/25 C2: 1/25 I1: 3/25 I2: 5/25	C1: 2/25 C2: 1/25 I1: 1/28 I2: 4/25	ns
Wong 1996	C1: succinylcholine 1 mg/kg	120/120	C1: propofol 3.0 mg/kg I1: propofol 2.6 mg/kg I2: propofol 2.6 mg/kg I3: propofol 3.1 mg/kg	C1: none I1: alfentanil 15 μg/kg I2: alfentanil 30 μg/kg I3: none	None	C1: 0/30 I1: 1/30 I2: 0/30 I3: 6/30	ns	ns
Yazdi 2016	C1: atracurium 0.5 mg/kg	66/66	C1: propofol 2.5 mg/kg I1: propofol 2.5 mg/kg	C1: none I1: remifentanil 2 μg/kg	None	C1: 4/31 I1: 14/35	ns	ns
ns = not specified

Table 2. Intervention

Ir a la tabla de la revisión

Comparison 1. Avoidance vs use of NMBA

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Difficult tracheal intubation: low risk of bias vs high or uncertain risk of bias Show forest plot	34	3565	Risk Ratio (M‐H, Random, 95% CI)	5.00 [3.49, 7.15]

1.1 Low risk of bias	4	508	Risk Ratio (M‐H, Random, 95% CI)	13.27 [8.19, 21.49]
1.2 High or uncertain risk of bias	30	3057	Risk Ratio (M‐H, Random, 95% CI)	4.14 [2.92, 5.87]
2 Difficult tracheal intubation: depolarizing vs non‐depolarizing NMBA Show forest plot	32	3413	Risk Ratio (M‐H, Random, 95% CI)	5.25 [3.61, 7.63]

2.1 Depolarizing NMBA	16	1540	Risk Ratio (M‐H, Random, 95% CI)	5.79 [2.64, 12.72]
2.2 Non‐depolarizing NMBA	16	1873	Risk Ratio (M‐H, Random, 95% CI)	4.72 [3.17, 7.02]
3 Difficult tracheal intubation: remifentanil vs no remifentanil Show forest plot	26	3008	Risk Ratio (M‐H, Random, 95% CI)	5.64 [3.82, 8.31]

3.1 Remifentanil	4	372	Risk Ratio (M‐H, Random, 95% CI)	15.86 [4.43, 56.71]
3.2 No remifentanil	22	2636	Risk Ratio (M‐H, Random, 95% CI)	5.23 [3.54, 7.74]
4 Difficult tracheal intubation: alfentanil vs no alfentanil Show forest plot	26	2618	Risk Ratio (M‐H, Random, 95% CI)	4.77 [3.25, 7.01]

4.1 Alfentanil	6	511	Risk Ratio (M‐H, Random, 95% CI)	4.46 [1.66, 11.98]
4.2 No alfentanil	20	2107	Risk Ratio (M‐H, Random, 95% CI)	5.10 [3.34, 7.79]
5 Difficult tracheal intubation: local anaesthesia vs no local anaesthesia Show forest plot	31	3184	Risk Ratio (M‐H, Random, 95% CI)	5.04 [3.48, 7.29]

5.1 Local anaesthesia	5	307	Risk Ratio (M‐H, Random, 95% CI)	1.90 [1.14, 3.18]
5.2 No local anaesthesia	26	2877	Risk Ratio (M‐H, Random, 95% CI)	6.26 [4.15, 9.44]
6 Difficult tracheal intubation: excluded anticipated DTI vs included anticipated DTI Show forest plot	34	3564	Risk Ratio (M‐H, Random, 95% CI)	5.00 [3.50, 7.16]

6.1 Exclusion of patients with anticipated difficult intubation	25	2886	Risk Ratio (M‐H, Random, 95% CI)	5.32 [3.54, 8.00]
6.2 No exclusion of patients with anticipated difficult intubation	9	678	Risk Ratio (M‐H, Random, 95% CI)	4.40 [1.71, 11.29]
7 Difficult tracheal intubation: "best‐case scenario" Show forest plot	34	2410	Risk Ratio (M‐H, Random, 95% CI)	5.99 [3.46, 10.38]

8 Difficult tracheal intubation excluding dose‐finding studies Show forest plot	16	1536	Risk Ratio (M‐H, Random, 95% CI)	3.40 [1.63, 7.10]

9 Difficult tracheal intubation: funding from pharmaceutical industry Show forest plot	34	3565	Risk Ratio (M‐H, Random, 95% CI)	5.00 [3.49, 7.15]

9.1 No funding from pharmaceutical industry	24	2550	Risk Ratio (M‐H, Random, 95% CI)	5.33 [3.16, 8.98]
9.2 Funding from pharmaceutical industry	10	1015	Risk Ratio (M‐H, Random, 95% CI)	4.10 [2.67, 6.31]
10 One or more events of upper airway discomfort or injury: low risk of bias vs high or uncertain risk of bias Show forest plot	7	844	Risk Ratio (M‐H, Random, 95% CI)	1.36 [1.08, 1.71]

10.1 Low risk of bias	1	73	Risk Ratio (M‐H, Random, 95% CI)	2.74 [1.21, 6.21]
10.2 High or uncertain risk of bias	6	771	Risk Ratio (M‐H, Random, 95% CI)	1.30 [1.08, 1.58]
11 One or more events of upper airway discomfort or injury: depolarizing vs non‐depolarizing NMBA Show forest plot	7	846	Risk Ratio (M‐H, Random, 95% CI)	1.37 [1.09, 1.74]

11.1 Depolarizing NMBA	2	180	Risk Ratio (M‐H, Random, 95% CI)	1.48 [0.83, 2.65]
11.2 Non‐depolarizing NMBA	5	666	Risk Ratio (M‐H, Random, 95% CI)	1.37 [0.97, 1.94]
12 One or more events of upper airway discomfort or injury: remifentanil vs no remifentanil Show forest plot	7	846	Risk Ratio (M‐H, Random, 95% CI)	1.37 [1.09, 1.74]

12.1 Remifentanil	2	193	Risk Ratio (M‐H, Random, 95% CI)	1.12 [0.61, 2.08]
12.2 No remifentanil	5	653	Risk Ratio (M‐H, Random, 95% CI)	1.42 [1.16, 1.75]
13 One or more events of upper airway discomfort or injury: alfentanil vs no alfentanil Show forest plot	5	446	Risk Ratio (M‐H, Random, 95% CI)	1.47 [0.85, 2.53]

13.1 No alfentanil	5	446	Risk Ratio (M‐H, Random, 95% CI)	1.47 [0.85, 2.53]
14 One or more events of upper airway discomfort or injury: excluded anticipated DTI vs included anticipated DTI Show forest plot	7	846	Risk Ratio (M‐H, Random, 95% CI)	1.37 [1.09, 1.74]

14.1 Excluded anticipated DTI	6	766	Risk Ratio (M‐H, Random, 95% CI)	1.37 [1.05, 1.79]
14.2 Included anticipated DTI	1	80	Risk Ratio (M‐H, Random, 95% CI)	2.0 [0.39, 10.31]
15 Difficult laryngoscopy: low risk of bias vs high or uncertain risk of bias Show forest plot	13	1308	Risk Ratio (M‐H, Random, 95% CI)	2.54 [1.53, 4.21]

15.1 Low risk of bias	1	78	Risk Ratio (M‐H, Random, 95% CI)	4.0 [0.47, 34.20]
15.2 High or uncertain risk of bias	12	1230	Risk Ratio (M‐H, Random, 95% CI)	2.47 [1.47, 4.16]

Comparison 1. Avoidance vs use of NMBA

Ir a la tabla de la revisión

The Cochrane Library

Scolaris Language Selector Scolaris Language Selector

Idioma de la Revisión Cochrane

Idioma de la web

Scolaris Content Language Banner Portlet Scolaris Content Language Banner Portlet

Scolaris Content Display Scolaris Content Display

Evitación versus uso de agentes bloqueadores neuromusculares para mejorar las condiciones durante la intubación traqueal o la laringoscopia directa en adultos y adolescentes

Información