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How to Get Pediatric ETT First-Pass Success – VL For the Win!

November 25, 2022

Written by Lillian Harry

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Previously, first-attempt success rates for pediatric intubations hovered around 50%. Video-assisted laryngoscopy significantly increased first-attempt success rates and also had fewer adverse outcomes.

Why does this matter?
Data published earlier this year by the VIPER Collaborative did not show significant improvement in intubation outcomes using videolaryngoscopy; however, that study strictly defined VL as indirect laryngoscopy (looking at the screen, not the patient). Pediatric intubation remains a low frequency, high risk procedure, and it is imperative to improve success rates.

The VL Wins Again
Two national airway consortiums collected data from 11 different pediatric EDs in the United States and Canada totalling 1,412 emergency pediatric intubations. This study differs from the VIPER Collaborative, where they only used the video monitor display during intubation. The primary outcomes were first-attempt success and adverse airway outcomes. In addition to all the adverse airway outcomes, hypoxia was also subcategorized into moderate (SpO2 <90%) and severe (SpO2 <80%). 

First-attempt success occurred in 970 of 1,386 (70.0%) encounters. The use of video-assisted laryngoscopy (VAL) was associated with a higher odds of first-attempt success (OR 2.01). 30.2% of encounters had at least one adverse airway outcome, 17.3% had severe adverse airway outcomes. 24.6% had moderate hypoxemia, and 18.7% had severe hypoxemia. Patients intubated with VAL didn’t have a significant reduction of any adverse outcome, but they did have a 30% reduced odds of experiencing severe adverse airway outcome. The sites that used VAL more often had higher odds of first-attempt success. Older children also had greater likelihood of first-attempt success and fewer adverse outcomes. 

When using the videolaryngoscope, providers often use a combination of direct laryngoscopy to visualize the anatomy in addition to the aid of the display screen from the videolaryngoscope to help improve chances of success. Given the lower risk of severe adverse outcomes and higher first-pass success, providers in all EDs should be comfortable with using VAL for pediatric intubations, and it will likely become the standard of care. 

Peer reviewed by Dr. Ketan Patel

Editor’s note: Future study of VL should specify the device used and blade geometry. It’s inadequate to only say ‘VL’; it’s not even enough to say ‘Storz’ or ‘Glidescope,’ as both have standard geometry and hyperangulated blades. ~Clay Smith

Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes. Ann Emerg Med. 2022 Oct 15:S0196-0644(22)00604-7. doi: 10.1016/j.annemergmed.2022.08.021. Epub ahead of print.

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