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Effect of cervical spine immobilization technique on pediatric advanced airway management: a high-fidelity infant
Akira Nishisaki1, Louis Scrattish, John Boulet
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. nishisaki@email.chop.edu
Insights
Manual in-line immobilization is recommended for infant orotracheal intubation. This technique, unlike cervical collars or no protection, significantly reduces cervical spine extension and improves laryngeal visualization without increasing intubation time or complications.
Area of Science:
- Pediatric Emergency Medicine
- Anesthesiology
- Trauma Care
Background:
- Current guidelines advocate for cervical spine immobilization in infants with suspected traumatic injury during orotracheal intubation.
- The effectiveness of different immobilization techniques on intubation performance in infants remains a critical area of investigation.
Purpose of the Study:
- To evaluate the impact of various cervical spine immobilization techniques on orotracheal intubation performance in a high-fidelity infant simulator.
Main Methods:
- A randomized controlled study involving certified pediatric practitioners performing intubations on an infant simulator.
- Three techniques were assessed: no physical protection, manual in-line immobilization, and cervical collar (C-collar).
- Key metrics included time to intubation, cervical extension angle, and intubation-associated events.
Main Results:
- Manual in-line immobilization significantly reduced the maximal cervical extension angle compared to no protection or C-collar (P < 0.0001).
- Laryngeal visualization was more difficult with the C-collar technique (P < 0.001).
- No significant differences were observed in time to intubation, number of attempts, or intubation-associated events among the techniques.
Conclusions:
- Cervical spine immobilization technique significantly impacts cervical extension and laryngeal visualization in infant intubation simulations.
- Manual in-line immobilization aligns with Advanced Trauma Life Support recommendations for infant intubation.
- Despite intubation-associated events occurring in 33% of attempts, they were not influenced by the immobilization method.
Objective:
Current guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator.
Methods:
A randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded.
Results:
Twenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 +/- 12.2 seconds in no physical protection, 33.0 +/- 17.4 seconds in C-collar, and 33.0 +/- 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 +/- 2.56 degrees ) and C-collar (2.65 +/- 1.79 degrees ) were significantly greater compared with 0.85 +/- 1.05 degrees in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001).
Conclusions:
In this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.
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