Tracheal Intubation: Developing a View on Video Laryngoscopy*

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For many years, tracheal intubation and ventilation has been one of the core services rendered to critically ill children by ICUs. Although mechanical ventilation has been a lifesaving measure for thousands of children, tracheal intubation has been one of the riskiest moments in that process (1), with considerable variation from unit to unit. Under the best of circumstances, tracheal intubation carries risks, and those risks escalate in the presence of complicating factors such as severe illness, respiratory failure, shock, and airways that may be difficult to visualize and/or access (2).
Recently, there have been innovations in the technology available to assist tracheal intubation, and an increased focus on the process of quality improvement and safety around PICU procedures (3–6). Over the same period, there has been an increase in the use of noninvasive ventilation (NIV) in PICU which may well have decreased the number of intubations performed in ICUs. Worryingly the rate of complications during tracheal intubation following NIV may be particularly high (7).
In this issue of Pediatric Critical Care Medicine, Grunwell et al (8) have published data from the National Emergency Airway Registry for Children showing how the use of video laryngoscopy (VL) for tracheal intubation in PICUs within the registry has increased progressively over a period of 5 years. Their data (analyzing 8,875 intubation events) showed marked variability in use of VL between different centers (median 2.6%, with range from 0% to 55%). Several devices (the C-MAC being the most common at 71.9%) were used for VL. VL was used most frequently in children with older age, higher Pediatric Index of Mortality 2 scores and in those with a history of difficult airways. While overall adverse events associated with tracheal intubation seemed to be less frequent with VL, there was no reduction in serious adverse events on intubation.
A meta-analysis of the use of VL in adult ICUs (vs conventional direct laryngoscopy) showed a reduced risk of difficult laryngeal visualization and orotracheal intubation with VL. In additional, oesophageal intubation was reduced and first attempt success was improved with VL (9). Similarly to Grunwell et al (8), the review showed no statistically significant improvement for severe hypoxemia, severe cardiovascular collapse, or airway injury (9). By contrast, a meta-analysis of VL in children demonstrated that although VLs improved glottis visualization, this was associated with prolonged time to intubation and increased failures (10).
One of the apparent advantages related to VL is the fact that images of the airway may be seen by people other than the intubator, and these images may be recorded during the procedure. That provides an opportunity for supervision of procedures and for training, as the supervisor is potentially able to provide real-time feedback to the operator as to how to optimize the situation and carry the intubation through to successful conclusion. Thus, VL may be an important adjunct to airway training (11), although it is probably still important for trainees to develop skills in direct laryngoscopy for intubation.
A relatively small proportion of urgent intubations outside of the operating theater environment would be classified as “difficult airways.” There are both adult (12) and pediatric data (10) to suggest that VL improves visualization of the airway during intubation, and this may contribute to a reduction in adverse events even when the airway is not complicated. There is even evidence that under extreme pressure such as intubation during cardiac arrest, the use of VL is associated with improved rates of successful intubation on first attempt (13). An aspect of airway management in the PICU that is rarely reviewed is the extubation of a child for whom intubation was difficult.

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