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What Can We Learn from Observing Pediatric Intubations? The VIPER Collaborative

March 15, 2022

Written by Aaron Lacy

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There was no difference in first pass success rate or hypoxemic events when children were intubated with videolaryngoscopy (VL) versus direct laryngoscopy (DL). Intubations in children that took longer than 45 seconds had a greater incidence of hypoxemia, and overall, there was very low utilization of apneic oxygenation during laryngoscopy.

Why does this matter?
Emergent intubation of children is a relatively low-incidence, high-risk event. The physiology of children makes them more prone to physiologic collapse during laryngoscopy, and it is crucial to both recognize and mitigate a potential adverse event during intubation. Can we take away lessons how best to serve this population by watching films of pediatric intubations?

The best intubators watch the game film
494 intubations in children from four separate tertiary care pediatric emergency departments were prospectively observed via videography. Primary outcomes included first pass intubation success, time of laryngoscopy, and incidence of hypoxemia (<90%).

Overall, first pass success rate was 67% (329/494), and successful intubation occurred in 97% of patients (480/494). VL was used in 48% of all attempts, with 44% of all attempts using VL for the entire duration of the procedure. The authors found no difference in either first pass success rate with full duration VL vs without (75% vs 73%) or incidence of hypoxemia with full duration VL vs without (17% vs 14%); risk differences (95%CI): 2% (-8% to 12%) and 3% (-8% to 14%), respectively. Intubations lasting longer than 45 seconds had a greater incidence of hypoxia (29% versus 6%). Despite a median time to successful tube placement being 6 seconds longer in the VL group (95%CI 1-12 seconds), as noted above, there was no difference in hypoxic events.

These results have similar first pass success and hypoxemia rates compared to other out of OR studies. To me the most striking finding was that only 8% of children underwent apneic oxygenation. While there is both known and theoretical risk to hyperoxygenation, most children being intubated in the emergency department are in some type of physiologic distress/shock. In this study 149/494 participants started out with a pulse ox reading of less than 90%. In my mind these children definitely fall in the camp of needing better preoxygenation and the proven benefit of apneic oxygenation in a similar population.

So, what can we take away from watching the film? Intubating kids outside of the OR is hard. Optimize your physiology and prepare for the worst. Your first attempt should be the best attempt, as the longer you go without a tube the higher the likelihood of a bad outcome. While limited to only four sites, this study could represent a slower adoption of ApOx in children as the literature trickles over from the adult population. In the ED, my bias is that apneic oxygenation saves lives, and we should be doing it.

Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative. Ann Emerg Med. 2022 Feb 3;S0196-0644(21)01533-X. doi: 10.1016/j.annemergmed.2021.12.014. Online ahead of print.

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