GlideScope video laryngoscope: a randomized clinical trial in 203 paediatric patients

A prospective randomized comparative trial of pediatric C-MAC D-blade video laryngoscope with McCoy direct laryngoscope for intubation in children posted for elective surgical procedures under general anesthesia

BACKGROUND

Pediatric airway management requires careful clinical evaluation and experienced execution due to anatomical, physiological, and developmental considerations. Video laryngoscopy in pediatric airways is a developing area of research, with recent data suggesting that video laryngoscopes are better than standard Macintosh blades. Specifically, there is a paucity of literature on the advantages of the C-MAC D-blade compared to the McCoy direct laryngoscope.

METHODS

After Ethics Committee approval, 70 American Society of Anesthesiologists physical status 1 and 2 children aged 4-12 years scheduled for elective surgery under general anesthesia were recruited. Patients were randomly allocated to intubation using a C-MAC video laryngoscope size 2 D-blade (Group 1) and a McCoy laryngoscope size 2 blade (Group 2). The Intubation Difficulty Scale (IDS) for ease of intubation was the primary outcome, while Cormack-Lehane grades, duration of laryngoscopy and intubation, hemodynamic responses, and incidence of any airway complications were secondary outcomes.

RESULTS

Both groups were comparable in terms of patient characteristics. The median (IQR) Intubation Difficulty Scale (IDS) score was better but was statistically nonsignificant with C-MAC (0 [0-0] vs. 0 [0-2], p = .055). The glottic views were superior (CL grade I in 32/35 vs. 23/35, p = .002), and the time to best glottic view (6 s [5-7] vs. 8.0 s [6-10], p = .006) was lesser in the C-MAC D-blade group while the total duration of intubation was comparable (20 s [16-22] vs. 18 s [15-22], p = .374). All the patients could be successfully intubated on the first attempt. None of the patients had any complications.

CONCLUSION

The C-MAC video laryngoscope size 2 D-blade provided faster and better glottic visualization but similar intubation difficulty compared to McCoy size 2 laryngoscope in children. The shorter time to achieve glottic view demonstrated with the C-MAC failed to translate into a shorter total duration of intubation when compared to the McCoy laryngoscope attributable to a pronounced curvature of the D-blade.

Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Intubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively.

RESULTS

Fourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD =  - 6.92, 95% CI [- 12.86, - 0.99], P = 0.02), intubation difficulty score (MD =  - 0.62, 95% CI [- 0.86, - 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05).

CONCLUSION

In emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.

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).

Network meta-analysis of comparative efficacy and safety of intubation devices in children

To evaluate the comparative efficacy and safety of different intubation devices on intubation outcomes in pediatric intubation. We identified relevant studies from previous meta-analyses and literature retrieval in PubMed, EMBASE, and Cochrane Library. The primary outcome was the first-pass success (FPS), and the secondary outcome included the time to intubation (TTI) and the risk of local complications (LC). Network meta-analysis was performed using STATA 14.0. Twenty-three randomized comparative trials (RCTs) including 12 devices were included. Compared with Macintosh, Airtraq (odds ratio [OR] = 13.05, 95% confidence interval [CI] = 4.68 to 36.38), Miller (OR = 4.77, 95%CI = 1.32 to 17.22), Glidescope (OR = 2.76, 95%CrI = 1.60 to 4.75) and McGrath (OR = 4.61, 95%CI = 1.18 to 17.99) obtained higher PFS. Meanwhile, Airtraq was superior to Glidescope (OR = 0.21, 95%CI = 0.07 to 0.65) for PFS. For TTI, Canada was superior to other intubation devices, as well as CMAC was superior to TruViewEVO2, Glidescope, and StorzDCI. Airtraq lowered the risk of LC compared with Macintosh and Pentax but there was no statistical difference between Airtraq and KingVision. Airtraq may be the optimal option for FPS, Canada for TTI, and KingVision for LC in pediatric intubation.

A Comparative Study of Video Laryngoscopy to Direct Laryngoscopy for Endotracheal Intubation in Pediatric Patients

Background

Direct laryngoscopy is the standard method for intubation in pediatric patients. The introduction of video laryngoscopy brought a paradigm shift in managing pediatric airways.

Objectives

We compared the tracheal intubation technique between direct and video laryngoscopy with McIntosh Blade 2 in pediatric patients 2 - 8 years of age requiring airway management. The glottic view and the first pass success rate were compared and analyzed.

Methods

An observational cross-sectional study was conducted with 120 children between 2 - 8 years with normal airways. They were divided into video laryngoscopy (Group V) and direct laryngoscopy (Group D). The primary outcome measures included time taken for intubation, number of attempts required, Cormack-Lehane glottic view, use of optimization maneuvers, the requirement of tube repositioning, and hemodynamic parameters before and after intubation.

Results

The time taken for intubation was longer in the video laryngoscopy group (group D, 24.28 sec vs. group V, 27.65 seconds (P = 0.01). The Cormack-Lehane glottic view was grade 1 in all the patients in the video laryngoscopy group, while only 35 children showed grade 1 in the direct laryngoscopy group. (P < 0.001). We observed a significant increase in both heart rate and mean arterial pressure in the video laryngoscopy group at 1, 3, 5, and 10 min after intubation (P < 0.001, P < 0.05).

Conclusions

The time taken for intubation was more in group V, but the glottic view was much better, and the requirement for external maneuvers was also less. Pressure response to intubation was more in group V compared to group D.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal intensive care unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation, and decrease adverse consequences of a delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. This is an update of a review first published in 2015, and updated in 2018.

OBJECTIVES

To determine the effectiveness and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate on first intubation attempt in neonates (0 to 28 days of age).

SEARCH METHODS

In November 2022, we updated the search for trials evaluating videolaryngoscopy for neonatal endotracheal intubation in CENTRAL, MEDLINE, Embase, CINAHL, and BIOSIS. We also searched abstracts of the Pediatric Academic Societies, clinical trials registries (www.

CLINICALTRIALS

gov; www.controlled-trials.com), and reference lists of relevant studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, or cross-over trials, in neonates (0 to 28 days of age), evaluating videolaryngoscopy with any device used for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Three review authors performed data collection and analysis, as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

The updated search yielded 7786 references, from which we identified five additional RCTs for inclusion, seven ongoing trials, and five studies awaiting classification. Three studies were included in the previous version of the review. For this update, we included eight studies, which provided data on 759 intubation attempts in neonates. We included neonates of either sex, who were undergoing endotracheal intubation in international hospitals. Different videolaryngoscopy devices (including C-MAC, Airtraq, and Glidescope) were used in the studies. For the primary outcomes; videolaryngoscopy may not reduce the time required for successful intubation when compared with direct laryngoscopy (mean difference [MD] 0.74, 95% confidence interval [CI] -0.19 to 1.67; 5 studies; 505 intubations; low-certainty evidence). Videolaryngoscopy may result in fewer intubation attempts (MD -0.08, 95% CI -0.15 to 0.00; 6 studies; 659 intubations; low-certainty evidence). Videolaryngoscopy may increase the success of intubation at the first attempt (risk ratio [RR] 1.24, 95% CI 1.13 to 1.37; risk difference [RD] 0.14, 95% CI 0.08 to 0.20; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 13; 8 studies; 759 intubation attempts; low-certainty evidence).  For the secondary outcomes; the evidence is very uncertain about the effect of videolaryngoscopy on desaturation or bradycardia episodes, or both, during intubation (RR 0.94, 95% CI 0.38 to 2.30; 3 studies; 343 intubations; very-low certainty evidence). Videolaryngoscopy may result in little to no difference in the lowest oxygen saturations during intubation compared with direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations; low-certainty evidence). Videolaryngoscopy likely results in a slight reduction in the incidence of airway trauma during intubation attempts compared with direct laryngoscopy (RR 0.21, 95% CI 0.05 to 0.79; RD -0.04, 95% CI -0.07 to -0.01; NNTB 25, 95% CI 14 to 100; 5 studies; 467 intubations; moderate-certainty evidence). There were no data available on other adverse effects of videolaryngoscopy. We found a high risk of bias in areas of allocation concealment and performance bias in the included studies.

AUTHORS' CONCLUSIONS

Videolaryngoscopy may increase the success of intubation on the first attempt and may result in fewer intubation attempts, but may not reduce the time required for successful intubation (low-certainty evidence). Videolaryngoscopy likely results in a reduced incidence of airway-related adverse effects (moderate-certainty evidence). These results suggest that videolaryngoscopy may be more effective and potentially reduce harm when compared to direct laryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered RCTS are necessary to confirm the efficacy and safety of videolaryngoscopy in neonatal intubation.

Video Laryngoscopy Using King Vision™ aBlade™ and Direct Laryngoscopy in Paediatric Airway Management: A Randomized Controlled Study about Device Learning by Anaesthesia Residents

Background: Airway management in children is challenging due to anatomical and physiological differences. This randomized trial investigates whether anaesthesia residents can intubate the paediatric trachea more quickly and with a higher success rate using the King Vision™ Paediatric aBlade™ video laryngoscope (KVL) compared to conventional direct laryngoscopy (DL). Methods: Eleven anaesthesia residents (mean age: 31 years, mean training status 47 months) were each asked to perform intubations with the KVL and DL in paediatric patients. The primary outcome was the first-attempt success rate. Secondary outcomes were the time to best view (TTBV), time to placement of the tracheal tube (TTP), time to ventilation (TTV), and participant-reported ease of use on a Likert scale. Results: 105 intubations with the KVL and 106 DL were performed by the residents. The success rate on the first attempt with the KVL was 81%, and the success rate on the first attempt within a given time limit of 30 s was 45%, which was lower than with DL (93% and 77% with time limit, p < 0.01). The median TTBV [IQR] on the first attempt with KVL was 7 [5−10] s, the median TTP was 28 [19−44] s, and the median TTV was 51 [39−66] s. DL-mediated intubation was significantly faster (TTP: 17 [13−23] s; p < 0.0001 and TTV: 34 [28−44] s; p < 0.001). Application of the KVL was rated as difficult or very difficult by 60% of the residents (DL: 5%). Conclusion: In contrast to promising data on the paediatric training manikin, residents took longer to intubate the airway in children with the KVL and were less successful compared to the DL. Therefore, the KVL should not be recommended for learning paediatric intubation by residents.

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.

Comparison of two sizes of GlideScope® blades in tracheal intubation of infants: a randomised clinicaltrial☆

BACKGROUND

The appropriate size of GlideScope® blade for tracheal intubation in neonates and premature infants has not been established. We evaluated the impact of the size of the GlideScope® blade on the time taken for intubation in infants weighing 2.5-3.6 kg.

METHODS

Sixty infants weighing 2.5-3.6 kg were randomly assigned to use of the size 1 blade (n=30) or the size 2 blade (n=30). The primary outcome was the time taken to intubate. Components related to the laryngoscopic view which could affect the duration of the intubating process were also analysed.

RESULTS

The time required for tracheal intubation was shorter with the size 2 blade than with the size 1 blade (16 [14-20] s vs 22 [18-25] s, P=0.002; median difference=-5; 95% confidence interval, -7 to -2). The rate at which the tip of the tracheal tube was located at the centre of the laryngeal inlet was higher with the size 2 blade than with the size 1 blade (83% vs 40%, P<0.001). Correlation analysis indicated that the time required to find the tip of the tube was related to how far the lower border of the arytenoid cartilages was located from the mid-horizontal line of the monitor (r=0.28, P=0.033).

CONCLUSION

Use of the size 2 blade significantly reduced the time required to intubate the trachea, compared with the size 1 GlideScope® blade in infants.

CLINICAL TRIAL REGISTRATION

KCT 0003867.

Comparison of the UEscope Video Laryngoscope with the Traditional Direct Laryngoscope in Neonates and Infants: A Randomized Clinical Trial

The role of video laryngoscopy in adults is well established, but its role in children is still inconclusive. Previous studies on the UEscope in pediatric patients with difficult airways showed that it could reduce the time to intubation (TTI) compared to a conventional direct laryngoscope. The main objective of the current study was to investigate if the use of the UEscope could reduce the TTI in neonates and infants. Forty patients under 12 months old were recruited from a single tertiary hospital from March 2020 to September 2021 and were randomly assigned to the direct laryngoscope group (n = 19, neonates = 4, infants = 15) or UEscope group (n = 21, neonates = 6, infants = 15). Although the quality of glottic view was comparable in both groups, the TTI was significantly lower in the UEscope group in both the “intention-to-treat” (–19.34 s, 95% confidence interval = –28.82 to –1.75, p = 0.0144) and “as treated” (–11.24 s, 95% confidence interval: –21.73 to 0, p = 0.0488) analyses. The UEscope may be a better choice for tracheal intubation than conventional direct laryngoscope in neonates and infants.

Success rate and duration of orotracheal intubation of premature infants by healthcare providers with different levels of experience using a video laryngoscope as compared to direct laryngoscopy in a simulation-based setting

BACKGROUND

Endotracheal intubation of very low birth weight infants (VLBWI) is an essential procedure in NICUs, but intubation experience is often limited. Video laryngoscopy (VL) has been described as a tool to improve intubation skills, but studies in high-risk neonatal populations are limited.

OBJECTIVE

The aim of this study was to investigate whether VL is a useful tool to support airway management in high-risk premature infants with inexperienced operators.

METHODS

In this crossover study predominantly inexperienced participants were exposed in random sequence to VL and conventional direct laryngoscopy (DL) for endotracheal intubation of a VLBWI simulation manikin to measure total time, number of attempts, success rate on first attempt, view of the vocal cords and perceived subjective safety until successful intubation.

RESULTS

In our study group of 94 participants there was no significant difference in the total time (mean VL: 34 s (±24 s); DL: 37 s (±28 s), p = 0.246), while the number of intubation attempts using VL was significantly lower (mean VL: 1.22 (±0.53); DL: 1.37 (±0.60), p = 0.023). Success rate of VL during the first attempt was significantly higher (VL: 84%; DL 69%, p = 0.016), view of the vocal cords was significantly better and perceived subjective safety was increased using VL.

CONCLUSIONS

Our study results suggest that with rather inexperienced operators, VL can be a useful tool to increase rate of successful endotracheal intubation of VLBWI and to improve their perceived safety during the procedure, which may have an impact on mortality and/or morbidity.

Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period

OBJECTIVE

There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED.

METHODS

This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age.

RESULTS

During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]).

CONCLUSIONS

In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.

Effects of tip-manipulated stylet angle on intubation using the GlideScope® videolaryngoscope in children: A prospective randomized controlled trial

BACKGROUND

An optimal endotracheal tube curve can be a key factor in successful intubation using the GlideScope videolaryngoscope.

AIMS

This study aimed to evaluate the effects of tube tip-modified stylet curve on the intubation time in children.

METHODS

Children aged 1-5 years were randomly assigned to either the standard curve (group S, n = 60) or tip-modified curve (group T, n = 60) groups. In group S, the endotracheal tube curve was similar to that in the GlideScope. In group T, a point approximately 1.5 cm from the tube tip was additionally angled to the left by 15°-20°. The primary outcome was the total intubation time, and the secondary outcomes were incidence of successful intubation in the first attempt, number of additional manipulations of the stylet curve, and visual analog scale (VAS) score for the easiness of intubation.

RESULTS

The mean total intubation time was significantly longer in group S than that in group T (13.9 [10.8] vs. 9.0 [3.4] sec, mean difference, 4.9 s; 95% confidence interval [CI], 2.0-7.8; p = .001). All patients in group T were successfully intubated in the first attempt, whereas those in group S were not (100% vs. 93.3%, relative risk [RR], 0.11; 95% CI, 0.01-2.02; p = .1376). Three patients in group S could be intubated after modifying the ETT curve similar to that in group T. Operators reported that tracheal intubation was easier in group T than in group S (median [interquartile range] for VAS; 1 [1-2] vs. 2 [1-3]; p < .001).

CONCLUSIONS

Having additional angle of the endotracheal tube tip to the left could be a useful technique to facilitate directing and advancing endotracheal tube into the vocal cords.

A randomized controlled trial comparing McGRATH series 5 videolaryngoscope with the Macintosh laryngoscope for nasotracheal intubation

Background and Aims:

The aim of this study was to compare the efficacy of McGRATH series 5 videolaryngoscope (VL) with Macintosh laryngoscope for nasotracheal intubation (NTI) in patients without anticipated difficult airways undergoing head and neck cancer surgeries.

Material and Methods:

We randomized 60 adult patients for NTI by experienced anesthetists with either Macintosh laryngoscope or McGRATH series 5 VL (VL group). The primary objective was to compare time taken for intubation (TTI). The secondary objectives included success rates, number of attempts, need for optimization maneuvers, Cormack and Lehane (CL) grade, and percentage of difficult intubations.

Results:

The mean TTI in the VL group was 43 (±10.6) versus 75 (±38.0) s in the Macintosh group (99% CI: 12.5; –51.6 s; P < 0.001). The overall intubation success rate was 100% in both groups. All 29 (100%) patients in the VL group were intubated in the first attempt versus 26 (86%) patients in the Macintosh group (99% CI –5; 33%; P = 0.11). In the Macintosh group, 20 (66%) patients needed optimization maneuver versus none in the VL group (99% CI 40; 91%; P < 0.001). In the VL group, 28 (96%) patients had a CL grade 1 view versus 9 (31%) in Macintosh group (99% CI 38; 92%; P < 0.001). There were no difficult intubations in the VL group versus 3 (10%) in the Macintosh group (99% CI: 7; 28%; P = 0.237). There was no trauma to oropharyngeal structures in either group.

Conclusion:

The McGRATH series 5 VL has faster TTI, better glottic visualization, and less need for optimization maneuvers than the Macintosh laryngoscope for NTI in patients with unanticipated difficult airways, when performed by experienced anesthetists.

Evolution of videolaryngoscopy in pediatric population

Direct laryngoscopy has remained the sole method for securing airway ever since the inception of endotracheal intubation. The recent introduction of video-laryngoscopes has brought a paradigm shift in the pratice of airway management. It is claimed that they improve the glottic view and first pass success rates in adult population. The airway management in children is more challenging than adults. The role of videolaryngoscopy for routine intubation in children is not clearly proven. This review attempts to discuss various videolaryngosocpes available for use in pediatric patients.

Comparison of paediatric King Vision™ videolaryngoscope and Macintosh laryngoscope for elective tracheal intubation in children of age less than 1 year: A randomised clinical trial

Background and Aims

Paediatric airway, because of its consistent anatomical differences from that of an adult, often encounters difficulty in aligning the line of sight with the laryngeal inlet during intubation. Paediatric videolaryngoscopes (VLs), by obviating the need for aligning the line of sight with the glottis, offer several advantages over direct laryngoscopy. Therefore, this study aimed to compare the recently introduced paediatric King Vision™ VL (KVL) and the direct laryngoscope with Macintosh blade for elective tracheal intubation in infants of age <1 year.

Methods

Seventy-eight infants of American Society of Anesthesiologists physical status 1 and 2, scheduled for elective surgery, were enrolled for this prospective randomised clinical trial and randomised into either of the two groups - Group K and Group C, where the infants were intubated using size 1 King Vision or direct laryngoscope with Macintosh blade. The primary objective of this study was the time taken for intubation and the first-attempt intubation success rate.

Results

Time to intubate (25.90 ± 2.34 s vs. 25.03 ± 1.42 s, P = 0.05) and first-attempt intubation success rate (100% vs. 100%, P = 1) were similar between the groups, whereas glottic visualisation (P = 0.01), alternate techniques used to assist intubation (P < 0.001), the ease of intubation (P = 0.02) and intubation difficulty score (P = 0.01) were better in Group K than that in Group C.

Conclusion

The outcome of KVL and Macintosh laryngoscope was similar in terms of time taken for intubation and first-attempt intubation success rate with KVL having superior glottic visualisation, better ease of intubation and lower intubation difficulty score for elective intubations in children of age <1 year.

The Comparison of Direct Laryngoscopy and Video Laryngoscopy in Pediatric Airways Management for Congenital Heart Surgery: A Randomized Clinical Trial

Background

Airway management in patients with hereditary heart disease is an important therapeutic intervention.

Objectives

The purpose of this study was to compare direct laryngoscopy (DL) with video laryngoscopy (VL) in pediatric airways management for congenital heart surgery.

Methods

This study was designed as a prospective randomized clinical trial. Two consecutive groups of 30 patients undergoing elective noncyanotic congenital heart surgery. The patients were divided into direct laryngoscopy versus video laryngoscopy for intubation of the trachea. The main outcomes were the number of success rate in the first attempt, and the secondary outcomes were the duration of successful intubation and complications, such as desaturation and bradycardia.

Results

Intubation procedure time was measured as 51.13 ± 17.88 seconds for the group with direct laryngoscopy and 59.66 ± 45.91 seconds for group with VL that was significant (P = 0.006). In DL group, 22 patients were intubated on the first attempt, 8 patients on the second attempt, and 6 patients on the third attempt, compared to 24, 6, and 2 respectively, in VL group. The differences were significant only in the third attempt between groups (P = 0.033). The important difference established in heart rate (HR) and SpaO₂ amounts between the two groups at any time (P < 0.05).

Conclusions

VL can produce better visualization for intubation of trachea in congenital heart disease, but this is time-consuming. Indeed, training in the use of the VL should be increased to reduce the time required for performance. Moreover, further studies are recommended to approve these helpful findings.

Efficacy and safety of videolaryngoscopy versus direct laryngoscopy in paediatric intubation: A meta-analysis of 27 randomized controlled trials

OBJECTIVE

Anatomical and physiological differences in paediatric and adult airways make intubation of paediatric patients a challenge. This study aimed to compare the efficacy and safety of video laryngoscopy (VL) to direct laryngoscopy (DL) on intubation outcomes in paediatric patients.

DESIGN

Systematic review and meta-analysis.

SETTING

Operating room.

PATIENTS

Paediatric patients who needed tracheal intubation.

INTERVENTION

Video laryngoscopy or direct laryngoscopy.

MEASUREMENTS

Electronic searches in PubMed, Embase, and the Cochrane Library were performed to identify relevant randomized controlled trials published through January 2020. Outcomes included time to intubate, intubation failure at first attempt, Cormack-Lehane laryngeal view grade, intubation difficulty scale (IDS), percentage of glottic opening score (POGO), optimal external laryngeal manipulation (OLEM), and complications. Relative risks and weighted mean difference (WMD), with 95% CI, were employed to calculate summary results using a random-effects model.

MAIN RESULTS

Overall, 27 trials including 2461 paediatric patients were analysed. Children with video laryngoscopy intubation required longer time to intubate than direct laryngoscopy intubation (WMD 3.41, 95% CI: 1.29-5.53, P = 0.002), whereas infants receiving video laryngoscopy and direct laryngoscopy intubation experienced similar time to intubate (WMD 1.72, 95% CI: -1.09-4.54, P = 0.230). No significant differences were observed on intubation failure at first attempt between video laryngoscopy and direct laryngoscopy intubations in children and infants, respectively. Video laryngoscopy improved the POGO and intubation trauma but not Cormack-Lehane laryngeal view grade, IDS, external laryngeal manipulation, hoarseness, or oxygen desaturation.

CONCLUSIONS

Compared with direct laryngoscopy intubation, there were no benefits for paediatric patients with video laryngoscopy on time to intubate and failure at first attempt, but there were benefits with regard to POGO and intubation trauma.

Evaluation of the C-MAC Miller Video Laryngoscope Sizes 0 and 1 During Tracheal Intubation of Infants Less Than 10 kg

STUDY OBJECTIVE

Video laryngoscopy has primarily been developed to assist in difficult airways. Using video laryngoscopy in pediatric airway management is an up-and-coming topic. The aim of the presented study was to compare the intubation conditions obtained when using the C-MAC video laryngoscope with Miller blades sizes 0 and 1 for standard direct laryngoscopy and indirect laryngoscopy in children weighing less than 10 kg.

DESIGN

This was a prospective study.

SETTING

The study was performed in a university hospital.

PATIENTS

Following ethical approval, 86 infants weighing less than 10 kg and undergoing surgery under general anesthesia were studied prospectively.

INTERVENTION

Indirect and direct laryngoscopy either with C-MAC Miller blade size 0 or size 1.

MEASUREMENTS

First, direct laryngoscopy was performed, and the best obtained view was graded without looking at the video monitor. A second investigator blinded to the view obtained under direct laryngoscopy graded the laryngeal view on the video monitor. Time to intubation, intubation conditions, and intubation attempts were recorded.

RESULTS

In infants less than 10 kg, intubation conditions were excellent. There were no significant differences between the use of Miller blade 0 or 1 in reference to Cormack-Lehane grade, time to intubation, time to best view, or intubation attempts. Comparing direct and indirect intubation conditions using either Miller blade 0 or 1 revealed that the use of indirect laryngoscopy provided a significantly better view (P < 0.05) of the vocal cords. In 3 infants weighing more than 8 kg, the Miller blade 0 was described as too short and narrow for intubation.

CONCLUSIONS

Both devices allowed for an excellent visualization of the vocal cords.

Comparison of Macintosh Laryngoscope and GlideScope® for Orotracheal Intubation in Children Older Than One Year

Objectives:

We aim to investigate intubation conditions, intubation times, and hemodynamic response with the GlideScope video laryngoscope or the Macintosh direct laryngoscope for orotracheal intubation in children older than one year.

Methods:

Eighty patients aged 1–12 years, scheduled to undergo elective surgery under general anesthesia with endotracheal intubation were included in a prospective, single-blinded, randomized trial. Exclusion criteria were risk of pulmonary aspiration, craniofacial malformation, difficult intubation, emergency surgery, cardiovascular disease, respiratory disease, and hemodynamic instability. After standard anesthesia induction, patients were randomized into two groups. The group G patients (n=40) were intubated with the GlideScope and the group M patients (n=40) were intubated with the Macintosh laryngoscope. Intubation time, number of attempts, Cormack–Lehane score, airway maneuvers, and visual analog score were recorded. Hemodynamic variables were recorded before and after anesthesia induction, at intubation, and 1., 3., and 5. minutes after intubation. Student’s t-test, Mann–Whitney U test, and the χ² test were used for statistical analysis, with p<0.05 considered significant.

Results:

The demographic data, operation time and hemodynamic parameters were similar between the two groups. The intubation time was longer in Group G than Group M. The incidence of Cormack–Lehane score 1 was higher in Group G than Group M while Cormack–Lehane score 2 was higher in Group M.

Conclusion:

We concluded that the GlideScope video laryngoscope provided better glottis visualization, but prolonged intubation time. There was no superiorty on hemodynamic effect with the video laryngoscope.

The usefulness of endotracheal tube twisting in facilitating tube delivery to glottis opening during GlideScope intubation in infants: randomized trial

Despite an excellent view of the glottis, technical difficulties with endotracheal tube delivery remains in GlideScope intubation. We evaluated whether a spiral-shape twisted tube can facilitate placement of the tracheal tube tip at the center of glottis opening compared to conventional tube for GlideScope intubation in infants. Eighty-six infants were randomly placed in either the conventional tube group (group C) or the twist tube group (group T). In group T, the shaft of the tube was manually twisted into a loose spiral shape. The primary outcome was the initial center location of the tube tip at the glottis opening, and the secondary outcome was total tube handling time. The initial center location rate of the tube tip at the glottis opening was significantly higher in group T than in group C (88% [38/43] vs. 47% [20/43], P < 0.001). In addition, total tube handling time (sec) was significantly shorter in group T than in group C (15.4 ± 4.7 vs. 18.2 ± 5.3, P = 0.012). In this study, the spiral shape twist tube successfully improved the rate of initial center location of the tube tip at glottis opening and facilitated tube delivery in GlideScope intubation in infants.

Airway devices in paediatric anaesthesia

Airway devices were first used in children since 1940 and thereafter an increasingly large number of paediatric airway devices have come into our armamentarium. To control and protect the airway in children during anaesthesia, in intensive care unit or in emergency department either tracheal intubation is performed under direct or indirect visualization of vocal cords with the help of laryngoscopes or video-laryngoscopes respectively or it can be done blindly or by using special instruments such as fiberoptic laryngoscope, lighted stylet or Bullard laryngoscope to name a few. Airway also can be maintained with the help of Laryngeal mask airways, oropharyngeal and nasopharyngeal airways. Updating our information and knowledge regarding these developments is pivotal to our practice of paediatric anaesthesia. With a thorough search of books, MEDLINE, MEDNET, clinical trials.gov.in, this article aims at focusing and understanding a brief basis of paediatric devices and their use.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study

Background and Objective

Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia.

Materials and Methods

Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded.

Results

TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5-28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8-32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45-100 and median = 82.4, range 10-100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt.

Conclusion

In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

GlideScope® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study

BACKGROUND AND OBJECTIVE

Anesthesiologists encounter difficulties during laryngoscopy and tracheal intubation of neonates with myelodysplasia. Tracheal intubation in lateral position in such cases deemed profitable but not easy because of the compromised laryngeal view. We compared GlideScope video laryngoscope (GVL) versus conventional Miller direct laryngoscope (DL) for tracheal intubation in laterally positioned neonates with myelodysplasia.

MATERIALS AND METHODS

Sixty neonates scheduled for elective surgical repair of meningeocele or meningeomyelocele under general anesthesia were allocated randomly for endotracheal intubation using GVL or DL. Percentage of glottis opening (POGO) scores, time to best glottis view (TBGV), endotracheal tube passage time (TPT), intubation time (IT), intubation attempts, and overall success rate of intubation were recorded.

RESULTS

TBGV was significantly shorter in GVL group (median = 6.8 s, range = 3.5-28.2 s) in comparison with DL group (median = 8.4 s, range = 4.8-32.7 s) (P = 0.01); however, TPT and IT were comparable. POGO scores were significantly higher with GVL group than DL group (median = 93.8, range = 45-100 and median = 82.4, range 10-100, respectively) (P = 0.001). Overall success of intubation was the same; however, three patients in GVL group required a second attempt for intubation in comparison with five patients in DL group. One patient in DL group required a third attempt.

CONCLUSION

In laterally positioned neonates, GVL is easier than DL with a similar intubation time, comparable time required for tube passage, better views of the glottis, shorter times to obtain the best glottic view, and high success rate as compared with DL. GlideScope seems to be an effective approach for endotracheal intubation of laterally positioned neonates with myelodysplasia.

Comparison of the C-MAC video laryngoscope size 2 Macintosh blade with size 2 C-MAC D-Blade for laryngoscopy and endotracheal intubation in children with simulated cervical spine injury: A prospective randomized crossover study

Background and Aims:

CMAC video laryngoscope size 2 D-Blade has been recently introduced for management of pediatric difficult airway. Our primary outcome was to compare glottic view, intubation time, and ease of intubation with the size 2 Macintosh versus D-Blade of C-MAC video laryngoscope in simulated cervical injury in children.

Material and Methods:

This randomized crossover study was conducted in a tertiary care hospital of Northern India. Forty children of 4–14 years of age were enrolled in this study. After induction of anesthesia, video laryngoscopy was performed either with size 2 CMAC Macintosh (group M) or D-Blade (group D) with manual in-line stabilization. After removal of the first blade, second video laryngoscopy was performed with the alternative blade. Endotracheal intubation was done with the second laryngoscopy. Best glottic view, time for best glottic view, and difficulty in blade insertion were recorded during both the video laryngoscopies. During second video laryngoscopy, difficulty of tube insertion and time for intubation were noted.

Results:

The glottic view grade was significantly better in group D compared with the group M (P = 0.0002). Insertion of D-Blade was more difficult than Macintosh blade (P = 0.0007). There was no statistical difference in terms of time for best glottic view in group M and group D (13.40 ± 4.90 vs 13.62 ± 5.60 s) and endotracheal tube insertion time (24.80 ± 7.90 vs 27.90 ± 10.90 s), respectively. Number of intubation attempts was similar in both the groups.

Conclusions:

Size 2 D-Blade of C-MAC video laryngoscope provided a better glottic view in children with simulated cervical spine injury as compared with CMAC Macintosh blade. Success of intubation, intubation time, and ease of intubation were comparable with both the blades.

Focused review on management of the difficult paediatric airway

Management of the difficult paediatric airway management may be associated with a high rate of complications. It is important that clinicians understand the patient profiles associated with difficult airway management, and the equipment and techniques available to effectively manage these children. The goal of this focused review is to highlight key airway management concepts when managing the paediatric difficult airway. This includes understanding the advantages and limitations of various airway equipment designed for children and reviewing the difficult airway algorithm with its unique considerations for the paediatric patient. Early recognition of known risk factors and thorough preparation may be helpful in reducing the risk of complications during difficult airway management in children.

Randomized equivalence trial of the King Vision aBlade videolaryngoscope with the Miller direct laryngoscope for routine tracheal intubation in children <2 yr of age

Background.

We conducted a randomized equivalence trial to compare direct laryngoscopy using a Miller blade (DL) with the King Vision videolaryngoscope (KVL) for routine tracheal intubation. We hypothesized that tracheal intubation times with DL would be equivalent to the KVL in children <2 yr of age.

Methods.

Two hundred children were randomly assigned to tracheal intubation using DL or KVL. The primary outcome was the median difference in the total time for successful tracheal intubation. Secondary outcomes assessed were tracheal intubation attempts, time to best glottic view, time for tracheal tube entry, percentage of glottic opening score, airway manoeuvres needed, and complications.

Results.

The median difference between the groups was 5.7 s, with an upper 95% confidence interval of 7.5 s, which was less than our defined equivalence time difference of 10 s. There were no differences in the number of tracheal intubation attempts and the time to best glottic view [DL median 5.3 (4.1-7.6) s vs KVL 5.0 (4.0-6.3) s; P =0.19]. The percentage of glottic opening score was better when using the KVL [median 100 (100-100) vs DL median 100 (90-100); P <0.0001]. Use of DL was associated with greater need for airway manoeuvres during tracheal intubation (33 vs 7%; P <0.001). Complications did not differ between devices.

Conclusions.

In children <2 yr of age, the KVL was associated with equivalent times for routine tracheal intubation when compared with the Miller blade.

Clinical trial registration

NCT02590237.

Comparison of GlideScope Video Laryngoscopy and Direct Laryngoscopy for Tracheal Intubation in Neonates

BACKGROUND

GlideScope video laryngoscope (GS) has been widely used to facilitate tracheal intubation in adults and pediatric patients because it can improve glottic view. Several investigations performed in pediatric patients have shown that GS provides a better view of the glottis than direct laryngoscope (DL). However, to date, there are no studies assessing the use of GS in neonates. Therefore, we conducted a prospective study to compare time to intubate (TTI) when either GS or DL was used for endotracheal intubation in neonates.

METHODS

Seventy neonates (American Society of Anesthesiologists physical status I and II, scheduled to undergo elective surgery under general anesthesia) were randomized to GS group (n = 35) and DL group (n = 35). The primary outcome variable of the study was TTI. As secondary outcomes, success rate of first intubation attempt of all neonates, intubation attempts, and adverse events were also evaluated. The glottic views (depicted by Cormack and Lehane [C&L] grades) obtained with GS and DL were compared.

RESULTS

There were no significant differences in TTIs of neonates with all C&L grades (95% CI, -7.36 to 4.44). There was also no difference in the subgroups of neonates with C&L grades I and II (n = 30 each; 95% CI, -0.51 to 5.04). However, GS significantly shortened the TTIs of neonates with C&L grades III and IV compared to DL (n = 5 each group; 95% CI, 4.94-46.67). GS improved the glottic view as compared to DL. Although the total tracheal intubation attempts in the GS group was fewer than that in the DL group (36 vs 41), there was no significant difference (P = .19).

CONCLUSIONS

GS use did not decrease the TTI of all neonates and neonates with C&L grades I and II as compared to DL use; however, GS significantly decreased the TTI of neonates with C&L grades III and IV. Additionally, GS use provided improved glottic views.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

BACKGROUND

Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.

OBJECTIVES

To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates.

SEARCH METHODS

We used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies.

SELECTION CRITERIA

RCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.

DATA COLLECTION AND ANALYSIS

Review authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

The search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427 intubations) (very low quality evidence). Moderate quality evidence suggested that videolaryngoscopy increased the success of intubation at first attempt (typical risk ratio (RR) 1.44, 95% CI 1.20 to 1.73; typical risk difference (RD) 0.19, 95% CI 0.10 to 0.28; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; 3 studies; 467 intubation attempts).Desaturation episodes during intubation attempts were similar between videolaryngoscopy and direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations) (low quality evidence). There was no difference in the incidence of airway trauma due to intubation attempts (RR 0.10, 95% CI 0.01 to 1.80; RD -0.04, 95% CI -0.09 to -0.00; 1 study; 213 intubations) (low quality evidence).There were no data available on other adverse effects of videolaryngoscopy.

AUTHORS' CONCLUSIONS

Moderate to very low quality evidence suggests that videolaryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation. However, these studies were conducted with trainees performing the intubations and these results highlight the potential usefulness of the videolaryngoscopy as a teaching tool. Well-designed, adequately powered RCTs are necessary to confirm efficacy and address safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates by trainees and those proficient in direct laryngoscopy.

Comparison of the GlideScope Cobalt® and Storz DCI® Video Laryngoscopes in Children Younger Than 2 Years of Age During Manual In-Line Stabilization: A Randomized Trainee Evaluation Study

OBJECTIVES

Video laryngoscopy facilitates tracheal intubation during manual in-line stabilization in adults, but it is not clear whether these findings translate to children. We compared trainee intubation times obtained using the GlideScope Cobalt® and Storz DCI® video laryngoscopes versus direct laryngoscopy in young children with immobilized cervical spines.

METHODS

Ninety-three children younger than 2 years underwent laryngoscopy with manual in-line stabilization using direct laryngoscopy, GlideScope Cobalt® video laryngoscopy, or Storz DCI® video laryngoscopy. Laryngoscopists were anesthesiology trainees in postgraduate training year of 3 or more. Total time to successful intubation (TTSI), best glottic view, and maximum degrees of neck deviation were recorded. An intubation time difference longer than 10 seconds was defined as clinically significant.

RESULTS

Data are reported as median; 95% confidence interval. The TTSI was similar among groups although Storz times were longer (median, 33.3 seconds; 95% confidence interval, 26.2-43.3 seconds) when compared to direct laryngoscopy (median, 23.3 seconds; 95% confidence interval, 20.7-26.5 seconds; P = 0.02). Obtaining a grade 1 Cormack-Lehane glottic view was less likely with direct laryngoscopy (P = 0.002). Maximum degrees of neck deviation were: Storz (median, 2.0; 95% confidence interval, 1.2-2.8), GlideScope (median, 2.0; 95% confidence interval, 1.4-2.6), and direct laryngoscopy (median, 1.9; 95% confidence interval, 1.2-2.1; P = 0.48).

CONCLUSIONS

Trainees were able to safely perform tracheal intubation in children younger than 2 years using any of the studied laryngoscopes, although Storz use resulted in a longer TTSI when compared to direct laryngoscopy. Video laryngoscopy may enhance best Cormack-Lehane glottic view during manual in-line cervical spine immobilization, but additional technical skills are needed to successfully complete tracheal intubation.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates)

BACKGROUND

Direct laryngoscopy is the method currently used for tracheal intubation in children. It occasionally offers unexpectedly poor laryngeal views. Indirect laryngoscopy involves visualizing the vocal cords by means other than obtaining a direct sight, with the potential to improve outcomes. We reviewed the current available literature and performed a meta-analysis to compare direct versus indirect laryngoscopy, or videolaryngoscopy, with regards to efficacy and adverse effects.

OBJECTIVES

To assess the efficacy of indirect laryngoscopy, or videolaryngoscopy, versus direct laryngoscopy for intubation of children with regards to intubation time, number of attempts at intubation, and adverse haemodynamic responses to endotracheal intubation. We also assessed other adverse responses to intubation, such as trauma to oral, pharyngeal, and laryngeal structures, and we assessed vocal cord view scores.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and trial registers (www.clinicaltrials.gov and www.controlledtrials) in November 2015. We reran the search in January 2017. We added new studies of potential interest to a list of 'Studies awaiting classification' and will incorporate them into formal review findings during the review update. We performed reference checking and citation searching and contacted the authors of unpublished data to ask for more information. We applied no language restrictions.

SELECTION CRITERIA

We included only randomized controlled trials. Participants were children aged 28 days to 18 years. Investigators performed intubations using any type of indirect laryngoscopes, or videolaryngoscopes, versus direct laryngoscopes.

DATA COLLECTION AND ANALYSIS

We used Cochrane standard methodological procedures. Two review authors independently reviewed titles, extracted data, and assessed risk of bias.

MAIN RESULTS

We included 12 studies (803 children) in this review and meta-analysis. We identified three studies that are awaiting classification and two ongoing studies.Trial results show that a longer intubation time was required when indirect laryngoscopy, or videolaryngoscopy, was used instead of direct laryngoscopy (12 trials; n = 798; mean difference (MD) 5.49 seconds, 95% confidence interval (CI) 1.37 to 9.60; I2 = 90%; very low-quality evidence). Researchers found no significant differences between direct and indirect laryngoscopy on assessment of success of the first attempt at intubation (11 trials; n = 749; risk ratio (RR) 0.96, 95% CI 0.91 to 1.02; I2 = 67%; low-quality evidence) and observed that unsuccessful intubation (five trials; n = 263) was significantly increased in the indirect laryngoscopy, or videolaryngoscopy, group (RR 4.93, 95% CI 1.33 to 18.31; I2 = 0%; low-quality evidence). Five studies reported the effect of intubation on oxygen saturation (n = 272; very low-quality evidence). Five children had desaturation during intubation: one from the direct laryngoscopy group and four from the indirect laryngoscopy, or videolaryngoscopy, group.Two studies (n = 100) reported other haemodynamic responses to intubation (very low-quality evidence). One study reported a significant increase in heart rate five minutes after intubation in the indirect laryngoscopy group (P = 0.007); the other study found that the heart rate change in the direct laryngoscopy group was significantly less than the heart rate change in the indirect laryngoscopy, or videolaryngoscopy, group (P < 0.001). A total of five studies (n = 244; very low-quality evidence) looked at evidence of trauma resulting from intubation. Investigators reported that only two children from the direct laryngoscopy group had trauma compared with no children in the indirect laryngoscopy, or videolaryngoscopy, group.Use of indirect laryngoscopy, or videolaryngoscopy, improved the percentage of glottic opening (five trials; n = 256). Studies noted no significant difference in Cormack and Lehane score (C&L) grade 1 (three trials; n = 190; RR 1.06, 95% CI 0.93 to 1.21; I2 = 59%).

AUTHORS' CONCLUSIONS

Evidence suggests that indirect laryngoscopy, or videolaryngoscopy, leads to prolonged intubation time with an increased rate of intubation failure when compared with direct laryngoscopy (very low-quality evidence due to imprecision, inconsistency, and study limitations). Review authors had difficulty reaching conclusions on adverse haemodynamic responses and other adverse effects of intubation, as only a few children were reported to have these outcomes. Use of indirect laryngoscopy, or videolaryngoscopy, might lead to improved vocal cord view, but marked heterogeneity between studies made it difficult for review authors to reach conclusions on this outcome.

A comparison of videolaryngoscopes for tracheal intubation in predicted difficult airway: a feasibility study

Background

Videolaryngoscopy has become increasingly attractive for the routine management of the difficult airway. Glidescope® is well studied in the literature while imago V-Blade® is a recent videolaryngoscope. This is a feasibility study with 1:1 case-control sequential allocation comparing Imago V-Blade ® and Glidescope® in predicted difficult airway settings.

Methods

Two senior anesthesiologists with no clinical experience in video assisted intubation but previously trained in a simulated scenario, performed the endotracheal intubations with Imago V-Blade® and Glidescope®. A third experienced anesthesiologist supervised the procedures. Forty-two patients, 21 for each group, with the presence of predicted difficult airway according to the Italian guideline were included. The primary end point is the feasibility of intubation. The secondary end-points are the success to intubate in the first attempt, the intubation time, the Cormack and Lehane score view, the comparison of the intubation difficulty scale (IDS) score and the need for maneuvers to aid the endotracheal intubation comparing Imago V-Blade® and Glidescope®.

Results

The intubation was achieved in 100% of cases in both groups. No differences were found in the first-attempt success rate (p = 0.383), intubation time (p = 0.280), Cormack and Lehane score view (p = 0.799) and IDS score (p = 0.252). Statistical differences were found in external laryngeal pressure (p = 0.005), advancement of the blade (p = 0.024) and use of increasing lifting force (p = 0.048).

Conclusions

This feasibility study showed that the intubation with the newly introduced Imago V-Blade® is feasible. Further randomized and/or non-inferiority trials are needed to evaluate the benefit of Imago V-Blade® in this procedure.

Trial registration

Clinicaltrials.gov NCT02897518. Retrospectively registered 25 August 2016

Use of the GlideScope video laryngoscope for intubation during ex utero intrapartum treatment in a fetus with a giant cyst of the 4th branchial cleft: A case report

INTRODUCTION

In fetuses who are predicted to be at risk of catastrophic airway obstruction at delivery, the ex utero intrapartum treatment (EXIT) procedure is useful for securing the fetal airway while maintaining fetal oxygenation via placental circulation. Factors, including poor posture of the fetus and physician, narrow visual field, and issues of contamination in the aseptic surgical field, make fetal intubation during the EXIT procedure difficult. Herein, we report our experience of the usefulness of the GlideScope video laryngoscope (GVL) for intubation during the EXIT procedure.

SYMPTOMS AND CLINICAL FINDINGS

A 28-year-old woman presented with a fetus having a cystic neck mass diagnosed on prenatal ultrasound at 25 weeks of gestation. We planned the EXIT procedure in conjunction with cesarean delivery at 38 weeks of gestation, as the mass enlarged to 4.9 cm × 3.2 cm, protruded externally at the neck, and subsequently resulted in polyhydramnios.

THERAPEUTIC INTERVENTION AND OUTCOMES

After induction of anesthesia using intravenous thiopental (300 mg), adequate uterine relaxation was achieved with sevoflurane (2.0-3.0 vol%) combined with continuous intravenous infusion of nitroglycerin (0.5-1.0 μg/kg/min) for maintaining uteroplacental circulation. After hysterotomy, the head and right upper limb of the fetus were partially delivered, and fetal heart tones were monitored with a sterile Doppler probe. After oropharyngeal suctioning to improve the visual field, the fetus was intubated successfully using a sterile GVL by an anesthesiologist, and the passage of the endotracheal tube beyond the vocal cords was confirmed on the screen of the GVL system. Immediately after the fetal airway was definitely secured, the fetus was fully delivered with umbilical cord clamping. After delivery, nitroglycerine administration was ceased and sevoflurane administration was reduced to 0.5 minimum alveolar concentration. Additionally, oxytocin (10 units) and carbetocin (100 μg) were administered for recovery of uterine contraction. Cesarean delivery was successfully performed without any problems, and the neonate successfully underwent surgery for removal of the neck mass under general anesthesia on the 7th day after delivery. The neonate is developing normally.

CONCLUSION

The GVL approach may be a useful noninvasive approach for establishing a clear fetal airway during the EXIT procedure.

Comparison Between Direct and Video-assisted Laryngoscopy for Intubations in a Pediatric Emergency Department

OBJECTIVES

The objective was to compare video-assisted laryngoscopy (VAL) to direct laryngoscopy (DL) on success rate and complication rate of intubations performed in a pediatric emergency department (ED).

METHODS

This is a retrospective cohort study of attempted intubations of children aged 0-18 years in a pediatric ED between 2004 and 2014 with first attempt by an ED provider. In VAL, the laryngoscopist attempts direct visualization of the glottis with a C-MAC video laryngoscope while the video monitor is used for real-time guidance by a supervisor, back-up visualization for the laryngoscopist should the direct view be inadequate, and confirmation of endotracheal tube passage through the vocal cords. We performed univariate comparisons of intubations using DL to intubations using VAL on rates of first-pass success, complications, and whether the patient was successfully intubated by an ED provider. We then created a logistic regression model to adjust for provider experience level, difficult airway characteristics, and indications for intubation to compare intubations using DL to intubations using VAL for each outcome.

RESULTS

We identified 452 endotracheal intubations of 422 unique patients, of which 445 intubations had a first attempt by an ED provider. Six intubations were excluded due to insufficient information available in the record. Of the included intubations, 240 (55%) were attempted with DL and 199 (45%) with VAL. The overall first-pass success rate was 71% in the DL group and 72% in the VAL group. After adjustment for covariates, the first-pass success rate was similar between laryngoscopy approaches (adjusted odds ratio = 1.23, 95% confidence interval = 0.78 to 1.94).

CONCLUSIONS

We found no difference between DL and VAL with regard to first-pass intubation success rate, complication rate, or rate of successful intubation by ED providers for children undergoing intubation in a pediatric ED.

Difficult endotracheal intubation secondary to tracheal deviation and stenosis in a patient with severe kyphoscoliosis: a case report

We report on a case of difficult endotracheal intubation in a patient with marked tracheal deviation at an angle of 90 degrees combined with stenosis due to kyphoscoliosis with vertebral body fusion. After induction of general anesthesia, a proper laryngeal view was easily obtained using a videolaryngoscope. But a tracheal tube could not be advanced more than 3 cm beyond the vocal cords due to resistance, despite various attempts, including the use of small size tubes, full rotation of the tube tip, and fiberoptic bronchoscopy. Ultimately, the airway was successfully secured by placing a tube tip above the area of resistance and by additionally packing saline-soaked gauzes around the tracheal inlet to minimize gas leakage and to fasten the tube in the trachea.

Assessment of TruviewPCD videolaryngoscope for intubation in children

OBJECTIVE

The aim of this observational prospective study was to evaluate the usefulness of TruviewPCD for tracheal intubation in clinical practice, and to provide data for future studies.

MATERIAL AND METHOD

A study was conducted on 86 consecutive children undergoing ear, nose and throat (ENT) or paediatric procedures under general anaesthesia with tracheal intubation. Children with two or more difficult airway criteria were excluded. A descriptive statistical analysis was performed.

RESULTS

Eighty-three patients were successfully intubated with TruviewPCD. Demographic data: Age 4.9 (2.8) years, weight 19.5 (7.7)kg. Seventy-nine children needed one attempt and four required two attempts at intubation. Time for glottis view and tracheal intubation was 10.8 (5.6) and 30 [27.9-37] seconds, respectively. Eighty-one patients were classified as easy or very easy to intubate, and only two cases were considered difficult. No significant complications were registered.

CONCLUSIONS

TruviewPCD is a good device for paediatric airway management. It would be interesting to have an intermediate blade between size 1 and 2, as the difference between both is too wide.

A comparison of the Truview PCD and the GlideScope Cobalt AVL video-laryngoscopes to the Miller blade for successfully intubating manikins simulating normal and difficult pediatric airways

BACKGROUND

Video-laryngoscopes provide better glottic visualization, but tracheal intubation times are longer, compared to conventional direct laryngoscopy in adult patients with normal airways. The objective of this randomized crossover study was to compare times to successful tracheal intubation with video-laryngoscope and direct laryngoscopy in manikins simulating infants with normal and abnormal airways.

METHODS

Thirty experienced pediatric anesthesia practitioners performed tracheal intubation in three distinct manikins simulating infants with (i) a normal airway (ii), an anterior larynx, and (iii) the Pierre Robin sequence anatomy. These were performed using a standard Miller #1 blade, the GlideScope Cobalt AVL, and the Truview PCD video-laryngoscope, first in a normal neck and then an unstable cervical spine scenario (18 intubations/subject). The specific assigned order of devices and manikins for each participant was based on a three by three Latin square design to minimize carryover effects between the model and the device. Predefined times to intubation were analyzed by Cox regression model and Kaplan-Meier survival curves.

RESULTS

Intubation times were shorter and success rates were higher with the Miller blade compared to either the GlideScope or the Truview videoscope in all three manikins in both scenarios, but did not differ between the GlideScope and the Truview devices. Improved intubation times and success rates in the unstable cervical spine scenario compared to the normal neck were attributed to learning effects with sequential intubation.

CONCLUSION

Higher success rates and shorter intubation times with the Miller blade compared to either video-laryngoscope may reflect greater experience with direct laryngoscopy, need for more video-laryngoscopy training, or result from the manikin design. Individual practitioners may differ in their preference of device for intubating a child with anticipated difficult airway based on their previous experiences, self-assessment of their skills, and evaluation of the child's airway anatomy.