A randomized comparison of the GlideScope videolaryngoscope to the standard laryngoscopy for intubation by pediatric residents in simulated easy and difficult infant airway scenarios

Use of in situ simulation to improve team performance and utilization of a rapid sequence intubation checklist

Background

Intubation checklists have emerged as tools to reduce adverse events and improve efficiency during rapid sequence intubation (RSI) in pediatric emergency departments (PEDs). This study aimed to use multidisciplinary simulation (SIM) training as an educational tool to improve PED team performance during RSI scenarios through utilization of an RSI checklist.

Methods

We created a checklist modeled after previously published PED checklists. PED multidisciplinary teams participated in video-recorded SIM training sessions involving a scenario requiring intubation three times, first without interruption then while receiving our intervention of rapid-cycle deliberate practice (RCDP) debriefing focusing on checklist utilization and team dynamics. Learners went through the scenario once more uninterrupted to apply learned skills. Team performance was evaluated via video review using the Simulation Team Assessment Tool (STAT) focusing on airway management and human factors sections. Scores were compared before and after intervention along with pre- and postintervention surveys.

Results

A total of 483 learners participated in 64 SIM training sessions, 44 of whom met inclusion criteria and were included for data analysis. Scores increased postintervention for airway management, human factors and in total. Least-squares mean differences for total, airway, and human factors scores were 9.55 (95% confidence interval [CI] 7.24-11.85), 4.22 (95% CI 2.91-5.52), and 5.33 (95% CI 3.86-6.8), respectively, which was statistically significant with p-value of <0.001 across all categories. Surveys demonstrated improved role understanding and checklist utilization comfort postintervention.

Conclusions

This study supports the benefit of multidisciplinary SIM training with RCDP-style methodology as an educational method for improving airway management, teamwork skills, and RSI checklist utilization for PED staff. Incorporation of additional maintenance SIM sessions for ongoing education is likely to be further beneficial and would allow evaluation of degradation of skills over time following initial training.

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.

Just Breathe: Tips and Highlights for Managing Pediatric Respiratory Distress and Failure

Anatomically, the airway is ever changing in size, anteroposterior alignment, and point of most narrow dimension. Special considerations regarding obesity, chronic and acute illness, underlying developmental abnormalities, and age can all affect preparation and intervention toward securing a definitive airway. Mechanical ventilation strategies should focus on limiting peak inspiratory pressures and optimizing lung protective tidal volumes. Emergency physicians should work toward minimizing risk of peri-intubation hypoxemia and arrest. With review of anatomic and physiologic principles in the setting of a practical approach toward evaluating and managing distress and failure, emergency physicians can successfully manage critical pediatric airway encounters.

Augmented Reality-Assisted Video Laryngoscopy and Simulated Neonatal Intubations: A Pilot Study

BACKGROUND

For novice providers, achieving competency in neonatal intubation is becoming increasingly difficult, possibly because of fewer intubation opportunities. In the present study, we compared intubation outcomes on manikins using direct laryngoscopy (DL), indirect video laryngoscopy (IVL) using a modified disposable blade, and augmented reality-assisted video laryngoscopy (ARVL), a novel technique using smart glasses to project a magnified video of the airway into the intubator's visual field.

METHODS

Neonatal intensive care nurses (n = 45) with minimal simulated intubation experience were randomly assigned (n = 15) to the following 3 groups: DL, IVL, and ARVL. All participants completed 5 intubation attempts on a manikin using their assigned modalities and received verbal coaching by a supervisor, who viewed the video while assisting the IVL and ARVL groups. The outcome and time of each attempt were recorded.

RESULTS

The DL group successfully intubated on 32% of attempts compared to 72% in the IVL group and 71% in the ARVL group (P < .001). The DL group intubated the esophagus on 27% of attempts, whereas there were no esophageal intubations in either the IVL or ARVL groups (P < .001). The median (interquartile range) time to intubate in the DL group was 35.6 (22.9-58.0) seconds, compared to 21.6 (13.9-31.9) seconds in the IVL group and 20.7 (13.2-36.5) seconds in the ARVL group (P < .001).

CONCLUSIONS

Simulated intubation success of neonatal intensive care nurses was significantly improved by using either IVL or ARVL compared to DL. Future prospective studies are needed to explore the potential benefits of this technology when used in real patients.

Comparison of the MultiViewScope Stylet Scope and the direct laryngoscope with the Miller blade for the intubation in normal and difficult pediatric airways: A randomized, crossover, manikin study

Background

Managing difficult pediatric airway is challenging. The MultiViewScope (MVS) Stylet Scope is reported to be useful in difficult pediatric airway. In this randomized crossover study, we compared the effectiveness of the MVS Stylet Scope to a standard direct laryngoscope with Miller #1 blade in simulated normal and difficult airways.

Methods

Fifteen expert anesthesiologists and Fifteen anesthesiology residents participated in the study. Participants were asked to perform intubation with the Airsim Baby manikin first, and then with the Airsim Pierre Robin manikin. Participants in each group used the intubation devices in a randomized order. The primary outcome was the time of successful intubation. The secondary outcomes were the force exerted on the incisors during intubation, Cormack–Lehane scale, the difficulty of intubation.

Results

There were no differences between MVS Stylet Scope and Direct laryngoscope in the time of successful intubation by the expert anesthesiologists or the anesthesiology residents in a normal or difficult pediatric airway. MVS Stylet Scope significantly improved the force exerted on the incisors during intubation in the expert anesthesiologists or the anesthesiology residents in a normal or difficult pediatric airway. MVS Stylet Scope significantly improved Cormack–Lehane scale, and the difficulty of intubation with difficult pediatric airway situation in both expert anesthesiologists and anesthesiology residents.

Conclusions

Although less forces on the incisors and improved view of glottis were observed with the MVS Stylet Scope, MVS Stylet Scope did not shorten the time of intubation. The results of this study mean that the MVS Stylet Scope may be a less invasive airway devise than the direct laryngoscope with the Miller blade in the pediatric airway management. For the next step, we need to evaluate the MVS Stylet Scope in the real patients as an observational study.

Video Versus Direct and Augmented Direct Laryngoscopy in Pediatric Tracheal Intubations

OBJECTIVES

With respect to first-attempt intubation success, the pediatric literature demonstrates either clinical equipoise or superiority of direct laryngoscopy (DL) when compared to video laryngoscopy (VL). Furthermore, it is unknown how VL compares to DL, when DL is "augmented" by maneuvers, such as optimal external laryngeal manipulation (OELM), upright or ramped positioning, or the use of the bougie. The objective of our study was to compare first-attempt success between VL and all DL, including "augmented DL" for pediatric intubations.

METHODS

We analyzed the National Emergency Airway Registry database of intubations of patients < 16 years. Variables collected included patient demographics, body habitus, impression of airway difficulty, intubating position, reduced neck mobility, airway characteristics, device, medications, and operator characteristics, adjusted for clustering by center. Primary outcome was the difference in first-attempt success for DL and augmented DL versus VL. Secondary outcomes included adverse events. In a planned sensitivity analysis, a propensity-adjusted analysis for first-attempt success and a subgroup analysis of children < 2 years was also performed.

RESULTS

Of 625 analyzable pediatric encounters, 294 (47.0%, 95% confidence interval [CI] = 25.1% to 69.0%) were DL; 332 (53.1%, 95% CI = 31.0% to 74.9%) were VL. Median age was 4 years (interquartile range = 1 to 10 years); 225 (36.0%, 95% CI = 30.8% to 41.2%) were < 2 years. Overall first-pass success was 79.6% (95% CI = 74.1% to 84.9%). VL first-pass success was 278/331 (84.0%) versus 219/294 for DL (74.5%), adjusted for clustering (odds ratio [OR] = 1.7, 95% CI = 1.3 to 2.5). Multivariable regression showed that VL yielded a higher odds of first-attempt success than DL augmented by OELM or use of a bougie (adjusted OR = 5.5, 95% CI = 1.7 to 18.1). Propensity-adjusted analyses supported the main results. Subgroup analysis of age < 2 years also demonstrated VL superiority (OR = 2.0, 95% CI = 1.1 to 3.3) compared with DL. Adverse events were comparable in both univariate and multivariable analysis.

CONCLUSIONS

When compared to DL, VL was associated with higher first-pass success in this pediatric population, even in the subgroup of patients < 2 years, as well as when DL was augmented. There were no differences in adverse effects between DL and VL.

A Comparison of Direct Laryngoscopy and Videolaryngoscopy for Endotracheal Intubation by Inexperienced Users: A Pediatric Manikin Study

OBJECTIVE

Direct laryngoscopy (DL) is the most common technique for endotracheal intubation, whereas videolaryngoscopy provides an indirect view of the glottis without the need to align the oral, pharyngeal, and tracheal axes. The current study compares videolaryngoscopy with DL among experienced and inexperienced users for endotracheal intubation using a pediatric manikin.

METHODS

Participants performed DL using Miller and Macintosh laryngoscopes and videolaryngoscopy using CMAC and GlideScope devices on a manikin (SimBaby; Laerdel, Wappingers Falls, NY). Time to endotracheal intubation, number of attempts, and successful intubation within 120 seconds were recorded.

RESULTS

Among 31 experienced users, time to endotracheal intubation with the CMAC (20 ± 13 seconds) did not differ from DL with either the Miller (30 ± 28 seconds) or Macintosh (27 ± 23 seconds) laryngoscopes. However, with the GlideScope, time to endotracheal intubation (85 ± 38 seconds) was longer. The results were similar among 12 inexperienced users, as time to endotracheal intubation with the CMAC (61 ± 34 seconds) was comparable with the Miller (72 ± 45 seconds) or Macintosh (72 ± 45 seconds) laryngoscopes but was longer with the GlideScope (118 ± 6 seconds) for each comparison.

CONCLUSIONS

The standard straight or curved laryngoscope blades including the CMAC were associated with shorter procedural time and higher success rate when compared with indirect videolaryngoscopy with an unconventional blade design such as the GlideScope in both experienced and inexperienced users. However, the current study demonstrates that results may be influenced by the anatomical design of the manikin.

Comparative evaluation of Airtraq™ and GlideScope® videolaryngoscopes for difficult pediatric intubation in a Pierre Robin manikin

Airway management in children is associated with anatomical and physiological challenges compared with adults. Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis, and cleft palate and related to a difficult airway. Both the Airtraq™ and GlideScope® have never been previously directly compared in PRS. Our aim was to evaluate the performance of these two airway devices in a PRS manikin for ethical and practical reasons. Between April and July 2017, 26, pediatric intensive care clinical fellows or trainees from a tertiary pediatric center were recruited to participate. In this prospective and randomized crossover trial, all participants first set up the Airtraq™ and the GlideScope® and then used these videolaryngoscopes to intubate an AirSim® PRS manikin. Our primary outcome measure was the duration of the successful intubation attempt. Duration of the successful intubation attempt was 18.1 (14.2-34.9 [10.2-51.3]) s for the Airtraq™ compared to 31.1 (18.7-55.6 [6.2-119]) s for the GlideScope® (p = 0.045). Setup time was 50.0 ± 6.9 s for the Airtraq™ and 27.8 ± 8.6 s for the GlideScope® (p < 0.001).Conclusion: Even though setup time was longer, the characteristics of intubation performance were superior with the Airtraq™ relative to the GlideScope® in an AirSim® PRS manikin. What is Known: • Several case reports have described the successful use of Airtraq™ to intubate children with Pierre Robin sequence. • The GlideScope® has demonstrated similar rates of first-attempt successful intubation to flexible fiberoptic bronchoscopy in a Pierre Robin sequence manikin. What is New: • In the hands of pediatric non-airway specialists, the characteristics of intubation performance, including the duration of the successful intubation attempt, are superior with the Airtraq™ compared with the GlideScope® in a Pierre Robin sequence manikin. • Setup time for the Airtraq™ is, however, longer relative to that for the GlideScope®.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study

Background and Objective

Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia.

Materials and Methods

Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded.

Results

TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5-28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8-32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45-100 and median = 82.4, range 10-100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt.

Conclusion

In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study

BACKGROUND AND OBJECTIVE

Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia.

MATERIALS AND METHODS

Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded.

RESULTS

TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5-28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8-32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45-100 and median = 82.4, range 10-100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt.

CONCLUSION

In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

A Randomized Controlled Trial of a Video-Enhanced Advanced Airway Curriculum for Pediatric Residents

PURPOSE

Pediatric advanced airway management is a low-frequency but critical procedure, making it challenging for trainees to learn. This study examined the impact of a curriculum integrating prerecorded videos of patient endotracheal intubations on performance related to simulated pediatric intubation.

METHOD

The authors conducted a randomized controlled educational trial for pediatric residents between January 2015 and June 2016 at Boston Children's Hospital. Investigators collecting data were blinded to the intervention. The control group received a standard didactic curriculum including still images, followed by simulation on airway trainers. The intervention group received a video-enhanced didactic curriculum including deidentified intubation clips recorded using a videolaryngoscope, followed by simulation. The study assessed intubation skills on simulated infant and pediatric airway scenarios of varying difficulty immediately after instruction and at three months.

RESULTS

Forty-nine trainees completed the curriculum: 23 received the video-enhanced curriculum and 26 received the standard curriculum. Median time to successful intubation was 18.5 and 22 seconds in the video-enhanced and standard groups, respectively. Controlling for mannequin age and difficulty, residents receiving the video-enhanced curriculum successfully intubated faster (hazard ratio [95% confidence interval]: 1.65 [1.25, 2.19]). Video-enhanced curriculum participants also demonstrated decreased odds of requiring multiple attempts and of esophageal intubation. At three-month follow-up, residents who received the video-enhanced curriculum remained faster at intubation (hazard ratio [95% confidence interval]: 1.93 [1.23, 3.02]).

CONCLUSIONS

Integrating videos of patient intubations into an airway management curriculum improved participating pediatric residents' intubation performance on airway trainers with sustained improvement at three months.

A comparison of two hyperangulated video laryngoscope blades to direct laryngoscopy in a simulated infant airway: a bicentric, comparative, randomized manikin study

Background

In infants, securing the airway is time-critical because of anatomical and physiological differences related to airway management in children less than 1 year old. The aim of this study was to compare the time to ventilation using two different hyperangulated video laryngoscope blades with the time to ventilation via conventional direct laryngoscopy in a normal airway [NA] and in a simulated difficult airway [DA].

Methods

This study was a comparative, bicentric, open-label, randomized controlled evaluation. An infant high-fidelity simulator (SimBaby™; Laerdal® Medical, Stavanger, Norway) was used, and two scenarios were proposed, as follows: NA and DA evoked with tongue edema and cervical collar. After theoretical and practical briefing, each participant compared in the two airway scenarios the novel King Vision™ Pediatric aBlade (KV) (Ambu® A/S, Bad Nauheim, Germany) video laryngoscope and the C-MAC™ D-blade Ped (DB) (Karl Storz® SE & Co. KG, Tuttlingen, Germany) video laryngoscope to conventional laryngoscopy using the Miller Blade (MiB) and the Macintosh Blade (MaB) in a random sequence.

Results

Eighty physicians (65 AN and 15 PCCM staff) were included. In the NA scenario, the median [IQR] time to successful time to ventilation (TTV) was significantly shorter for the KV at 13 s [12–15 s] than for the MaB at 14.5 s [13–16 s], DB at 14.5 s [13–16] and MiB at 16 s [14–19] (p < 0.001). In DA, the KV also shortened TTV to 14 s [13–16], whereas TTV was 23 s with the MaB [20–26], 19 s with the DB [16–21], and 27 s with the MiB [22–31] (p < 0.001). There were no differences in first-pass intubation success rates (FPAs) between hyperangulated blades and direct laryngoscopes in NA. In DA, the hyperangulated blades enabled 92 (DB) to 100% (KV) FPAs compared with 65 (MiB) to 76% (MaB) for conventional laryngoscopy (p < 0.001).

Conclusion

Video laryngoscopes with hyperangulated blades were associated with shorter TTV in normal and difficult infant airway situations. The higher FPAs of hyperangulated blades in DA may avoid desaturations and decrease adverse events in pediatric airway management.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0580-y) contains supplementary material, which is available to authorized users.

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association

Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Video Laryngoscopy vs. Direct Laryngoscopy in Teaching Neonatal Endotracheal Intubation: A Simulation-Based Study

BACKGROUND

Neonatal endotracheal intubation is a life-saving procedural skill where best practices have been developed from expert opinion. Few empirical studies have examined how this skill should be taught.

OBJECTIVE

To determine whether a video laryngoscope (VL) assisted intubation training curriculum compared to a traditional direct laryngoscope (DL) assisted curriculum improves neonatal intubation performance of novice intubators in a simulated setting.

METHODS

A randomized trial of novice intubators was conducted at the University of Texas-Houston from 6/2013-8/2013. Eligible candidates were randomly assigned to control group (DL curriculum) or intervention group (VL curriculum). Those in the intervention group received instruction with VL videos and practice with Storz C-MAC® VL (Karl Storz, Tuttlingen, Germany) in addition to a traditional curriculum. Intubation performance was evaluated in a simulated setting using a SimNewB® (Laerdal, NY, USA) manikin and traditional intubation equipment. The number of intubation attempts, outcome of each attempt, and time to successful intubation were recorded. The data was analyzed using Fisher's exact test and logistic regression where appropriate.

RESULTS

One hundred twenty-three trainees were enrolled, 62 (50%) in DL group and 61 (50%) in the VL group. Intubation success on first attempt was achieved by 69% (43/62) of the DL group vs. 61% (37/61) of the VL group, P=0.35. Time to successful intubation was 25 sec (interquartile range (IQR) 18, 32) in the DL group and 26.5 sec (IQR 20, 43) in the VL group, P=0.27. Those in the VL group were more likely to need more than two attempts to achieve intubation success, OR=3.09 (95% CI 1.03-9.28).

CONCLUSIONS

In a simulated setting, teaching with a VL curriculum did not improve intubation performance compared to teaching with DL. Further studies are needed to determine if VL-based teaching has an impact on clinical intubation performance.

A comparison of McGrath MAC® and standard direct laryngoscopy in simulated immobilized cervical spine pediatric intubation: a manikin study

Emergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal.

CONCLUSION

Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated. What is known : • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting. What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

Comparison of the Success of Two Techniques for the Endotracheal Intubation with C-MAC Video Laryngoscope Miller Blade in Children: A Prospective Randomized Study

Background. Ease of endotracheal intubation with C-MAC video laryngoscope (VLS) with Miller blades 0 and 1 has not been evaluated in children. Methods. Sixty children weighing 3-15 kg with normal airway were randomly divided into two groups. Intubation was done with C-MAC VLS Miller blade using either nonstyletted endotracheal tube (ETT) (group WS) or styletted ETT (group S). The time for intubation and total procedure, intubation attempts, failed intubation, blade repositioning or external laryngeal maneuver, and complications were recorded. Results. The median (minimum/maximum) time for intubation in group WS and group S was 19.5 (9/48) seconds and 13.0 (18/55) seconds, respectively (p = 0.03). The median (minimum/maximum) time for procedure in group WS was 30.5 (18/72) seconds and in group S was 24.5 (14/67) seconds, respectively (p = 0.02). Intubation in first attempt was done in 28 children in group WS and in 30 children in group S. Repositioning was required in 14 children in group WS and in 7 children in group S (p = 0.06). There were no failure to intubate, desaturation, and bradycardia in both groups. Conclusion. Styletted ETT significantly reduces time for intubation and time for procedure in comparison to nonstyletted ETT.

Comparison of Pentax-AWS Airwayscope and Glidescope for Infant Tracheal Intubation by Anesthesiologists during Cardiopulmonary Arrest Simulation: A Randomized Crossover Trial

BACKGROUND

Recent guidelines for infant cardiopulmonary resuscitation emphasize that all rescuers should minimize interruption of chest compressions, even for endotracheal intubation. We compared the utility of the Pentax-AWS Airwayscope (AWS) with the Glidescope (GS) during chest compressions on an infant manikin.

METHODS

Twenty-four anesthesiologists with more than two years of experience performed tracheal intubation on an infant manikin using the AWS and GS, with or without chest compressions.

RESULTS

In GS trials, none of the participants failed without compressions, while three failed with compressions. In AWS trials, all participants succeeded regardless of chest compressions. Intubation time was significantly longer with chest compressions with the GS (P < 0.05), but not with the AWS. Difficulty of operation on a visual analog scale (VAS) for laryngoscopy did not increase significantly with chest compressions with either the GS or the AWS, while the VAS for tube passage through the glottis increased with compressions with the GS, but not with the AWS.

CONCLUSION

We conclude that in infant simulations managed by anesthesiologists, the AWS performed better than the GS for endotracheal intubation with chest compressions.

Do you see what I see? A randomised pilot study to evaluate the effectiveness and efficiency of simulation-based training with videolaryngoscopy for neonatal intubation

Introduction

Direct laryngoscopy (DL) and airway intubation are critical for neonatal resuscitation. A challenge in teaching DL is that the instructor cannot assess the learners’ airway view. Videolaryngoscopy (VL), which allows display of a patient's airway on a monitor, enables the instructor to view the airway during the procedure. This pilot study compared deliberate practice using either VL with instruction (I-VL) or traditional DL. We hypothesised that I-VL would improve the efficiency and effectiveness of neonatal intubation (NI) training.

Methods

Participants (students, paediatric interns and neonatal fellows) were randomised to I-VL or DL. Baseline technical skills were assessed using a skills checklist and global skills assessment. Following educational sessions, deliberate practice was performed on mannequins using the Storz C-MAC. With I-VL, the instructor could guide training using a real-time airway monitor view. With DL, feedback was based solely on technique or direct visual confirmation, but the instructor and learner views were not concurrent. During summative assessment, procedural skills checklists were used to evaluate intubation ability on a neonatal airway trainer. The duration of attempts was recorded, and recorded airway views were blindly reviewed for airway grade. ‘Effectiveness’ reflected achievement of the minimum passing score (MPS). ‘Efficiency’ was the duration of training for learners achieving the MPS.

Results

58 learners were randomised. Baseline demographics were similar. All participants had a significant improvement in knowledge, skills and comfort/confidence following training. There were no significant differences between randomised groups in efficiency or effectiveness, but trends towards improvement in each were noted. Fellows were more likely to achieve ‘competency’ postinstruction compared to non-fellows (p<0.001).

Conclusions

This educational intervention to teach NI increased the learner's knowledge, technical skills and confidence in procedural performance in both groups. I-VL did not improve training effectiveness. The small sample size and participant diversity may have limited findings, and future work is indicated.

Predicting neonatal intubation competency in trainees

BACKGROUND AND OBJECTIVES

Pediatric residency training programs are graduating residents who are not competent in neonatal intubation, a vital skill needed for any pediatrician involved in delivery room resuscitations. However, a precise definition of competency during training is lacking. The objective of this study was to more precisely define the trajectory toward competency in neonatal intubation for pediatric residents, as a framework for later evaluating complementary training tools.

METHODS

This is a retrospective single-center observational study of resident-performed neonatal intubations at Duke University Medical Center between 2005 and 2013. Using a Bayesian statistical model, intubation competency was defined when the resident attained a 75% likelihood of intubating their next patient successfully.

RESULTS

A total of 477 unique intubation attempts by 105 residents were analyzed. The path to proficiency was defined by a categorical or milestone learning event after which all learners move toward competency in a similar manner. In our cohort, 4 cumulative successes were needed to achieve competency. Only 24 of 105 (23%) achieved competency during the study period. Residents who failed their first 2 opportunities, compared with those successful on their first 2 opportunities, needed nearly double the intubation exposure to achieve competency.

CONCLUSIONS

Bayesian statistics may be useful to more precisely describe neonatal intubation competency in residents. Achieving competency in neonatal intubation appears to be a categorical or milestone learning event whose timing varies between residents. The current educational environment does not provide adequate procedural exposure to achieve competency for most residents.

Tracheal intubation of pediatric manikins during ongoing chest compressions. Does Glidescope® videolaryngoscope improve pediatric residents' performance?

Our objective was to test the ability of pediatric residents to intubate the trachea of infant and child manikins during continuous chest compressions (CC) by means of indirect videolaryngoscopy with Glidescope® versus standard direct laryngoscopy. A randomized crossover simulation trial was designed. Twenty-three residents trained to intubate child and infant manikins were eligible for the study. They were asked to perform tracheal intubation in manikins assisted by both standard laryngoscopy and Glidescope® while a colleague delivered uninterrupted chest compressions. In the infant cardiac arrest scenario, the median (IQR) total time for intubation was significantly shorter with the Miller laryngoscope [28.2 s (20.4-34.4)] than with Glidescope® [38.0 s (25.3-50.5)] (p = 0.021). The number of participants who needed more than 30 s to intubate the manikin was also significantly higher with Glidescope® (n = 13) than with the Miller laryngoscope (n = 7, p = 0.01). In the child scenario, the total time for intubation and number of intubation failures were similar with Macintosh and Glidescope® laryngoscopes. The participants' subjective difficulty of the procedure was similar for direct and videolaryngoscopy.

CONCLUSION

In simulated infant and child cardiac arrest scenarios, pediatric residents are able to intubate the trachea during CC. The videolaryngoscope Glidescope® does not improve performance in this setting.

Pediatric video laryngoscope versus direct laryngoscope: a meta-analysis of randomized controlled trials

BACKGROUND

We reviewed the updated literature and performed a meta-analysis based on randomized controlled trials in children to compare the clinical efficacy between video laryngoscopes (VLs) and direct laryngoscopes (DLs).

METHODS

We searched articles published in English matching the key words 'video laryngoscope (including Airtraq, GlideScope, Storz, TruView, AWS, Bullard, McGrath)' AND 'direct laryngoscope' AND 'children (including pediatric, infant, neonate)' in PubMed, Ovid, Google Scholar, and the Cochrane Library databases. Only prospective randomized controlled trials (RCTs), which compared the use of VLs and DLs in children, were included. The relative risk (RR), weighted mean difference (WMD), and their corresponding 95% confidence interval (95% CI) were calculated using the quality effects model of the metaxl 1.3 software for outcome data.

RESULTS

Fourteen studies were included in this meta-analysis. Although VLs improved the glottis visualization in most children either with normal airways or with potentially difficult intubations, the time to intubation (TTI) was prolonged in comparison to DLs (WMD: 4.9 s; 95% CI: 2.6-7.1). Subgroup analysis showed the GlideScope (WMD: 5.2 s; 95% CI: 2.0-8.5), TruView (WMD: 5.1 s; 95% CI: 0.7-9.5), Storz (WMD: 6.4 s; 95% CI: 4.8-8.1), and Bullard (WMD: 37.5 s; 95% CI: 21.0-54.0) rather than Airtraq (WMD: 0.6 s; 95% CI: -7.7-8.9) prolonged TTI. Although the success rate of the first attempt (RR: 0.96; 95% CI: 0.92-1.00) and associated complications (RR: 1.11; 95% CI: 0.39-3.16) were similar in both groups, VLs were associated with a higher incidence of failure (RR: 6.70; 95% CI: 1.53-29.39).

CONCLUSION

This meta-analysis demonstrates that although VLs improved glottis visualization in pediatric patients, this was at the expense of prolonged TTI and increased failures. However, further studies are needed to clarify the efficacy and safety of VLs in hands of nonexperts and in children with airway problems.

Designing and conducting simulation-based research

As simulation is increasingly used to study questions pertaining to pediatrics, it is important that investigators use rigorous methods to conduct their research. In this article, we discuss several important aspects of conducting simulation-based research in pediatrics. First, we describe, from a pediatric perspective, the 2 main types of simulation-based research: (1) studies that assess the efficacy of simulation as a training methodology and (2) studies where simulation is used as an investigative methodology. We provide a framework to help structure research questions for each type of research and describe illustrative examples of published research in pediatrics using these 2 frameworks. Second, we highlight the benefits of simulation-based research and how these apply to pediatrics. Third, we describe simulation-specific confounding variables that serve as threats to the internal validity of simulation studies and offer strategies to mitigate these confounders. Finally, we discuss the various types of outcome measures available for simulation research and offer a list of validated pediatric assessment tools that can be used in future simulation-based studies.

Alternative airways for the pediatric emergency department

Securing the pediatric airway in the emergency setting is an uncommon event that is complicated by anatomic, physiologic, and environmental factors. Even more uncommonly, practitioners are faced with the added complication of a difficult airway, and the question of what alternatives to traditional endotracheal intubation are available and most useful may arise. Timely and effective intervention determines the patient's clinical outcome. The purpose of this review was to detail specific alternative airway management strategies and tools for use in the pediatric emergency department.

Comparison of success rates using video laryngoscopy versus direct laryngoscopy by residents during a simulated pediatric emergency

OBJECTIVE

Emergency airway situations are relatively rare events in pediatrics with most graduating residents having little exposure to intubate. Newer video technology offers the promise of reducing complications associated with intubation. This study proposes that video laryngoscopy (VL) should aid less skilled residents to intubate an infant mannequin with greater success and speed as compared with traditional direct laryngoscopy (DL).

METHODS

Pediatric (PED) and emergency medicine (EM) residents were randomized in a prospective controlled study. A standard respiratory failure scenario was conducted using SimBaby with an uncomplicated airway. Residents who inadvertently performed esophageal intubation were made aware as part of the scenario and allowed to reattempt until successful.

RESULTS

Sixty-nine residents voluntarily participated, 49% EM and 51% PED. Seven subjects in the DL group required multiple attempts (21%), compared with 6 subjects in the VL group (17%) (P = 0.718). Median time to intubation was 30 seconds (95% confidence interval [CI], 19-41 seconds) for DL and 39 seconds (95% CI, 36-42 seconds) for VL (P = 0.111). Comparison of programs revealed a 77% PED success rate versus 85% EM success rate (P = 0.578) and median time to intubation of 38 seconds (95% CI, 31-45 seconds) for PED compared with 32 seconds (95% CI, 23-41 seconds) for EM residents (P = 0.316). In a subanalysis, subjects successful at first attempt revealed a 13-second median difference (DL, 23 seconds [95% CI, 18-28 seconds] vs. VL, 36 seconds [95% CI, 29-43 seconds; P = 0.01).

CONCLUSIONS

In a simulated respiratory failure scenario involving residents, VL provided no additional success over DL with slightly longer time to intubation.

Utilization of exploration-based learning and video-assisted learning to teach GlideScope videolaryngoscopy

BACKGROUND

GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL).

PURPOSES

This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels.

METHODS

Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded.

RESULTS

Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups.

CONCLUSIONS

A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.

[Glottiscopes and videolaryngoscopes: a rational choice?]

Different airway devices can be used by paediatrician anaesthesiologists for difficult airway management in infant younger than 2 years. The four devices analyzed (Airtraq® [Prodol Meditec]; Glidescope® Cobalt [Verathon]; Vidéolaryngoscope [Storz]; laryngoscope Truview® [Truphatek]) increase the Cormack and Lehane grade against direct laryngoscopy and optimized external larynx movements. They need training, on manikin then in vivo, for an optimal use. The needed number of in vivo successful intubations is not determined. It is probably between 10 and 20. The choice between these devices, in accordance with the published studies, which compared the devices, is difficult. The manikin studies allow to standardize airway, but the results are not transposable in vivo. Concerning the airway devices with disposable blade, the Glidescope®, for oral intubation, seems to be better than Airtraq® if we take into account the oropharyngeal volume needed.

Comparison of GlideScope Videolaryngoscopy to Direct Laryngoscopy for Intubation of a Pediatric Simulator by Novice Physicians

Objective. To compare novice clinicians' performance using GlideScope videolaryngoscopy (GVL) to direct laryngoscopy (DL). Methods. This was a prospective, randomized crossover study. Incoming pediatric interns intubated pediatric simulators in four normal and difficult airway scenarios with GVL and DL. Primary outcomes included time to intubation and rate of successful intubation. Interns rated their satisfaction of the devices and chose the preferred device. Results. Twenty-five interns were included. In the normal airway scenario, there were no differences in mean time for intubation with GVL or DL (61.4 versus 67.4 seconds, P = NS) or number of successful intubations (19 versus 18, P = NS). In the difficult airway scenario, interns took longer to intubate with GVL than DL (87.7 versus 61.3 seconds, P = 0.018), but there were no differences in successful intubations (14 versus 15, P = NS). There was a trend towards higher satisfaction for GVL than DL (7.3 versus 6.4, P = NS), and GVL was chosen as the preferred device by a majority of interns (17/25, 68%). Conclusions. For novice clinicians, GVL does not improve time to intubation or intubation success rates in a pediatric simulator model of normal and difficult airway scenarios. Still, these novice clinicians overall preferred GVL.

A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department

STUDY OBJECTIVE

There is growing use of video laryngoscopy in US emergency departments (EDs). This study seeks to compare intubation success between the GlideScope video laryngoscope and the C-MAC video laryngoscope (C-MAC) in ED intubations.

METHODS

This was an analysis of quality improvement data collected during a 3-year period in an academic ED. After each intubation, the operator completed a standardized data form reporting patient demographics, indication for intubation, device(s) used, reason for device selection, difficult airway characteristics, number of attempts, and outcome of each attempt. An attempt was defined as insertion of the device into the mouth regardless of attempt at tube placement. The primary outcomes were first pass and overall intubation success. The study compared success rates between the GlideScope video laryngoscope and the C-MAC groups, using multivariable logistic regression and adjusting for potential confounders.

RESULTS

During the 3-year study period, there were 463 intubations, including 230 with the GlideScope video laryngoscope as the initial device and 233 with the C-MAC as the initial device. The GlideScope video laryngoscope resulted in first-pass success in 189 of 230 intubations (82.2%; 95% confidence interval [CI] 76.6% to 86.9%) and overall success in 221 of 230 intubations (96.1%; 95% CI 92.7% to 98.2%). The C-MAC resulted in first-pass success in 196 of 233 intubations (84.1%; 95% CI 78.8% to 88.6%) and overall success in 225 of 233 intubations (96.6%; 95% CI 93.4% to 98.5%). In a multivariate logistic regression analysis, the type of video laryngoscopic device was not associated with first-pass (odds ratio 1.1; 95% CI 0.6 to 2.1) or overall success (odds ratio 1.2; 95% CI 0.5 to 3.1).

CONCLUSION

In this study of video laryngoscopy in the ED, the GlideScope video laryngoscope and the C-MAC were associated with similar rates of intubation success.

Perioperative management of pediatric trauma patients

Pediatric trauma presents significant challenges to the anesthesia provider.

This review describes the current trends in perioperative anesthetic management, including airway management, choice of anesthesia agents, and fluid administration.

The review is based on the PubMed search of literature on perioperative care of severely injured children.

Prospective model-based comparison of different laryngoscopes for difficult intubation in infants

BACKGROUND

Difficult intubation in infants is uncommon but may be a challenge for the anesthesiologist. Many optical-assisted techniques are available to ease endotracheal placement of tube but have not been systemically evaluated for pediatric practice.

AIM

The study was performed to compare conventional pediatric Macintosh - with different optical laryngoscopes in difficult endotracheal intubation in infants. We hypothesized that inexperienced anesthetists would perform more successful with optical devices and that differences between the devices would be found.

METHODS/MATERIALS

In this randomized controlled study, 30 anesthesia residents performed endotracheal intubation in an infant model of difficult airway presenting with airway obstruction and neck immobilization. Primary endpoints were intubation success rate and intubation time. Beyond that glottis view, dental trauma and difficulty of technique were evaluated and measured by a study observer. Macintosh, Airtraq(®), Storz DCI(®) -, and Gyrus Infant Bullard(®) laryngoscopes were used in random order. After standardized briefing every resident had three attempts of at most 120 s with every device to place a 3-mm tube into the trachea. Glottis view and difficulty of technique were rated by the residents using classification of Cormack/Lehane and Visual Analogue Scale (VAS; 0 = easy to 10 = very difficult).

RESULTS

Success rate was 41% with conventional Macintosh, 43% with Airtraq(®), 62% with Storz DCI(®), and 100% with Bullard(®) laryngoscopes. Median time from passing the lips to first ventilation was 67 s (Storz DCI(®) laryngoscope), 54 s (Macintosh laryngoscope), 45 s (Airtraq(®) laryngoscope), and 21 s (Bullard(®) laryngoscope), respectively. Dental trauma did not occur with Bullard(®) laryngoscope and was frequent with Storz DCI(®) laryngoscope (39%) and Macintosh laryngoscope (42%). Glottis view was best with Bullard(®) laryngoscope (Grade 1 in 100%) and worst with Macintosh laryngoscope (Grade 1 in 2%). Difficulty of technique was rated with a VAS score of 2 (Bullard(®) laryngoscope), 4.5 (Storz DCI(®) laryngoscope) and 6 (Airtraq(®) - and Macintosh laryngoscopes).

CONCLUSIONS

Inexperienced anesthetists have higher success rates and shorter intubation times with optical-assisted laryngoscopes compared with conventional Macintosh laryngoscope. Gyrus Infant Bullard(®) laryngoscope significantly undertakes best success rate and shortest intubation time with mildest impact to maxillary dents and easiest technique. Our findings support the hypothesis that optical laryngoscopes can be used successfully by inexperienced anesthetists in simulated difficult pediatric airway conditions.