(725) Assessing Laryngoscope Blade Positioning During Pediatric Intubation by Video Review

Introduction: Traditional instruction in laryngoscopy technique during pediatric tracheal intubation (TI) recommends the use of straight blades to lift the epiglottis and curved blades in the vallecula. Clinical data outside the operating room supporting this approach is lacking in current literature. We aim to determine the impact of laryngoscope blade tip position on procedural outcomes during pediatric TI.

Methods: Prospective observational study in the emergency department and intensive care unit of a tertiary children’s hospital. Children undergoing TI from November 2017 - December 2018 using a videolaryngoscope with recorded images available for review. Data collected during each TI attempt included patient data (age, indication for TI), intubator (training level), and technical aspects (indirect vs direct visualization). The 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. Hypoxemia was defined as oxyhemoglobin desaturation to < 90%. Univariate analysis between blade tip positions and TI outcomes was performed by chi-square 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: 278 intubation attempts were analyzed. First attempt success rate was 78%. Blade tip position was in the vallecula for 96/143 (67%) attempts with curved blades and 59/129 (46%) with straight blades. No univariate association found between blade tip position and patient or procedural factors. TI attempts with blade in the vallecula were more successful than attempts with the blade under the epiglottis (83% vs. 73%, p=0.05). On multivariate analysis controlling for patient age and blade type, blade in vallecula was independently associated with TI success (aOR 2.07, 95% CI 1.09 – 3.96).

Conclusions: During pediatric TI, laryngoscope blade tip position in the vallecula was associated with success when compared with placement under the epiglottis.