Written by Aaron Lacy
A 2-inch shoulder roll lowered the line of sight for direct laryngoscopy in infants but had no effect on view of the glottic opening.
Why does this matter?
Whether you are an experienced pediatric anesthesiologist or an emergency physician, any intervention to improve likelihood of intubation success in an infant should be implemented during laryngoscopy.
First attempt = Best attempt
In this prospective crossover control trial, 20 infants undergoing elective urologic procedures underwent direct laryngoscopy with and without a 2-inch shoulder roll. Primary outcome, vertical distance from angle of proceduralists eye to OR table, and secondary outcome, percent of glottic opening (POGO) were calculated. There was significant reduction of proceduralist eye height to table, with no significant difference in POGO between those with and without shoulder roll (100% POGO versus 97.5% POGO, P =0.39).
The proceduralists in this study were pediatric anesthesiologists and had extensive experience in infant intubation. While they found (in a small sample size) no significant difference in POGO or intubation attempts/complications, this may be hard to generalize to other environments. In the emergency department, where proceduralists may have a less controlled environment combined with possible less infant laryngoscopy experience, every attempt should be made to maximize first-pass success rate. At this point in time, there is no evidence to show that a shoulder roll helps with first-pass success, and providers should use whatever they feel comfortable with to maximize their chances of success.
Editor’s note: A shoulder roll may help open the airway when infants are supine and spontaneously breathing, given the large occiput. It just may not make intubating easier. ~Clay Smith
The Effects of a Shoulder Roll During Laryngoscopy in Infants: A Randomized, Single-Blinded, Crossover Study. Anesth Analg. 2020 Apr 10. doi: 10.1213/ANE.0000000000004802. [Epub ahead of print]
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