Airway Management In Children Research Articles

Excessive Use of Benzodiazepines Is a Risk Factor for Endotracheal Intubation in Children Who Present to Emergency With Prehospital Status Epilepticus.

There is lack of evidence-based information on the use and timing of endotracheal intubation (ETI) in children with prehospital status epilepticus (SE). The aim of this study was to investigate ETI use, timing, risk factors, and outcomes in children presenting to a single-center children's emergency (CE) with prehospital SE, over a 5-year period. A total of 118 events involving children presenting to CE with ongoing prehospital SE were included, and 39% (46/118) of the events required ETI. The most common indication for ETI was respiratory depression. The median time to intubation after arrival at CE was 20.0 minutes (1-155 minutes). Risk factors associated with ETI use include the administration of more than 2 benzodiazepines (26.1% vs 4.2%, P < 0.001) and the use of second- or third-line antiepileptic therapy (P < 0.001). The use of more than 2 doses of benzodiazepines was found in 12.7% (15/118) of the patients. In patients who received excessive benzodiazepines, 87% (13/15) of them required intubation. Excessive use of benzodiazepine was found to be a main risk factor for ETI in patients with prehospital SE. Avoidance of the excessive use of benzodiazepines and adhering to clinical management guidelines may reduce the risk for ETI in the CE. The best approach to airway management in children with prehospital SE is lacking and urgently needed.

Airway management in children with Pierre Robin sequence

Resumen En el paciente pediátrico los problemas respiratorios constituyen una de las principales causas de morbi-mortalidad perioperatoria. En determinadas patologías, estos problemas se ven gravemente acentuados. A la vulnerabilidad respiratoria hay que sumar lo difícil que resulta la valoración de la vía aérea en el niño. Un ejemplo de todos estos desafíos lo constituye el paciente con Secuencia de Pierre Robin. Actualmente no existen guías estandarizadas en anestesia para el manejo de la vía aérea en estos pacientes, aunque sí publicaciones que sitúan al fibrobroncoscopio óptico como el Gold Standar para la intubación. Presentamos el caso de una paciente con Secuencia de Pierre Robin intubada con éxito mediante videolaringoscopio GlideScope®.    

[Characteristics of the fetal and infant respiratory system : What the pediatric anesthetist should know].

Respiratory complications are the most frequent incidents in pediatric anesthesia after cardiac events. The pediatric respiratory physiology and airway anatomy are responsible for the particular respiratory vulnerability in this stage of life. This article explains the aspects of pulmonary embryogenesis relevant for anesthesia and their impact on the respiration of preterm infants and neonates. The respiratory distress syndrome and bronchopulmonary dysplasia are highlighted as well as the predisposition to apnea of preterm infants and neonates. Due to the anatomical characteristics, the low size ratios and the significantly shorter apnea tolerance, airway management in children frequently represents a challenge. This article gives useful assistance and provides an overview of formulas for calculating the appropriate tube size and depth of insertion. Finally, the pathophysiology and adequate treatment of laryngospasm are explained.

Comparative Evaluation of I-Gel with Uncuffed Endotracheal Tube for Adequacy of Ventilation in Elective Paediatric Surgeries

Background: Uncuffed endotracheal tubes (ETTs) are standard of care for airway management in children up to eight years of age. Direct Laryngoscopy and endotracheal intubation are invasive techniques which may cause hemodynamic changes and can give rise to airway complication. Supraglottic airway devices have been introduced since the past few decades for the management of airway in both adults and children. I-Gel, a second generation supraglottic airway device, is used frequently for securing airway for children.&#x0D; Methods: Total of 90 children of age 2-8 years of age were randomized into two groups, 45 children were ventilated with I-Gel and remaining 45 were ventilated with an uncuffed ETT. Ventilatory parameters like oropharyngeal leak, peak airway pressure and airway sealing quality (ASQ) score were monitored intraoperatively and possible complications were observed at a timely interval after removal of device.&#x0D; Results: Mean oropharyngeal leak pressure in the I-Gel and uncuffed ETT group observed were 20 cmH2O and 19.56 cmH2O respectively. ASQ score was comparable in both groups. Ten patients in the I-Gel group while two in the uncuffed ETT group had blood staining of the device after removal and the difference was statistically significant. Incidence of cough and sore throat post-extubation and after six hours was significantly higher in the ETT group as compared to the I-Gel group.&#x0D; Conclusion: Both devices were comparable and equally effective for adequacy of ventilation while blood staining of the device was observed in the I-Gel group however, cough and sore throat were observed in the ETT group.

[Strategies for airway management in neonates : Results of asurvey of German perinatal centers levelsII andIII].

Airway management in children, especially in patients with adifficult airway, remains amajor challenge for anesthesiologists, pediatricians, and emergency medicine physicians. In recent years new tools have been introduced into the clinical practice. The aim was to present the current strategies for securing the airway in neonates in perinatal centers levelsII andIII in Germany, and to collect data on the rare event of coniotomy. From 5April 2021 to 15 June 2021, physicians practicing intensive care in pediatrics and neonatology at perinatal centers levels II and III in Germany were surveyed by means of an anonymized online questionnaire. The questionnaire was designed by the authors and verified by pretesting with the help of five pediatric specialists. Contact was made digitally via the e‑mail addresses provided on the websites of the respective centers. The survey was administered through the fee for service provider LimeSurvey©. The collected data were transferred to the IBM© statistical package for the social scientists (SPSS, version28, IBM© Corporation, Armonk, NY, USA) and statistically analyzed. Pearson's χ2-test was used to perform significance testing (significance level p = < 0.05). Only completed questionnaires were included in the analysis. A total of 219participants completed the questionnaire. Available airway devices: 94.5% (n = 207) nasopharyngeal tubes, 79.9% (n = 175) video laryngoscope/fiber optic, 73.1% (n = 160) laryngeal masks, 64.8% (n = 142) oropharyngeal tube (Guedel). Of the participants 6 (2.7%) performed coniotomy (⌀1.6children). Out of six cases five (83.3%) were resuscitation situations caused by complex anatomical malformations. Training of coniotomy was not provided in 98.6% (n = 216). AStandard Operating Procedure (SOP) for difficult airway in neonates was possessed by 20.1% (n = 44). The comparison with international studies showed that the equipment of German perinatal centers is above average. The trend towards acquisition of avideo laryngoscope and its importance in clinical routine could be confirmed by our data; however, the fact that 20% of the respondents did not have access to video laryngoscopy suggests that further acquisitions will have to be made here in the future. Front of neck access (FONA) methods remain acritically questioned component of neonatal difficult airway algorithms due to their rarity and the resulting lack of data. In summary of the recommendations of the British Association of Perinatal Medicine (BAPM) and the collected data on the theoretical and practical education of the FONA methods in Germany, the implementation of the FONA methods by pediatricians and neonatologists cannot be recommended. As most resuscitation situations were caused by complex anatomical malformations, the early detection of such malformations by means of high-resolution ultrasound seems to be of particular importance. With improvement of early detection, neonates with potentially unmanageable airway problems can be left on uteroplacental circulation for aprolonged period in order to perform necessary interventions, such as tracheostomy, bronchoscopy, or extracorporeal membrane oxygenation (ECMO) device known as the ex utero intrapartum treatment (EXIT) procedure.

[Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for Critical Care and Emergency Medicine (DIVI), the Medical Directors of Emergency Medical Services in Bavaria (ÄLRD), the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI), the Scientific Working Group for Emergency Medicine of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the Society of Neonatology and Pediatric Critical Care Medicine (GNPI)].

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present aliterature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine. Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors. The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have agastric drainage possibility. Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of alocal emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

A Comparison of the bébé VieScope™ and Direct Laryngoscope for Use While Wearing PPE-AGP: A Randomized Crossover Simulation Trial.

This study aimed to compare the intubation effectiveness of the bébé Vie Scope™ (VieScope) and direct laryngoscopy for emergency intubation in a pediatric manikin model performed by paramedics with and without personal protective equipment for aerosol generating procedures (PPE-AGP). Participants performed endotracheal intubation using VieScope and standard Macintosh laryngoscope (MAC) in two research scenarios: (1) without PPE-AGP, and (2) with PPE-AGP. Fifty-one paramedics without any previous experience with the VieScope participated in this study. In the PPE-AGP scenario, in the VieScope group, the percentage of successful tracheal intubation on the first attempt was higher compared to the MAC group (94.1 vs. 78.4%, p = 0.031), intubation time was shorter (29.8 vs. 33.9 s, p &lt; 0.001), and percentage of glottic opening (POGO) score was higher 91.0 vs 77.8 (p &lt; 0.001). On the Cormack-Lehane scale, intubation with VieScope intubation was associated with higher scores rated at 1 (64.7 vs. 29.4%) than in the MAC group (p = 0.001). For intubation in the non-PPE scenario, there were no statistically significant differences between VieScope and MAC in relation to above parameters. Summarize, the bébé VieScope™ under PPE-AGP wearing conditions has proven to be a useful device for airway management in children providing better visualization of the larynx, better intubation conditions, and a higher success rate of tracheal intubation on the first attempt and reduced intubation time compared to the standard Macintosh laryngoscope.

Airway Management in Pediatric Patients: Cuff-Solved Problem?

Traditionally, uncuffed tubes were used in pediatric patients under 8 years in pursuit of reducing the risk of postextubation stridor. Although computed tomography and magnetic resonance imaging studies confirmed that the subglottic area remains the narrowest part of pediatric airway, the use of uncuffed tubes failed to reduce the risk of subglottic swelling. Properly used cuffed tubes (correct size and correct cuff management) are currently recommended as the first option in emergency, anesthesiology and intensive care in all pediatric patients. Clinical practice particularly in the intensive care area remains variable. This review aims to analyze the current recommendation for airway management in children in emergency, anesthesiology and intensive care settings.

Video Laryngoscopy Using King Vision™ aBlade™ and Direct Laryngoscopy in Paediatric Airway Management: A Randomized Controlled Study about Device Learning by Anaesthesia Residents.

Background: Airway management in children is challenging due to anatomical and physiological differences. This randomized trial investigates whether anaesthesia residents can intubate the paediatric trachea more quickly and with a higher success rate using the King Vision™ Paediatric aBlade™ video laryngoscope (KVL) compared to conventional direct laryngoscopy (DL). Methods: Eleven anaesthesia residents (mean age: 31 years, mean training status 47 months) were each asked to perform intubations with the KVL and DL in paediatric patients. The primary outcome was the first-attempt success rate. Secondary outcomes were the time to best view (TTBV), time to placement of the tracheal tube (TTP), time to ventilation (TTV), and participant-reported ease of use on a Likert scale. Results: 105 intubations with the KVL and 106 DL were performed by the residents. The success rate on the first attempt with the KVL was 81%, and the success rate on the first attempt within a given time limit of 30 s was 45%, which was lower than with DL (93% and 77% with time limit, p < 0.01). The median TTBV [IQR] on the first attempt with KVL was 7 [5–10] s, the median TTP was 28 [19–44] s, and the median TTV was 51 [39–66] s. DL-mediated intubation was significantly faster (TTP: 17 [13–23] s; p < 0.0001 and TTV: 34 [28–44] s; p < 0.001). Application of the KVL was rated as difficult or very difficult by 60% of the residents (DL: 5%). Conclusion: In contrast to promising data on the paediatric training manikin, residents took longer to intubate the airway in children with the KVL and were less successful compared to the DL. Therefore, the KVL should not be recommended for learning paediatric intubation by residents.

Air-Q ILA as a conduit for orotracheal intubation in children: A randomized control trial for comparison between supine and lateral patient positions.

Airway management in children is always challenging and becomes a concern if required in the lateral position. We evaluated the efficacy of orotracheal intubation using the Air-Q intubating laryngeal Airway (Air-Q ILA) in supine and lateral positions in children. This study included 100 children weighing 7-30 kg, scheduled for elective surgeries under general anesthesia. They were randomized into the supine (S) group or lateral (L) group. After anesthesia induction, the child was placed in a standard sniffing position for conventional laryngoscopy in the S group, and the child was turned into the lateral position in the L group. Both Air-Q ILA and endotracheal tube were placed blindly in the supine position in the S group and lateral position in group L. The grading of glottic view, success rate, insertion time of the Air-Q ILA, and endotracheal intubation were noted in both the groups. The Air-Q ILA was successfully placed at the first attempt in 47 children in group S and 48 in group L. The overall blind orotracheal intubations, including first and second attempts, were successful in 45 children in the S group and 47 in the L group (P = 0.715). Eighty percent of patients in group L and 70% in group S had glottis grade 1 or 2 compared to grade 3, 4,5 (P = 0.249). The mean time of Air-Q ILA placement in groups S and L was 15.73 ± 5.64 s and 14.42 ± 4.16 s (P = 0.195). The mean duration of blind endotracheal intubation through the Air-Q ILA was 24.88 ± 14.75 s in group S and 17.57 ± 5.35 s in group L (P = 0.002). In both the groups, none of the children had bronchospasm, laryngospasm, desaturation, or aspiration. The airway trauma evident by blood staining on the Air-Q ILA on removal was revealed in 2 cases in group S, and 3 cases in group L. None of the children in group S and 4 children in group L had postoperative stridor. Postoperative hoarseness was reported in 3 children in group S and none in group L within 24 hours. The Air-Q ILA can be used as a conduit for blind orotracheal intubation in children in both supine and lateral positions while maintaining an effective airway seal.

Indian Association of Paediatric Anaesthesiologists advisory for paediatric airway management

The pediatric airway poses a challenge particularly for those who do not anesthetize small children on a regular basis. Anatomical and physiological variations of the airway at different ages have an impact on the decision of which medication to administer with regard to route, dosage, and duration of action as well as the choice of equipment. Knowledge of this helps in the routine management of airway in children. Technological advancements and research have rendered numerous pediatric airway devices available for securing the airway in elective and emergency scenarios. However, their availability alone does not solve all problems. Having the knowledge, the ability to promptly recognize difficulty and to know when to call for help early are key factors for a favorable outcome. This advisory is formulated as a guide for a successful and safe airway management in children for the anesthesiologist involved in the care of pediatric patients.

Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department

BackgroundChallenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric...

Error traps in pediatric difficult airway management.

Difficult airway management in children is associated with significant morbidity. This narrative review on error traps in airway management aims to highlight the common pitfalls and proposes solutions to optimize best practices for pediatric difficult airway management. We have categorized common errors of pediatric difficult airway management into three main error traps: preparation, performance, and proficiency, and present potential strategies to improve patient safety and successful tracheal intubation in infants and children with difficult airways.

Comparison of Proseal LMA with i-Gel in children under controlled ventilation: a prospective randomised clinical study

BackgroundSupraglottic airway device is presently the most common modality of airway management in children for short surgical procedures. The i-gel is one such novel supraglottic airway device with a non-inflatable cuff. The objective of the present study was to evaluate the efficiency of i-gel compared to LMA Proseal regarding oropharyngeal leak pressure, insertion time, ease of insertion, and fibreoptic view of larynx. MethodsAfter obtaining ethical clearance and parental consent, 70 children aged 2–10 years, weighing 10–30 kg were randomised to receive LMA Proseal or i-gel for airway management. Data with respect to oropharyngeal leak pressure, insertion time, ease of insertion, number of attempts, and fibreoptic score were collected. The primary outcome was the oropharyngeal leak pressure with the two supraglottic airway devices measured by manometric stability. ResultsDemographic data were comparable between the two groups. The oropharyngeal leak pressure (LMA Proseal vs. i-gel, 20.51 ± 4.71 cmH2O vs. 19.57 ± 5.71 cmH2O), ease of insertion, number of attempts, and fibreoptic view score was similar between the two groups. The insertion time was faster with i-gel (22.63 ± 5.79 s) compared to LMA Proseal (43.26 ± 7.85 s). ConclusionI-gel was similar to LMA Proseal with respect to oropharyngeal leak pressure in children under controlled ventilation.

Airway management in children with COVID-19.

The novel coronavirus disease (COVID-19) may result in acute respiratory distress syndrome and respiratory failure, necessitating mechanical respiratory support. Healthcare professionals are exposed to a particularly high risk of contracting the virus while providing resuscitation and respiratory support, which may in turn result in grave consequences and even death. Although COVID-19 has been shown to cause milder disease in children, paediatricians and intensivists who provide care for children must be prepared to provide optimal respiratory support without putting themselves or other medical, nursing, and paramedical staff at undue risk. We propose an airway management approach that is especially relevant in the current COVID-19 pandemic and provides instructions for: (1) Elective intubation for respiratory failure; and (2) Emergency intubation during cardiopulmonary resuscitation. To minimise risk, intubation methods must be kept as straightforward as possible and should include the provision of appropriate personal protection and equipment to healthcare workers. We identify two key considerations: that bag-mask ventilation should be avoided if possible and that bacterial and viral filters should be placed in the respiratory circuit. Our novel approach provides a framework for airway management that could benefit paediatric critical care practitioners who provide care for any children with a novel viral illness, with a focus on infection prevention during high-risk airway management procedures.

Use of Airway Ultrasound in Infants With Unexpected Subglottic Stenosis During Anesthesia Induction: A Case Report

Point-of-care ultrasound has been integrated into airway management because it allows for rapid and noninvasive assessments. We present 2 cases of unexpected subglottic stenosis in infants during induction of anesthesia. Intubation failed even with endotracheal tubes that were small for patients' age. Airway ultrasound was used to measure the subglottic airway diameters, which were 2.0 and 3.0 mm in first and second cases, respectively. The severity of subglottic stenosis in the first case was grade III, requiring emergent tracheostomy. In conclusion, airway ultrasound helps to assess possibility of intubation and plan further airway management in children with unexpected difficult airway.

Evolution of videolaryngoscopy in pediatric population.

Direct laryngoscopy has remained the sole method for securing airway ever since the inception of endotracheal intubation. The recent introduction of video-laryngoscopes has brought a paradigm shift in the pratice of airway management. It is claimed that they improve the glottic view and first pass success rates in adult population. The airway management in children is more challenging than adults. The role of videolaryngoscopy for routine intubation in children is not clearly proven. This review attempts to discuss various videolaryngosocpes available for use in pediatric patients.

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study.

Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-hcycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or≥1year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.

Evaluation of Different Positive End-Expiratory Pressures Using Supreme™ Airway Laryngeal Mask during Minor Surgical Procedures in Children.

Background and objectives: The laryngeal mask is the method of choice for airway management in children during minor surgical procedures. There is a paucity of data regarding optimal management of mechanical ventilation in these patients. The Supreme™ airway laryngeal mask offers the option to insert a gastric tube to empty the stomach contents of air and/or gastric juice. The aim of this investigation was to evaluate the impact of positive end-expiratory positive pressure (PEEP) levels on ventilation parameters and gastric air insufflation during general anesthesia in children using pressure-controlled ventilation with laryngeal mask. Materials and Methods: An observational trial was carried out in 67 children aged between 1 and 11 years. PEEP levels of 0, 3 and 5 mbar were tested for 5 min in each patient during surgery and compared with ventilation parameters (dynamic compliance (mL/cmH2O), etCO2 (mmHg), peak pressure (mbar), tidal volume (mL), respiratory rate (per minute), FiO2 and gastric air (mL)) were measured at each PEEP. Air was aspirated from the stomach at the start of the sequence of measurements and at the end. Results: Significant differences were observed for the ventilation parameters: dynamic compliance (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001), peak pressure (PEEP 5 vs. PEEP 3: p < 0.0001, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001) and tidal volume (PEEP 5 vs. PEEP 3: p = 0.0048, PEEP 5 vs. PEEP 0: p < 0.0001, PEEP 3 vs. PEEP 0: p < 0.0001). All parameters increased significantly with higher PEEP, with the exception of etCO2 (significant decrease) and respiratory rate (no significant difference). We also showed different values for air quantity in the comparisons between the different PEEP levels (PEEP 5: 2.8 ± 3.9 mL, PEEP 3: 1.8 ± 3.0 mL; PEEP 0: 1.6 ± 2.3 mL) with significant differences between PEEP 5 and PEEP 3 (p = 0.0269) and PEEP 5 and PEEP 0 (p = 0.0209). Conclusions: Our data suggest that ventilation with a PEEP of 5 mbar might be more lung protective in children using the Supreme™ airway laryngeal mask, although gastric air insufflation increased with higher PEEP. We recommend the use of a laryngeal mask with the option of inserting a gastric tube to evacuate potential gastric air.

Midline versus paraglossal laryngoscopic approach using the Miller blade in small children: A randomised, controlled, cross-over study

Background: Airway management in children is different from that of adults and needs special consideration. Laryngoscopy in children with the Miller straight blade can be performed via midline (MID) or paraglossal (PGL) approach. This study aimed to find out whether there was any advantage of one approach over the other in small children. Patients and Methods: After obtaining parental consent and approval from the Institutional Ethical Committee, this randomised, controlled, cross-over study was conducted in 110 children aged 2–24 months belonging to the American Society of Anesthesiologists Physical Status I or II. Children scheduled for elective surgeries under general anaesthesia were allocated randomly into one of the following two groups: A (PGL/MID) or B (MID/PGL) with 55 patients in each group. Following induction of anaesthesia and neuromuscular blockade, laryngoscopy was performed in a cross-over manner with either the PGL or MID approach first. The tip of the blade was placed at the vallecula. Intubation was performed following the second laryngoscopy. Glottic views with and without optimal external laryngeal manipulation (OELM) and ease of intubation were observed. Data were analysed, and P