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Using Video-recorded Laryngoscopy to Evaluate Laryngoscopic Blade Approach and Adverse Events in Children
Israel Green-Hopkins1, Heidi Werner2, Michael C Monuteaux1
1Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
Objectives:
Using recordings of endotracheal intubation attempts obtained with a video-enabled laryngoscope with Miller and Macintosh blades, the authors sought to evaluate the association between laryngoscopic approach (right-sided vs. midline) and intubation success, as well as adverse event rates in the pediatric emergency department (ED).
Methods:
This was a retrospective cohort study of children younger than 21 years who underwent endotracheal intubation with a C-MAC video laryngoscope in a tertiary care ED between August 2009 and May 2013. The primary outcome was successful endotracheal intubation on the first attempt. The secondary outcomes included time to intubation, video-recorded adverse events (oropharyngeal mucosal injury and aspiration), and physiologic adverse events. Multivariate regression models were used to determine the relationship between laryngoscope blade position and outcome measures adjusted for patient and provider factors.
Results:
The cohort consisted of complete video recordings for 105 of 143 (73%) patient encounters with intubations. The first-pass success rate did not significantly differ based on laryngoscopic approach (adjusted odds ratio [aOR] = 0.76, 95% confidence interval [CI] = 0.29 to 2.0). Among patients successfully intubated on the first attempt, the median time to intubation was longer for the right-sided approach compared to the midline approach (42 seconds vs. 31.5 seconds; p < 0.05). The odds of mucosal injury and aspiration were higher among patients intubated using a right-sided approach compared to a midline approach (aOR = 4.1, 95% CI = 1.2 to 14.5; aOR = 7.7, 95% CI = 1.5 to 39.5, respectively). Rates of physiologic adverse events did not differ based on approach.
Conclusions:
First-pass success rate did not differ based upon laryngoscopic approach type; however, a right-sided approach was associated with a longer time to intubation, as well as higher rates of mucosal injury and aspiration among patients undergoing video-enabled intubation in a pediatric ED.
Insights
In pediatric emergency departments, a right-sided laryngoscopic approach for endotracheal intubation did not affect first-attempt success rates. However, this approach was linked to longer intubation times and increased risks of mucosal injury and aspiration.
Area of Science:
- Emergency Medicine
- Pediatric Critical Care
- Anesthesiology
Background:
- Video laryngoscopy is increasingly used for endotracheal intubation in pediatric emergency settings.
- The choice of laryngoscopic approach (right-sided vs. midline) may influence intubation outcomes and safety.
- Understanding these differences is crucial for optimizing pediatric airway management.
Purpose of the Study:
- To compare the association of right-sided versus midline laryngoscopic approaches with first-attempt endotracheal intubation success in children.
- To evaluate the impact of laryngoscopic approach on intubation time and adverse event rates in a pediatric emergency department.
Main Methods:
- Retrospective cohort study of pediatric patients (<21 years) undergoing endotracheal intubation with a C-MAC video laryngoscope.
- Analysis of video recordings to assess first-pass success, intubation time, mucosal injury, aspiration, and physiologic adverse events.
- Multivariate regression models adjusted for patient and provider factors to compare outcomes between right-sided and midline approaches.
Main Results:
- First-pass endotracheal intubation success rates were similar between right-sided and midline laryngoscopic approaches (aOR = 0.76, 95% CI = 0.29 to 2.0).
- The right-sided approach was associated with a significantly longer median time to intubation (42s vs. 31.5s; p < 0.05).
- Higher odds of oropharyngeal mucosal injury (aOR = 4.1, 95% CI = 1.2 to 14.5) and aspiration (aOR = 7.7, 95% CI = 1.5 to 39.5) were observed with the right-sided approach.
Conclusions:
- Laryngoscopic approach type (right-sided vs. midline) did not influence the success rate of first-attempt endotracheal intubation in pediatric patients.
- A right-sided approach in pediatric video laryngoscopy is associated with increased intubation time and a higher incidence of mucosal injury and aspiration.
- These findings suggest that a midline approach may be preferable for optimizing safety and efficiency in pediatric endotracheal intubation using video laryngoscopy.
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