Pediatric Intubation Research Articles

Safety of paediatric tracheal intubation after non-invasive ventilation failure.

Non-invasive ventilation (NIV) is increasingly used in pediatric intensive care units to limit the complications associated with intubation. However, NIV may fail, and the delay in initiating invasive ventilation may be associated with adverse outcomes. The objective of this retrospective study was to evaluate the safety of tracheal intubation after NIV failure. Consecutive tracheal intubation procedures were prospectively evaluated in our PICU from 01/2011 to 02/2012, as part of the National Emergency Airway Registry for Children (NEAR4KIDS) collaborative. The incidence of severe tracheal intubation associated events (TIAEs, including cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, malignant hyperthermia, pneumothorax, and pneumomediastinum) and severe desaturation (below 80% when pre-intubation saturation was greater than 94%) were recorded prospectively. NIV use before intubation was retrospectively assessed. 100 consecutive intubation events were analyzed, 46 of which followed NIV failure. NIV exposed and non-exposed groups had different baseline characteristics, with lower weight, more frequent lower airway and lung disorder, and lower PIM2 score at admission in NIV failure patients (all P < 0.05). The nasal route for intubation was more frequent in NIV patients (P < 0.01). The incidence of severe TIAE or desaturation was 41% in the NIV failure group and 24% in primarily intubated patients (P = 0.09). Complications occurred in 41% of intubations after NIV failure in this series. Further research is warranted to evaluate strategies to prevent these complications and to identify conditions in which intubation should not be delayed for a trial of NIV.

Comparison of the TruView PCD video laryngoscope and macintosh laryngoscope for pediatric tracheal intubation by novice paramedics: a randomized crossover simulation trial.

The aim of the present study was to evaluate whether the TruView video laryngoscope (TruView) facilitates pediatric endotracheal intubation (ETI) more quickly and safely than conventional Macintosh laryngoscope (MAC) in three manikin-based airway scenarios. This was a randomized crossover manikin study including 120 novice paramedics. The participants performed tracheal intubations using both TruView and MAC on a pediatric manikin in a control scenario (A), chest compression scenario (B), and chest compression cervical stabilization scenario (C). The sequence of scenarios was randomized. The primary outcome was time to intubation. Secondary outcomes were overall success rates, incidence of dental trauma, and ease of intubation. All intubation attempts were assessed by a trained assistant. The overall success rate was significantly higher with the TruView compared than the MAC in scenario B (100 vs. 81.7 %; p = 0.011) and scenario C (100 vs. 68.3 %; p < 0.001). The intubation time was significantly lower with the TruView than the MAC (18.5 vs. 24.3 s, p = 0.017, for scenario A; 21.6 vs. 25.7 s, p = 0.023, for scenario B; and 28.9 vs. 45.4 s, p < 0.001, for scenario C). Glottic view quality was better with TruView than the MAC in all scenarios, p < 0.001.Conclusions: The TruView offers better intubation conditions than the MAC on a pediatric manikin in the control scenario, chest compression scenario, and chest compression scenario with cervical stabilization scenario. The TruView may be used to elevate the epiglottis for orotracheal intubation. Further clinical studies are necessary to confirm these initial positive findings.Trial Registration: clinicaltrials.gov Identifier: NCT02289872. What is Known: •Prehospital pediatric intubation using a standard laryngoscope is varied and ranges from 63.4 to 82 %. What is New: •This is the first study showing efficiency of pediatric endotracheal intubation using the TruView PCD by paramedics in tree simulation scenarios. •TruView PCD offers better pediatric intubation conditions than the Macintosh laryngoscope.

G73 Paediatric difficult airway equipment in emergency departments: a regional audit

Aims The 4th National Audit Project by the Royal College of Anaesthetists highlighted that difficult intubations account for 9% of all intubations in emergency departments (EDs).1 It subsequently recommends that all paediatric EDs should have a difficult airway trolley (DAT) dedicated to paediatric use. The 2012 emergency care standard by RCPCH4 also specified a list of recommended airway equipment in emergency situations. Previous surveys demonstrated a general low availability of a paediatric DAT in anaesthetics departments (16%)2 and PICU/HDUs (42%).3 This audit aims to survey the availability of paediatric DATs and difficult airway equipment in regional paediatric emergency units. Methods A standard questionnaire for DAT and difficult airway equipment was devised according to the RCPCH guideline.4 In February 2014, data was collected from senior nursing staff in all 34 regional paediatric EDs via telephone, email or in person. Results 30 out of 34 units were included. Only 40% had a paediatric DAT on the unit, although all units had some paediatric difficult intubation equipment. A significant number of departments did not have capnography recording (23%), cuffed endotracheal tubes of all sizes (33%), or a cricoidotomy set (33%). Variation in the choice of laryngeal blades reflected individual preferences by specialists. 90% of units kept a daily checking rota. Conclusion This survey highlights the need for improved availability of paediatric DATs and intubation equipment. Particular effort should be made to secure the more advanced equipment, and ensure the availability of a full size range for basic equipment.

Intubation in Pediatric/Neonatal Critical Care Transport: National Performance

Background: There are nearly 200,000 US infants/children transported annually for specialty care and there are no published best practices in transport intubation. Objective: Respiratory interventions are a priority in pediatric and neonatal critical care transport (PNCCT). A recent Delphi study identified intubation performance as an important PNCCT quality metric, though data are insufficient. The objective of the study is to determine multi-center rates of first attempt intubation success in pediatric/neonatal transport and identify practice processes associated with higher performing centers. Methods: Retrospective chart review where data was collected from the 9 participating centers over a 6-month period from January–June 2013. Data describing intubation training and practices were gathered using SurveyMonkey® (Palo Alto, CA). Data were tabulated in Microsoft Excel (Redmond, WA) and analyzed using descriptive statistics. Through the determination of 1st intubation success rate across multiple pediatric/neonatal critical care transport programs, we hypothesized that the features of higher and lower performing centers can be identified to inform practice. Results: 9 of 14 invited institutions participated. The median (IQR) 6-month transport volume for neonates(neo) was 289(35-646) and pediatric (ped) 510(122-831). On average, 7%(+/−3.0) of neo and 1.6%(+/−0.7) of ped transport patients required intubation. Individual centers had their initial success rate calculated and a 95% confidence interval was determined for those centers satisfying the np > 5 and n(1-p) > 5 sample size requirement for normality assumption of proportions. Since the overall success rate was 64%, it was determined that n = 14 initial intubation attempts would be the minimum number needed per center in order to fulfill the sample size requirement for normality assumption. Centers whose 95% confidence interval did not contain the initial overall success rate were identified. Conclusion: This represents the first multi-center neo/ped intubation dataset in PNCCT. First attempt intubation success lags behind reported anesthesia intubation rates but parallels pediatric emergency department intubation success rates. Training and operational processes are variable in PNCCT, though top performing teams require live-patient intubation success to achieve initial intubation competency.

Comparison of the Pentax, Truview, GlideScope, and the Miller laryngoscope for child intubation during resuscitation

The study was designed to compare the effectiveness of 3 video laryngoscopes with the Miller laryngoscope during pediatric resuscitation. This was a randomized crossover study involving 87 paramedics and 54 nurses. The primary end point of the study was the success rate of blind tracheal intubation, whereas the secondary end point was defined as the time from insertion of a device to the first manual ventilation of the manikin's lungs. The median time to intubation using the Pentax, Truview, GlideScope, and Miller varied with the times being 20.6 (interquartile range [IQR], 18-27) vs 20.1 (IQR, 18-23.3) vs 30.2 (IQR, 29.6-35) vs 41.3 (IQR, 33-45.2) seconds, respectively. The overall success ratios of intubation for the devices were 100% vs 100% vs 100% vs 79.4%. We concluded that, in a pediatric manikin scenario, the video laryngoscopes are safe devices and can be used for pediatric intubation during uninterrupted chest compressions. Further clinical studies are necessary to confirm these initial positive findings.

Pediatric and neonatal intubation training gap analysis: instruction, assessment, and technology.

Summary statement: Intubating adult patients presents numerous challenges for clinicians. Procedural complexities associated with performing pediatric and neonatal intubation, along with a lower frequency of a need for intubating pediatric and neonatal patients, further amplifies the difficulties associated with acquiring and maintaining relevant clinical skills. Clinicians must develop and maintain competency through training and continuing medical education. A systematic review was conducted through June 2012 to examine current instructional methods, assessment tools, and training models in pediatric and neonatal intubation training. Variability among the included literature on instruction, assessment, and models used to support training makes direct comparison problematic. The results of this review emphasize the need for improvement of current instructional methods to promote competency acquisition; development of valid, reliable assessment tools to evaluate clinician competency; and identification of a superior training model to promote acquisition and maintenance of skills associated with intubation of pediatric patients.

Efficacy of the Airway Scope (Pentax-AWS) for training in pediatric intubation.

The aim of this study was to evaluate the efficacy of the Airway Scope (AWS) in the training of residents in pediatric intubation using high-performance simulators. A total of 51 residents were recruited. Baby SIM is a high-performance simulator with a built-in physiological program that reduces SpO2 if it stops breathing and increases SpO2 if assisted ventilation is provided using a bag mask. Therefore, real-life situations can be simulated with this program. Trial 1: after respiration of Baby SIM was stopped, intubation was initiated. If the intubation time was too long, a built-in physiological program led to desaturation. The intubation time and frequency of SpO2 <90% were compared between the Miller laryngoscope and the AWS. Trial 2: an ALS Baby, which is more difficult to intubate than Baby SIM, was used in comparison of intubation time and frequency of failure to intubate within 60 s between the two laryngoscopes. Mann-Whitney and chi-squared tests were used for statistical analysis. Intubation time was significantly shorter using the AWS than the Miller laryngoscope in both trials. Furthermore, desaturation occurred significantly less frequently with the AWS than the Miller laryngoscope in trial 1. The frequency of intubation failure within 60 s was also significantly lower for the AWS than the Miller laryngoscope in trial 2. The inclusion of both direct laryngoscopy and the AWS in pediatric resident programs might give pediatricians the option of using a safer and more reliable intubation method for children.

TF-13 A Just-in-Time Training Module for Emergency Intubations

TF-13 A Just-in-Time Training Module for Emergency Intubations

Utilization of Exploration-Based Learning and Video-Assisted Learning to Teach GlideScope Videolaryngoscopy

Background: GlideScope (GS) is used in pediatric endotracheal intubation (ETI) but requires a different technique compared to direct laryngoscopy (DL). Purposes: This article was written to evaluate the efficacy of exploration-based learning on procedural performance using GS for ETI of simulated pediatric airways and establish baseline success rates and procedural duration using DL in airway trainers among pediatric providers at various levels. Methods: Fifty-five pediatric residents, fellows, and faculty from Pediatric Critical Care, NICU, and Pediatric Emergency Medicine were enrolled. Nine physicians from Pediatric Anesthesia benchmarked expert performance. Participants completed a demographic survey and viewed a video by the GS manufacturer. Subjects spent 15 minutes exploring GS equipment and practicing the intubation procedure. Participants then intubated neonatal, infant, child, and adult airway simulators, using GS and DL, in random order. Time to ETI was recorded. Results: Procedural performance after exploration-based learning, measured as time to successful ETI, was shorter for DL than for GS for neonatal and child airways at the.05 significance level. Time to ETI in adult airway using DL was correlated with experience level (p =.01). Failure rates were not different among subgroups. Conclusions: A brief video and period of exploration-based learning is insufficient for implementing a new technology. Pediatricians at various levels of training intubated simulated airways faster using DL than GS.

ABSTRACT 464

Background and aims: Airway Scope (AWS) might be better to be applied for child intubation than direct laryngoscopy. Aims: We aimed to evaluate the efficacy of AWS on the education of the residents in terms of pediatric intubation by the randomized control trial. Methods: Fifty-one residents were recruited. Trial 1. After respiration of Baby SIM was stopped, the intubation started. If the intubation time were too long, Baby SIM could show desaturation during the trial based on the built-in physiological program. The intubation time and the frequency of SpO2<90% were compared between Miller laryngoscopy and AWS. Trial 2. ALS Baby of which intubation is more difficult than Baby SIM was used to compare the intubation time and the frequency of failure in intubation within 60 sec between the two laryngoscopies. Mann-Whitney test and chi-squared test were used for the statistical analysis. Results: The intubation time was significantly shorter in AWS than Miller laryngoscopy in both trials (Trial 1: 21+23 sec vs. 37+34 sec, p<0.05, Trial 2: 24+15 sec vs. 40+17 sec, p<0.05). The frequency of desaturation was significantly less in AWS than Miller laryngoscopy in Trial 1 (5cases vs. 17cases, P<0.05). The frequency of failure in intubation within 60 sec was significantly less in AWS than Miller laryngoscopy in Trial 2 (2 cases vs. 16 cases, P<0.05). Conclusions: The practice of both direct laryngoscopy and AWS in the resident programs of pediatrics might give pediatricians the option of the intubation method which could result in the safer and more reliable intubation for children than direct laryngoscopy.

OSATS Tool for Pediatric Rapid Sequence Intubation

Abstract Introduction Being procedurally competent to perform pediatric rapid sequence intubation (pRSI) is an ACGME requirement for emergency medicine residents. There are few assessment tools to ...

Propofol for pediatric tracheal intubation with deep anesthesia during sevoflurane induction: dosing according to elapsed time for two age groups

Study ObjectiveTo determine, for two different age groups, the effect of duration of sevoflurane administration on the amount of propofol needed when performing tracheal intubation. DesignClassic Dixon’s Up-and-Down sequential method. SettingUniversity based operating rooms. Patients106 ASA physical status 1 and 2 patients aged one to 11 years. InterventionsPatients were allocated to the 1–6 year (≥ 12 and < 72 mos) and 6–11 year (≥ 72 and < 132 mos) age groups. Midazolam 0.5 mg/kg was given orally to the 1–6 year group, and all patients were induced with 8% dialed sevoflurane and 67% nitrous oxide (N2O), with N2O discontinued and sevoflurane dialed to 5% after one minute and 1.5 minutes for the younger and older age groups, respectively. Intravenous access was obtained and propofol was promptly administered. Propofol dose was determined according to age group and whether propofol was given 2–4, 4–6, or 6–8 minutes after the start of sevoflurane induction, with Dixon’s Up and Down Method used separately for each specific age/time group. Tracheal intubation conditions one minute after propofol were evaluated. MeasurementsIsotonic regression determined propofol ED50 estimates for excellent tracheal intubation conditions, and linear regression determined the effect of propofol dose on change in systolic blood pressure (SBP). Main ResultsEstimated propofol ED50 doses for 1–6 year olds, with 95% confidence intervals (CIs), were 1.48 mg/kg (0.80, 2.03), 0.00 mg/kg (0.00, 0.38), and 0.07 mg/kg (0.00, 0.68) in the 2–4, 4–6, and 6–8 minute groups, respectively, with estimated differences between the 2–4 minute group versus the 4–6 and 6–8 minute groups being 1.47 mg/kg (95% CI = 1.04, 2.06) and 1.41 mg/kg (95% CI = 0.74, 2.04), respectively. Estimated propofol ED50 doses for 6–11 year olds, with 95% CIs, were 2.35 mg/kg (1.97, 2.45) and 2.33 mg/kg (1.59, 2.45) in the 2–4 and 4–6 minute groups, respectively. Diminutions in SBP at one minute and two minutes after propofol administration were dose dependent for children 1–6 years of age, decreasing 5.3% and 8.1% for each 1 mg/kg of propofol, respectively. ConclusionThe amount of propofol needed to supplement sevoflurane in children 1–6 years of age can be expected to decrease after 4 minutes of sevoflurane.

Awake fibreoptic intubation in a 10‐year‐old patient with a known difficult airway due to Goldenhar syndrome

SummaryA 10‐yr‐old female with Goldenhar syndrome presented for elective dental surgery. She was known to have a difficult airway and it was suggested that she should have an elective tracheostomy under sedation as the safest option to secure her airway prior to surgery. The patient and her parents refused tracheostomy and were keen to explore other options. We proceeded to secure her airway using awake fibreoptic intubation. Surgery was uneventful and the patient was extubated and discharged on the same day. The use of a fibreoptic scope is well described in children; however awake intubation in paediatrics is uncommon, with most procedures being performed under deep sedation or general anaesthesia due to problems with patient cooperation [1,2]. This case report describes the use of awake fibreoptic intubation in paediatrics for the management of an anticipated difficult airway.

Tracheal intubation in paediatric surgeries without muscle relaxation using magnesium sulphate as an adjuvant

Background Tracheal intubation under deep inhalational anaesthesia is a common practice in paediatrics; however, since the introduction of short-acting opioids, intubation has become more successful when these drugs are used in combination with propofol, avoiding the use of neuromuscular blocking agents with their unwanted side effects. Several techniques and adjuvants have been used to improve intubating conditions. We studied the interaction between magnesium sulphate and the anaesthetic agent's propofol and fentanyl to facilitate intubation in paediatrics. Patients and methods A total of 40 preschool and school-aged patients scheduled for short urogenital procedures were randomly assigned in a double-blind study to be administered either a 5-min infusion of magnesium sulphate (30 mg/kg) in 0.9% saline 5 ml/kg (magnesium group, n = 20), or the same volume of saline (control group, n = 20). Anaesthesia was induced (1 μg/kg) fentanyl followed by propofol (2.5 mg/kg). Intubating conditions were assessed by Copenhagen score. Blood pressure, heart rate, respiratory rate and EtCO 2 were recorded. Serum magnesium was measured, and Aldrete recovery score was assessed. Results The two groups were comparable regarding demographic data. Intubating conditions were better in the magnesium group than in the control group (0 vs. 60%). There were no differences between both groups regarding haemodynamic variables. The duration of intubation was insignificantly shorter in the magnesium group. Aldrete recovery score showed no difference between both groups. Serum magnesium increased from 1.92 to 3.18 mg/dl in the magnesium group, but with no signs of hypermagnesemia. Conclusion Adding magnesium sulphate to propofol and fentanyl improves intubating conditions without the use of muscle relaxants during the start of procedures in paediatrics.

4,871 Emergency Airway Encounters by Air Medical Providers: A Report of the Air Transport Emergency Airway Management (NEAR VI: "A-TEAM") Project

IntroductionPre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system.MethodsWe retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant.Results4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway.ConclusionAirway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.

415

Introduction: Objective The epidemiology and predictive factors of difficult pediatric tracheal intubations (TIs) in ICU environment are unknown. To describe the occurrence and risk factors for difficult pediatric tracheal intubations (TI) in pediatric intensive care units (PICU). We evaluated two hypotheses: History of difficult airway and clinical morphological features are associated with the occurrence of difficult TIs. Difficult TIs are also associated with oxygen desaturation and the occurrence of adverse TI associated events. Methods: Using the National Emergency Airway Registry for Children (NEAR4KIDS), tracheal intubation quality improvement data were prospectively collected for initial TIs in 15 PICUs from 7/2010–12/2011. Patient characteristics were collected using a standardized data collection instrument. Difficult pediatric TI was defined as endotracheal tube placement by direct laryngoscopy which required ≥3 attempts by fellow/attending level physician provider, or a failure of the course. Adverse TI associated events (TIAEs) and severe events were recorded by standard NEAR4KIDS operational definitions. Because of uncertainty regarding the definition of difficult TIs, we conducted a sensitivity analysis using two expanded definitions. The first expanded definition included primary oral TIs that required ≥3 attempts by any providers including resident trainees. The second expanded difficult TI definition included primary oral TIs performed with an indirect laryngoscope or fiberoptic laryngoscope. Chi2 test and Wilcoxon rank-sum test were used with p<0.05 as significant. Receiver operation curve (ROC) analysis was performed to evaluate clinical feasibility of difficult TI prediction by providing 1 point for each difficult airway feature. Results: A total of 1516 primary oral TIs were reported. Median age was 2 years (interquartile range: 0–8 years). Among those, 1469 used a direct laryngoscope as a device (97%). With the proposed definition, the prevalence of difficult TI was 8.8%. Patients with difficult TI were younger (median 1 (0–5) yr vs. 2 (0–8) yr, p=0.046), had a reported history of difficult airway (22% vs. 8%, p<0.001), and had more anatomic features considered predictive of difficult airway (limited neck extension, limited mouth opening, small thyromental space, upper airway obstruction, or midface hypoplasia, all p<0.02) when compared to patients without difficult TI. The presence of a difficult TI was associated with more desaturation <80% (48% vs.15%, p<0.001), a higher incidence of adverse TIAEs (53% vs. 20%, p<0.001), and severe TIAEs (13% vs. 6%. P=0.003). The length of PICU stay was longer (median 15 days vs. 11 days, p=0.02). There was no difference in PICU mortality (12.2% vs. 11.8%, p=0.93). In sensitivity analysis the incidence of difficult TIs varied from original definition (8.6%) to expanded definition 1 (16.7%), and expanded definition 2 (10.8%). The incidence of oxygen desaturation, and TIAEs did not differ substantially across those three definitions. The predictive value of each clinical difficult airway feature was similar across those three definitions. The area under the ROC curve for original definition was 0.66 (95% CI: 0.61–0.70), 0.61 (95% CI: 0.58–0.65) for extended definition 1 and 0.68 (95% CI: 0.64–0.72) for extended definition 2. Conclusions: Difficult TIs in pediatric ICUs requiring ≥3 attempts by non-resident providers were reported in 8.8% of all intubations. Tracheal intubation encounters with difficult TIs were associated with a higher incidence of desaturation, adverse TIAEs, and severe TIAEs. Difficult pediatric TIs were associated with a longer PICU stay. The presence of a history of a difficult TI and/or unfavorable physical features were significantly associated with difficult TI. However, the absence of these features does not assure TI without difficulty. Further study is warranted to optimize an airway approach for this high risk population.

Straight video blades are advantageous than curved blades in simulated pediatric difficult intubation

It is still controversial which laryngoscope may be a better option in unanticipated difficult airway in pediatric patients. The aim of the present study was to compare two direct and two video-assisted laryngoscope devices for the management of difficult pediatric airway. Forty-five anesthesiology residents and nurse anesthetists participated in the study. Macintosh, Miller, Storz Miller, and McGrath Mac curved laryngoscopes were used for tracheal intubation of 3-6-month Airsim Pierre Robin manikin. We compared the duration of successful intubation, number of attempts, glottic view grades, severity of dental trauma, the use of optimization maneuvers, and the difficulty of use of the devices with straight and curved laryngoscope blades. Successful intubation duration was significantly lower in Storz Miller device, and the number of intubation attempts was significantly higher in the Macintosh laryngoscope (P<0.01). According to the Cormack and Lehane classification, Grades 1 and 2 glottic view was 20% for Macintosh and 40% for Miller laryngoscope, while it was 100% for Storz Miller and 80% for McGrath (P<0.001). Difficulty VAS scores of Storz Miller device were significantly lower than the scores of Macintosh, Miller, and McGrath laryngoscopes (15.7±14.89, 34.7±26.44, 31.5±26.74, 33.4±26.67mm, respectively; P<0.01). The severity of dental trauma was significantly lower in Storz Miller compared with Macintosh, Miller, and McGrath laryngoscopes (0.96±1.04, 1.67±1.15, 1.38±1.05, 1.42±1.27, respectively; P<0.01). Storz Miller laryngoscope was found to have advantages over the other laryngoscopes in regard to glottic view, duration of successful intubation, number of attempts, dental trauma severity, need for additional maneuvers, and ease of use.

Comparaison de 3 vidéo-laryngoscopes à la laryngoscopie directe : une étude expérimentale sur mannequin nourrisson

ObjectiveThe primary purpose of this experimental study was to compare intubation times for direct laryngoscopy with a Miller blade and for 3 VL: GlideScope® videolaryngoscope, Airtraq®, and McGrath®. MethodsSeventy-seven operators, with various experience of pediatric tracheal intubation (from none to expert), performed 10 attempts of orotracheal intubation with each device on an infant manikin. The main outcome was intubation time and secondary outcome was failure rate. ResultsThere was a significant decrease in intubation time from the first to the 10th intubation attempt with all devices (P<0.05). This decrease was no more significant following the third attempt with VL and following the fifth attempt with DL. At the time of the 10th attempt, intubation time was significantly shorter with Airtraq® as compared with all the other devices (P<0.05), but the differences were tight. Failure was significantly more frequent with DL. ConclusionIn this infant manikin model, the learning curve of the different VL was 3 attempts and the Airtraq® VL appears the airway device enabling the quickest orotracheal intubation. These experimental results need to be confirmed by clinical studies in infants and children.

Temporal variation of the leak pressure of uncuffed endotracheal tubes following pediatric intubation: an observational study

Uncuffed endotracheal tubes are still preferred over cuffed tubes in certain situations in pediatric anesthesia. Inaccurately sized uncuffed endotracheal tubes may lead to inadequate ventilation or tracheal mucosal damage during anesthesia. Endotracheal tube size in children is usually assessed by measuring the audible leak pressure; if the fit of the tube and the leak pressure decrease significantly with time, reintubation during surgery as a result of inability to ventilate effectively may be challenging, and could lead to patient morbidity. There is no evidence to indicate whether leak pressure increases or decreases with time following endotracheal intubation with uncuffed tubes in children. We measured leak pressure for 30min following tracheal intubation in 46 ASA I children age 0-7years after excluding factors known to modify leak pressure. The largest mean change in leak pressure occurred between time points 0 and 15min, an increase of 3.5cmH2O. Endotracheal tube size and type of procedure were associated with the leak pressure. In the final linear mixed model, there were no statistically significant variations in leak pressure over time (P=0.129) in this group of children. We did not identify a consistent change in leak pressure within 30min following tracheal intubation with uncuffed endotracheal tubes in this group of children.

An observational study of paediatric pre-hospital intubation and anaesthesia in 1933 children attended by a physician-led, pre-hospital trauma service

IntroductionTrauma accounts for 16–44% of childhood deaths. The number of severely injured children who require pre-hospital advanced airway intervention is thought to be small but there is little published data detailing the epidemiology of these interventions. This study was designed to evaluate the children who received pre-hospital intubation (with or without anaesthesia) in a high volume, physician-led, pre-hospital trauma service and the circumstances surrounding the intervention. MethodsWe conducted a 12 year retrospective database analysis of paediatric patients attended by a United Kingdom, physician-led, pre-hospital trauma service. All paediatric patients (<16 years of age) that were attended and received pre-hospital advanced airway intervention were included. The total number of pre-hospital intubations and the proportion that received a rapid sequence induction (RSI) were established. To illustrate the context of these interventions the ages, injury mechanisms and intervention success rates were recorded. ResultsBetween 1 January 2000 and 31 October 2011 the service attended 1933 children. There were 315 (16.3%) pre-hospital intubations. Of those intubated, 81% received a rapid sequence induction and 19% were intubated without anaesthesia in the setting of near or actual cardiac arrest. Nearly three quarters of the patients were in the age range of 6–15 years with only 3 patients under the age of 1 year. The most common injury mechanisms that required intubation were Road Traffic Crashes (RTC) and ‘falls from height’. These accounted for 79% of patients receiving intubation. Intubation success rate was 99.7% with a single failed intubation during the study period. ConclusionPre-hospital paediatric intubation is not infrequent in this high-volume trauma service. The majority of patients received a rapid sequence induction. The commonest injury mechanisms were RTCs and ‘falls from height’. Pre-hospital paediatric intubation is associated with a high success rate in this physician-led service.