Videolaryngoscopy in Neonates, Infants, and Children

Airway management in a two-year-old child with a tongue tumor using video laryngoscope-assisted flexible bronchoscopic nasotracheal intubation (hybrid technique)

Airway management in children can be challenging. A hybrid technique using a video laryngoscope-assisted flexible bronchoscopic nasotracheal intubation allowed a successful airway management in a two-year-old child with a large tongue tumor.

Usefulness of C-curved stylet for intubation with the C-MAC® Miller videolaryngoscope in neonates and infants: a prospective randomized controlled trial

BACKGROUND

Optimizing endotracheal tube (ETT) shape is important for successful videolaryngoscope-aided intubation. This prospective randomized controlled study aimed to compare the tube-handling time between a C-curved and hockey stick-shaped stylet in infants and neonates using the C-MAC® videolaryngoscope Miller blade.

METHODS

A total of 110 infants (age < 1 year) were randomly assigned to either the hockey stick-curved stylet group (group H, n = 53) or the C-curved stylet group (group C, n = 57). The primary outcome was tube handling time after glottis visualization and the secondary outcomes were the total intubation time, incidence of successful intubation, initial tube tip location at the laryngeal inlet, and numerical rating scale for ease of intubation.

RESULTS

Tube insertion time and total intubation duration (both in seconds) were significantly shorter in group C than in group H (13.3 ± 8.9 vs. 25.1 ± 27.0, P = 0.002; 19.9 ± 9.4 vs. 32.8 ± 27.1, P = 0.001, respectively). Group C displayed a higher rate of intubation success within 30 s than group H (87.7% vs. 69.8%, P = 0.029). The initial tube tip was located at the center in 34 children in group C (59.6%) and 12 children in group H (26.1%, P < 0.001). Laryngoscope operators rated intubation as easier when provided with a C-curved stylet.

CONCLUSIONS

In neonates and infants, modification of the ETT shape into a C-curve may reduce tube handling time compared to the conventional hockey stick-shaped tube during intubation using a C-MAC® video laryngoscope Miller blade.

An approach to difficult airway in infants: Comparison of GlideScope® Spectrum LoPro, GlideScope® Spectrum Miller and conventional Macintosh and Miller blades in a simulated Pierre Robin sequence performed by 90 anesthesiologists

BACKGROUND

Airway management can be challenging in neonates and infants. The Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis and airway obstruction. The airway management of these patients poses great challenges for anesthesiologists and pediatricians alike. To date, there has been no direct comparison of the hyperangulated GlideScope® Spectrum LoPro (GLP), the straight GlideScope® Spectrum Miller (GSM), a conventional Macintosh (MC) and a conventional Miller blade (ML) in patients with PRS.

METHODS

For this purpose, 90 anesthesiologists (43 with limited experience, 47 with extensive experience) performed orotracheal intubation on an Air-Sim® Pierre Robin X manikin using GLP, GSM, MC and ML in randomized order. 'Time-to-vocal-cords', 'time-to-intubate', 'time-to-ventilate', the severity of oral-soft-tissue-trauma and the subjective evaluation of each device were recorded.

RESULTS

A significantly faster and better view of the vocal cords and lower oral-soft-tissue-trauma was achieved using the GLP (p<0.001). Though, there were no significant differences in the 'time-to-intubate' or 'time-to-ventilate'. The highest intubation success rate was found with GSM and the lowest with GLP (GSM 100%, ML 97.8%, MC 96.7%, GLP 93.3%). When using the videolaryngoscopes, there were no undetected esophageal intubations but in six cases prolonged attempts of intubation (>120s) with the GLP. In the sub-group with extensive experience, we found significantly shorter intubation times for the GSM and ML. The GLP was the tool of choice for most participants, while the conventional MC received the lowest rating.

CONCLUSIONS

Videolaryngoscopy leads to increased safety for the prevention of undetected esophageal intubation in the airway management in a PRS manikin. Hyperangulated blades may ensure a good and fast view of the vocal cords and low oral-soft-tissue-trauma but pose a challenge during the placement of the tube. Specific skills and handling seem to be necessary to ensure a safe tube placement with this sort of blades.

Applied forces with direct versus indirect laryngoscopy in neonatal intubation: a randomized crossover mannequin study

PURPOSE

In adult mannequins, videolaryngoscopy improves glottic visualization with lower force applied to upper airway tissues and reduced task workload compared with direct laryngoscopy. This trial compared oropharyngeal applied forces and subjective workload during direct vs indirect (video) laryngoscopy in a neonatal mannequin.

METHODS

We conducted a randomized crossover trial of intubation with direct laryngoscopy, straight blade videolaryngoscopy, and hyperangulated videolaryngoscopy in a neonatal mannequin. Thirty neonatal/pediatric/anesthesiology consultants and residents participated. The primary outcome measure was the maximum peak force applied during intubation. Secondary outcome measures included the average peak force applied during intubation, time needed to intubate, and subjective workload.

RESULTS

Direct laryngoscopy median forces on the epiglottis were 8.2 N maximum peak and 6.8 N average peak. Straight blade videolaryngoscopy median forces were 4.7 N maximum peak and 3.6 N average peak. Hyperangulated videolaryngoscopy median forces were 2.8 N maximum peak and 2.1 N average peak. The differences were significant between direct laryngoscopy and straight blade videolaryngoscopy, and between direct laryngoscopy and hyperangulated videolaryngoscopy. Significant differences were also found in the top 10th percentile forces on the epiglottis and palate, but not in the median forces on the palate. Time to intubation and subjective workload were comparable with videolaryngoscopy vs direct laryngoscopy.

CONCLUSIONS

The lower force applied during videolaryngoscopy in a neonatal mannequin model suggests a possible benefit in reducing potential patient harm during intubation, but the clinical implications require assessment in future studies.

REGISTRATION

ClinicalTrials.gov (NCT05197868); registered 20 January 2022.

Which Device Is Favorable for Intubation Attempts of Pediatric Residents on Four Different Pediatric Airway Simulations?

OBJECTIVES

Endotracheal intubation is an essential skill for the pediatric airway management. Although direct laryngoscopy (DL) is the standard method, several videolaryngoscopes (VLs) have been recently enhanced as an alternative especially for difficult intubations. We aimed to compare McGrath MAC (McG) and Storz C-MAC PM (ST) VLs with DL in terms of intubation success rate, time to intubation (TTI), and duration of obtaining glottis view of intubation attempts performed by pediatric residents on different pediatric airway manikins.

METHODS

The pediatric residents with no experience in videolaryngoscopy were included. After a brief demonstration, intubation attempts with 3 randomly handled different devices with 6 different blades were performed on a child manikin, an infant manikin, a Pierre-Robin sequence infant manikin, and a child manikin with cervical immobilization sequentially.

RESULTS

Fifty pediatric residents were enrolled. The attempts of DL on child manikin and attempts of all devices on child with cervical immobilization simulation were completely successful. For the attempts on both infant manikin and Pierre-Robin sequence infant manikin, the success rate of McG was significantly lower than ST and DL (P = 0.011 and P = 0.001). In the child manikin, McG and ST had prolonged TTI compared with DL (P = 0.016 and P = 0.001). For the child with cervical immobilization simulation, TTI of DL was significantly shorter than McG and ST (P = 0.011 and P = 0.001). Time to intubation of McG was significantly longer than DL and ST for the attempts on both 2 infant manikins. The rate of Cormack-Lehane grade I glottis view was similar for the attempts on both 2 child airway simulations. For infant manikin and Pierre-Robin sequence infant simulation, the rate of Cormack-Lehane grade I of ST was higher than attempts of DL and McG.

CONCLUSIONS

The attempts of pediatric residents on infant normal airway and Pierre-Robin sequence infant airway simulations resulted with enhanced glottis view by the utilization of Storz C-MAC PM, but both 2 VLs did not provide the improvement of intubation success rate and TTI compared with DL on these 4 different pediatric manikins. Further clinical studies of different VLs in different clinical courses are required for a reliable utilization in children.

Effects of tip-manipulated stylet angle on intubation using the GlideScope® videolaryngoscope in children: A prospective randomized controlled trial

BACKGROUND

An optimal endotracheal tube curve can be a key factor in successful intubation using the GlideScope videolaryngoscope.

AIMS

This study aimed to evaluate the effects of tube tip-modified stylet curve on the intubation time in children.

METHODS

Children aged 1-5 years were randomly assigned to either the standard curve (group S, n = 60) or tip-modified curve (group T, n = 60) groups. In group S, the endotracheal tube curve was similar to that in the GlideScope. In group T, a point approximately 1.5 cm from the tube tip was additionally angled to the left by 15°-20°. The primary outcome was the total intubation time, and the secondary outcomes were incidence of successful intubation in the first attempt, number of additional manipulations of the stylet curve, and visual analog scale (VAS) score for the easiness of intubation.

RESULTS

The mean total intubation time was significantly longer in group S than that in group T (13.9 [10.8] vs. 9.0 [3.4] sec, mean difference, 4.9 s; 95% confidence interval [CI], 2.0-7.8; p = .001). All patients in group T were successfully intubated in the first attempt, whereas those in group S were not (100% vs. 93.3%, relative risk [RR], 0.11; 95% CI, 0.01-2.02; p = .1376). Three patients in group S could be intubated after modifying the ETT curve similar to that in group T. Operators reported that tracheal intubation was easier in group T than in group S (median [interquartile range] for VAS; 1 [1-2] vs. 2 [1-3]; p < .001).

CONCLUSIONS

Having additional angle of the endotracheal tube tip to the left could be a useful technique to facilitate directing and advancing endotracheal tube into the vocal cords.

Comparison of Glidescope Core, C-MAC Miller and conventional Miller laryngoscope for difficult airway management by anesthetists with limited and extensive experience in a simulated Pierre Robin sequence: A randomized crossover manikin study

BACKGROUND

Video laryngoscopy is an effective tool in the management of difficult pediatric airway. However, evidence to guide the choice of the most appropriate video laryngoscope (VL) for airway management in pediatric patients with Pierre Robin syndrome (PRS) is insufficient. Therefore, the aim of this study was to compare the efficacy of the Glidescope® Core™ with a hyperangulated blade, the C-MAC® with a nonangulated Miller blade (C-MAC® Miller) and a conventional Miller laryngoscope when used by anesthetists with limited and extensive experience in simulated Pierre Robin sequence.

METHODS

Forty-three anesthetists with limited experience and forty-three anesthetists with extensive experience participated in our randomized crossover manikin trial. Each performed endotracheal intubation with the Glidescope® Core™ with a hyperangulated blade, the C-MAC® with a Miller blade and the conventional Miller laryngoscope. "Time to intubate" was the primary endpoint. Secondary endpoints were "time to vocal cords", "time to ventilate", overall success rate, number of intubation attempts and optimization maneuvers, Cormack-Lehane score, severity of dental trauma and subjective impressions.

RESULTS

Both hyperangulated and nonangulated VLs provided superior intubation conditions. The Glidescope® Core™ enabled the best glottic view, caused the least dental trauma and significantly decreased the "time to vocal cords". However, the failure rate of intubation was 14% with the Glidescope® Core™, 4.7% with the Miller laryngoscope and only 2.3% with the C-MAC® Miller when used by anesthetists with extensive previous experience. In addition, the "time to intubate", the "time to ventilate" and the number of optimization maneuvers were significantly increased using the Glidescope® Core™. In the hands of anesthetists with limited previous experience, the failure rate was 11.6% with the Glidescope® Core™ and 7% with the Miller laryngoscope. Using the C-MAC® Miller, the overall success rate increased to 100%. No differences in the "time to intubate" or "time to ventilate" were observed.

CONCLUSIONS

The nonangulated C-MAC® Miller facilitated correct placement of the endotracheal tube and showed the highest overall success rate. Our results therefore suggest that the C-MAC® Miller could be beneficial and may contribute to increased safety in the airway management of infants with PRS when used by anesthetists with limited and extensive experience.

Pediatric bronchoscopy: recent advances and clinical challenges

Introduction: During the last 40 years equipment has been improved with smaller instruments and sufficient size working channels. This has ensured that bronchoscopy offers therapeutic and interventional options.Areas covered: We provide a review of recent advances and clinical challenges in pediatric bronchoscopy. This includes single-use bronchoscopes, endobronchial ultrasound, and cryoprobe. Bronchoscopy in persistent preschool wheezing and asthma is included. The indications for interventional bronchoscopy have amplified and included balloon dilatation, endoscopic intubation, the use of airway stents, whole lung lavage, closing of fistulas and air leak, as well as an update on removal of foreign bodies. Others include the use of laser and microdebrider in airway surgery. Experience with bronchoscope during the COVID-19 pandemic has been included in this review. PubMed was searched for articles on pediatric bronchoscopy, including rigid bronchoscopy as well as interventional bronchoscopy with a focus on reviewing literature in the past 5 years.Expert opinion: As the proficiency of pediatric interventional pulmonologists continues to grow more interventions are being performed. There is a scarcity of published evidence in this field. Courses for pediatric interventional bronchoscopy need to be developed. The COVID-19 experience resulted in safer bronchoscopy practice for all involved.

Neonatal Intubation Practice and Outcomes: An International Registry Study

BACKGROUND AND OBJECTIVES

Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety.

METHODS

We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression.

RESULTS

We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57).

CONCLUSIONS

We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.

Management of the Difficult Airway in the Pediatric Patient

Loss of airway control in children, if not resolved quickly, will lead to devastating consequences. Successful management of the pediatric difficult airway, both anticipated and unanticipated, is facilitated by preprocedure assessment and preparation. Accessibility of and continued hands-on training with modern airway instruments, familiarization with difficult airway guidelines, and collaboration with multidisciplinary airway teams can aid in the management of the difficult pediatric airway. This review outlines the importance of airway assessment and advanced airway equipment for children. It also discusses difficult airway management techniques and algorithms for the management and rescue of the pediatric difficult airway.

Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs

OBJECTIVES

Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events.

DESIGN

Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014.

SETTING

International PICUs.

PATIENTS

Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs.

INTERVENTIONS

tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia.

MEASUREMENTS AND MAIN RESULTS

A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001).

CONCLUSIONS

In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.