Endotracheal Intubation In Pediatric Patients Using Video Laryngoscopy: An Evidence-Based Review

Table of Contents

 

1. Abstract
2. Case Presentations
3. Introduction
   1. The Need For Improved Devices In The Pediatric Population
      1. Unique Pediatric Considerations
      2. Decreased Clinical Opportunities
4. Critical Appraisal Of The Literature
5. Video Laryngoscopy: Rationale For Development And Use
   1. History Of Video Laryngoscopy
   2. Video Laryngoscopes And Device Types In The Pediatric Setting
6. Potential Benefits Of Video Laryngoscopy
   1. Line Of Sight
   2. Supervision And Training
   3. Procedural Review
7. Video Laryngoscopy Use And Success Rates
   1. Use Of Video Laryngoscopy In Adults In The Emergency Department
   2. Use Of Video Laryngoscopy In Pediatric Patients In The Operative Setting
   3. Use Of Video Laryngoscopy In Pediatric Patients Outside The Operating Room
8. The Difficult Airway
   1. Video Laryngoscopy In The Adult Difficult Airway
   2. Video Laryngoscopy In The Pediatric Difficult Airway
9. Video Laryngoscopy In Special Populations
   1. Video Laryngoscopy In Patients With Cervical Spine Immobilization
   2. Video Laryngoscopy In Neonates
   3. Video Laryngoscopy In The Prehospital Setting
10. Are There Benefits Of One Device Over Another?
11. Use Of Video Laryngoscopy In Pediatric Patients In The Emergency Department
    1. Indications For Use
    2. Contraindications For Use
12. Video Laryngoscopic Device Review
    1. Storz C-MAC® Video Laryngoscope
       1. Technique
       2. Challenges
       3. GlideScope® Video Laryngoscope
       4. Technique
       5. Challenges
       6. Airtraq Optical Laryngoscope
       7. Technique
       8. Challenges
       9. Video Laryngoscopes: Device Selection
       10. Other Nonpediatric Devices
13. Universal Challenges
    1. Device Insertion
    2. Endotracheal Tube Insertion
    3. Adjusting The View
14. Cautions And Complications With Video Laryngoscopes
15. Controversies
    1. Slowed Adoption Of Video Laryngoscopy
16. Potential Future Directions For Video Laryngoscopy
    1. Education And Quality Assurance Opportunities
17. Summary
18. Risk Management Pitfalls In Video Laryngoscopy In Pediatric Patients
19. Time- And Cost-Effective Strategies
20. Case Conclusions
21. Tables and Figures
    1. Table 1. Comparison Of The Storz C-MAC, GildeScope, And Airtraq Laryngoscopes
    2. Figure 1. Video Laryngoscopy Publications In PubMed Over Time (As Of November 10, 2014)
    3. Figure 2. A Visual Comparison Of The GlideScope, Airtraq, and C-MAC Devices
    4. Figure 3. Video Laryngoscopy Changes The Visual Vantage Point
    5. Figure 4. Alignment Of Oral, Pharyngeal, And Laryngeal Axes
    6. Figure 5. Cormack-Lehane Grading System
    7. Figure 6. C-MAC Video Laryngoscope
    8. Figure 7. C-MAC Video Laryngoscope With Monitors
    9. Figure 8. Comparison Of C-MAC Handle Size To Direct Laryngoscope Size
    10. Figure 9. Hyperangulation Of The GildeScope
    11. Figure 10. Disposable GildeScope With Attached Light Source
    12. Figure 11. The GildeScope And Projection To Its Accompanying Monitor
    13. Figure 12. Reverse Loading The Endotracheal Tube When Using The GildeScope
    14. Figure 13. Viewing Options For The Airtraq Device
    15. Figure 14. The Guided Channel In The Airtraq For Endotracheal Tube Delivery
22. References

Abstract

Endotracheal intubation of pediatric patients is an infrequent, though high-risk, procedure in emergency medicine. Emergency clinicians should be aware of available approaches to assist with successful intubation in pediatric patients. Video laryngoscopy involves the utilization of optical and video technology to facilitate indirect visualization of laryngeal structures during intubation. This technology can be advantageous when intubating patients with normal or difficult airways, and it is increasingly being used in the care of patients in the emergency department. A number of pediatric devices are now available, each with benefits as well as limitations and nuances in technique for use. This evidence-based review describes the emergence of video laryngoscopy into the pediatric and emergency medicine settings. A summary of the existing data on video laryngoscopy use in routine and difficult airways is included, and practical instruction on the use of 3 specific devices approved for use in pediatric patients is provided.

Case Presentations

An 8-year-old boy is brought into the ED after a motor vehicle crash in which he was an unrestrained passenger. His mental status is depressed, with a GCS score of 7, and his cervical spine has been immobilized in a collar. His capnography shows bradypnea and hypercarbia, and he is intermittently desaturating. He has scattered ecchymoses over his chest wall. The pediatric emergency medicine fel low managing the airway has not previously intubated a trauma patient in the ED. You consider the best method to intubate this patient and provide guidance to the fellow…

A 5-year-old girl with a seizure disorder presented in status epilepticus, and is now somnolent after receiving 3 rounds of benzodiazepines and a loading dose of fosphe nytoin. She has intermittent apnea and hypotension. Her end-tidal CO₂ remains elevated at 55 mm Hg, and she requires bag-valve mask ventilation during her apneic pe riods. Her last intubation procedure note reports a grade 2 Cormack-Lehane view. You are concerned about perform ing any diagnostic tests prior to securing the airway in this patient…

A 2-year-old girl with Pierre Robin sequence presents to the ED with respiratory distress and fever. She is ill-appearing, hypoxic to 88% despite a nonrebreather mask on 10 L/min of oxygen, and she is in moderate respiratory distress. A chest x-ray demonstrates multifocal pneu monia. She has a history of requiring airway support for pneumonia, and noninvasive support has been historically challenging secondary to her facial dysmorphisms. You wonder if intubating this patient will be difficult…

Introduction

Emergent endotracheal intubation is an infrequent, yet critical, procedure in pediatric patients in the emergency medicine setting. It can be lifesaving, though it also carries risks of significant morbidity (eg, hypoxia, aspiration, and esophageal intubation) and even mortality. Several studies have identified a clear relationship between an increased likelihood of adverse events and multiple attempts at intubation.^1-3 Yet, data from both single and multicenter pediatric studies demonstrate that first-pass success rates for emergent intubation are variable, ranging from 37% to 78%.^4-7 It comes as little surprise, then, that adverse event rates in pediatric intubation in acute settings have been shown to be as high as 21%.⁷ Therefore, efforts to improve rates of first-pass success and decrease intubation-related complica tions are essential.

The concept of integrating video technology into laryngoscopy has led to changes in advanced airway management. The quantity of available data has increased in the anesthesia, critical care, and emergency medicine literature in recent years. (See Figure 1.) Given the high success rates for orotracheal intubation, particularly in the operating room setting, video laryngoscopy (VL) devices were generally only considered as alternative strategies for use in patients with difficult airways. However, with improving technology, decreasing cost, and wider availability, the use of VL has become increasingly common for routine cases and across more practice settings, including emergency departments (EDs) that care for children.

This review covers the available literature regarding VL use in emergency medicine and the pediatric setting, including use in the context of potentially difficult airways, and provides practical instruction on the 3 VL devices approved for use across the entire spectrum of pediatric ages: the GlideScope^®, the Airtraq, and the Storz C-MAC^®. (See Figure 2.)

Risk Management Pitfalls In Video Laryngoscopy In Pediatric Patients

1. “Passing the ETT using a GlideScope^® is no different than when using a direct laryngoscope.”
   The increased curvature of the blade of the GlideScope^® is designed to provide optimal viewing around the curve of the airway toward anterior/superior airways. Passing an ETT around this same curved path can be challenging, particularly in children, as there is no commercially available rigid stylet to guide the tube. To overcome this challenge, use the stiffest stylet available, and bend the tube to match the shape of the blade. To facilitate tube passage once the tip has passed the vocal cords, withdraw the stylet slightly to prevent the tube from advancing into the anterior tracheal wall and allow it to travel down the length of the tracheal lumen.
2. “VL devices are too large to be used in neonates. I would only use direct laryngoscopy in this age group.”
   Although there are no large comparative trials on the use of VL in neonates, case reports and series have shown success in this age group. Becoming comfortable with the size of the blades and the technique for use in this population requires experience. However, many devices (including the C-MAC^®, GlideScope^®, and Airtraq) have blade sizes designed for use in children of all ages, including neonates. For emergency clinicians with training, these devices can offer the same advantages as in older pediatric patients and adult patients. Emergency clinicians who are comfortable with airway management in this age group and with VL may safely use VL in neonates.
3. “The VL screen went blank as I was preparing to intubate.”
   Although VL offers technical advantages, like any equipment, there is a risk of malfunction. All electronic connections from the blade to the screen, as well as the power source, should be checked to ensure proper function. It is also important to have a back-up intubation plan in place.
4. “I am most familiar with adult-sized blades, so I will plan to use them when I intubate children. “
   Each of the VL devices reviewed here has a range of different-sized blades to be used based on the age and size of the child. Just as with direct laryngoscopy, choosing appropriately sized equipment is key to success with this procedure. Use of incorrectly sized equipment may compromise procedural success and can be potentially harmful to the patient.
5. “Our ED is looking to purchase every available VL device for use in pediatrics so that we have a device for every circumstance.”
   Although each VL device may have some advantage in different clinical circumstances, gaining and maintaining proficiency in many devices can be challenging, particularly if they are not used frequently. For emergency clinicians committed to being prepared to use each, it is important to have sufficient training and frequent practice opportunities. If these opportunities do not arise in the ED, then maintenance of skills using either simulation or dedicated time in an operating room or other controlled setting can be valuable.
6. “The patient was in a motor vehicle crash and arrived in cervical spine immobilization with a hard collar. Is it safe to use a VL in this patient?”
   VL can be used safely in trauma patients and may offer the additional advantage of providing an improved glottic view without the need to move the head and neck. It should be noted, however, that, in some cases blood, secretions, or vomit may obscure the camera lens.
7. “I had trouble sweeping the tongue to the left when using the GlideScope^®.”
   The GlideScope^® is designed for indirect laryngoscopy only, and, therefore, there is no need to sweep the tongue. Unlike direct laryngoscope blades, the GlideScope^® blade does not have a flange to control the tongue. Instead, it is recommended that the device should be inserted in the midline until the glottic structures are visualized.
8. “I have an Airtraq available in my difficult airway cart. I have never tried it before, but I will use it as my rescue device with my next crash intubation.”
   Although some use video and optical devices as back-up or rescue devices, emergency clinicians should only use equipment on which they have been trained and feel comfortable. There are nuances to the technique for each device, and the opportunity to learn these is not during a difficult or crash airway. Becoming familiar with the devices that are available in a given clinical environment and the circumstances in which it might be used is paramount for anyone who might be emergently managing a child’s airway.
9. “The patient has bronchiolitis and copious oral secretions. Is that a contraindication to using VL?”
   Secretions, vomitus, or blood can cover the camera lens and compromise visualization. Although this is not an absolute contraindication to the use of VL, preparations such as suction, gauze to wipe the camera, and back-up blades may be helpful. In addition, availability of a device that allows for direct visualization (either a C-MAC^® or a traditional laryngoscope) may help obviate the risk of reliance on an indirect (camera) view.
10. “I did not use VL because of the risk of lip or dental trauma.”
    There is a tendency to look at the image in the viewfinder or on the projected screen when using VL, which can result in advertent lip or dental injury when the VL is being introduced or adjusted in the oral cavity. To mitigate this risk, emergency clinicians should proceed in the following order: (1) Look in the mouth as the VL blade is inserted past the dentition; (2) then look at the screen to guide movement of the blade tip; (3) then, again directly visualize the ETT as it enters the mouth; and (4) return to the VL screen view to guide final indirect positioning of the tube.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

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2. * Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71-78. (Retrospective study; 1828 intubations)
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73. Burnett AM, Frascone RJ, Wewerka SS, et al. Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial. Prehosp Emerg Care. 2014;18(2):231-238. (Prospective study; 107 patients)
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