The Impact of Videolaryngoscopy on Endotracheal Intubation Success by a Pediatric/Neonatal Critical Care Transport Team

Approaches to neonatal intubation training: A scoping review

Introduction

Neonatal intubation is a lifesaving skill that a variety of clinicians need to establish as it can be required anywhere babies are born or hospitalised and cannot depend on the immediate availability of an experienced senior clinician. However, neonatal intubation is complex and risky, requiring technical and non-technical skill competence. Studies report that rates of successful neonatal intubation by junior clinicians are low, providing a mandate to examine the best methods to improve skill acquisition, retention, and transfer.

Method

We utilised PRISMA-ScR methodology to capture the range of training approaches in the simulation and clinical settings, and to assess the range of technical and non-technical skill outcome measures that were used in the included studies. Databases were searched from inception to August 2024 to identify studies reporting outcomes for medical practitioners-in-training, nurses, and nurse practitioners. Identified studies meeting inclusion criteria underwent data charting with study characteristics tabulated.

Results

Twenty-six studies (involving 1449 participants) were included. Training methodology was diverse and included self-directed learning, didactic education, demonstration, simulation-based training (SBT), instructor feedback, debriefing and supervised clinical practice. Most of the studies (96 %) used multiple training methods with education and SBT most frequently used. Thirteen studies reported outcomes in clinical settings, including seven that demonstrated changes in technical skills following education and SBT. Two studies that assessed transfer of skills failed to show successful transfer from simulation to a clinical setting. Two articles reported the transfer of skills between direct and video laryngoscope devices. Only one study evaluated skill retention (at 6-9 months) but did not demonstrate proficiency after initial training or at follow up. No studies described the effects of training on non-technical skills.

Conclusion

No included studies or combination of studies seems likely to provide a high-certainty evidence-basis for optimal training methodology. Results suggested using a training bundle including education, SBT and supervision. Knowledge gaps remain, including the most effective methodology for non-technical skill training. In addition, the evidence of technical skill retention beyond the immediate training episode, and transfer to a variety of clinical environments is very limited. Given the importance of successful neonatal intubation, more research in these areas is justified.

Early experience in use of videolaryngoscopy by a neonatal pre-hospital and retrieval service

OBJECTIVE

To describe initial experience with use of the Glidescope Go videolaryngoscope by an Australian neonatal pre-hospital and retrieval service.

METHODS

We conducted a 31-month retrospective review of an airway registry for neonates intubated by MedSTAR Kids clinicians.

RESULTS

Twenty-two patients were intubated using the Glidescope Go, compared with 50 using direct laryngoscopy. First-pass success was 17/22 (77.3%) with the Glidescope Go and 38/50 (76%) with direct laryngoscopy. Complications occurred in 7/22 (32%) and 8/50 (16%), respectively.

CONCLUSIONS

On initial review of this practice change, videolaryngoscopy allows neonatal tracheal intubation with a comparable success rate to direct laryngoscopy in a pre-hospital and retrieval setting.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

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).

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

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 (1С). 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 (1С). 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 CO 2 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).

Out-of-Hospital Pediatric Video Laryngoscopy With an Adult Device: A Case Series Presented With a Contemporary Group Intubated With Direct Laryngoscopy

OBJECTIVES

After introducing an adult video laryngoscope (VL) in our physician-paramedic prehospital and retrieval medical service, our quality assurance process identified this blade being used during pediatric intubations. We present a case series of pediatric intubations using this oversized adult VL alongside a contemporaneous group of direct laryngoscopy (DL) intubations.

METHODS

We performed a retrospective review of intubated patients 15 years or younger in our electronic quality assurance registry from January 1, 2017, to December 31, 2020. Data collected were demographic details, intubation equipment, drug doses, the number of intubation attempts, and complications. Results are presented according to those intubated with C-MAC4 VL (Karl Storz) alongside age-appropriate DL sizes.

RESULTS

Ninety-nine pediatric patients were intubated, 67 (67%) by CMAC4 and 32 (33%) by DL. Video laryngoscopy had a first-attempt success rate of 96% and DL 91%. A Cormach and Lehane view 1 or 2 was found in 66 VL (99%) and 29 DL patients (91%). Desaturation was reported in two VL and 1 DL patient.

CONCLUSIONS

Adult VL became the most common method of intubation in patients older than 1 year during the study period. An adult C-MAC4 VL could be considered for clinicians who prefer VL when a pediatric VL is unavailable or as a second-line device if a pediatric VL is not present when intubating children older than 1 year.

The Use of Video Laryngoscopy Did Not Lead to Greater First-Pass or Overall Success Rates Compared to Direct Laryngoscopy in Pediatric Intubation in a Helicopter Emergency Medical Service

OBJECTIVE

We hypothesized that video laryngoscopy (VL) would significantly increase the first attempt and final success rates over direct laryngoscopy (DL) in helicopter emergency medical services.

METHODS

This was a study of an emergency medical service in the Midwestern United States. Pediatric patients (age < 18 years) transported between January 1, 2010, and July 31, 2016, with an attempted intubation were identified. Demographics (age group and sex), first-pass success (FPS), and total attempts by intubation type were abstracted and compared with a historical control.

RESULTS

Fifty-five pediatric patient runs were abstracted (DL: n = 28, VL: n = 27). There were no significant differences between the DL and VL groups based on sex (DL: 54% male, VL: 70% male; P = .200) or age group (P = .239). Analyses of FPS between DL and VL showed no difference (DL: 82.1% success vs. VL: 70.4% success; P = .304). There was no difference for final success rate between DL and VL (DL: 85.7%, VL: 96.3%; P = .172). A significantly larger number of difficult airways were reported in the VL group (37.0%) compared with DL (7.1%, P = .007).

CONCLUSION

VL did not improve FPS over DL nor did it improve the final endotracheal intubation success rate over DL. The VL group had more airways reported as being difficult by the flight crew than the DL group.

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.

Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS

OBJECTIVE

We hypothesized that videolaryngoscope use for tracheal intubations would differ across NICUs, be associated with higher first attempt success and lower adverse events.

STUDY DESIGN

Data from the National Emergency Airway Registry for Neonates (01/2015 to 12/2017) included intubation with direct laryngoscope or videolaryngoscope. Primary outcome was first attempt success. Secondary outcomes were adverse tracheal intubation associated events and severe desaturation.

RESULTS

Of 2730 encounters (13 NICUs), 626 (23%) utilized a videolaryngoscope (3% to 64% per site). Videolaryngoscope use was associated with higher first attempt success (p < 0.001), lower adverse tracheal intubation associated events (p < 0.001), but no difference in severe desaturation. After adjustment, videolaryngoscope use was not associated with higher first attempt success (OR:1.18, p = 0.136), but was associated with lower tracheal intubation associated events (OR:0.45, p < 0.001).

CONCLUSION

Videolaryngoscope use is variable, not independently associated with higher first attempt success but associated with fewer tracheal intubation associated events.

Afflux massif de victimes pédiatriques

Toute crise sanitaire (épidémie, pandémie, actes terroristes, catastrophes naturelles ou faits de guerre) doit être anticipée par la mise en place d’un plan local, régional mais aussi national adapté aux enfants compte tenu de leur vulnérabilité. La faible expérience des équipes associée à une littérature pauvre nous oblige à extrapoler les concepts appliqués à l’adulte et à la médecine de guerre alors que les particularités anatomo-physiologiques liés à l’âge imposent des lésions et des stratégies de prise en charge spécifiques. Le shock index ajusté sur l’âge (SIPA) est un bon reflet de l’état de choc hémorragique ainsi qu’un bon indicateur des besoins de transfusion, d’admission en soins critiques, de ventilation et de mortalité chez les enfants traumatisés et pourrait être utile au triage. L’afflux de victimes pédiatriques reste un défi organisationnel, médical et humain. L’optimisation de la prise en charge repose sur une mutualisation des connaissances et une implication des différents acteurs (pédiatre, urgentiste, anesthésiste, réanimateur et chirurgien) afin de maintenir la qualité des soins. Il est important d’homogénéiser l’organisation et la formation en ciblant une communication multimodale, en s’appuyant sur des recommandations argumentées et des outils innovants qui s’inspirent de ceux qui ont été utilisés durant la récente pandémie (place du numérique). La simulation (procédurale, humaine, numérique, de masse) est un outil nécessaire et efficace pour l’entraînement régulier des équipes afin de faire face à ces situations exceptionnelles.