Using Video‐recorded Laryngoscopy to Evaluate Laryngoscopic Blade Approach and Adverse Events in Children

Abstract

Objectives: Using recordings of endotracheal intubation attempts obtained with a video-enabled laryngoscope with Miller and Macintosh blades, the authors sought to evaluate the association between laryngoscopic approach (right-sided vs. midline) and intubation success, as well as adverse event rates in the pediatric emergency department (ED).Methods: This was a retrospective cohort study of children younger than 21 years who underwent endotracheal intubation with a C-MAC video laryngoscope in a tertiary care ED between August 2009 and May 2013. The primary outcome was successful endotracheal intubation on the first attempt. The secondary outcomes included time to intubation, video-recorded adverse events (oropharyngeal mucosal injury and aspiration), and physiologic adverse events. Multivariate regression models were used to determine the relationship between laryngoscope blade position and outcome measures adjusted for patient and provider factors.Results: The cohort consisted of complete video recordings for 105 of 143 (73%) patient encounters with intubations. The first-pass success rate did not significantly differ based on laryngoscopic approach (adjusted odds ratio [aOR] = 0.76, 95% confidence interval [CI] = 0.29 to 2.0). Among patients successfully intubated on the first attempt, the median time to intubation was longer for the right-sided approach compared to the midline approach (42 seconds vs. 31.5 seconds; p < 0.05). The odds of mucosal injury and aspiration were higher among patients intubated using a right-sided approach compared to a midline approach (aOR = 4.1, 95% CI = 1.2 to 14.5; aOR = 7.7, 95% CI = 1.5 to 39.5, respectively). Rates of physiologic adverse events did not differ based on approach.Conclusions: First-pass success rate did not differ based upon laryngoscopic approach type; however, a right-sided approach was associated with a longer time to intubation, as well as higher rates of mucosal injury and aspiration among patients undergoing video-enabled intubation in a pediatric ED.

Comparison Between Direct and Video‐assisted Laryngoscopy for Intubations in a Pediatric Emergency Department

“…A final potential benefit of the C‐MAC is that it allows intubation attempts to be recorded and later reviewed for educational purposes and to assess performance metrics such as number of attempts, time to intubation, and complications . This method of QA allows for both impartiality and expert review of the procedure, a substantial improvement over self‐report.…”

Advanced Pediatric Emergency Airway Management: A Multimodality Curriculum Addressing a Rare but Critical Procedure

“…3,[12][13][14][15][16][17][18] In the face of this challenge, we developed our curriculum through the construct of learn, see, practice, prove, do, maintain, progressing learners through variable learning modalities and exposing them to novel airway educational interventions such as the use of real patient laryngoscopy videos. 14,15,[19][20][21][22] As such, our curriculum differs from existing resources and thereby offers a unique contribution to the literature as it offered extensive resources specific to pediatrics, highlighted the video laryngoscope as both a patient safety and educational adjunct, and provided learners multiple opportunities to apply their understanding of key concepts through both deliberate practice, coaching, and simulation. 12,19,[23][24][25] While components of our curriculum can be implemented with any learner along the medical education continuum, we have targeted our curriculum to the following learners: senior pediatric residents, pediatric emergency medicine fellows, pediatric intensive care fellows, emergency medicine residents, critical care transport paramedics and community hospital emergency medicine physicians, physician assistants, and nurse practitioners.…”

The midline approach for endotracheal intubation using GlideScope video laryngoscopy could provide better glottis exposure in adults: a randomized controlled trial

“…To obtain adequate direct visualization during intubation, the tongue is commonly swept to the left according to guidance [4, 13]. Although the midline approach has been proposed for intubation by some experts in the early twentieth century, they point to direct laryngoscopy not video laryngoscopy [5, 13–15]. Additionally, no clear evidence exists to support the clinical experience until now.…”

“…The midline approach without sweep of the tongue is commonly recommended to achieve an unobstructed view of the larynx by VL, but there is a lack of published supporting evidence. Israel and colleagues conducted a retrospective cohort study of children who had undergone endotracheal intubation using VL and found no difference in successful intubation on the first attempt based on the laryngoscopic approach type [5]. However, many factors, including glottis visualization, pre-shaped angulation of the tube, level of trainee and presence of difficult airway predictors, are all correlated with first-pass success (FPS) [6–8].…”