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Warinton E, Ahmed Z. Comparing the effectiveness and safety of videolaryngoscopy and direct laryngoscopy for endotracheal intubation in the paediatric emergency department: a systematic review and meta-analysis. Front Med (Lausanne) 2024; 11:1373460. [PMID: 39364015 PMCID: PMC11446787 DOI: 10.3389/fmed.2024.1373460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 09/06/2024] [Indexed: 10/05/2024] Open
Abstract
Introduction Endotracheal intubation is an uncommon procedure for children in the emergency department but can be technically difficult and cause significant adverse effects. Videolaryngoscopy (VL) offers improved first-pass success rates over direct laryngoscopy (DL) for both adults and children undergoing elective surgery. This systematic review was designed to evaluate current evidence regarding how the effectiveness and safety of VL compares to DL for intubation of children in emergency departments. Methods Four databases (MEDLINE, Embase, CENTRAL and Web of Science) were searched on 11th May 2023 for studies comparing first-pass success of VL and DL for children undergoing intubation in the emergency department. Studies including adult patients or where intubation occurred outside of the emergency department were excluded. Quality assessment of included studies was carried out using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was undertaken for first-pass success and adverse event rate. Results Ten studies met the inclusion criteria representing 5,586 intubations. All included studies were observational. Significantly greater first-pass success rate was demonstrated with VL compared to DL (OR 1.64, 95% CI [1.21-2.21], p = 0.001). There was no significant difference in risk of adverse events between VL and DL (OR 0.79, 95% CI [0.52-1.20], p = 0.27). The overall risk of bias was moderate to serious for all included studies. Conclusion VL can offer improved first-pass success rates over DL for children intubated in the emergency department. However, the quality of current evidence is low and further randomised studies are required to clarify which patient groups may benefit most from use of VL. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=415039, Identifier CRD42023415039.
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Affiliation(s)
- Emma Warinton
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, United Kingdom
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research Queen Elizabeth Hospital, Birmingham, United Kingdom
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Khanam D, Schoenfeld E, Ginsberg-Peltz J, Lutfy-Clayton L, Schoenfeld DA, Spirko B, Brown CA, Nishisaki A. First-Pass Success of Intubations Using Video Versus Direct Laryngoscopy in Children With Limited Neck Mobility. Pediatr Emerg Care 2024; 40:454-458. [PMID: 37751531 DOI: 10.1097/pec.0000000000003058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE It is not clear whether video laryngoscopy (VL) is associated with a higher first-pass success rate in pediatric patients with limited neck mobility when compared with direct laryngoscopy (DL). We sought to determine the association between the laryngoscopy method and first-pass success. METHODS In this retrospective cohort study, we examined intubation data extracted from 2 prospectively collected, multicenter, airway management safety databases (National Emergency Airway Registry and the National Emergency Airway Registry for children), obtained during the years 2013-2018 in the emergency department. Intubations were included if patients were aged younger than 18 and had limited neck mobility. We compared first-pass success rates for ED intubations that were performed using VL versus DL. We built a structural causal model to account for potential confounders such as age, disease category (medical or trauma condition), other difficult airway characteristics, use of sedatives/paralytics, and laryngoscopist training level. We also analyzed adverse events as a secondary outcome. RESULTS Of 34,239 intubations (19,071 in the National Emergency Airway Registry and 15,168 in the National Emergency Airway Registry for children), a total of 341 intubations (1.0%) met inclusion criteria; 168 were performed via VL and 173 were performed via DL. The median age of patients was 124 months (interquartile range, 48-204). There was no difference in first-pass success between VL and DL (79.8% vs 75.7%, P = 0.44). Video laryngoscopy was not associated with higher first-pass success (odds ratio, 1.11; 95% confidence interval 0.84-1.47, with DL as a comparator) when a structural causal model was used to account for confounders. There was no difference in the adverse events between VL and DL groups (13.7% vs 8.7%, P = 0.19). CONCLUSION In children with limited neck mobility receiving tracheal intubation in the ED, neither VL nor DL was associated with a higher first-pass success rate.
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Affiliation(s)
- Dilruba Khanam
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Elizabeth Schoenfeld
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Julien Ginsberg-Peltz
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Lucienne Lutfy-Clayton
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | | | - Blake Spirko
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
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3
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Takeuchi R, Hoshijima H, Mihara T, Kokubu S, Sato (Boku) A, Nagumo T, Mieda T, Shiga T, Mizuta K. Comparison of Indirect and Direct Laryngoscopes in Pediatric Patients with a Difficult Airway: A Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2023; 11:60. [PMID: 38255373 PMCID: PMC10814718 DOI: 10.3390/children11010060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024]
Abstract
This meta-analysis was performed to determine whether an indirect laryngoscope is more advantageous than a direct laryngoscope for tracheal intubation in the setting of a difficult pediatric airway. Data on the intubation failure and intubation time during tracheal intubation were extracted from prospective and retrospective studies identified through a comprehensive literature search. Data from 10 individual articles (11 trials) were combined, and a DerSimonian and Laird random-effects model was used to calculate either the pooled relative risk (RR) or the weighted mean difference (WMD) and the corresponding 95% confidence interval (CI). Meta-analysis of the 10 articles indicated that the intubation failure of tracheal intubation with an indirect laryngoscope was not significantly different from that of a direct laryngoscope in patients with a difficult airway (RR 0.86, 95% CI 0.51-1.46; p = 0.59; Cochrane's Q = 50.5; I2 = 82%). Intubation time with an indirect laryngoscope was also similar to that with a direct laryngoscope (WMD 4.06 s; 95% CI -1.18-9.30; p = 0.13; Cochrane's Q 39.8; I2 = 85%). In conclusion, indirect laryngoscopes had the same intubation failure and intubation time as direct laryngoscopes in pediatric patients with a difficult airway. Currently, the benefits of indirect laryngoscopes have not been observed in the setting of a difficult pediatric airway.
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Affiliation(s)
- Risa Takeuchi
- Bunkoukai Special Needs Center, 2765-5 Ujiie, Sakura 329-1311, Tochigi, Japan; (R.T.); (K.M.)
| | - Hiroshi Hoshijima
- Division of Dento-Oral Anesthesiology, Graduate School of Dentistry, Tohoku University, 4-1 Seiryomachi, Aoba, Sendai 980-8575, Miyagi, Japan
| | - Takahiro Mihara
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama 236-0004, Kanagawa, Japan;
| | - Shinichi Kokubu
- Department of Anesthesiology, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsugagun 321-0293, Tochigi, Japan;
| | - Aiji Sato (Boku)
- Department of Anesthesiology, School of Dentistry, Aichi Gakuin University, 2-11 Suemori-dori, Chikusa-ku, Nagoya 465-8651, Aichi, Japan;
| | - Takumi Nagumo
- Department of Anesthesiology, Saitama Medical University Hospital, Irumagun 350-0495, Saitama, Japan; (T.N.); (T.M.)
| | - Tsutomu Mieda
- Department of Anesthesiology, Saitama Medical University Hospital, Irumagun 350-0495, Saitama, Japan; (T.N.); (T.M.)
| | - Toshiya Shiga
- Department of Anesthesiology and Pain Medicine, International University of Health and Welfare Ichikawa Hospital, 6-1-4 Kounodai, Ichikawa 272-0827, Chiba, Japan;
| | - Kentaro Mizuta
- Bunkoukai Special Needs Center, 2765-5 Ujiie, Sakura 329-1311, Tochigi, Japan; (R.T.); (K.M.)
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Pacheco GS, Leetch AN, Patanwala AE, Hurst NB, Mendelson JS, Sakles JC. The Pediatric Rigid Stylet Improves First-Pass Success Compared With the Standard Malleable Stylet and Tracheal Tube Introducer in a Simulated Pediatric Emergency Intubation. Pediatr Emerg Care 2023; 39:423-427. [PMID: 35876757 DOI: 10.1097/pec.0000000000002802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI. METHODS This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct. RESULTS Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm). CONCLUSIONS Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.
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Affiliation(s)
| | | | - Asad E Patanwala
- The University of Sydney School of Pharmacy Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Abstract
ABSTRACT Airway management is a fundamental component of care during resuscitation of critically ill and injured children. In addition to predicted anatomic and physiologic differences in children compared with adults, certain conditions can predict potential difficulty during pediatric airway management. This review presents approaches to identifying pediatric patients in whom airway management is more likely to be difficult, and discusses strategies to address such challenges. These strategies include optimization of effective bag-mask ventilation, alternative approaches to laryngoscopy, use of adjunct airway devices, modifications to rapid sequence intubation, and performance of surgical airways in children. The importance of considering systems of care in preparing for potentially difficult pediatric airways is also discussed.
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Affiliation(s)
- Kelsey A Miller
- From the Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Michael P Goldman
- Section of Pediatric Emergency Medicine, Yale New Haven Children's Hospital, Yale University School of Medicine, New Haven, CT
| | - Joshua Nagler
- From the Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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6
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Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand T, Goldman MP, Prieto MM, Wing R, Breuer R, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes. Ann Emerg Med 2023; 81:113-122. [PMID: 36253297 DOI: 10.1016/j.annemergmed.2022.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
| | | | - Andrew F Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Phillip M Thomas
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Tara Neubrand
- Department of Emergency Medicine - Pediatric Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, CT
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, RI
| | - Ryan Breuer
- Department of Pediatrics - Pediatric Critical Care, Oishei Children's Hospital, Buffalo, NY
| | - Jenn D'Mello
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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7
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Pacheco GS, Patanwala AE, Leetch AN, Mendelson JS, Hurst NB, Sakles JC. Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success. Pediatr Emerg Care 2022; 38:e1271-e1276. [PMID: 35482505 DOI: 10.1097/pec.0000000000002592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED. METHODS This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients. RESULTS Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77). CONCLUSIONS In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.
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Affiliation(s)
| | - Asad E Patanwala
- University of Sydney School of Pharmacy Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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8
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Capone CA, Emerson B, Sweberg T, Polikoff L, Turner DA, Adu‐Darko M, Li S, Glater‐Welt LB, Howell J, Brown CA, Donoghue A, Krawiec C, Shults J, Breuer R, Swain K, Shenoi A, Krishna AS, Al‐Subu A, Harwayne‐Gidansky I, Biagas KV, Kelly SP, Nuthall G, Panisello J, Napolitano N, Giuliano JS, Emeriaud G, Toedt‐Pingel I, Lee A, Page‐Goertz C, Kimura D, Kasagi M, D'Mello J, Parsons SJ, Mallory P, Gima M, Bysani GK, Motomura M, Tarquinio KM, Nett S, Ikeyama T, Shetty R, Sanders RC, Lee JH, Pinto M, Orioles A, Jung P, Shlomovich M, Nadkarni V, Nishisaki A. Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS). Acad Emerg Med 2022; 29:406-414. [PMID: 34923705 DOI: 10.1111/acem.14431] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/23/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. METHODS Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. RESULTS A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. CONCLUSIONS While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.
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Affiliation(s)
- Christine A. Capone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Beth Emerson
- Department of Pediatrics Yale University School of Medicine New Haven Connecticut USA
| | - Todd Sweberg
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Lee Polikoff
- Division of Critical Care Medicine, Department of Pediatrics The Warren Alpert Medical School of Brown University Providence Rhode Island USA
| | - David A. Turner
- Division of Pediatric Critical Care, Department of Pediatrics Duke Children's Hospital and Health Center Durham North Carolina USA
| | - Michelle Adu‐Darko
- Division of Pediatric Critical Care Medicine Department of Pediatrics University of Virginia Children's Hospital Charlottesville Virginia USA
| | - Simon Li
- Department of Pediatrics Robert Wood Johnson University New Brunswick New Jersey USA
| | - Lily B. Glater‐Welt
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Joy Howell
- Pediatric Critical Care Medicine Department of Pediatrics New York Presbyterian Hospital/Weill Cornell Medical Center New York New York USA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
| | - Aaron Donoghue
- Division of Emergency Medicine Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Penn State Health Children's Hospital Hershey Pennsylvania USA
| | - Justine Shults
- Division of Biostatistics Department of Biostatistics and Epidemiology University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Ryan Breuer
- Department of Pediatrics John R. Oishei Children's Hospital Buffalo New York USA
| | - Kelly Swain
- Pediatric and Cardiac Critical Care Duke University Medical Center Durham North Carolina USA
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Ashwin S. Krishna
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Awni Al‐Subu
- Division of Pediatric Critical Care Medicine Department of Pediatrics UW Health American Family Children's Hospital University of Wisconsin‐Madison Madison Wisconsin USA
| | - Ilana Harwayne‐Gidansky
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Katherine V. Biagas
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Serena P. Kelly
- Department of Pediatrics Oregon Health & Science University Doernbecher Children's Hospital Portland Oregon USA
| | - Gabrielle Nuthall
- Pediatric Critical Care Medicine Starship Children's Hospital Auckland New Zealand
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Natalie Napolitano
- Respiratory Care Department The Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - John S. Giuliano
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Guillaume Emeriaud
- Pediatric Critical Care Medicine CHU Sainte Justine Université de Montréal Montreal Quebec Canada
| | - Iris Toedt‐Pingel
- Division of Pediatric Critical Care University of Vermont Children's Hospital Burlington Vermont USA
| | - Anthony Lee
- Division of Critical Care Medicine Nationwide Children's Hospital Ohio State University College of Medicine Columbus Ohio USA
| | | | - Dai Kimura
- Department of Pediatrics University of Tennessee Health Science Center Le Bonheur Children's Hospital Memphis Tennessee USA
| | - Mioko Kasagi
- Pediatric Critical Care & Emergency Medicine Tokyo Metropolitan Children's Medical Center Tokyo Japan
| | - Jenn D'Mello
- Section of Pediatric Emergency Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Simon J. Parsons
- Section of Critical Care Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Palen Mallory
- Department of Pediatrics Duke University Durham North Carolina USA
| | - Masafumi Gima
- Critical Care Medicine National Center for Child Health and Development Tokyo Japan
| | | | - Makoto Motomura
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine Department of Pediatrics Emory University School of Medicine Children's Healthcare of Atlanta Egleston Georgia USA
| | - Sholeen Nett
- Section of Pediatric Critical Care Medicine Children's Hospital at Dartmouth, Dartmouth‐Hitchcock Medical Center Lebanon New Hampshire USA
| | - Takanari Ikeyama
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Rakshay Shetty
- Department of Pediatrics Rainbow Children's Hospital Bangalore India
| | - Ronald C. Sanders
- Section of Critical Care University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Jan Hau Lee
- Children's Intensive Care Unit KK Women's and Children's Hospital Singapore Singapore
| | - Matthew Pinto
- Pediatric Critical Care Medicine Maria Fareri Children's Hospital Valhalla New York USA
| | - Alberto Orioles
- Division of Critical Care Children's Hospitals and Clinics of Minnesota Minneapolis Minnesota USA
| | - Philipp Jung
- Paediatric Department University Hospital Schleswig‐Holstein Campus Lübeck Germany
| | - Mark Shlomovich
- Division of Pediatric Critical Care Medicine Albert Einstein College of Medicine Children's Hospital at Montefiore Bronx New York USA
| | - Vinay Nadkarni
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Akira Nishisaki
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
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9
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Frascone R, Delp C, Kolbet K, Pasquarella C, Pasquarella J, Dalrymple KA, Wewerka S. 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. Air Med J 2022; 41:243-247. [PMID: 35307151 DOI: 10.1016/j.amj.2021.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/29/2021] [Accepted: 10/30/2021] [Indexed: 11/28/2022]
Abstract
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.
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10
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Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative. Ann Emerg Med 2022; 79:333-343. [DOI: 10.1016/j.annemergmed.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/14/2021] [Accepted: 12/21/2021] [Indexed: 12/31/2022]
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11
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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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12
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Elonheimo L, Ljungqvist H, Harve‐Rytsälä H, Jäntti H, Nurmi J. Frequency, indications and success of out-of-hospital intubations in Finnish children. Acta Anaesthesiol Scand 2022; 66:125-131. [PMID: 34514584 DOI: 10.1111/aas.13980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Earlier studies have shown variable results regarding the success of paediatric emergency endotracheal intubation between different settings and operators. We aimed to describe the paediatric population intubated by physician-staffed helicopter emergency medical service (HEMS) and evaluate the factors associated with overall and first-pass success (FPS). METHODS We conducted a retrospective observational cohort study in Finland including all children less than 16 years old who required endotracheal intubation by a HEMS physician from January 2014 to August 2019. Utilising a national HEMS database, we analysed the incidence, indications, overall and first-pass success rates of endotracheal intubation. RESULTS A total of 2731 children were encountered by HEMS, and intubation was attempted in 245 (9%); of these, 22 were younger than 1 year, 103 were aged 1-5 years and 120 were aged 6-15 years. The most common indications for airway management were cardiac arrest for the youngest age group, neurological reasons (e.g., seizures) for those aged 1-5 years and trauma for those aged 6-15. The HEMS physicians had an overall success rate of 100% (95% CI: 98-100) and an FPS rate of 86% (95% CI: 82-90). The FPS rate was lower in the youngest age group (p = .002) and for patients in cardiac arrest (p < .001). CONCLUSIONS Emergency endotracheal intubation of children is successfully performed by a physician staffed HEMS unit even though these procedures are rare. To improve the care, emphasis should be on airway management of infants and patients in cardiac arrest.
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Affiliation(s)
- Lauri Elonheimo
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
| | | | - Heini Harve‐Rytsälä
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
| | - Helena Jäntti
- Center for Prehospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - Jouni Nurmi
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
- FinnHEMS Research and Development Unit Vantaa Finland
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13
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Dean P, Edmunds K, Shah A, Frey M, Zhang Y, Boyd S, Kerrey BT. Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department. Ann Emerg Med 2021; 79:323-332. [PMID: 34952729 DOI: 10.1016/j.annemergmed.2021.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance. METHODS We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model. RESULTS From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90). CONCLUSION We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.
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Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, San Diego, CA
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yin Zhang
- Division of Emergency Medicine, and the Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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14
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Pacheco GS, Patanwala AE, Mendelson JS, Sakles JC. Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period. Pediatr Emerg Care 2021; 37:e1098-e1103. [PMID: 31503130 DOI: 10.1097/pec.0000000000001911] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Garrett S Pacheco
- From the Departments of Emergency Medicine and Pediatrics, University of Arizona College of Medicine, Banner University Medical Center Tucson, Tucson, AZ
| | - Asad E Patanwala
- The University of Sydney School of Pharmacy|Royal Prince Alfred Hospital, 1Faculty of Medicine and Health|The University of Sydney|NSW, Sydney, Australia
| | | | - John C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ
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15
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Miller KA, Eisenberg MA, Abid ES, Nagler J. Use of the C-MAC Macintosh 0 Blade for Intubation of Infants in the Emergency Department. Pediatr Emerg Care 2021; 37:e404-e405. [PMID: 30422949 DOI: 10.1097/pec.0000000000001665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT First-pass success rates during intubation of infants in the emergency department have been shown to be low. Video laryngoscopy is being increasingly used during advanced airway management in the emergency department, but available data have not supported improved outcomes with use in pediatrics. The newly available Macintosh size 0 (curved) blade for the C-MAC video laryngoscope offers a narrower blade for use in infants. We describe the use of the new C-MAC Macintosh 0 blade for intubation of 2 infants with apnea secondary to respiratory syncytial virus bronchiolitis. The included video recording demonstrates the favorable glottic view and improved maneuverability offered by the narrower blade but also highlights the limitation in use beyond young infants given the short blade length.
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Affiliation(s)
- Kelsey A Miller
- From the Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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16
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Anil AB, Anil M, Durak F, Altuğ Ü, Özçifçi G, Yalçın G, Demir Ş. Comparison of direct and video laryngoscope endotracheal intubations by pediatric residents: A study of a child model with normal airway. Turk Arch Pediatr 2021; 56:224-229. [PMID: 34104913 DOI: 10.5152/turkarchpediatr.2021.20074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/22/2020] [Indexed: 11/22/2022]
Abstract
Objective This study aimed to compare the efficacy of direct and videolaryngoscopy procedures performed by pediatric residents who had limited experience of direct endotracheal intubation and had not previously used video laryngoscopes in a normal airway child manikin. Material and Methods The endotracheal intubations performed by pediatric residents with a direct laryngoscope and Storz C-MAC videolaryngoscope on a pediatric manikin with a normal airway were compared. Theoretical and practical training was given before the study. In the first attempt, the success of the intubation procedure, glottis visual duration, and endotracheal tube insertion time were determined. Practitioners grouped the glottis image between 1-4 according to the Cormack-Lehane Staging (Stage 1 ideal image). After the intervention, the participants scored one to ten points on direct and videolaryngoscopy (1 not useful, 10 very useful). Results The success of direct and videolaryngoscopy of 51 pediatric residents on the same manikin was 48 out of 51 (94%) for each method (P> 0.05). Glottis visual duration was similar in both methods (P>0.05); tube insertion and total intubation time were shorter in the video laryngoscope group (P<0.05); glottis image was better in the video laryngoscope group according to Cormack-Lehane Classification (P<0.05). Participants' rating was higher on videolaryngoscope (P<0.05). Conclusion Users with limited endotracheal intubation experience use Video laryncoscope more effectively than direct laryngoscope in children with normal airway model after training.
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Affiliation(s)
- Ayşe Berna Anil
- Department of Pediatric Intensive Care Unit, İzmir Katip Çelebi University, School of Medicine, İzmir,Turkey
| | - Murat Anil
- Pediatric Emergency Clinic, University of Health Sciences Tepecik Training and Research Hospital Izmir, Turkey
| | - Fatih Durak
- Pediatric Intensive Care Clinic, University of Health Sciences, Tepecik Training and Research Hospital İzmir, Turkey
| | - Ümüt Altuğ
- Pediatric Intensive Care Clinic, University of Health Sciences, Tepecik Training and Research Hospital İzmir, Turkey
| | - Gökçen Özçifçi
- Pediatric Intensive Care Clinic, University of Health Sciences, Tepecik Training and Research Hospital İzmir, Turkey
| | - Gülşen Yalçın
- Pediatric Emergency Clinic, University of Health Sciences Tepecik Training and Research Hospital Izmir, Turkey
| | - Şule Demir
- Pediatric Emergency Clinic, University of Health Sciences Tepecik Training and Research Hospital Izmir, Turkey
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17
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Terheggen U, Heiring C, Kjellberg M, Hegardt F, Kneyber M, Gente M, Roehr CC, Jourdain G, Tissieres P, Ramnarayan P, Breindahl M, van den Berg J. European consensus recommendations for neonatal and paediatric retrievals of positive or suspected COVID-19 patients. Pediatr Res 2021; 89:1094-1100. [PMID: 32634819 DOI: 10.1038/s41390-020-1050-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The 2020 novel coronavirus (SARS-Cov-2) pandemic necessitates tailored recommendations addressing specific procedures for neonatal and paediatric transport of suspected or positive COVID-19 patients. The aim of this consensus statement is to define guidelines for safe clinical care for children needing inter-facility transport while making sure that the clinical teams involved are sufficiently protected from SARS-CoV-2. METHODS A taskforce, composed of members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Transport section and the European Society for Paediatric Research (ESPR), reviewed the published literature and used a rapid, two-step modified Delphi process to formulate recommendations regarding safety and clinical management during transport of COVID-19 patients. RESULTS The joint taskforce consisted of a panel of 12 experts who reached an agreement on a set of 17 recommendations specifying pertinent aspects on neonatal and paediatric COVID-19 patient transport. These included: case definition, personal protective equipment, airway management, equipment and strategies for invasive and non-invasive ventilation, special considerations for incubator and open stretcher transports, parents on transport and decontamination of transport vehicles. CONCLUSIONS Our consensus recommendations aim to define current best-practice and should help guide transport teams dealing with infants and children with COVID-19 to work safely and effectively. IMPACT We present European consensus recommendations on pertinent measures for transporting infants and children in times of the coronavirus (SARS-Cov-2 /COVID-19) pandemic. A panel of experts reviewed the evidence around transporting infants and children with proven or suspected COVID-19. Specific guidance on aspects of personal protective equipment, airway management and considerations for incubator and open stretcher transports is presented. Based on scant evidence, best-practice recommendations for neonatal and paediatric transport teams are presented, aiming for the protection of teams and patients. We highlight gaps in knowledge and areas of future research.
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Affiliation(s)
- Ulrich Terheggen
- Department of Critical Care, Paediatric and Cardiac Intensive Care Unit, Al Jalila Children's Hospital, Dubai, United Arab Emirates.
| | - Christian Heiring
- Department of Neonatal and Paediatric Intensive Care, Rigshospitalet, the National University Hospital in Denmark, Copenhagen, Denmark
| | - Mattias Kjellberg
- Department of Neonatal Intensive Care, Uppsala University Children's Hospital, Uppsala, Sweden
| | - Fredrik Hegardt
- Department of Pediatrics, Neonatal Intensive Care Unit, Umeå University Hospital, Umeå, Sweden
| | - Martin Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University, Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Maurizio Gente
- Maternal Infant Department, Policlinico Umberto I, Sapienza University of Roma, Roma, Italy
| | - Charles C Roehr
- National Perinatal Epidemiology Unit Clinical Trials Unit, Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK.,Newborn Services, Women's Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Gilles Jourdain
- Division of Pediatrics, Neonatal Critical Care and Transportation, Medical Center "A.Béclère", Paris Saclay University Hospitals, APHP, Paris, France
| | - Pierre Tissieres
- Pediatric Intensive Care Unit, Bicêtre University Hospital, AP-HP, Paris Saclay University, Le Kremlin-Bicêtre, France.,Integrative Biology of the Cell, CNRS, CEA, Paris South University, Paris Saclay University, Gif-sur-Yvette, France
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service (CATS), Great Ormond Street Hospital, London, UK.,Paediatric Intensive Care Unit, St Mary's Hospital, London, UK
| | - Morten Breindahl
- Department of Neonatal and Paediatric Intensive Care, Rigshospitalet, the National University Hospital in Denmark, Copenhagen, Denmark
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18
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Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
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Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
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Miller KA, Monuteaux MC, Nagler J. Technical factors associated with first-pass success during endotracheal intubation in children: analysis of videolaryngoscopy recordings. Emerg Med J 2020; 38:125-131. [PMID: 33172879 DOI: 10.1136/emermed-2020-209700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/16/2020] [Accepted: 10/04/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND First-pass success (FPS) during intubation is associated with lower morbidity for paediatric patients. Using videolaryngoscopy (VL) recordings, we reviewed technical aspects of intubation, including factors associated with FPS in children. METHODS We performed a retrospective study of intubation attempts performed using video-assisted laryngoscopy in a paediatric ED between January 2014 and December 2018. Data were abstracted from a quality assurance database, the electronic medical record and VL recordings. Our primary outcome was FPS. Intubation practices were analysed using descriptive statistics. Patient and procedural characteristics associated with FPS in univariate testing and clinical factors identified from the literature were included as covariates in a multivariable logistic regression. An exploratory analysis examined the relationship between position of the glottic opening on the video screen and FPS. RESULTS Intubation was performed during 237 patient encounters, with 231 using video-assisted laryngoscopy. Data from complete video recordings were available for 129 attempts (59%); an additional 31 (13%) had partial recordings. Overall, 173 (73%) of first attempts were successful. Adjusting for patient age, placing the blade tip into the vallecula adjusted OR ((aOR) 7.2 (95% CI 1.7 to 30.1)) and obtaining a grade 1 or 2a-modified Cormack-Lehane glottic view on the videolaryngoscope screen (aOR 6.1 (95% CI 1.5 to 25.7) relative to grade 2b) were associated with increased FPS in the subset of patients with complete recordings. Exploratory analysis suggested that FPS is highest (81%) and duration is shortest when the glottic opening is located in the second quintile of the video screen. CONCLUSIONS Placement of the blade tip into the vallecula regardless of blade type, sufficient glottic visualisation and locating the glottic opening within the second quintile of the video screen were associated with FPS using video-assisted laryngoscopy in the paediatric ED.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Direct laryngoscopy assisted fiberoptic intubation: A novel technique for the pediatric airway. Int J Pediatr Otorhinolaryngol 2020; 137:110232. [PMID: 32896347 DOI: 10.1016/j.ijporl.2020.110232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To introduce a novel intubation technique for difficult pediatric airways. METHODS This two-provider technique requires a direct laryngoscope and a flexible fiberoptic laryngoscope. One provider performs direct laryngoscopy which allows for introduction of the flexible laryngoscope. The second provider inserts the flexible laryngoscope with the endotracheal tube loaded, through the oropharynx in to the subglottis. RESULTS We report three pediatric patients that were initially unable to be intubated by conventional methods. We were ultimately able to successfully intubate these patients with difficult airways using our novel technique. CONCLUSIONS We found that this technique of direct laryngoscopy assisted flexible fiberoptic intubation is a useful adjunct in select pediatric difficult airway patients.
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Couto TB, Reis AG, Farhat SCL, Carvalho VEDL, Schvartsman C. Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department. Medicine (Baltimore) 2020; 99:e22289. [PMID: 32957386 PMCID: PMC7505323 DOI: 10.1097/md.0000000000022289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to compare the success of first-attempt tracheal intubation in pediatric patients >1-year old performed using video versus direct laryngoscopy and compare the frequency of tracheal intubation-associated events and desaturation among these patients.Prospective observational cohort study conducted in an Academic pediatric tertiary emergency department. We compared 50 children intubated with Mcgrath Mac video laryngoscope (VL group) and an historical series of 141 children intubated with direct laryngoscopy (DL group). All patients were aged 1 to 18 years.The first attempt success rates were 68% (34/50) and 37.6% (53/141) in the VL and DL groups (P < .01), respectively. There was a lower proportion of tracheal intubation-associated events in the VL group (VL, 31.3% [15/50] vs DL, 67.8% [97/141]; P < .01) and no significant differences in desaturation (VL, 35% [14/50] vs DL 51.8% [72/141]; P = .06). The median number of attempts was 1 (range, 1-5) for the VL group and 2 (range, 1-8) for the DL group (P < .01). Multivariate logistic regression showed that video laryngoscope use was associated with higher chances of first-attempt intubation with an odds ratio of 4.5 (95% confidence interval, 1.9-10.4, P < 0.01).Compared with direct laryngoscopy, VL was associated with higher success rates of first-attempt tracheal intubations and lower rates of tracheal intubation-associated events.
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Abid ES, McNamara J, Hall P, Miller KA, Monuteaux M, Kleinman ME, Nagler J. The Impact of Videolaryngoscopy on Endotracheal Intubation Success by a Pediatric/Neonatal Critical Care Transport Team. PREHOSP EMERG CARE 2020; 25:325-332. [PMID: 32347776 DOI: 10.1080/10903127.2020.1761492] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Endotracheal intubation may be required for the transport of critically ill neonates and children. Data suggest that first pass success (FPS) is associated with lower rates of complications. Thus, understanding factors associated with FPS can have important implications for clinical outcomes. We aimed to determine the impact of videolaryngoscopy (VL) on FPS by a pediatric critical care transport team (CCTT). Methods: We performed a retrospective cross-sectional study on pediatric patients (≤ 18 years of age) requiring endotracheal intubation by a tertiary care-based pediatric CCTT between 2011 and 2019. Patients were categorized as neonatal (≤ 28 days of age, either preterm or term) or pediatric (> 28 days of age). All intubation attempts using VL were performed with the C-MAC videolaryngoscope. Our primary outcome was rate of FPS. Descriptive statistics of patient, provider, and procedure characteristics were calculated. Multivariate regression was used to test the association between FPS and type of laryngoscope (video versus direct) adjusting for significant clinical predictors. Results: Over the study period, 135 patients were intubated by the CCTT. Sixty percent of these patients were neonates, and 40% were pediatric. The overall FPS rate was 61%, with lower rates in neonates (54%) and higher rates in pediatric patients (70%). Use of videolaryngoscopy increased over the study period. First pass success rate using the C-MAC videolaryngoscope was 72% compared to 42% for direct laryngoscopy across the whole study population. In adjusted analyses, FPS using VL was significantly higher in the pediatric patient population (aOR 12.42 [95%CI 3.33, 46.29]), but not in neonates (aOR 1.08 [0.44, 2.63]). Use of VL increased significantly over the study period. Conclusion: We found use of a C-MAC videolaryngoscope by a critical care transport team was associated with improved FPS during endotracheal intubation of pediatric patients but not neonates, after controlling for other patient and provider characteristics. In addition to the impact on FPS, use of VL may offer additional educational and quality benefits.
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Kaji AH, Shover C, Lee J, Yee L, Pallin DJ, April MD, Carlson JN, Fantegrossi A, Brown CA. Video Versus Direct and Augmented Direct Laryngoscopy in Pediatric Tracheal Intubations. Acad Emerg Med 2020; 27:394-402. [PMID: 31617640 DOI: 10.1111/acem.13869] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/25/2019] [Accepted: 10/13/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES With respect to first-attempt intubation success, the pediatric literature demonstrates either clinical equipoise or superiority of direct laryngoscopy (DL) when compared to video laryngoscopy (VL). Furthermore, it is unknown how VL compares to DL, when DL is "augmented" by maneuvers, such as optimal external laryngeal manipulation (OELM), upright or ramped positioning, or the use of the bougie. The objective of our study was to compare first-attempt success between VL and all DL, including "augmented DL" for pediatric intubations. METHODS We analyzed the National Emergency Airway Registry database of intubations of patients < 16 years. Variables collected included patient demographics, body habitus, impression of airway difficulty, intubating position, reduced neck mobility, airway characteristics, device, medications, and operator characteristics, adjusted for clustering by center. Primary outcome was the difference in first-attempt success for DL and augmented DL versus VL. Secondary outcomes included adverse events. In a planned sensitivity analysis, a propensity-adjusted analysis for first-attempt success and a subgroup analysis of children < 2 years was also performed. RESULTS Of 625 analyzable pediatric encounters, 294 (47.0%, 95% confidence interval [CI] = 25.1% to 69.0%) were DL; 332 (53.1%, 95% CI = 31.0% to 74.9%) were VL. Median age was 4 years (interquartile range = 1 to 10 years); 225 (36.0%, 95% CI = 30.8% to 41.2%) were < 2 years. Overall first-pass success was 79.6% (95% CI = 74.1% to 84.9%). VL first-pass success was 278/331 (84.0%) versus 219/294 for DL (74.5%), adjusted for clustering (odds ratio [OR] = 1.7, 95% CI = 1.3 to 2.5). Multivariable regression showed that VL yielded a higher odds of first-attempt success than DL augmented by OELM or use of a bougie (adjusted OR = 5.5, 95% CI = 1.7 to 18.1). Propensity-adjusted analyses supported the main results. Subgroup analysis of age < 2 years also demonstrated VL superiority (OR = 2.0, 95% CI = 1.1 to 3.3) compared with DL. Adverse events were comparable in both univariate and multivariable analysis. CONCLUSIONS When compared to DL, VL was associated with higher first-pass success in this pediatric population, even in the subgroup of patients < 2 years, as well as when DL was augmented. There were no differences in adverse effects between DL and VL.
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Affiliation(s)
- Amy H. Kaji
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Carolyn Shover
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Jennifer Lee
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Lisa Yee
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston MA
| | - Michael D. April
- Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium (SAUSHEC) Fort Sam Houston TX
| | - Jestin N. Carlson
- Department of Emergency Medicine St. Vincent Hospital Allegheny Health Network Erie PA
| | - Andrea Fantegrossi
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston MA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston MA
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A randomized trial of the glottic views with the classic Miller, Wis-Hipple and C-MAC (videolaryngoscope and direct views) straight size 1 blades in young children. J Clin Anesth 2020; 60:57-61. [DOI: 10.1016/j.jclinane.2019.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 11/17/2022]
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Ramgopal S, Button SE, Owusu-Ansah S, Manole MD, Saladino RA, Guyette FX, Martin-Gill C. Success of Pediatric Intubations Performed by a Critical Care Transport Service. PREHOSP EMERG CARE 2020; 24:683-692. [PMID: 31800336 DOI: 10.1080/10903127.2019.1699212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel.Methods: We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation.Results: 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).Conclusion: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.
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26
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Medizinische Ausrüstung zur Versorgung von Kindernotfällen im Rettungsdienst. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0559-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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O'Connell KJ, Yang S, Cheng M, Sandler AB, Cochrane NH, Yang J, Webman RB, Marsic I, Burd R. Process conformance is associated with successful first intubation attempt and lower odds of adverse events in a paediatric emergency setting. Emerg Med J 2019; 36:520-528. [PMID: 31320332 DOI: 10.1136/emermed-2018-208133] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 06/20/2019] [Accepted: 06/23/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. METHODS An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence. RESULTS We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99). CONCLUSIONS Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.
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Affiliation(s)
- Karen J O'Connell
- Department of Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - Sen Yang
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, New Jersey, USA
| | - Megan Cheng
- Division of Trauma and Burn Surgery, Children's National Health System, Washington, District of Columbia, USA
| | - Alexis B Sandler
- Department of Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - Niall H Cochrane
- Department of Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
| | - JaeWon Yang
- Division of Trauma and Burn Surgery, Children's National Health System, Washington, District of Columbia, USA
| | - Rachel B Webman
- Division of Trauma and Burn Surgery, Children's National Health System, Washington, District of Columbia, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, New Jersey, USA
| | - Randall Burd
- Division of Trauma and Burn Surgery, Children's National Health System, Washington, District of Columbia, USA
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Abstract
Airway management is the cornerstone to resuscitation efforts for many critically ill pediatric patients presenting for emergency care. Pediatric endotracheal intubation is uncommon in emergency medicine, making it challenging to maintain comfort with this critical procedure. This article offers strategies to facilitate pediatric airway management by addressing predictable anatomic and physiologic differences in children. Also reviewed are alternative approaches to airway management (eg, noninvasive ventilation and videolaryngoscopy) that might be used in cases of recognized difficult airways. Finally, recommendations for maintaining procedural skills in providers who may have limited clinical exposure to critically ill children requiring airway interventions are provided.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Monette DL, Brown CA, Benoit JL, McMullan JT, Carleton SC, Steuerwald MT, Eyre A, Pallin DJ. The Impact of Video Laryngoscopy on the Clinical Learning Environment of Emergency Medicine Residents: A Report of 14,313 Intubations. AEM EDUCATION AND TRAINING 2019; 3:156-162. [PMID: 31008427 PMCID: PMC6457358 DOI: 10.1002/aet2.10316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/05/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND The introduction of video laryngoscopy (VL) may impact emergency medicine (EM) residents' intubation practices. METHODS We analyzed 14,313 intubations from 11 EM training sites, July 1, 2002, to December 31, 2012, assessing the likelihood of first-attempt success and likelihood of having a second attempt, by rank and device. We determined whether direct laryngoscopy (DL) first-attempt success decreased as VL became more prevalent using a logistic regression model with proportion of encounters initiated with VL at that center in the prior 90 and 365 days as predictors of DL first-attempt success. RESULTS First-attempt success by PGY-1s was 71% (95% confidence interval [CI] = 63% to 78%); PGY-2s, 82% (95% CI = 78% to 86%); and PGY-3+, 89% (95% CI = 85% to 92%). Residents' first-attempt success rate was higher with the C-MAC video laryngoscope (C-MAC) versus DL, 92% versus 84% (risk difference [RD] = 8%, 95% CI = 4% to 11%), but there was no statistical difference between the GlideScope video laryngoscope (GVL) and DL, 80% versus 84% (RD = -4%, 95% CI = -10% to 1%). PGY-1s were more likely to have a second intubation attempt after first-attempt failure with VL versus DL: 32% versus 18% (RD = 14%, 95% CI = 5% to 23%). DL first-attempt success rates did not decrease as VL became more prevalent. CONCLUSIONS First-attempt success increases with training. Interns are more likely to have a second attempt when using VL. The C-MAC may be associated with increased first-attempt success for EM residents compared with DL or GVL. The increasing prevalence of VL is not accompanied by a decrease in DL success.
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Affiliation(s)
- Derek L. Monette
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
- Departments of Emergency MedicineMassachusetts General Hospital and Harvard Medical SchoolBostonMA
| | - Calvin A. Brown
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Justin L. Benoit
- Department of Emergency MedicineUniversity of CincinnatiCincinnatiOH
| | - Jason T. McMullan
- Department of Emergency MedicineUniversity of CincinnatiCincinnatiOH
| | | | | | - Andrew Eyre
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
| | - Daniel J. Pallin
- Departments of Emergency MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMA
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Comparison of blind intubation with different supraglottic airway devices by inexperienced physicians in several airway scenarios: a manikin study. Eur J Pediatr 2019; 178:871-882. [PMID: 30903306 PMCID: PMC6511343 DOI: 10.1007/s00431-019-03345-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 02/09/2019] [Accepted: 02/12/2019] [Indexed: 10/31/2022]
Abstract
Endotracheal intubation is the gold standard for airway management. Supraglottic airway devices (SADs) are useful in airway abnormalities. SAD blind intubation enables airway management with better ventilation and a reduced risk of gastric content aspiration. The aim was to compare various SADs in blind intubation performed by inexperienced physicians in several pediatric airway scenarios. One hundred sixteen physicians with no previous experience with SAD performed blind endotracheal intubations with (1) iGEL, (2) Air-Q intubating laryngeal airway, and (3) Ambu AuraGain disposable laryngeal mask in a pediatric manikin in three airway scenarios: (A) normal airway without chest compressions, (B) normal airway with continuous chest compressions with the CORPULS CPR system, and (C) difficult airway with continuous chest compressions with the CORPULS CPR system. Intubation tube with 5.0 internal diameter was used for all blind intubation attempts. First intubation success rate, median time to SAD placement, time to endotracheal intubation with SAD, and ease to perform the intubation were investigated in this study. All these parameters were better or non-inferior for iGEL in all investigated scenarios.Conclusion: Our manikin study demonstrated that iGEL was the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios. What is Known: • For pediatric resuscitation, bag-mask ventilation is the first-line method for airway control and ventilation. • Endotracheal intubation is considered by many scientific societies the gold standard for airway management. • Supraglottic airway devices are particularly useful when bag-mask ventilation is difficult or impossible but can be also used for blind intubation. What is New: • The iGEL laryngeal mask turns out the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios. • It may be a reasonable first emergency blind intubation technique for inexperienced physicians in pediatric patients in normal airway with and without continuous chest compressions, as well as in difficult airway with continuous chest compressions.
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Comparison of Miller laryngoscope and UEScope videolaryngoscope for endotracheal intubation in four pediatric airway scenarios: a randomized, crossover simulation trial. Eur J Pediatr 2019; 178:937-945. [PMID: 30976922 PMCID: PMC6511341 DOI: 10.1007/s00431-019-03375-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 03/21/2019] [Accepted: 03/26/2019] [Indexed: 12/19/2022]
Abstract
With different videolaryngoscopes for pediatric patients available, UEScope can be used in all age groups. The aim of this study was to compare the Miller laryngoscope and UEScope in pediatric intubation by paramedics in different scenarios. Overall, 93 paramedics with no experience in pediatric intubation or videolaryngoscopy performed endotracheal intubation in scenarios: (A) normal airway without chest compressions, (B) difficult airway without chest compressions, (C) normal airway with uninterrupted chest compressions, (D) difficult airway with uninterrupted chest compressions. Scenario A. Total intubation success with both laryngoscopes: 100%. First-attempt success: 100% for UEScope, 96.8% for Miller. Median intubation time for UEScope: 13 s [IQR, 12.5-17], statistically significantly lower than for Miller: 14 s [IQR, 12-19.5] (p = 0.044). Scenario B. Total efficacy: 81.7% for Miller, 100% for UEScope (p = 0.012). First-attempt success: 48.4% for Miller, 87.1% for UEScope (p = 0.001). Median intubation time: 27 s [IQR, 21-33] with Miller, 15 s [IQR, 14-21] with UEScope (p = 0.001). Scenario C. Total efficiency: 91.4% with Miller, 100% with UEScope (p = 0.018); first-attempt success: 67.7 vs. 90.3% (p = 0.003), respectively. Intubation time: 21 s [IQR, 18-28] for Miller, 15 s [IQR, 12-19.5] for UEScope. Scenario D. Total efficiency: 65.6% with Miller, 98.9% with UEScope (p < 0.001); first-attempt success: 29.1 vs. 72% (p = 0.001), respectively. Intubation time: 38 s [IQR, 23-46] for Miller, 21 s [IQR, 17-25.5] for UEScope.Conclusion: In pediatric normal airway without chest compressions, UEScope is comparable with Miller. In difficult pediatric airways without chest compressions, UEScope offers better first-attempt success, shorted median intubation time, and improved glottic visualization. With uninterrupted chest compressions in normal or difficult airway, UEScope provides a higher first-attempt success, a shorter median intubation time, and a better glottic visualization than Miller laryngoscope. What is Known: • Endotracheal intubation is the gold standard for adult and children airway management. • More than two direct laryngoscopy attempts in children with difficult airways are associated with a high failure rate and increased incidence of severe complications. What is New: • In difficult pediatric airways with or without chest compressions, UEScope in inexperienced providers in simulated settings provides better first-attempt efficiency, median intubation time, and glottic visualization.
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Louie MC, Chang TP, Grundmeier RW. Recent Advances in Technology and Its Applications to Pediatric Emergency Care. Pediatr Clin North Am 2018; 65:1229-1246. [PMID: 30446059 DOI: 10.1016/j.pcl.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Advances in technology are continuously transforming medical care, including pediatric emergency medicine. The increasing adoption of point-of-care ultrasound examination can improve timely diagnoses without radiation and aids the performance of common procedures. The recent dramatic increase in electronic health record adoption offers an opportunity for enhanced clinical decision-making support. Simulation training and advances in technologies can provide continued proficiency training despite decreasing opportunities for pediatric procedures and cardiorespiratory resuscitation performance. This article reviews these and other recent advances in technology that have had the greatest impact on the current practice of pediatric emergency medicine.
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Affiliation(s)
- Marisa C Louie
- Department of Emergency Medicine, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA; Department of Pediatrics, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA.
| | - Todd P Chang
- Pediatric Emergency Medicine, Keck School of Medicine at University of Southern California, Children's Hospital Los Angeles, 4650 Sunset Boulevard Mailstop 113, Los Angeles, CA 90027, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Roberts Center, 2716 South Street, 15th Floor, Philadelphia, PA 19146, USA
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Xue FS, Liu YY, Li HX, Yang GZ. Paediatric video laryngoscopy and airway management: What's the clinical evidence? Anaesth Crit Care Pain Med 2018; 37:459-466. [DOI: 10.1016/j.accpm.2017.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 12/20/2022]
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Video Laryngoscopy: What We Can See and What We Cannot. Pediatr Crit Care Med 2017; 18:491-492. [PMID: 28475534 DOI: 10.1097/pcc.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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