366 - The effect of laryngoscope blade tip position on outcomes from pediatric tracheal intubation

Tracheal intubation (TI) is a fundamental procedure in acute care.  Traditional instruction in laryngoscopy recommends the use of straight blades (SB) to lift the epiglottis in younger children and curved blades (CB) in the vallecula in older children.  Clinical data supporting these approaches is lacking.

Objective:

To determine the impact of laryngoscope blade tip position on procedural outcomes during pediatric TI.

Design/Methods:

Prospective observational study in the emergency department (ED) and pediatric intensive care unit (PICU) of a children’s hospital.  Children undergoing TI using a video laryngoscope (VL) with recorded images available for review were eligible for inclusion.  Data collected during each TI attempt included patient (age, indication for TI, difficult airway features), provider (training level), and technical aspects (use of indirect visualization via VL), and outcomes.  Each TI attempt was independently reviewed, and blade tip position was dichotomously categorized as ‘in the vallecula’ or ‘under the epiglottis.’  TI success was defined as observation of the tube entering the trachea.  Laryngoscopy duration was defined as the total time from blade insertion to blade removal.  Univariate analysis between blade tip position and TI outcome was performed by χ2 testing for dichotomous variables and nonparametric methods for continuous variables. Multivariable logistic regression was used to determine the independent association between blade tip position (vallecula vs. epiglottis) and TI success while controlling for relevant confounders.

 

Results:

191 intubation attempts were analyzed.  First attempt success was 76%.  All attempts in infants were made using SB (n=49); in older children, CB were used in 91/142 (64%).  Blade tip position was in the vallecula for 65/92 (72%) attempts with CB and 49/99 (50%) with SB. There was no univariate association between blade tip position and patient or procedural factors.  TI attempts with blade in vallecula were more successful than attempts with the blade under epiglottis (85% vs. 65%, p< 0.001).  Laryngoscopy duration was shorter for TI attempts with blade in vallecula (43 sec vs. 54 sec, p< 0.001).  On multivariate analysis controlling for patient age and blade type, blade in vallecula was independently associated with TI success (aOR 2.7, 95% CI 1.2 – 6.0).

Conclusion(s):

 During pediatric TI, laryngoscope blade tip position in the vallecula was associated with increased success when compared with placement under the epiglottis.  Future research should identify patient groups for whom specific blade placement technique optimizes outcomes.