Randomized trial of three airway management techniques for restricted access in a simulated pediatric scenario.

PURPOSE: Emergency pediatric airway management during restricted access to the head is challenging and may relate to an entrapped motor vehicle trauma. Video laryngoscopy and supraglottic airways have separately been described to facilitate face-to-face airway management. We hypothesized that video laryngoscopy might be superior to direct laryngoscopy or supraglottic device use to establish ventilation during face-to-face airway management, studied in a simulated pediatric entrapped motor vehicle scenario. METHODS: Ethics approval was obtained from local REB. 45 experienced airway practitioners managed the airway of a pediatric manikin representing a 6 year old (SimJunior). With a cervical collar applied and in the sitting position, the manikin's head was only accessible from the left anterolateral side. Following a standardized demonstration, airway management using a Macintosh #2 blade (DL), a Storz C-MAC® D-Blade (VL) and a #2.5 LMA Supreme™ (SGD) was performed once each in a random order. Outcomes included success rate, time to ventilation (TTV), percentage of glottic opening (POGO) for DL and VL and ease of use on a 10-point Likert scale (VAS). Data was analyzed using analysis of variance for TTV and VAS and t-test for POGO. Statistical significance was deemed at P < 0.05. Data are presented as median and interquartile range. RESULTS: Success rate was 95% for both DL and SGD and 93% for VL. TTV was significantly less with SGD compared to DL and VL. TTV was 31 s (28, 35) for DL, 46 s (31, 62) for VL and 20 s (17, 24) for SGD. POGO was significantly improved with VL (100%) compared to DL (80%). Participants rated SGD significantly easier to use than VL, but not easier than DL. DISCUSSION: All three techniques have high success rates. Time to establish ventilation with the SGD was significantly faster compared to DL and VL and participants rated SGD easiest to use. The utility of VL was limited due to significantly longer time to ventilation, despite significantly improved view compared to DL, similar to adult studies. Since time and success are clinically important, this study suggests that supraglottic devices should be considered for primary emergency pediatric airway management in situations with restricted access to the head.

A comparison of the GlideScope video laryngoscope and standard direct laryngoscopy in children with immobilized cervical spine.

OBJECTIVES: Airway management in children with cervical spine may make direct laryngoscopy difficult. Video laryngoscopy is an alternative to direct laryngoscopy. The GlideScope video laryngoscope, successfully used in expected and unexpected difficult pediatric airway situations, has not been studied so far in children with cervical spine immobilization. METHODS: A total of 23 children underwent laryngoscopy with manual cervical spine immobilization using the GlideScope and a direct laryngoscope (Miller 1 or Macintosh 2 blade). Percentage of glottis opening score, Cormack-Lehane score, and time to best view were recorded. RESULTS: Percentage of glottis opening score using the GlideScope was 50% (1%-87%) and 90% (60%-100%) using direct laryngoscopy (P < 0.001). Cormack-Lehane score using the GlideScope was 1 (1-2.7) and 1 (1-1) in direct laryngoscopy (P < 0.001). Time to best view with the GlideScope was 21 seconds (12.2-28 seconds) and 7 seconds (6-8.7 seconds) in direct laryngoscopy (P < 0.05). Data are presented as median and interquartile range and analyzed using paired t test. CONCLUSIONS: In simulated difficult pediatric airway, using the GlideScope resulted in a significantly declined view to the glottic entrance. This result is in contrast to studies in children with difficult airway anatomy due to an anterior larynx, where the GlideScope resulted in improved views.

A comparison of bonfils fiberscope-assisted laryngoscopy and standard direct laryngoscopy in simulated difficult pediatric intubation: a manikin study.

INTRODUCTION: Difficult airway management in children is challenging. One alternative device to the gold standard of direct laryngoscopy is the STORZ Bonfils fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany), a rigid fiberoptic stylette-like scope with a curved tip. Although results in adults have been encouraging, reports regarding its use in children have been conflicting. We compared the effectiveness of a standard laryngoscope to the Bonfils fiberscope in a simulated difficult infant airway. METHODS: Ten pediatric anesthesiologists were recruited for this study and asked to perform three sets of tasks. For the first task, each participant intubated an unaltered manikin (SimBaby (TM), Laerdal, Puchheim, Germany) five times using a styletted 3.5 endotracheal tube (ETT) and a Miller 1 blade (group DL-Normal). For the second task, a difficult airway configuration simulating a Cormack-Lehane grade 3B view was created by fixing a Miller-1 blade into position in the manikin using a laboratory stand. Each participant then intubated the manikin five times with a styletted 3.5 ETT using conventional technique but without touching the laryngoscope (group DL-Difficult). In the third task, the manikin was kept in the same difficult airway configuration, and each participant intubated the manikin five times using a 3.5-mm ETT mounted on the Bonfils fiberscope as an adjunct to direct laryngoscopy with the Miller-1 blade (group BF-Difficult). Primary outcomes were time to intubate and success rate. RESULTS: A total of 150 intubations were performed. Correct ETT placement was achieved in 100% of attempts in group DL-Normal, 90% of attempts in group DL-Difficult and 98% of attempts in BF-Difficult. Time to intubate averaged 14 s (interquartile range 12-16) in group DL-Normal; 12 s (10-15) in group DL-Difficult; and 11 s (10-18) in group BF-Difficult. The percentage of glottic opening seen (POGO score) was 70% (70-80) in group DL-Normal; 0% (0-0) in group DL-Difficult; and 100% (100-100) in group BF-Difficult. DISCUSSION: The Bonfils fiberscope-assisted laryngoscopy was easier to use and provided a better view of the larynx than simple direct laryngoscopy in the simulated difficult pediatric airway, but intubation success rate and time to intubate were not improved. Further studies of the Bonfils fibrescope as a pediatric airway adjunct are needed.

A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway--a randomized clinical trial.

INTRODUCTION: Direct laryngoscopy can be challenging in infants and neonates. Even with an optimal line of sight to the glottic opening, the viewing angle has been measured at 15 degrees . The STORZ DCI video laryngoscope (Karl Storz, Tuttlingen, Germany) incorporates a fiberoptic camera in the light source of a standard laryngoscope of variable sizes. The image is displayed on a screen with a viewing angle of 80 degrees . We studied the effectiveness of the STORZ DCI as an airway tool compared to standard direct laryngoscopy in children with normal airway. METHODS: In this prospective, randomized study, 56 children (ages 4 years or younger) undergoing elective surgery with the need for endotracheal intubation were divided into two groups: children who underwent standard direct laryngoscopy using a Miller 1 or Macintosh 2 blade (DL) and children who underwent video laryngoscopy using the STORZ DCI video laryngoscope with a Miller 1 blade (VL). Time to best view (TTBV), time to intubate (TTI), Cormack-Lehane (CL), and percentage of glottis opening seen (POGO) score were recorded. RESULTS: TTBV in DL was 5.5 (4-8) s and 7 (4.2-9) s in VL. TTI in DL was 21 (17-29) s and in VL 27 (22-37) s (P = 0.006). The view as assessed by POGO score was 97.5% (60-100%) in DL and 100% (100-100%) in the VL (P = 0.003). Data are presented as median and interquartile range and analyzed using t-test. DISCUSSION: This study demonstrates that the STORZ DCI video laryngoscope provides an improved view to the glottis in children with normal airway anatomy, but requires a longer time for intubation.