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How to Get the Best Glottic View in Kids

July 14, 2023

Written by Vivian Lei

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Emergency intubation in children has similar procedural success rates when directly or indirectly lifting the epiglottis. When indirectly lifting the epiglottis, engagement of the median glossoepiglottic fold is associated with better visualization and success.

The view is better with VL
Kids are less tolerant of prolonged and multiple intubation attempts compared to adults, so it is helpful to know how to get the best view and maximize your chances of success. Based on video-based prospective observational data of pediatric emergency department intubations using Macintosh and Miller laryngoscope blades, researchers assessed glottic visualization and procedural success in 171 intubation attempts with intraoral video recordings. The blade tip was placed in the vallecula 71.9% of the time (indirectly lifting the epiglottis). Patients who had the epiglottis lifted indirectly were older (average age of 41.2 months vs 10.4 months). When placing the blade tip in the vallecula, median glossoepiglottic fold engagement occurred in 68% of cases and was associated with improved glottic visualization, improved attempt success, and shorter attempt duration. Directly lifting the epiglottis was associated with better glottic visualization but not with improved procedural success.

How will this change my practice?
I may not always choose to indirectly lift the epiglottis during pediatric intubations. But when I do, I will make sure my laryngoscope blade engages the median glossoepiglottic fold.

Editor’s note: We have seen this before in adults. The key to lifting the epiglottis is engagement of the median glossoepiglottic fold. ~Clay Smith

The Importance of Median Glossoepiglottic Fold Engagement on Laryngeal View and Tracheal Intubation Success in Children. Ann Emerg Med. 2023 Jun;81(6):658-666. doi: 10.1016/j.annemergmed.2022.12.027. Epub 2023 Feb 15.

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