Comparison of the McGrath ® MAC video laryngoscope with direct Macintosh laryngoscopy for novice laryngoscopists in children without difficult intubation: A randomised controlled trial

Comparison of the HugeMed video laryngoscope with the Macintosh direct laryngoscope for nasotracheal tracheal intubation in children undergoing dental treatment: a randomized controlled clinical study

OBJECTIVES

The aim of this study was to compare the performance of the HugeMed® videolaryngoscope with a direct Macintosh laryngoscope for nasotracheal intubation.

METHODS

Eighty-eight children aged 4-10 years were randomly assigned to either the HugeMed® videolaryngoscope (HVL) or the Macintosh direct laryngoscope (MDL) group. Intubation difficulty, glottic view grade, time-to-intubation, number of tracheal intubation attempts, use of external laryngeal manipulation and Magill forceps, recovery time, pediatric-anesthesia-delirium-scale (PAEDS) scores, pain due to tracheal intubation, and laryngeal bleeding were evaluated.

RESULTS

Easy tracheal intubation incidence was higher in the HVL group than that in the MDL group (p = 0.001). Glottic view was better in the HVL group as compared to the MDL group (p = 0.027). There was no difference between the groups in terms of time-to-tracheal intubation, number of tracheal intubation attempts, Magill forceps usage, pain, and bleeding due to tracheal intubation. The need for external laryngeal manipulation (p = 0.004) and PAEDS scores (p = 0.006) were higher in the MDL group than those in the HVL group.

CONCLUSION

HugeMed® videolaryngoscope may provide easier tracheal intubation, create a better glottic view, and significantly reduce the need for additional manipulation compared to the Macintosh direct laryngoscope, for nasotracheal intubation.

CLINICAL TRIAL REGISTRATION

www.clinicaltrial.gov identifier is NCT05121597.

Efficacy of McGRATH®MAC videolaryngoscope blade 1 for tracheal intubation in small children: a randomized controlled clinical study

BACKGROUND

Videolaryngoscopes may not be as effective in small children as they are in older children and in adults. The size 1 blade is commercially available for the McGRATH®MAC videolaryngoscope (Covidien, Medtronic, Tokyo, Japan), but its efficacy in comparison with a Macintosh laryngoscope blade 1 is not known.

AIM

The main aim of this study was to assess the efficacy of McGrath®MAC blade 1 in comparison with a conventional Macintosh laryngoscope blade 1, in children aged less than 24 months.

METHODS

Thirty-eight children aged less than 24 months were randomly allocated to one of two groups, and tracheal intubation was attempted using either a direct laryngoscope with a Macintosh blade 1 or a videolaryngoscope with a McGRATH®MAC blade 1. In another 12 children aged 2-4 years, the same comparisons were made with blade 2. The primary outcome measure was time to tracheal intubation using a size 1 blade.

RESULTS

Tracheal intubation took significantly longer with a McGRATH®MAC blade 1 (median (interquartile range): 38.0 (31.8-43.5) s) than with the Macintosh blade 1(27.4 (25.9-29.2) s) (p < 0.0001; median difference (95% CI for the median difference): 10.6 (6.4-14.0) s), mainly due to difficulty in advancing a tube into the trachea. No significant difference was observed for the size 2.

CONCLUSIONS

In small children without predicted difficult airways, time to intubate the trachea was significantly longer for a McGRATH®MAC blade 1 than a Macintosh blade 1.

CLINICAL TRIAL REGISTRATION

jRCT1032220366.

Effectiveness of Indirect and Direct Laryngoscopes in Pediatric Patients: A Systematic Review and Network Meta-Analysis

This research aimed to produce a coherent ranking of the effectiveness of intubation devices in pediatric patients using network meta-analysis (NMA). We searched the electric databases for prospective randomized studies that compared different tracheal intubation devices in pediatric patients. The primary outcome was intubation failure at the first attempt. Secondary outcomes were glottic visualization and intubation time. The statistical analysis performed used DerSimonian and Laird random-effects models. Frequentist network meta-analysis was conducted, and network plots and network league tables were produced. Subgroup analysis was performed after excluding rigid-fiberscope-type indirect laryngoscopes. Thirty-four trials comparing 13 devices were included. Most laryngoscopes had the same intubation failure rate as the Macintosh reference device. Only the Truview PCD™ had a significantly higher intubation failure rate than the Macintosh (odds ratio 4.78, 95% confidence interval 1.11–20.6) The highest-ranking laryngoscope was the Airtaq™ (P score, 0.90), and the AirwayScope™, McGrath™, and Truview EVO2™ ranked higher than the Macintosh. The Bullard™ had the lowest ranking (P score, 0.08). All laryngoscopes had the same level of glottic visualization as the Macintosh and only the C-MAC™ had a significantly shorter intubation time. Intubation time was significantly longer when using the GlideScope™, Storz DCI™, Truview PCD™, or Bullard™ compared with the Macintosh. P score and ranking of devices in the subgroup analyses were similar to those in the main analysis. We applied NMA to create a consistent ranking of the effectiveness of intubation devices in pediatric patients. The findings of NMA suggest that there is presently no laryngoscope superior to the Macintosh laryngoscope in terms of tracheal intubation failure rate and glottic visualization in pediatric patients.

Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review

OBJECTIVE

Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization.

METHODS

We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization.

RESULTS

We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies.

CONCLUSIONS

Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.

Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department

STUDY OBJECTIVE

Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance.

METHODS

We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model.

RESULTS

From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90).

CONCLUSION

We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.

Impact of Environmental Noise Levels on Endotracheal Intubation Performance Among Pediatric Emergency Providers: A Simulation Study

BACKGROUND

The emergency department is a stressful workplace environment with environmental stimuli and distractions, including noise. This has potential effects on perceived stress for providers and critical procedure performance.

OBJECTIVE

This study aimed to characterize the impact of environmental noise levels on the time to intubate, the quality of intubation, and physiologic stress response in pediatric emergency department providers.

METHODS

This was a randomized control simulation-based study in which experienced pediatric providers intubated an adult manikin 3 times while experiencing 3 different ambient noise levels (60, 75, 80 dB) in random order. Participants' times to intubate were measured, as was the endotracheal tube depth. The quality of each intubation attempt was assessed via video review against a standardized checklist. Lastly, participants' heart rates were monitored in real time to assess for physiologic stress response. Differences in performance were analyzed using a repeated-measures analysis of variance.

RESULTS

No significant difference was found between noise levels and time to intubate (P = 0.19), although each subsequent attempt shortened the time to intubate (P = 0.01). Physiological heart rate changes did not differ by noise level (P = 0.35). Subjectively, "time and economy of motion" and "overall performance" did not differ by noise level but did improve for each subsequent attempt number (P < 0.046).

CONCLUSIONS

Intubation performance improved with attempt number, but no differences in performance were seen between noise levels. This suggests that rehearsing and practice impacts performance more than environmental noise levels.

Comparative efficacy of C-MAC® Miller videolaryngoscope versus McGrath® MAC size "1" videolaryngoscope in neonates and infants undergoing surgical procedures under general anesthesia: A prospective randomized controlled trial

BACKGROUND

Various anatomical and physiological factors make intubation in infants challenging. C-MAC videolaryngoscope shows better results as compared to the conventional direct laryngoscopy for intubation in infants. McGrath MAC size-1 with a disposable Macintosh type blade has recently been introduced for use in infants and has not been formally evaluated in this population.

AIMS

This study aims to evaluate the intubation characteristics of C-MAC Miller and McGrath MAC in neonates and infants with the primary objective to compare the time with the two devices.

METHODS

After informed consent from the parents, 140 neonates and infants scheduled for surgical procedures were randomized to undergo intubation with either C-MAC Miller or McGrath MAC after standard general anesthesia. The two devices were compared in terms of total intubation time, Percent of Glottic Opening score, Cormack Lehane grades, time to glottis view, intubation difficulty score, overall success rate, first attempt success rate, and complications.

RESULTS

The median glottic view time (6 s [4-9] vs. 6 s [4-9]; p = .40) and intubation time (27 s [25.5-28] vs. 27 s [24.5-29.5]; p = .87) were similar. The mean difference (95% CI) in time to tracheal intubation and time to glottic view was 0.49 s [-3.1 to 2.1] and -1.7 s [-3.8 to 0.47], respectively. However, the Percent of Glottic Opening score, Cormack Lehane grades, and subjective intubation difficulty were significantly better with C-MAC. The first attempt success rates, overall success rates (100% vs. 97.5%), and intubation difficulty scores were comparable. There were two failed intubations with McGrath which were successfully intubated with C-MAC.

CONCLUSION

The C-MAC Miller blade showed similar intubation timings, success rates, and intubation difficulty score as compared to McGrath MAC in neonates and infants, though the former provided superior glottic views. Both the videolaryngoscopes may be safely used in infants and neonates for routine intubation scenarios.

Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department

The aim of this study was to compare the success of first-attempt tracheal intubation in pediatric patients >1-year old performed using video versus direct laryngoscopy and compare the frequency of tracheal intubation-associated events and desaturation among these patients.Prospective observational cohort study conducted in an Academic pediatric tertiary emergency department. We compared 50 children intubated with Mcgrath Mac video laryngoscope (VL group) and an historical series of 141 children intubated with direct laryngoscopy (DL group). All patients were aged 1 to 18 years.The first attempt success rates were 68% (34/50) and 37.6% (53/141) in the VL and DL groups (P < .01), respectively. There was a lower proportion of tracheal intubation-associated events in the VL group (VL, 31.3% [15/50] vs DL, 67.8% [97/141]; P < .01) and no significant differences in desaturation (VL, 35% [14/50] vs DL 51.8% [72/141]; P = .06). The median number of attempts was 1 (range, 1-5) for the VL group and 2 (range, 1-8) for the DL group (P < .01). Multivariate logistic regression showed that video laryngoscope use was associated with higher chances of first-attempt intubation with an odds ratio of 4.5 (95% confidence interval, 1.9-10.4, P < 0.01).Compared with direct laryngoscopy, VL was associated with higher success rates of first-attempt tracheal intubations and lower rates of tracheal intubation-associated events.

Management of the child's airway under anaesthesia: The French guidelines

OBJECTIVE

To provide French guidelines about "Airway management during paediatric anaesthesia".

DESIGN

A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded.

METHODS

The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology.

RESULTS

The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions.

CONCLUSIONS

Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.