Pediatrics/original researchVideolaryngoscopy Versus Direct Laryngoscopy in Simulated Pediatric Intubation
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)
Demographic disparities in tracheal intubation success rates during infant out-of-hospital cardiac arrest
2023, Trends in Anaesthesia and Critical CareCitation 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.
Success of prehospital tracheal intubation during cardiac arrest varies based on race/ethnicity and sex
2022, Trends in Anaesthesia and Critical CareAwake C-MAC® video laryngoscopy for cystic hygroma in neonatal intensive care:A land less travelled
2022, Trends in Anaesthesia and Critical CareCitation 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.
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 MedicineCitation 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
Simulation-based Randomized Paired Cross-over Comparison of Direct versus Video-assisted Laryngoscopy for Endotracheal Intubation by Inexperienced Operators
2019, Health Professions EducationCitation 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
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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