Using Video-recorded Laryngoscopy to Evaluate Laryngoscopic Blade Approach and Adverse Events in Children

Abstract

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.