Abstract 348: Laryngoscopy With Vallecula Blade Position is Associated With Higher Success in Tracheal Intubation for Critically Ill Children

Abstract

Introduction: Classical teaching in pediatric laryngoscopy advocates the use of straight blades to be placed underneath the epiglottis, whereas curved blades are placed in the vallecula. Anesthesia studies suggest that straight blade positioning in the vallecula may be a satisfactory technique for small children. We sought to assess laryngoscope blade tip position during pediatric tracheal intubation (TI) and its association with intubation success. Methods: Observational single center study. Children undergoing TI from November 2017 until December 2018 in a pediatric emergency department (ED) and pediatric intensive care unit (PICU) using a CMAC video laryngoscope with recorded images available for review were eligible for inclusion. Patient and provider characteristics were obtained from quality improvement database. Each video was independently reviewed, and the blade tip position was determined by study personnel as ‘in vallecula’ or ‘under epiglottis’. TI success was defined as observation of the tube entering the trachea on video. Univariate analysis between blade tip position and success, as well as potential confounders, was performed by chi 2 testing. Multivariable logistic regression to determine the independent association between blade tip position and success while controlling for relevant confounders. Results: 95 TI attempts were analysed. 58% of attempts were successful (14/35 in infants, 8/15 in 1-7 yr old, 33/45 in 8+ yr, p=0.01). Blade tip position was in the vallecula for 20/31 (65%) attempts with curved blades and 23/64 (36%) with straight blades. In univariate analysis, TI attempts with blade tip position ‘in vallecula’ were significantly more successful than attempts with ‘under epiglottis’ (37% vs. 84%, p<0.001). Median duration of laryngoscopy was 41 sec (IQR 27-59), not significantly different between two blade tip positions (p=0.06). After controlling for patient age and blade type (potential confounders), TI attempts with blade tip ‘in vallecula’ was independently associated with success (aOR 7.2, 95% CI 2.6 - 20.1). Conclusion: During pediatric TI, laryngoscope blade tip position in the vallecula was independently associated with success when compared with placement under the epiglottis.