Videographic assessment of tracheal intubation technique in a network of pediatric emergency departments: a report by the videography in pediatric resuscitation (VIPER) collaborative
Donoghue A, O’Connell K, Neubrand T, et al. Ann Emerg Med. 2022;79(4):333-343.
Pediatric airways have lower first-pass success rates and higher rates of physiologic deterioration than adult airways, probably because they are performed less often, and because of differences in airway anatomy and in physiologic predisposition to bradycardia.
The value of video laryngoscopy (VL) remains debated. A Cochrane meta-analysis including 12 trials and 803 children has concluded that VL is associated with higher intubation failure and longer intubation times, whereas data from the National Emergency Airway Registry (NEAR) group have shown superiority of VL, and the Videolaryngoscopy in Small Infants (VISI) trial (from an OR) has indicated a 5% higher first-pass success rate and lower rates of esophageal intubation with VL than direct laryngoscopy in infants <1 year old.
This article reports data from the Videography in Pediatric Resuscitation (VIPER) Collaborative.
The study examined observational data from 4 EDs where all resuscitations are video-recorded, and focused on 3 outcomes of interest: (1) tracheal intubation success, (2) time of laryngoscopy, and (3) occurrence of hypoxemia.
The patients were categorized as infants (<1 year old) or children (>1 year old).
Successful attempts were defined by successful endotracheal tube placement in the trachea before removal of the laryngoscope (1 blade insertion, not 1 ET tube insertion).
Of 494 patients with video data, the overall first-pass success rate was 67%, and the eventual success rate was 97%; the median duration of laryngoscopy was 35 seconds, and hypoxemia occurred in 15% of patients.
VL was used in 48% of attempts, and showed no association with success or the incidence of hypoxemia. VL intubations were longer, but the clinical significance of this finding was unclear (6-second difference between medians).
Other interesting observations included that apneic oxygenation was observed in only 8% of cases, and adjunctive techniques, such as cricoid pressure, external laryngeal manipulation, and lip retraction, were very rarely used.
This study provides a good picture of the landscape of pediatric airways, seen through the lens of pediatric EDs.
A unique aspect was the use of video review to collect data; excellent inter-rater reliability was observed, and the data had very little missing information and almost no poor-quality clips.
The major study limitation is that it used observational data and was not a trial; moreover, why a given method was chosen over the other in any cases is unknown.
EDITOR’S COMMENTARY: In this multisite observational study, the authors did not observe an increased success rate when VL was used in pediatric patients. The overall first-pass success rate was two-thirds, which validates just how difficult this procedure is even in pediatric EDs. The absence of a clear advantage with VL is a meaningful message suggesting that we don’t need to immediately invest in pediatric VL equipment and training—it is probably good to have as a backup but is not a mandatory new first line.