Video Laryngoscopy: What We Can See and What We Cannot*

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In this issue of Pediatric Critical Care Medicine, Drs. Balabon and Tobias (1) provide an informative review of the characteristics of various commercially available video laryngoscopes and discuss their potential application in children with normal and difficult to visualize airways. This review is timely since over the past 10 years, video laryngoscopes have been adapted for use in our smallest patients, and there has been an explosion in the literature that describes endotracheal intubation in pediatric critical care. For the pediatric intensivist, the emergence of video laryngoscopy (VL) expands the options for intubation in critically ill children beyond standard direct laryngoscopy (DL). VL provides shared team views of the airway, creates novel opportunities for instruction in endotracheal intubation, and offers new options for difficult airway management.
VL has significant appeal in teaching trainees endotracheal intubation because it allows the instructor to see what the trainee sees and to provide corrective direction. In the PICU, most endotracheal intubations are likely to be nonelective and in children with poor tolerance for extended apnea time or repeated attempts by trainees. In a reports of more than 1,200 PICU endotracheal intubations, trainees had decreased success and increased complications (2, 3). Additionally, the increasing use of noninvasive methods of respiratory support makes opportunities for endotracheal intubation less frequent. Through the shared view, VL allows instructors to provide more specific and real-time feedback. In a randomized controlled trial (RCT) of 206 neonatal intubations comparing teaching with VL versus standard teaching (the video laryngoscope screen was covered), trainees had greater first attempt success when the instructor could see the video laryngoscope screen (66% vs 41%) (4). VL also provides a view of intubation for the entire team that allows all team members to more fully participate in the procedure and have common knowledge and experience.
Although there may be benefits to VL during trainee instruction, it is not clear that routine use of VL in nondifficult airways is beneficial. Multiple studies have demonstrated no superiority to standard DL in routine airways. A retrospective comparison of DL versus VL by experienced providers in more than 400 pediatric emergency patients found no difference in first attempt success, complications, or intubation success rate (5). A 2014 meta-analysis of RCTs comparing VL with DL in children found that VL had improved glottis visualization but increased time to intubate, higher frequency of intubation failure, and no difference in first attempt success rate (6).
VL also provides the pediatric intensivist with an additional modality for difficult airway management. The literature supports the value of VL in both children and adults with difficult airway. A 2016 Cochrane review of VL versus DL in over 7,000 adult endotracheal intubations in 64 studies concluded that VL may reduce number of failed intubation attempts in patients with difficult airway (7). In a pediatric difficult airway multicenter registry including 1,000 difficult airway encounters, VL increased intubation success rate (55%) versus DL (3%) and was similar to fiberoptic bronchoscopy (54%) (8). VL maybe more accessible and appealing to pediatric intensivists than fiberoptic bronchoscopy with a blade structure and airway approach similar to DL.
How to best incorporate VL into teaching trainees or managing difficult airways in the PICU is unclear. In order to effectively use VL, a degree of expertise with the device must be maintained. Despite a lack of superior outcomes in normal airway management and increased purchase and maintenance costs, there are compelling reasons to suggest VL should be routinely incorporated into the practice of endotracheal intubation of critically ill patients.

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