The Pediatric Rigid Stylet Improves First-Pass Success Compared With the Standard Malleable Stylet and Tracheal Tube Introducer in a Simulated Pediatric Emergency Intubation.
Journal
Pediatric emergency care
ISSN: 1535-1815
Titre abrégé: Pediatr Emerg Care
Pays: United States
ID NLM: 8507560
Informations de publication
Date de publication:
01 Jun 2023
01 Jun 2023
Historique:
medline:
2
6
2023
pubmed:
26
7
2022
entrez:
25
7
2022
Statut:
ppublish
Résumé
Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI. This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct. Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm). Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.
Sections du résumé
BACKGROUND
BACKGROUND
Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI.
METHODS
METHODS
This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct.
RESULTS
RESULTS
Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm).
CONCLUSIONS
CONCLUSIONS
Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.
Identifiants
pubmed: 35876757
doi: 10.1097/PEC.0000000000002802
pii: 00006565-202306000-00012
doi:
Types de publication
Randomized Controlled Trial
Observational Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
423-427Informations de copyright
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
Disclosure: The authors declare no conflict of interest.
Références
Pacheco GS, Patanwala AE, Mendelson JS, et al. Clinical experience with the C-MAC and GlideScope in a pediatric emergency department over a 10-year period. Pediatr Emerg Care . 2021;37:e1098–e1103.
Kaji AH, Shover C, Lee J, et al. Video versus direct and augmented direct laryngoscopy in pediatric tracheal intubations. Acad Emerg Med . 2020;27:394–402.
Sakles JC, Patanwala AE, Mosier JM, et al. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Intern Emerg Med . 2014;9:93–98.
Sakles JC, Augustinovich CC, Patanwala AE, et al. Improvement in the safety of rapid sequence intubation in the emergency department with the use of an airway continuous quality improvement program. West J Emerg Med . 2019;20:610–618.
Levitan RM, Pisaturo JT, Kinkle WC, et al. Stylet bend angles and tracheal tube passage using a straight-to-cuff shape. Acad Emerg Med . 2006;13:1255–1258.
Xue FS, Luo LK, Tong SY, et al. Study of the safe threshold of apneic period in children during anesthesia induction. J Clin Anesth . 1996;8:568–574.
Donoghue AJ, Ades AM, Nishisaki A, et al. Videolaryngoscopy versus direct laryngoscopy in simulated pediatric intubation. Ann Emerg Med . 2013;61:271–277.
Rinderknecht AS, Mittiga MR, Meinzen-Derr J, et al. Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data. Acad Emerg Med . 2015;22:431–440.
Sakles JC, Kalin L. The effect of stylet choice on the success rate of intubation using the GlideScope video laryngoscope in the emergency department. Acad Emerg Med . 2012;19:235–238.
Funakoshi H, Kunitani Y, Goto T, et al. Association between repeated tracheal intubation attempts and adverse events in children in the emergency department. Pediatr Emerg Care . 2022;38:e563–e568.
Abid ES, Miller KA, Monuteaux MC, et al. Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department. Emerg Med J . 2021.
Jaber S, Rollé A, Godet T, et al. Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients. Intensive Care Med . 2021;47:653–664.
Eisenberg MA, Green-Hopkins I, Werner H, et al. Comparison between direct and video-assisted laryngoscopy for intubations in a pediatric emergency department. Acad Emerg Med . 2016;23:870–877.
Miller KA, Monuteaux MC, Nagler J. Technical factors associated with first-pass success during endotracheal intubation in children: analysis of videolaryngoscopy recordings. Emerg Med J . 2021;38:125–131.
Driver B, Dodd K, Klein LR, et al. The bougie and first-pass success in the emergency department. Ann Emerg Med . 2017;70:473–478.e1.
Driver BE, Prekker ME, Klein LR, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. JAMA . 2018;319:2179–2189.
Ohchi F, Komasawa N, Kadono N, et al. A successful case of pediatric tracheal tube exchange utilizing gum-elastic bougie and videolaryngoscope. J Pediatr Intensive Care . 2014;3:79–80.
Semjen F, Bordes M, Cros AM. Intubation of infants with Pierre Robin syndrome: the use of the paraglossal approach combined with a gum-elastic bougie in six consecutive cases. Anaesthesia . 2008;63:147–150.
Camkiran A, Pirat A, Akovali NV, et al. Combination of laryngeal mask airway and pediatric Boussignac bougie for difficult tracheal intubation in a newborn with Goldenhar syndrome. Anesth Analg . 2012;115:737–738.
Wilson E, Reynolds K, Peutrell J. A bougie for a 2.5mm tracheal tube. Paediatr Anaesth . 2000;10:227.
Komasawa N, Hyoda A, Matsunami S, et al. Utility of a gum-elastic bougie for difficult airway management in infants: a simulation-based crossover analysis. Biomed Res Int . 2015;2015:617805.
Cho T, Komasawa N, Hattori K, et al. Gum-elastic bougie efficacy for tracheal intubation during continuous chest compression in infants—a crossover simulation trial. J Emerg Med . 2016;51:19–24.
Bai W, Golmirzaie K, Burke C, et al. Evaluation of emergency pediatric tracheal intubation by pediatric anesthesiologists on inpatient units and the emergency department. Paediatr Anaesth . 2016;26:384–391.
Strobel AM, Driver BE, Slusher T, et al. Adjunct devices for the pediatric difficult airway: a case report. Ann Emerg Med . 2022;79:348–351.
Driver BE, Semler MW, Self WH, et al. Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients undergoing tracheal intubation: a randomized clinical trial. JAMA . 2021;326:2488–2497.