Videolaryngoscopy Versus Direct Laryngoscopy in Simulated Pediatric Intubation

doi:10.1016/j.annemergmed.2012.09.008

Annals of Emergency Medicine

Volume 61, Issue 3, March 2013, Pages 271-277

https://doi.org/10.1016/j.annemergmed.2012.09.008 Get rights and content

Study objective

We determine whether videolaryngoscopy results in a higher prevalence of first-attempt intubation success and improved glottic visualization than direct laryngoscopy when performed by pediatric emergency medicine providers in simulated patients.

Methods

This was a cross-sectional study at a single institution. Fellows and faculty in pediatric emergency medicine were invited to participate. Each subject performed intubations on 3 simulators (newborn, infant, adult), using a videolaryngoscope; each simulator was intubated by each subject with and without use of video. Primary outcome was first-attempt intubation success; secondary outcome was percentage of glottic opening score (POGO).

Results

Twenty-six participants performed 156 intubations; complete data were available for 148 intubations. First-attempt success in the neonate was 88%; in the infant, 79%; and in the adult, 60%. In the adult simulator, videolaryngoscopy use showed a first-attempt success in 81% of subjects compared with 39% with direct laryngoscopy (difference 43%; 95% confidence interval [CI] 18% to 67%). There was no difference in first-attempt success rates between videolaryngoscopy and direct laryngoscopy in the newborn or infant simulators. Videolaryngoscopy use led to increased POGO scores in all 3 simulators, with a difference of 25% (95% CI 2% to 48%) in newborn simulators, 23% (95% CI 2% to 48%) in infant simulators, and 42% (95% CI 18% to 66%) in adult simulators.

Conclusion

Videolaryngoscopy was associated with greater first-attempt success during intubation by pediatric emergency physicians on an adult simulator. POGO score was significantly improved in all 3 simulators with videolaryngoscopy.

Introduction

Intubation is a fundamental procedural skill for acute care providers. In most cases, it is accomplished by direct laryngoscopy, in which a laryngoscope is used to establish a direct line of sight from the intubator through the patient's mouth to the glottic opening. Videolaryngoscopy is a term used for techniques applied to intubation in which the glottic opening is visualized indirectly with a camera, allowing the intubator to place an endotracheal tube without seeing the larynx directly. Preliminary studies in anesthesia have shown that this technique is effective in routine and difficult airway management, including in children.1, 2 Preliminary data in out-of-hospital care and emergency medicine have shown videolaryngoscopy to be effective outside the operating room in adult patients.3, 4 Two published studies have compared direct laryngoscopy and videolaryngoscopy on simulated infants and neonates with novice intubators as subjects; both studies failed to demonstrate a difference in intubation success. To our knowledge, no studies have evaluated videolaryngoscopy as a technique for pediatric emergency physicians.

Published studies demonstrate success rates in pediatric patients that are less than those of adult patients within given care provider subsets. Data on training and experience in pediatrics have consistently shown that clinical encounters involving intubation are uncommon and decreasing in frequency for pediatric trainees, as well as fellows and attending physicians in acute care pediatric fields.5, 6, 7, 8 Data from pediatric emergency departments (EDs) and ICUs have shown a moderate frequency of adverse events occurring during or after intubation in critically ill children.9, 10 The need for techniques that enhance the success rates and safety associated with intubation remains great.

We designed a study of intubation in simulated pediatric patients in which we sought to compare the effect of videolaryngoscopy versus direct laryngoscopy performed by trained pediatric emergency physicians on outcomes related to intubation. Our primary endpoint was the proportion of subjects achieving first-attempt intubation success. As a secondary endpoint, we collected the self-reported percentage of glottic opening (POGO) score. We hypothesized that, in this group of experienced intubators, the use of videolaryngoscopy would result in improved first-attempt success rates at intubation and improved glottic visualization as measured by POGO score.

Section snippets

Study Design and Setting

This was a cross-sectional study performed in the simulation center at a single tertiary care pediatric hospital with more than 80,000 annual ED patient visits. The study was exempted from review by the institutional review board of the Children's Hospital of Philadelphia. In the hospital's ED, videolaryngoscopy was not in use during the study period and was not a part of the standard training of pediatric emergency medicine fellows or faculty.

Selection of Participants

Fellows and faculty in pediatric emergency medicine

Characteristics of Study Subjects

Of a total of 40 faculty and 13 fellows in pediatric emergency medicine, 13 faculty and 13 fellows volunteered to participate. These 26 subjects performed 156 intubations; technical difficulty with video capture led to some loss of data, and 148 intubations were used for final analysis. Background data on all subjects are shown in Table 1. No study subjects had any experience with videolaryngoscopy in patients or simulators.

Main Results

Overall first-attempt success rate was 42 of 48 intubations (88%) for

Limitations

Several limitations to this study should be mentioned. As with all simulation studies involving psychomotor performance of a technical skill, generalizing results to real patients may be difficult. Any patient simulator has a limited number of manipulable features pertaining to airway management, and thus the spectrum of experience in direct laryngoscopy and videolaryngoscopy on any given simulator is limited.

Additionally, subjects may have been performing intubation in a manner that does not

Discussion

In our study, videolaryngoscopy with a curved blade resulted in a statistically significant improvement in first-attempt success in intubation of an adult simulator; the effect of videolaryngoscopy on first-attempt success with straight blades on newborn and infant simulators was not significant.

As a secondary outcome, POGO score was significantly higher with videolaryngoscopy in all simulators. These data are consistent with previously published data in simulated pediatric patients in the

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Cited by (52)

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines
2024, British Journal of Anaesthesia
Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong ‘1’ or weak ‘2’ recommendation with high ‘A’, medium ‘B’ or low ‘C’ quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO₂ waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).
Demographic disparities in tracheal intubation success rates during infant out-of-hospital cardiac arrest
2023, Trends in Anaesthesia and Critical Care
Citation Excerpt :
The disparities we identified may also be indicative of differences in EMS preparedness. As an example, better-resourced agencies may be more likely to be equipped with technologies shown to improve intubation success (eg. video laryngoscopy) or be able to bring more clinicians to cardiac arrest calls [25–28]. Variations in local protocols and EMS training opportunities may also account for some of these disparities: advanced EMS providers at some agencies may have more frequent opportunities to practice and perform intubations.
Tracheal intubation is a skill performed by qualified emergency medical services (EMS) providers during out-of-hospital cardiac arrest (OHCA) in adult and pediatric patients. Unsuccessful intubation can negatively impact a patient's likelihood of survival. Thus, intubation success rates are an important quality improvement benchmark. Given other demographic disparities that have been reported in adults and children, we hypothesize there might be disparities in intubation success across infant race/ethnicity and/or sex.
We examined a national-level registry of EMS activations in the United States (NEMSIS). Inclusion criteria were OHCA calls involving infant patients (under 1 years of age) between January 2017 and May 2022 where EMS attempted tracheal intubation, documented whether the procedure was successful, and documented information about the patient's demographics (eg. race/ethnicity and sex). Intubation success rates across patient sex and racial/ethnic categories with more than one-hundred cardiac arrests with intubation attempts were compared.
A total of 3663 infant cardiac arrests where tracheal intubation was attempted met inclusion criteria. White infants were associated with significantly higher rates of intubation success (62.2%) when compared with Black or African American infants (58.1%) and Hispanic/Latino infants (56.2%) (p < .01). Female infants were associated with slightly higher rates of intubation success than male infants, but this difference was not significant (p > .2).
Significant demographic disparities in endotracheal intubation success rates exist among infants who experience OHCA. Future studies should continue to examine these disparities with the goal of identifying why these differences occur and concrete mechanisms for eliminating such disparities.
Success of prehospital tracheal intubation during cardiac arrest varies based on race/ethnicity and sex
2022, Trends in Anaesthesia and Critical Care
Tracheal intubation is a high-risk procedure often performed in the prehospital setting by emergency medical services (EMS) on patients experiencing cardiac arrest. Because of the high potential for adverse consequences resulting from unsuccessful intubation, intubation success rates are a topic of significant concern. There has been little research examining whether cardiac arrest intubation success rates vary based on patient race/ethnicity and patient sex.
We examined a national registry of EMS calls in the United States. Inclusion criteria were tracheal intubations (2017–2021) performed on adult cardiac arrest patients where EMS providers documented the patient's race/ethnicity and patient sex and whether the intubation was successful. A total of 210,992 cardiac arrests met inclusion criteria. When considering patient sex, intubation was more common in male patients than female patients, but intubation success rates were significantly higher in female patients (p < .01). When considering patient race/ethnicity, intubation success rates were highest in White patients and significantly lower in patients of all other races/ethnicities (p < .01).
Intubation success rates were higher in female patients and White patients. Further studies need to examine disparities and identify strategies to improve intubation success for all patients with cardiac arrest. Possible explanations for the obtained results are differences in patient health, in provider familiarity with intubation, and in the availability of assistive technologies that facilitate intubation (e.g. video laryngoscopy).
Awake C-MAC® video laryngoscopy for cystic hygroma in neonatal intensive care:A land less travelled
2022, Trends in Anaesthesia and Critical Care
Citation Excerpt :
Video laryngoscopy has the added advantage of having lesser lifting force as compared to conventional laryngoscopy. Furthermore, the operator and assistant can easily coordinate this for the need for cricoid pressure and ETT manipulation due to visualization of glottic structures on the screen [3]. Though we have both the CMAC Miller and Macintosh blade size 0, we selected the Macintosh blade as in our experience a curved blade creates more space in the oral cavity for ETT manipulation.
Airway management in neonates with cystic hygroma is challenging. Preservation of spontaneous ventilation and inhalational induction with sevoflurane in 100% O₂ may be the best option, but not feasible during an emergency where the extent of lesion and compression of airway structures were not known, particularly in a remote location due to risk of apnoea by sedation or intravenous induction of anaesthesia with compromised respiration.
We present a successful emergency airway management by awake intubation using a C-MAC® video laryngoscope in a 2-day old term neonate weighing 2.2 kg with 12 × 9 cm cystic hygroma extending up to the thoracic inlet.
Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative
2022, Annals of Emergency Medicine
Citation Excerpt :
This lattermost study reported a median of 20 pediatric intubations per year at their sites, which likely means that few of the sites were tertiary children’s hospitals. Children with more complicated medical conditions and intubators with more limited ongoing exposure to intubations are likely to present at children’s hospitals and may account for some of this difference.6,9 Additionally, our data may support the notion that video review is a more accurate and unbiased data source for studying airway management.1,11
We sought to describe the tracheal intubation technique across a network of children’s hospitals and explore the association between intubation technical adjuncts and first-attempt success as well as between laryngoscopy duration and the incidence of hypoxemia.
We conducted a prospective observational study in 4 tertiary pediatric emergency departments of the Videography in Pediatric Resuscitation Collaborative. Children undergoing tracheal intubation captured on video were eligible for inclusion. Data on intubator background, patient characteristics, technical characteristics (eg, use of videolaryngoscopy and apneic oxygenation), and procedural outcomes were obtained through a video review.
We obtained complete data on first attempts in 494 patients. The first-attempt success rate was 67%, the median laryngoscopy duration was 35 seconds (interquartile range 25 to 40), and hypoxemia occurred in 15% of the patients. Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia. Attempts in which videolaryngoscopy was used for the entire procedure (compared with direct laryngoscopy for the entire procedure) had a longer duration (the difference between the medians was 6 seconds; 95% confidence interval, 1 to 12 seconds). Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts.
Among children undergoing tracheal intubation in a group of pediatric emergency departments, first-attempt success occurred in 67% of the patients. Videolaryngoscopy use was associated with longer laryngoscopy durations but was not associated with success or the incidence of hypoxemia.
Simulation-based Randomized Paired Cross-over Comparison of Direct versus Video-assisted Laryngoscopy for Endotracheal Intubation by Inexperienced Operators
2019, Health Professions Education
Citation Excerpt :
Consequently, VL – not requiring a direct optical view of the larynx – is recommended for difficult airway management including failure with DL.6,7,17,18 Although DL and VL have also been compared by others for endotracheal intubation,9,10,14,19,20 this is the first simulation-based study with a prospective randomized cross-over design, enabling intra-individual paired comparisons based on repeated individual intubation procedures. Other advantages of the present study are the high number of participants, reproducible and identical methods of teaching (by consistently designed instructional films), manikins providing identical anatomical upper-airway conditions, and well-defined, easily assessable outcome measures.11
Direct laryngoscopy (DL) is the standard technique for endotracheal intubation. Video-assisted laryngoscopy (VL) has emerged as an alternative, particularly for difficult airway management. Nevertheless, DL and VL have not been systematically compared for simulation-based endotracheal intubation by inexperienced operators.
A prospective, randomized cross-over study was carried out at Lund University Faculty of Medicine, Malmö, Sweden, in 50 medical undergraduate students with no previous experience of endotracheal intubation in manikins or patients. Identical manikins (Rescue Anne^TM, Laerdal AS, Stavanger, Norway) were consecutively intubated using DL with the Macintosh-type blade, and VL with the hyper-curved Glidescope^TM blade. Similarly designed and extensive instructional films on DL and VL techniques were shown to each study participant immediately before each training session, comprising ten consecutive individual intubation attempts with that specific device. No further instructions or feedback were provided by the study investigators.
The VL technique was found to be overall faster than DL, and also associated with fewer intubation failures (P = 0.0209), dental manipulations (P < 0.001), and oesophageal intubations (P < 0.0001).
Since VL for endotracheal intubation by inexperienced operators was more successful and associated with fewer adverse events than was DL, we propose that VL might be preferable to DL for endotracheal intubation by less experienced users. Further research is however strongly encouraged to validate these findings.

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: Supervising editor: Steven M. Green, MD

: Author contributions: AJD was responsible for study design, obtaining funding, and conducting study sessions. AJD, AA, and AN were responsible for subject recruitment. All authors were responsible for data collection and review. AJD was responsible for drafting the article, and all authors contributed substantially to its revision. AJD takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was supported by the University of Pennsylvania School of Medicine Educational Research Initiative, the Endowed Chair of Critical Care Medicine of the Children's Hospital of Philadelphia, and Karl Storz Endoscopy–America, Inc. (El Segundo, CA).

: Please see page 272 for the Editor's Capsule Summary of this article.

: Publication date: Available online October 18, 2012.

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Pediatrics/original researchVideolaryngoscopy Versus Direct Laryngoscopy in Simulated Pediatric Intubation

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design and Setting

Selection of Participants

Characteristics of Study Subjects

Main Results

Limitations

Discussion

J Emerg Med

J Pediatr

Ann Emer Med

J Clin Anesth

J Emerg Med

A comparison between the GlideScope video laryngoscope and direct laryngoscope in paediatric patients with difficult airways—a pilot study

Anaesthesia

A prospective randomized equivalence trial of the GlideScope Cobalt® video laryngoscope to traditional direct laryngoscopy in neonates and infants

Anesthesiology

The C-MAC videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study

Emerg Med J

Pediatrics/original research
Videolaryngoscopy Versus Direct Laryngoscopy in Simulated Pediatric Intubation

A prospective randomized equivalence trial of the GlideScope Cobalt^® video laryngoscope to traditional direct laryngoscopy in neonates and infants