Video-assisted laryngoscopy for pediatric tracheal intubation in the emergency department: a multicenter study of clinical outcomes
Miller KA, Dechnik A, Miller AF, et al. Ann Emerg Med. Published online October 15, 2022. doi:10.1016/j.annemergmed.2022.08.021
Pediatric airways have lower first-pass success rates (reported to be as low as 50%) 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) is a major point of discussion among providers, who often have strong options on the topic, as well as in the literature. Overall studies and meta-analyses have yielded mixed results. The most recent large published effort was the Videography in Pediatric Resuscitation (VIPER) trial, which did not report a higher success rate with VL among approximately 500 children.
In this study, the authors essentially asked the same question as that in VIPER, and used of 2 existing prospectively collected data sets (from the National Emergency Airway Registry for Children [NEAR4KIDS] and Pediatric Emergency Medicine Airway Education Collaborative) comprising data from 11 pediatric EDs in the United States and Canada from 2017 to 2021.
Successful attempts were defined as successful endotracheal tube placement in the trachea before removal of the laryngoscope (1 blade insertion, not 1 endotracheal tube insertion).
Data from 1,412 intubations were analyzed: the median patient age was 37 months, and VL was used in 76.2% of cases.
The overall first-attempt success rate was 70%, and the site-level variation ranged from 56.4% to 85.1%.
In multivariable regression models, VL was associated with higher first-attempt success (adjusted OR 2.01).
The authors analyzed many minor and severe adverse airway outcomes and found that patients intubated with VL had nonsignificantly lower odds of any adverse airway outcome (adjusted OR 0.74), and significantly lower odds of experiencing a severe adverse airway outcome (adjusted OR 0.70) or severe hypoxemia, defined by oxygen saturation <80% (adjusted OR 0.70).
Substantial site-level variation in VL use was observed (range from 12.9% to 97.8%), and sites with high use of VL (>80%) had higher first-attempt success even after adjustment for laryngoscope use in individual patients (adjusted OR 2.30).
This was a well-done study whose primary limitation was that it was not a trial; therefore, why VL was used in some cases and not others, or why the site-specific variation was so high, is unknown. Because practitioners could use direct VL, indirect VL, or both, the use of direct VL might perhaps have driven the difference (eg, resident looking in the mouth with a CMAC and attending looking at the screen with some coaching), but unfortunately, data on how many cases received each form of DL are not reported, and video was not collected for all cases, as in the VIPER trial, so this aspect cannot be reviewed.
EDITOR’S COMMENTARY: The authors of this well-done study come out reasonably strong in saying that we should move toward VL for all pediatric intubations, because of a combination of higher first-pass success and lower adverse airway outcomes. However, the data are observational, and despite adjustments and an excellent statistical plan, unmeasured variables might possibly explain the observed difference. Also, we need to consider the data in the context of other published studies on the topic, including VIPER, which showed no difference. It does seem like the more you use VL, the better you get at it (which makes sense), and this study opens the door to the idea that not all VL may be the same, and some techniques and devices may be better than others. I think we are at the point where you should practice and learn VL on kids but not at the point of mandated use for all cases.
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