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

Routine Use of Videolaryngoscopy in Airway Management

Tracheal intubation is a fundamental facet of airway management, for which the importance of achieving success at the first attempt is well recognized. Failure to do so can lead to significant morbidity and mortality if there is inadequate patient oxygenation by alternate means. The evidence supporting the benefits of a videolaryngoscope in attaining this objective is now overwhelming (in adults). This has led to its increasing recognition in international airway management guidelines and its promotion from an occasional airway rescue tool to the first-choice device during routine airway management. However, usage in clinical practice does not currently reflect the increased worldwide availability that followed the upsurge in videolaryngoscope purchasing during the coronavirus disease 2019 pandemic. There are a number of obstacles to widespread adoption, including lack of adequate training, fears over de-skilling at direct laryngoscopy, equipment and cleaning costs, and concerns over the environmental impact, among others. It is now clear that in order for patients to benefit maximally from the technology and for airway managers to fully appreciate its role in everyday practice, proper training and education are necessary. Recent research evidence has addressed some existing barriers to default usage, and the emergence of techniques such as awake videolaryngoscopy and video-assisted flexible (bronchoscopic) intubation has also increased the scope of clinical application. Future studies will likely further confirm the superiority of videolaryngoscopy over direct laryngoscopy, therefore, it is incumbent upon all airway managers (and their teams) to gain expertise in videolaryngoscopy and to use it routinely in their everyday practice..

A Comparative Study of Video Laryngoscopy to Direct Laryngoscopy for Endotracheal Intubation in Pediatric Patients

Background

Direct laryngoscopy is the standard method for intubation in pediatric patients. The introduction of video laryngoscopy brought a paradigm shift in managing pediatric airways.

Objectives

We compared the tracheal intubation technique between direct and video laryngoscopy with McIntosh Blade 2 in pediatric patients 2 - 8 years of age requiring airway management. The glottic view and the first pass success rate were compared and analyzed.

Methods

An observational cross-sectional study was conducted with 120 children between 2 - 8 years with normal airways. They were divided into video laryngoscopy (Group V) and direct laryngoscopy (Group D). The primary outcome measures included time taken for intubation, number of attempts required, Cormack-Lehane glottic view, use of optimization maneuvers, the requirement of tube repositioning, and hemodynamic parameters before and after intubation.

Results

The time taken for intubation was longer in the video laryngoscopy group (group D, 24.28 sec vs. group V, 27.65 seconds (P = 0.01). The Cormack-Lehane glottic view was grade 1 in all the patients in the video laryngoscopy group, while only 35 children showed grade 1 in the direct laryngoscopy group. (P < 0.001). We observed a significant increase in both heart rate and mean arterial pressure in the video laryngoscopy group at 1, 3, 5, and 10 min after intubation (P < 0.001, P < 0.05).

Conclusions

The time taken for intubation was more in group V, but the glottic view was much better, and the requirement for external maneuvers was also less. Pressure response to intubation was more in group V compared to group D.

Success rate and duration of orotracheal intubation of premature infants by healthcare providers with different levels of experience using a video laryngoscope as compared to direct laryngoscopy in a simulation-based setting

BACKGROUND

Endotracheal intubation of very low birth weight infants (VLBWI) is an essential procedure in NICUs, but intubation experience is often limited. Video laryngoscopy (VL) has been described as a tool to improve intubation skills, but studies in high-risk neonatal populations are limited.

OBJECTIVE

The aim of this study was to investigate whether VL is a useful tool to support airway management in high-risk premature infants with inexperienced operators.

METHODS

In this crossover study predominantly inexperienced participants were exposed in random sequence to VL and conventional direct laryngoscopy (DL) for endotracheal intubation of a VLBWI simulation manikin to measure total time, number of attempts, success rate on first attempt, view of the vocal cords and perceived subjective safety until successful intubation.

RESULTS

In our study group of 94 participants there was no significant difference in the total time (mean VL: 34 s (±24 s); DL: 37 s (±28 s), p = 0.246), while the number of intubation attempts using VL was significantly lower (mean VL: 1.22 (±0.53); DL: 1.37 (±0.60), p = 0.023). Success rate of VL during the first attempt was significantly higher (VL: 84%; DL 69%, p = 0.016), view of the vocal cords was significantly better and perceived subjective safety was increased using VL.

CONCLUSIONS

Our study results suggest that with rather inexperienced operators, VL can be a useful tool to increase rate of successful endotracheal intubation of VLBWI and to improve their perceived safety during the procedure, which may have an impact on mortality and/or morbidity.

A comparative study of the efficacy of Glidescope versus Macintosh direct laryngoscopy for intubation in pediatric patients undergoing cardiac surgery

Background:

The Glidescope is a novel, portable, reusable video laryngoscope that has provided superior laryngeal visualization to facilitate tracheal intubation, especially in the management of difficult airways. In this study, we aimed to compare the efficacy of the Glidescope (video-laryngoscope) against the Macintosh direct laryngoscope.

Methods:

Fifty patients were randomly selected via simple randomization using computer-generated random numbers, and sorted into two groups of 25 patients: the Glidescope group and the Macintosh group. We included pediatric patients undergoing cardiac surgery for the repair of congenital heart disease. Those with suspected difficult intubation, preterm babies with low body weight, and patients at risk of aspiration were all excluded.

Results:

Patients’ baseline demographic and clinical characteristics were found to be comparable in the two groups. The mean intubation time was 24.1 ± 13.6 s in the Glidescope group, as compared to 18.1 ± 5.9 s in the Macintosh group. Blade insertion was easy in 92% and 96% of the patients in the Glidescope and Macintosh groups, respectively. Tracheal intubation was considered easy in 84% of the Glidescope group, compared to 92% of the Macintosh group. There was a statistically significant correlation between the ease of tracheal intubation and the used intubation method (rho = –0.35; P = 0.014).

Conclusion:

Our findings indicate that the Glidescope can be used as an efficient modality for obtaining successful intubations with no complications. Ease of tracheal intubation was the only outcome that was found to be affected by the used modality. Further investigations with proper sample sizes are needed.

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.

Comparison of Miller laryngoscope and UEScope videolaryngoscope for endotracheal intubation in four pediatric airway scenarios: a randomized, crossover simulation trial

With different videolaryngoscopes for pediatric patients available, UEScope can be used in all age groups. The aim of this study was to compare the Miller laryngoscope and UEScope in pediatric intubation by paramedics in different scenarios. Overall, 93 paramedics with no experience in pediatric intubation or videolaryngoscopy performed endotracheal intubation in scenarios: (A) normal airway without chest compressions, (B) difficult airway without chest compressions, (C) normal airway with uninterrupted chest compressions, (D) difficult airway with uninterrupted chest compressions. Scenario A. Total intubation success with both laryngoscopes: 100%. First-attempt success: 100% for UEScope, 96.8% for Miller. Median intubation time for UEScope: 13 s [IQR, 12.5-17], statistically significantly lower than for Miller: 14 s [IQR, 12-19.5] (p = 0.044). Scenario B. Total efficacy: 81.7% for Miller, 100% for UEScope (p = 0.012). First-attempt success: 48.4% for Miller, 87.1% for UEScope (p = 0.001). Median intubation time: 27 s [IQR, 21-33] with Miller, 15 s [IQR, 14-21] with UEScope (p = 0.001). Scenario C. Total efficiency: 91.4% with Miller, 100% with UEScope (p = 0.018); first-attempt success: 67.7 vs. 90.3% (p = 0.003), respectively. Intubation time: 21 s [IQR, 18-28] for Miller, 15 s [IQR, 12-19.5] for UEScope. Scenario D. Total efficiency: 65.6% with Miller, 98.9% with UEScope (p < 0.001); first-attempt success: 29.1 vs. 72% (p = 0.001), respectively. Intubation time: 38 s [IQR, 23-46] for Miller, 21 s [IQR, 17-25.5] for UEScope.Conclusion: In pediatric normal airway without chest compressions, UEScope is comparable with Miller. In difficult pediatric airways without chest compressions, UEScope offers better first-attempt success, shorted median intubation time, and improved glottic visualization. With uninterrupted chest compressions in normal or difficult airway, UEScope provides a higher first-attempt success, a shorter median intubation time, and a better glottic visualization than Miller laryngoscope. What is Known: • Endotracheal intubation is the gold standard for adult and children airway management. • More than two direct laryngoscopy attempts in children with difficult airways are associated with a high failure rate and increased incidence of severe complications. What is New: • In difficult pediatric airways with or without chest compressions, UEScope in inexperienced providers in simulated settings provides better first-attempt efficiency, median intubation time, and glottic visualization.

Pediatric Trainees Managing a Difficult Airway: Comparison of Laryngeal Mask Airway, Direct, and Video-Assisted Laryngoscopy

Objective

Difficult airway management is a key skill required by all pediatric physicians, yet training on multiple modalities is lacking. The objective of this study was to compare the rate of, and time to, successful advanced infant airway placement with direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult airway simulator. This study is the first to compare the success with 3 methods for difficult airway management among pediatric trainees.

Study Design

Randomized crossover pilot study.

Setting

Tertiary academic medical center.

Methods

Twenty-two pediatric residents, interns, and medical students were tested. Participants were provided 1 training session by faculty using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of a Robin sequence. Success was defined as confirmed endotracheal intubation or correct LMA placement by the testing instructor in ≤120 seconds.

Results

Direct laryngoscopy demonstrated a significantly higher placement success rate (77.3%) than video-assisted laryngoscopy (36.4%, P = .0117) and LMA (31.8%, P = .0039). Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds; 95% CI, 59.4-110.1) versus direct laryngoscopy (44.9 seconds; 95% CI, 33.8-55.9) and LMA placement (36.6 seconds; 95% CI, 24.7-48.4).

Conclusions

Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway simulator model. However, given the potential lifesaving implications of advanced airway adjuncts, including video-assisted laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for trainees.

Effects of an elevated position on time to tracheal intubation by novice intubators using Macintosh laryngoscopy or videolaryngoscopy: randomized crossover trial

Objective

To investigate the time to tracheal intubation using Glidescope videolaryngoscopy (GVL) compared to that of standard laryngoscopy, by using a Macintosh blade (SLM) in a human patient simulator in supine and elevated (ramped) positions.

Methods

In this randomized crossover design, novice intubators (first-year medical students), using both laryngoscopic techniques, attempted tracheal intubation on a human patient simulator with a “normal airway” anatomy (Cormack-Lehane grade I). The simulator was placed in both supine and ramped positions using a commercial mattress system. The mean time to intubation and complications were compared between GVL and SLM in both positions. The percentage of glottic opening (POGO, GVL only) was estimated during intubation in the ramped and supine positions. The primary outcome was time to intubation, and the secondary outcomes included complication rates such as esophageal intubation and dental trauma.

Results

There was no difference in the mean time to intubation in either position (P=0.33). The SLM intubation was significantly faster than GVL (mean difference, 1.5 minutes; P<0.001). The mean POGO score for GVL improved by 8% in the ramped position compared to that in supine position (P=0.018). The esophageal intubation rate for SLM was 15% to 17% compared to 1.3% for GVL; dental trauma occurred in 53% to 56% of GVL, compared to 2% to 6% for SLM (P<0.001, respectively).

Conclusion

Novices had shorter intubation times using standard laryngoscopy with a SLM compared to GVL in both supine and ramped positions. GVL resulted in fewer esophageal intubations, but more dental trauma than standard laryngoscopy.

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

OBJECTIVES

The objective was to compare video-assisted laryngoscopy (VAL) to direct laryngoscopy (DL) on success rate and complication rate of intubations performed in a pediatric emergency department (ED).

METHODS

This is a retrospective cohort study of attempted intubations of children aged 0-18 years in a pediatric ED between 2004 and 2014 with first attempt by an ED provider. In VAL, the laryngoscopist attempts direct visualization of the glottis with a C-MAC video laryngoscope while the video monitor is used for real-time guidance by a supervisor, back-up visualization for the laryngoscopist should the direct view be inadequate, and confirmation of endotracheal tube passage through the vocal cords. We performed univariate comparisons of intubations using DL to intubations using VAL on rates of first-pass success, complications, and whether the patient was successfully intubated by an ED provider. We then created a logistic regression model to adjust for provider experience level, difficult airway characteristics, and indications for intubation to compare intubations using DL to intubations using VAL for each outcome.

RESULTS

We identified 452 endotracheal intubations of 422 unique patients, of which 445 intubations had a first attempt by an ED provider. Six intubations were excluded due to insufficient information available in the record. Of the included intubations, 240 (55%) were attempted with DL and 199 (45%) with VAL. The overall first-pass success rate was 71% in the DL group and 72% in the VAL group. After adjustment for covariates, the first-pass success rate was similar between laryngoscopy approaches (adjusted odds ratio = 1.23, 95% confidence interval = 0.78 to 1.94).

CONCLUSIONS

We found no difference between DL and VAL with regard to first-pass intubation success rate, complication rate, or rate of successful intubation by ED providers for children undergoing intubation in a pediatric ED.

Comparison of GlideScope video laryngoscope with Macintosh laryngoscope in adult patients undergoing elective surgical procedures

Background:

GlideScope (GS) is a video laryngoscope that allows a real-time view of the glottis and endotracheal intubation. It provides a better view of the larynx without the need for alignment of the airway axes.

Aim:

This prospective randomized comparative study is designed to compare the intubation time, hemodynamic response, and complications associated with intubation using a GS or Macintosh laryngoscope (ML) in adult subjects undergoing elective surgical procedures.

Materials and Methods:

Sixty American Society of Anesthesiologists physical status 1–2 patients were included in this prospective randomized comparative study. Patients were randomized to be intubated using either a GS or an ML. The primary outcome measure was the intubation time. The secondary outcome measures were the hemodynamic response to intubation and the incidence of mucosal injury.

Statistical Analysis:

Mean and standard deviation were calculated for different parameters under the study. The observed results were analyzed using Student's t-test for quantitative data and Z-test of proportions. P<0.05 was considered statistically significant.

Results:

Intubation time was longer in GS group (45.7033 ± 11.649 s) as compared to ML (27.773 ± 5.122 s) P< 0.0001 with 95% confidence interval (95% CI) −13.2794 to −22.5806. GS provided better Cormack and Lehane laryngoscopic view (P = 0.0016 for grade 1 view) with 95% CI −0.1389 to −0.5951. GS group exhibited more laryngoscopic response than ML group with more increase in blood pressure and heart rate, but the difference was not statistically significant. More cases of mucosal trauma were documented in GS group.

Conclusion:

Use of GS to facilitate intubation led to better glottic view but took a longer time to achieve endotracheal intubation. GS was associated with more hemodynamic response to intubation and mucosal injury in comparison with an ML.

Intubation of a Paediatric Manikin in Tongue Oedema and Face-to-Face Simulations by Novice Personnel: a Comparison of Glidescope, Airtraq and Direct Laryngoscopy

OBJECTIVE

Glidescope and Airtraq were designed for facilitating intubation and for teaching regarding the airway anatomy. We aimed to evaluate their efficacy in normal airway, tongue oedema and face-to-face orotracheal intubation models when used by novice personnel.

METHODS

After the local human research ethics committee approval, 36 medical students who were in the beginning of their third year were enrolled in this study. After watching a video regarding intubation using one of these devices, the students intubated a paediatric manikin with a Glidescope or Airtraq via the normal airway, tongue oedema and face-to-face approach.

RESULTS

Although the insertion and intubation times were similar among the groups, the intubation success rate of the Glidescope was higher in the normal airway (100% vs 67%) and tongue oedema (89% vs. 50%) compared with the Airtraq (p=0.008 and p=0.009). The success rates with the paediatric manikin by the face-to-face approach were similar among the groups (50%) (p=0.7). The need for manoeuvres in the Glidescope was lower in the normal and tongue oedema models (p=0.02 and p=0.002). In addition, oesophageal intubation was low in the control and tongue oedema models with the Glidescope (p=0.03 and p<0.001).

CONCLUSION

Novice personnel could more easily intubate the trachea with the Glidescope than with the Airtraq. Intubation with the Glidescope was superior to that with the Airtraq in the normal and tongue oedema models. The face-to-face intubation success rates were both low with both the Glidescope and Airtraq groups.

Displacement of deciduous tooth into hypopharynx due to endotracheal intubation

Intubation may lead to several dental complications. Furthermore, a tooth damaged during intubation may be subsequently dislocated. In the present case, the upper primary incisor was avulsed during intubation and, unbeknownst to the anesthesiologist, displaced to the larynx. We report here on the findings and indicate appropriate treatment. Intubation for general anesthesia in children can result in tooth damage and/or dislocation of primary teeth with subsequent root resorption. Prevention is key, and thus it is critical to evaluate the patient's dental status before and after intubation. Furthermore, anesthesiologists and dentists should pay close attention to this risk to prevent any avulsed, dislocated, or otherwise displaced teeth from remaining undetected and subsequently causing serious complications.