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.
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…
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.)
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.
Money-back GuaranteeIsrael Green-Hopkins, MD;Joshua Nagler, MD, MHPE
August 2, 2015
September 1, 2018
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