A comparison of Truview infant EVO2 laryngoscope with the Miller blade in neonates and infants

Comparison of video laryngoscopy and direct laryngoscopy for urgent intubation in newborn infants: A meta-analysis

BACKGROUND

Securing a stable airway is a critical component in neonatal resuscitation. Compared to direct laryngoscopy, video laryngoscopy provides improved visualization of the glottis, potentially enhancing the success rate of intubation. This systematic review and meta-analysis were conducted to assess and compare the efficacy and safety of video laryngoscopy versus direct laryngoscopy in neonatal intubation.

METHODS

A thorough search was performed across CENTRAL, Embase, and PubMed databases to identify relevant randomized controlled trials (RCTs) that evaluated the use of video laryngoscopy in comparison with direct laryngoscopy for neonatal intubation. The data extraction and analysis were conducted in alignment with Cochrane guidelines. The primary outcome of interest was the time required for intubation, while secondary outcomes included the number of intubation attempts and the success rate on the first attempt.

RESULTS

The meta-analysis included nine RCTs, encompassing a total of 719 neonates. The findings revealed that video laryngoscopy was associated with a longer intubation time (mean difference [MD] 3.23 s, 95 % confidence interval [CI] 2.42 to 4.04; I2 = 96 %). However, it also significantly improved the first-attempt success rate (risk ratio [RR] 1.31, 95 % CI 1.20 to 1.44; I2 = 76 %) and borderline reduced the total number of intubation attempts (MD -0.08, 95 % CI -0.15 to 0.00; I2 = 53 %).

CONCLUSIONS

While video laryngoscopy is associated with a modest increase in intubation time, it provides clear benefits by enhancing the success rate of first-attempt intubations and reducing the need for multiple attempts in neonatal intubation procedures.

Videolaryngoscopy in neonatal clinical care

Endotracheal intubation is a life-saving procedure for many newborns. Historically, it has been achieved by obtaining an airway view through the mouth via direct laryngoscopy. It is a skill that takes time and practice to achieve proficiency. Increasing evidence for the benefit of videolaryngoscopy in adults and the new development of technology has allowed videolaryngoscopy to become a reality in neonatal care. Studies have examined its use as both a technique to improve intubation safety and success, and as a training tool for those learning the skill in this vulnerable population. We present the current evidence for videolaryngoscopy in neonates in different settings where intubation may be required, in addition to exploring the challenges and practicalities of implementing this technique into clinical practice.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal intensive care unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation, and decrease adverse consequences of a delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. This is an update of a review first published in 2015, and updated in 2018.

OBJECTIVES

To determine the effectiveness and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate on first intubation attempt in neonates (0 to 28 days of age).

SEARCH METHODS

In November 2022, we updated the search for trials evaluating videolaryngoscopy for neonatal endotracheal intubation in CENTRAL, MEDLINE, Embase, CINAHL, and BIOSIS. We also searched abstracts of the Pediatric Academic Societies, clinical trials registries (www.

CLINICALTRIALS

gov; www.controlled-trials.com), and reference lists of relevant studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, or cross-over trials, in neonates (0 to 28 days of age), evaluating videolaryngoscopy with any device used for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Three review authors performed data collection and analysis, as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

The updated search yielded 7786 references, from which we identified five additional RCTs for inclusion, seven ongoing trials, and five studies awaiting classification. Three studies were included in the previous version of the review. For this update, we included eight studies, which provided data on 759 intubation attempts in neonates. We included neonates of either sex, who were undergoing endotracheal intubation in international hospitals. Different videolaryngoscopy devices (including C-MAC, Airtraq, and Glidescope) were used in the studies. For the primary outcomes; videolaryngoscopy may not reduce the time required for successful intubation when compared with direct laryngoscopy (mean difference [MD] 0.74, 95% confidence interval [CI] -0.19 to 1.67; 5 studies; 505 intubations; low-certainty evidence). Videolaryngoscopy may result in fewer intubation attempts (MD -0.08, 95% CI -0.15 to 0.00; 6 studies; 659 intubations; low-certainty evidence). Videolaryngoscopy may increase the success of intubation at the first attempt (risk ratio [RR] 1.24, 95% CI 1.13 to 1.37; risk difference [RD] 0.14, 95% CI 0.08 to 0.20; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 13; 8 studies; 759 intubation attempts; low-certainty evidence).  For the secondary outcomes; the evidence is very uncertain about the effect of videolaryngoscopy on desaturation or bradycardia episodes, or both, during intubation (RR 0.94, 95% CI 0.38 to 2.30; 3 studies; 343 intubations; very-low certainty evidence). Videolaryngoscopy may result in little to no difference in the lowest oxygen saturations during intubation compared with direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations; low-certainty evidence). Videolaryngoscopy likely results in a slight reduction in the incidence of airway trauma during intubation attempts compared with direct laryngoscopy (RR 0.21, 95% CI 0.05 to 0.79; RD -0.04, 95% CI -0.07 to -0.01; NNTB 25, 95% CI 14 to 100; 5 studies; 467 intubations; moderate-certainty evidence). There were no data available on other adverse effects of videolaryngoscopy. We found a high risk of bias in areas of allocation concealment and performance bias in the included studies.

AUTHORS' CONCLUSIONS

Videolaryngoscopy may increase the success of intubation on the first attempt and may result in fewer intubation attempts, but may not reduce the time required for successful intubation (low-certainty evidence). Videolaryngoscopy likely results in a reduced incidence of airway-related adverse effects (moderate-certainty evidence). These results suggest that videolaryngoscopy may be more effective and potentially reduce harm when compared to direct laryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered RCTS are necessary to confirm the efficacy and safety of videolaryngoscopy in neonatal intubation.

The relationship between years of anesthesia experience and first-time intubation success rate with direct laryngoscope and video laryngoscope in infants: a retrospective observational study

PURPOSE

Studies in adults have reported that video laryngoscope is more useful than direct laryngoscope when training less experienced anesthesiologists. However, whether this is true for infants remains unclear. Therefore, this study aimed to evaluate whether the use of video laryngoscope would result in smaller differences in success rate according to anesthesiologists' expertise than those in direct laryngoscope.

METHODS

Medical records and video recordings from the operating room of patients aged < 1 year who underwent non-cardiac surgery between March 2019 and September 2021 were reviewed. Tracheal intubations between April 8, 2020, and June 20, 2021, were excluded due to the shortage of video laryngoscope blades during the COVID-19 pandemic. Rates of first-time tracheal intubation success were compared by years of anesthesia experience and initial intubation device.

RESULTS

In total, 125 of 175 tracheal intubations were analyzed (direct laryngoscope group, n = 72; video laryngoscope group, n = 53). The first-time tracheal intubation success rate increased with years of experience as an anesthesiologist in the direct laryngoscope group (odds ratio OR 1.70, 95% confidence interval CI 1.15, 2.49; P = 0.0070), but not the video laryngoscope group (OR 0.99, 95% CI 0.74, 1.35; P = 0.99).

CONCLUSION

The differences in success rate according to the anesthesiologists' years of experience were non-significant when using video laryngoscope in infants, compared to those in direct laryngoscope.

Effectiveness of Indirect and Direct Laryngoscopes in Pediatric Patients: A Systematic Review and Network Meta-Analysis

This research aimed to produce a coherent ranking of the effectiveness of intubation devices in pediatric patients using network meta-analysis (NMA). We searched the electric databases for prospective randomized studies that compared different tracheal intubation devices in pediatric patients. The primary outcome was intubation failure at the first attempt. Secondary outcomes were glottic visualization and intubation time. The statistical analysis performed used DerSimonian and Laird random-effects models. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. Subgroup analysis was performed after excluding rigid-fiberscope-type indirect laryngoscopes. Thirty-four trials comparing 13 devices were included. Most laryngoscopes had the same intubation failure rate as the Macintosh reference device. Only the Truview PCD™ had a significantly higher intubation failure rate than the Macintosh (odds ratio 4.78, 95% confidence interval 1.11–20.6) The highest-ranking laryngoscope was the Airtaq™ (P score, 0.90), and the AirwayScope™, McGrath™, and Truview EVO2™ ranked higher than the Macintosh. The Bullard™ had the lowest ranking (P score, 0.08). All laryngoscopes had the same level of glottic visualization as the Macintosh and only the C-MAC™ had a significantly shorter intubation time. Intubation time was significantly longer when using the GlideScope™, Storz DCI™, Truview PCD™, or Bullard™ compared with the Macintosh. P score and ranking of devices in the subgroup analyses were similar to those in the main analysis. We applied NMA to create a consistent ranking of the effectiveness of intubation devices in pediatric patients. The findings of NMA suggest that there is presently no laryngoscope superior to the Macintosh laryngoscope in terms of tracheal intubation failure rate and glottic visualization in pediatric patients.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Evolution of videolaryngoscopy in pediatric population

Direct laryngoscopy has remained the sole method for securing airway ever since the inception of endotracheal intubation. The recent introduction of video-laryngoscopes has brought a paradigm shift in the pratice of airway management. It is claimed that they improve the glottic view and first pass success rates in adult population. The airway management in children is more challenging than adults. The role of videolaryngoscopy for routine intubation in children is not clearly proven. This review attempts to discuss various videolaryngosocpes available for use in pediatric patients.

Efficacy and safety of videolaryngoscopy versus direct laryngoscopy in paediatric intubation: A meta-analysis of 27 randomized controlled trials

OBJECTIVE

Anatomical and physiological differences in paediatric and adult airways make intubation of paediatric patients a challenge. This study aimed to compare the efficacy and safety of video laryngoscopy (VL) to direct laryngoscopy (DL) on intubation outcomes in paediatric patients.

DESIGN

Systematic review and meta-analysis.

SETTING

Operating room.

PATIENTS

Paediatric patients who needed tracheal intubation.

INTERVENTION

Video laryngoscopy or direct laryngoscopy.

MEASUREMENTS

Electronic searches in PubMed, Embase, and the Cochrane Library were performed to identify relevant randomized controlled trials published through January 2020. Outcomes included time to intubate, intubation failure at first attempt, Cormack-Lehane laryngeal view grade, intubation difficulty scale (IDS), percentage of glottic opening score (POGO), optimal external laryngeal manipulation (OLEM), and complications. Relative risks and weighted mean difference (WMD), with 95% CI, were employed to calculate summary results using a random-effects model.

MAIN RESULTS

Overall, 27 trials including 2461 paediatric patients were analysed. Children with video laryngoscopy intubation required longer time to intubate than direct laryngoscopy intubation (WMD 3.41, 95% CI: 1.29-5.53, P = 0.002), whereas infants receiving video laryngoscopy and direct laryngoscopy intubation experienced similar time to intubate (WMD 1.72, 95% CI: -1.09-4.54, P = 0.230). No significant differences were observed on intubation failure at first attempt between video laryngoscopy and direct laryngoscopy intubations in children and infants, respectively. Video laryngoscopy improved the POGO and intubation trauma but not Cormack-Lehane laryngeal view grade, IDS, external laryngeal manipulation, hoarseness, or oxygen desaturation.

CONCLUSIONS

Compared with direct laryngoscopy intubation, there were no benefits for paediatric patients with video laryngoscopy on time to intubate and failure at first attempt, but there were benefits with regard to POGO and intubation trauma.

Association Between Video Laryngoscopy and Adverse Tracheal Intubation-Associated Events in the Neonatal Intensive Care Unit

The effect of video laryngoscopy on adverse events during neonatal tracheal intubation is unknown. In this single site retrospective cohort study, video laryngoscopy was independently associated with decreased risk for adverse events during neonatal intubation.

Laryngoscopes for difficult airway scenarios: a comparison of the available devices

INTRODUCTION

According to the American Society of Anesthesiologists, the incidence of difficult intubation in the operating room is 1.2-3.8%; however, in emergency conditions, this rate is higher and reaches even 5.3%. Successful emergency airway management is an essential component of the modern practice of medicine.

AREAS COVERED

The aim of the study is to review the literature regarding different devices used to perform endotracheal intubation (Macintosh, Miller, and McCoy laryngoscopes; ETView, GlideScope, TruView, Airtraq, McGrath MAC, Pentax AWS, Trachlight, Shikani, and Bullard) and discuss their clinical and experimental role in difficult airway management.

EXPERT COMMENTARY

Owing to the development of medical technology, there are an increasing number of videolaryngoscopes and other devices facilitating endotracheal intubation in difficult airway scenarios, including cardiopulmonary resuscitation, cervical spine injury, or face-to-face intubation. Each of these devices may bring benefits in the form of increasing the intubation effectiveness, as well as shortening the procedure, provided that the person performing intubation is familiar with the use of the device.

Comparison of GlideScope Video Laryngoscopy and Direct Laryngoscopy for Tracheal Intubation in Neonates

BACKGROUND

GlideScope video laryngoscope (GS) has been widely used to facilitate tracheal intubation in adults and pediatric patients because it can improve glottic view. Several investigations performed in pediatric patients have shown that GS provides a better view of the glottis than direct laryngoscope (DL). However, to date, there are no studies assessing the use of GS in neonates. Therefore, we conducted a prospective study to compare time to intubate (TTI) when either GS or DL was used for endotracheal intubation in neonates.

METHODS

Seventy neonates (American Society of Anesthesiologists physical status I and II, scheduled to undergo elective surgery under general anesthesia) were randomized to GS group (n = 35) and DL group (n = 35). The primary outcome variable of the study was TTI. As secondary outcomes, success rate of first intubation attempt of all neonates, intubation attempts, and adverse events were also evaluated. The glottic views (depicted by Cormack and Lehane [C&L] grades) obtained with GS and DL were compared.

RESULTS

There were no significant differences in TTIs of neonates with all C&L grades (95% CI, -7.36 to 4.44). There was also no difference in the subgroups of neonates with C&L grades I and II (n = 30 each; 95% CI, -0.51 to 5.04). However, GS significantly shortened the TTIs of neonates with C&L grades III and IV compared to DL (n = 5 each group; 95% CI, 4.94-46.67). GS improved the glottic view as compared to DL. Although the total tracheal intubation attempts in the GS group was fewer than that in the DL group (36 vs 41), there was no significant difference (P = .19).

CONCLUSIONS

GS use did not decrease the TTI of all neonates and neonates with C&L grades I and II as compared to DL use; however, GS significantly decreased the TTI of neonates with C&L grades III and IV. Additionally, GS use provided improved glottic views.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.

OBJECTIVES

To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates.

SEARCH METHODS

We used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies.

SELECTION CRITERIA

RCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Review authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

The search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427 intubations) (very low quality evidence). Moderate quality evidence suggested that videolaryngoscopy increased the success of intubation at first attempt (typical risk ratio (RR) 1.44, 95% CI 1.20 to 1.73; typical risk difference (RD) 0.19, 95% CI 0.10 to 0.28; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; 3 studies; 467 intubation attempts).Desaturation episodes during intubation attempts were similar between videolaryngoscopy and direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations) (low quality evidence). There was no difference in the incidence of airway trauma due to intubation attempts (RR 0.10, 95% CI 0.01 to 1.80; RD -0.04, 95% CI -0.09 to -0.00; 1 study; 213 intubations) (low quality evidence).There were no data available on other adverse effects of videolaryngoscopy.

AUTHORS' CONCLUSIONS

Moderate to very low quality evidence suggests that videolaryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation. However, these studies were conducted with trainees performing the intubations and these results highlight the potential usefulness of the videolaryngoscopy as a teaching tool. Well-designed, adequately powered RCTs are necessary to confirm efficacy and address safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates by trainees and those proficient in direct laryngoscopy.

Improving neonatal intubation safety: A journey of a thousand miles

Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation.

Comparison of intubation conditions with CMAC Miller videolaryngoscope and conventional Miller laryngoscope in lateral position in infants: A prospective randomized trial

BACKGROUND

Endotracheal intubation in lateral position in infants is a challenge. This difficulty may be surmounted to some extent by using videolaryngoscopes but the routine use of these devices as a tool to secure the airway in lateral position remains unevaluated. Therefore, we conducted a prospective, randomized controlled trial to compare the intubation conditions achieved with the CMAC videolaryngoscope and the Miller Laryngoscope in lateral position in infants. We hypothesized that CMAC videolaryngoscope would provide a better laryngoscopic view and reduce the time to intubation compared to the Miller blade.

METHODS

Sixty-four children aged <1 year, belonging to American Society of Anesthesiologists physical status I-III requiring endotracheal intubation were randomized to undergo tracheal intubation with either the Miller laryngoscope (n = 32) or the CMAC videolaryngoscope (n = 32) in left lateral position. Anesthesia was induced with sevoflurane or thiopentone 5-8 mg/kg IV and atracurium 0.5 mg/kg IV. Total time taken to intubate was assessed as the primary outcome. Laryngoscopic view, intubation difficulty score, success rate of tracheal intubation, number of attempts, maneuvers used, and any airway complications were recorded as secondary outcomes.

RESULTS

The difference in the mean time to intubate (95% confidence interval) between the Miller and CMAC group was 6.1 (1.7-10.4) seconds. Furthermore, the CMAC videolaryngoscope provided a better laryngoscopic view compared to the conventional Miller blade. In addition, the Intubation Difficulty Scale score was less in the CMAC videolaryngoscope group.

CONCLUSION

The CMAC videolaryngoscope decreases the time taken to intubate and reduces the intubation difficulty when compared to the Miller laryngoscope. Therefore, the CMAC videolaryngoscope may be more useful device when intubating the trachea of infants in the lateral position.

Mind the gap: can videolaryngoscopy bridge the competency gap in neonatal endotracheal intubation among pediatric trainees? a randomized controlled study

BACKGROUND

To study the impact of videolaryngoscopy (VL) on intubation success among pediatric trainees compared with direct laryngoscopy (DL).

METHODS

One hundred pediatric residents were enrolled in a randomized, crossover, simulation study comparing VL to DL. Following a didactic session on neonatal intubation, residents intubated a standard neonatal mannequin. Three Neonatal Resuscitation Program (NRP) scenarios were then conducted, followed by a mannequin intubation with the alternate device. Number of attempts and time to intubation were recorded for all intubations.

RESULTS

Proportion of successful intubations on first attempt was greater with VL compared with DL (88% versus 63%; P=0.008). The DL group increased success after crossover with VL (63% versus 89%; P=0.008). Exposure to VL also reduced intubation time after device crossover (median intubation time: 31 versus 17 s; P=0.048).

CONCLUSIONS

VL increased the success of endotracheal intubation by pediatric residents in simulation, with skills transferrable to DL.

A randomised trial to compare Truview PCD®, C-MAC® and Macintosh laryngoscopes in paediatric airway management

AIM

To evaluate and compare the Truview PCD and C-MAC laryngoscopes to the standard Macintosh laryngoscope in paediatric patients.

METHODS

One hundred and fifty ASA I-II patients in the age group of 1-6 years (10-20 kg) scheduled for elective surgery were randomised into three equal groups for laryngoscopy and intubation with either Truview PCD (Group T), C-MAC (Group C) or Macintosh (Group M) laryngoscopes under general anaesthesia. Percentage of glottic opening (POGO) score, application of external laryngeal manoeuvre, time to intubation, number of attempts at intubation, failed intubations, episodes of desaturation and trauma caused were recorded and statistically analysed. A p value of <0.05 was taken as significant.

RESULTS

POGO scores were significantly better with Truview PCD as compared with C-MAC and Macintosh laryngoscopes (94.7 ± 12.9/82 ± 25.0/85.1 ± 17.1; p < 0.01). There were no failed attempts, episodes of desaturation or trauma in any of the patients. The mean intubation time taken was 19.2 s in group T, 12.3 s in group C and 10.7 s in group M, respectively. There is a statistically significant difference among groups (p < 0.01). Eight patients in group T, 21 out of 50 patients in group C and 19 out of 50 patients in group M needed OELM, respectively. There is significant difference among the groups (p < 0.01) CONCLUSION: Using Truview PCD to assist intubation offers excellent view field of glottic opening after OLEM and the mean time taken is less than 20 s. The Truview PCD tool is suitable for paediatric patients.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates)

BACKGROUND

Direct laryngoscopy is the method currently used for tracheal intubation in children. It occasionally offers unexpectedly poor laryngeal views. Indirect laryngoscopy involves visualizing the vocal cords by means other than obtaining a direct sight, with the potential to improve outcomes. We reviewed the current available literature and performed a meta-analysis to compare direct versus indirect laryngoscopy, or videolaryngoscopy, with regards to efficacy and adverse effects.

OBJECTIVES

To assess the efficacy of indirect laryngoscopy, or videolaryngoscopy, versus direct laryngoscopy for intubation of children with regards to intubation time, number of attempts at intubation, and adverse haemodynamic responses to endotracheal intubation. We also assessed other adverse responses to intubation, such as trauma to oral, pharyngeal, and laryngeal structures, and we assessed vocal cord view scores.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and trial registers (www.clinicaltrials.gov and www.controlledtrials) in November 2015. We reran the search in January 2017. We added new studies of potential interest to a list of 'Studies awaiting classification' and will incorporate them into formal review findings during the review update. We performed reference checking and citation searching and contacted the authors of unpublished data to ask for more information. We applied no language restrictions.

SELECTION CRITERIA

We included only randomized controlled trials. Participants were children aged 28 days to 18 years. Investigators performed intubations using any type of indirect laryngoscopes, or videolaryngoscopes, versus direct laryngoscopes.

DATA COLLECTION AND ANALYSIS

We used Cochrane standard methodological procedures. Two review authors independently reviewed titles, extracted data, and assessed risk of bias.

MAIN RESULTS

We included 12 studies (803 children) in this review and meta-analysis. We identified three studies that are awaiting classification and two ongoing studies.Trial results show that a longer intubation time was required when indirect laryngoscopy, or videolaryngoscopy, was used instead of direct laryngoscopy (12 trials; n = 798; mean difference (MD) 5.49 seconds, 95% confidence interval (CI) 1.37 to 9.60; I2 = 90%; very low-quality evidence). Researchers found no significant differences between direct and indirect laryngoscopy on assessment of success of the first attempt at intubation (11 trials; n = 749; risk ratio (RR) 0.96, 95% CI 0.91 to 1.02; I2 = 67%; low-quality evidence) and observed that unsuccessful intubation (five trials; n = 263) was significantly increased in the indirect laryngoscopy, or videolaryngoscopy, group (RR 4.93, 95% CI 1.33 to 18.31; I2 = 0%; low-quality evidence). Five studies reported the effect of intubation on oxygen saturation (n = 272; very low-quality evidence). Five children had desaturation during intubation: one from the direct laryngoscopy group and four from the indirect laryngoscopy, or videolaryngoscopy, group.Two studies (n = 100) reported other haemodynamic responses to intubation (very low-quality evidence). One study reported a significant increase in heart rate five minutes after intubation in the indirect laryngoscopy group (P = 0.007); the other study found that the heart rate change in the direct laryngoscopy group was significantly less than the heart rate change in the indirect laryngoscopy, or videolaryngoscopy, group (P < 0.001). A total of five studies (n = 244; very low-quality evidence) looked at evidence of trauma resulting from intubation. Investigators reported that only two children from the direct laryngoscopy group had trauma compared with no children in the indirect laryngoscopy, or videolaryngoscopy, group.Use of indirect laryngoscopy, or videolaryngoscopy, improved the percentage of glottic opening (five trials; n = 256). Studies noted no significant difference in Cormack and Lehane score (C&L) grade 1 (three trials; n = 190; RR 1.06, 95% CI 0.93 to 1.21; I2 = 59%).

AUTHORS' CONCLUSIONS

Evidence suggests that indirect laryngoscopy, or videolaryngoscopy, leads to prolonged intubation time with an increased rate of intubation failure when compared with direct laryngoscopy (very low-quality evidence due to imprecision, inconsistency, and study limitations). Review authors had difficulty reaching conclusions on adverse haemodynamic responses and other adverse effects of intubation, as only a few children were reported to have these outcomes. Use of indirect laryngoscopy, or videolaryngoscopy, might lead to improved vocal cord view, but marked heterogeneity between studies made it difficult for review authors to reach conclusions on this outcome.

Videolaryngoscopy in Neonates, Infants, and Children

Airway management is vital during anesthetic care and during resuscitative efforts in the PICU, the emergency department, and the delivery room. Given specific anatomic and physiologic differences, neonates and infants may be more prone to complications during airway management. Videolaryngoscopy may offer an alternative to or advantages over direct laryngoscopy in specific clinical scenarios. The following article reviews some of the basic types of videolaryngoscopy and discusses their potential applications in the pediatric population.

A comparison of the Truview PCD and the GlideScope Cobalt AVL video-laryngoscopes to the Miller blade for successfully intubating manikins simulating normal and difficult pediatric airways

BACKGROUND

Video-laryngoscopes provide better glottic visualization, but tracheal intubation times are longer, compared to conventional direct laryngoscopy in adult patients with normal airways. The objective of this randomized crossover study was to compare times to successful tracheal intubation with video-laryngoscope and direct laryngoscopy in manikins simulating infants with normal and abnormal airways.

METHODS

Thirty experienced pediatric anesthesia practitioners performed tracheal intubation in three distinct manikins simulating infants with (i) a normal airway (ii), an anterior larynx, and (iii) the Pierre Robin sequence anatomy. These were performed using a standard Miller #1 blade, the GlideScope Cobalt AVL, and the Truview PCD video-laryngoscope, first in a normal neck and then an unstable cervical spine scenario (18 intubations/subject). The specific assigned order of devices and manikins for each participant was based on a three by three Latin square design to minimize carryover effects between the model and the device. Predefined times to intubation were analyzed by Cox regression model and Kaplan-Meier survival curves.

RESULTS

Intubation times were shorter and success rates were higher with the Miller blade compared to either the GlideScope or the Truview videoscope in all three manikins in both scenarios, but did not differ between the GlideScope and the Truview devices. Improved intubation times and success rates in the unstable cervical spine scenario compared to the normal neck were attributed to learning effects with sequential intubation.

CONCLUSION

Higher success rates and shorter intubation times with the Miller blade compared to either video-laryngoscope may reflect greater experience with direct laryngoscopy, need for more video-laryngoscopy training, or result from the manikin design. Individual practitioners may differ in their preference of device for intubating a child with anticipated difficult airway based on their previous experiences, self-assessment of their skills, and evaluation of the child's airway anatomy.

WITHDRAWN: A randomized trial to compare the Truview picture capture device, C-MAC laryngoscope, and Macintosh laryngoscope in pediatric airway management

AIM

To evaluate and compare the Truview picture capture device (PCD) and C-MAC laryngoscope to the standard Macintosh laryngoscope in pediatric patients.

METHODS

One hundred and fifty patients with American Society of Anesthesiology status Grade I-II (ASA I-II) who were 1-6 years old (10-20 kg) were scheduled for elective surgery. They were randomized into three equal groups for laryngoscopy and intubation by either the Truview PCD (Group T), C-MAC (Group C), or Macintosh laryngoscope (Group M) under general anesthesia. The percentage of glottic opening (POGO) score, application of external laryngeal maneuver, time to intubation, number of attempts at intubation, failed intubations, episodes of desaturation, and trauma were recorded and statistically analyzed. A value of p < 0.05 was considered significant.

RESULTS

The POGO scores were significantly better with the Truview PCD (94.7 ± 12.91) than with the C-MAC and Macintosh laryngoscopes (82 ± 24.97 and 85.1 ± 17.07, respectively; p < 0.01). There were no failures, episodes of desaturation, or trauma in any of the patients. It took 19.24 seconds to intubate with the Truview PCD, compared to 12.32 seconds with the C-MAC laryngoscope and 10.7 seconds with the Macintosh laryngoscope (p < 0.01). An external laryngeal maneuver was required in 42% of patients in group C, compared to 38% in Group M and 16% in group T (p < 0.01).

CONCLUSION

The Truview PCD offers the best laryngeal view, although it takes a longer time for intubation. The C-MAC laryngoscope provides similar laryngeal views as the Macintosh blade, and is an excellent teaching aid.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of secure airway is a critical part of neonatal resuscitation both in the delivery room and in the neonatal unit. Videolaryngoscopy is a new technique that has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.

OBJECTIVES

To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required and increasing the success rate for endotracheal intubation in neonates.

SEARCH METHODS

We used the search strategy of the Cochrane Neonatal Review Group. We searched for randomized controlled trials evaluating videolaryngoscopy for neonatal endotracheal intubation in May 2013 in the electronic databases; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; abstracts of the Pediatric Academic Societies; websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com; and in the reference lists of relevant studies.

SELECTION CRITERIA

Randomized or quasi-randomized trials in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Review authors performed data collection and analysis as recommended by the Cochrane Neonatal Review Group. Two review authors (KL and MP) independently assessed studies identified by the search strategy for inclusion.

MAIN RESULTS

Our search strategy performed in May 2013 yielded 7057 references. Two review authors (MP and KL) independently assessed all references for inclusion. We did not find any completed studies for inclusion but identified three ongoing trials and one study awaiting classification.

AUTHORS' CONCLUSIONS

There was insufficient evidence to recommend or refute the use of videolaryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered randomized controlled studies are necessary to address efficacy and safety of videolaryngoscopy for endotracheal intubation in neonates.

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.

Comparison of the TruView infant EVO2 PCD™ and C-MAC video laryngoscopes with direct Macintosh laryngoscopy for routine tracheal intubation in infants with normal airways

OBJECTIVE

Videolaryngoscopy has mainly been developed to facilitate difficult airway intubation. However, there is a lack of studies demonstrating this method's efficacy in pediatric patients. The aim of the present study was to compare the TruView infant EVO2 and the C-MAC videolaryngoscope with conventional direct Macintosh laryngoscopy in children with a bodyweight ≤10 kg in terms of intubation conditions and the time to intubation.

METHODS

In total, 65 children with a bodyweight ≤10 kg (0-22 months) who had undergone elective surgery requiring endotracheal intubation were retrospectively analyzed. Our database was screened for intubations with the TruView infant EVO2, the C-MAC videolaryngoscope, and conventional direct Macintosh laryngoscopy. The intubation conditions, the time to intubation, and the oxygen saturation before and after intubation were monitored, and demographic data were recorded. Only children with a bodyweight ≤10 kg were included in the analysis.

RESULTS

A total of 23 children were intubated using the C-MAC videolaryngoscope, and 22 children were intubated using the TruView EVO2. Additionally, 20 children were intubated using a standard Macintosh blade. The time required for tracheal intubation was significantly longer using the TruView EVO2 (52 sec vs. 28 sec for C-MAC vs. 26 sec for direct LG). However, no significant difference in oxygen saturation was found after intubation.

CONCLUSION

All devices allowed excellent visualization of the vocal cords, but the time to intubation was prolonged when the TruView EVO2 was used. The absence of a decline in oxygen saturation may be due to apneic oxygenation via the TruView scope and may provide a margin of safety. In sum, the use of the TruView by a well-trained anesthetist may be an alternative for difficult airway management in pediatric patients.

[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 the Truview PCD™ and the GlideScope(®) video laryngoscopes with direct laryngoscopy in pediatric patients: a randomized trial

INTRODUCTION

The GlideScope(®) video laryngoscope has a 60° angled blade and the blade of the Truview PCD™ video laryngoscope has an optical lens that provides a 46° refraction of the viewing angle. Despite successful results using the GlideScope in adults, few studies have been published regarding its use in pediatric patients. We therefore tested our joint primary hypothesis that the GlideScope and the Truview PCD video laryngoscopes provide superior visualization to direct laryngoscopy and are non-inferior regarding time to intubation.

METHODS

One hundred thirty-four patients (neonate to ten years of age, American Society of Anesthesiologists physical status I-III) scheduled for general surgical procedures were randomized to tracheal intubation using the Truview PCD or GlideScope video laryngoscope or direct laryngoscopy (Macintosh blade). The laryngoscopic view was scored using the Cormack-Lehane scale. Time to intubation (defined as the time from the moment the device entered the patient's mouth until end-tidal CO2 was detected) and the number of attempts were recorded.

RESULTS

The Cormack-Lehane views attained using the GlideScope (P > 0.99) and Truview PCD (P = 0.18) were not superior to the views attained with direct laryngoscopy. Furthermore, the view attained using the GlideScope was significantly worse than that attained using direct laryngoscopy (P < 0.001). Fewer patients showed Cormack-Lehane grade I views with the GlideScope than with the Truview PCD (14% vs 82%, respectively; 95% confidence interval [CI] -91% to -46%). The observed median [Q1, Q3] times to intubation were: 39 [31, 59] sec, 44 [28, 62] sec, and 23 [21, 28] sec with the GlideScope, Truview PCD, and direct laryngoscopy, respectively, with median differences of 14 sec (95% CI 7 to 26, GlideScope - direct laryngoscopy) and 17 sec (95% CI 6 to 28, Truview PCD - direct laryngoscopy).

CONCLUSION

The Cormack-Lehane views attained using the GlideScope and the Truview PCD video laryngoscopes were not superior to views attained using direct laryngoscopy. Visualization with the GlideScope was significantly worse than with direct laryngoscopy. Use of the GlideScope and Truview PCD systems should be restricted to patients with specific indications.

The difficult pediatric airway--a review of new devices for indirect laryngoscopy in children younger than two years of age

During the last decade, several new look-around-corner or video airway devices have proven useful in clinical adult practice. Only four of them are currently available in sizes that may be used in children younger than 2 years of age: the AIRTRAQ® Disposable Optical Laryngoscope (Prodol Meditec, Vizcaya, Spain), the GlideScope® Video Laryngoscope (Verathon, Bothell, WA, USA), the Storz DCI® Video Laryngoscope (Karl Storz, Tuttlingen, Germany), and the Truview PCD™ Infant (Truphatek, Netanya, Israel). Here, we review the literature and describe the clinical use of each device in this age-group. The four new laryngoscopes are generally effective and may solve many of the problems with difficult intubations in children younger than 2 years of age. The size of the device and the mouth opening it requires determines its usefulness in the smallest infants. Training will be necessary in implementing and deciding when to use the new airway devices, although one of the big challenges of the future will be to maintain the teaching and training of fiber-optic-guided intubations, which remain the gold standard in difficult endotracheal intubations.

A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway--a randomized clinical trial

INTRODUCTION

Direct laryngoscopy can be challenging in infants and neonates. Even with an optimal line of sight to the glottic opening, the viewing angle has been measured at 15 degrees . The STORZ DCI video laryngoscope (Karl Storz, Tuttlingen, Germany) incorporates a fiberoptic camera in the light source of a standard laryngoscope of variable sizes. The image is displayed on a screen with a viewing angle of 80 degrees . We studied the effectiveness of the STORZ DCI as an airway tool compared to standard direct laryngoscopy in children with normal airway.

METHODS

In this prospective, randomized study, 56 children (ages 4 years or younger) undergoing elective surgery with the need for endotracheal intubation were divided into two groups: children who underwent standard direct laryngoscopy using a Miller 1 or Macintosh 2 blade (DL) and children who underwent video laryngoscopy using the STORZ DCI video laryngoscope with a Miller 1 blade (VL). Time to best view (TTBV), time to intubate (TTI), Cormack-Lehane (CL), and percentage of glottis opening seen (POGO) score were recorded.

RESULTS

TTBV in DL was 5.5 (4-8) s and 7 (4.2-9) s in VL. TTI in DL was 21 (17-29) s and in VL 27 (22-37) s (P = 0.006). The view as assessed by POGO score was 97.5% (60-100%) in DL and 100% (100-100%) in the VL (P = 0.003). Data are presented as median and interquartile range and analyzed using t-test.

DISCUSSION

This study demonstrates that the STORZ DCI video laryngoscope provides an improved view to the glottis in children with normal airway anatomy, but requires a longer time for intubation.

Pediatric difficult airway management: current devices and techniques

The anesthesiologist confronting the difficult pediatric airway is presented with a unique set of challenges. Adult difficult airway management techniques, such as awake or invasive approaches to airway management, often cannot be applied to children because of inadequate cooperation. Consequently, awake intubation in pediatrics is uncommon; most intubations are performed under general anesthesia or deep sedation. From a physiologic perspective, children have higher rates of oxygen consumption, significantly shortening the period of apnea that can be safely tolerated. Normal developmental anatomic differences of the pediatric airway and the presence of craniofacial dysmorphisms, presents additional challenges to tracheal intubation.