Tracheal intubation is a routine and sometimes lifesaving procedure which is often required in anaesthetised infants. There are increased risks of complications including neurological injury, cardiac arrest and death with repeated intubation attempts and unsuccessful tracheal intubations.
The most popular tool used for tracheal intubation in infants is the standard Miller direct laryngoscope, where the clinician intubates with a direct line of sight. However, video laryngoscopes are becoming more widely used. These have a camera at their distal tip that displays a magnified image of the airway on a monitor.
An advantage of video laryngoscopes is that inexperienced operators can be guided by more experienced staff who can see the image on the monitor, allowing coaching and guidance, or intervention if needed, thus improving training of anaesthetists and safety for children being intubated.
Video laryngoscopes are associated with a higher first-attempt success rate than standard direct laryngoscopes in infants with difficult airways. Video laryngoscopes can have standard blades, similar to those on the traditional direct laryngoscopes or have non-standard blades which are acutely curved. The different blade designs have different learning curves and techniques for intubation.
There is still some discussion around which type of laryngoscopy (direct or video) and which type of videolaryngoscope blade (standard or non-standard) allow the easiest tracheal intubation and which have the best first-attempt success rate in children. The optimum choice may be dependent on age and difficulty of intubation.
In order to resolve this uncertainty for infants, a recent study was conducted by the Pediatric Difficult Intubation Registry group (PeDI-Reg). The group is an international collaboration dedicated to assessing, understanding and improving the outcomes of children with Difficult Direct Laryngoscopy with the aim of making airway management safer.
This study was an international, multicentre, randomised controlled clinical trial at four children’s hospitals in the US and Perth Children’s Hospital in WA, which aimed to compare the first-attempt success rate using a video laryngoscope with a standard blade with direct laryngoscopy for orotracheal intubation. Children aged younger than 12 months, undergoing a non-cardiac procedure lasting longer than 30 minutes that required general anaesthesia, were intubated by an anaesthetist.
In total 282 infants were assigned to each group – standard video laryngoscopy or direct laryngoscopy. Unsuccessful intubation with either device was rare with 93% of patients having a successful first attempt with standard video laryngoscopy compared with 88% in the direct laryngoscopy group. The number of attempts was lower in the video laryngoscopy group than in the direct laryngoscopy group. Fewer severe complications occurred in the video laryngoscopy group than in the direct laryngoscopy group.
The finding that video laryngoscopy was associated with fewer oesophageal intubations has important clinical implications. Assuming that 500,000 infants are orotracheally intubated annually worldwide, an improvement in first-attempt success rate from 88% to 93% will prevent 25,000 multiple intubations and 10,500 oesophageal intubations and their potential associated adverse events.
Overall, it was found that, among infants presenting for elective surgery, the first-attempt success rate of orotracheal intubation in infants was higher using video laryngoscopy with a standard blade compared with direct laryngoscopy and was associated with fewer severe complications. The first-attempt success rate of video laryngoscopy was markedly greater than that of direct laryngoscopy for infants weighing 6.5kg or less.
Author competing interests – the author was involved in the trial mentioned