Videolaryngoscopy Versus Fiber-Optic Intubation Through a Supraglottic Airway in Children With a Difficult Airway

An Analysis From the Multicenter Pediatric Difficult Intubation Registry

Nicholas E. Burjek, M.D.; Akira Nishisaki, M.D., M.S.C.E.; John E. Fiadjoe, M.D.; H. Daniel Adams, B.S.; Kenneth N. Peeples, M.P.H., M.S.W.; Vidya T. Raman, M.D.; Patrick N. Olomu, M.D.; Pete G. Kovatsis, M.D.; Narasimhan Jagannathan, M.D.

Disclosures

Anesthesiology. 2017;127(3):432-440. 

In This Article

Abstract and Introduction

Abstract

Background: The success rates and related complications of various techniques for intubation in children with difficult airways remain unknown. The primary aim of this study is to compare the success rates of fiber-optic intubation via supraglottic airway to videolaryngoscopy in children with difficult airways. Our secondary aim is to compare the complication rates of these techniques.

Methods: Observational data were collected from 14 sites after management of difficult pediatric airways. Patient age, intubation technique, success per attempt, use of continuous ventilation, and complications were recorded for each case. First-attempt success and complications were compared in subjects managed with fiber-optic intubation via supraglottic airway and videolaryngoscopy.

Results: Fiber-optic intubation via supraglottic airway and videolaryngoscopy had similar first-attempt success rates (67 of 114, 59% vs. 404 of 786, 51%; odds ratio 1.35; 95% CI, 0.91 to 2.00; P = 0.16). In subjects less than 1 yr old, fiber-optic intubation via supraglottic airway was more successful on the first attempt than videolaryngoscopy (19 of 35, 54% vs. 79 of 220, 36%; odds ratio, 2.12; 95% CI, 1.04 to 4.31; P = 0.042). Complication rates were similar in the two groups (20 vs. 13%; P = 0.096). The incidence of hypoxemia was lower when continuous ventilation through the supraglottic airway was used throughout the fiber-optic intubation attempt.

Conclusions: In this nonrandomized study, first-attempt success rates were similar for fiber-optic intubation via supraglottic airway and videolaryngoscopy. Fiber-optic intubation via supraglottic airway is associated with higher first-attempt success than videolaryngoscopy in infants with difficult airways. Continuous ventilation through the supraglottic airway during fiber-optic intubation attempts may lower the incidence of hypoxemia.

Introduction

ANESTHETIC-RELATED adverse events in children are often preceded by severe hypoxemia.[1] Multiple tracheal intubation attempts, age, weight, and abnormal airway anatomy have been associated with severe complications such as cardiac arrest in children with difficult airways.[2–4] Intubation techniques with high first pass success rates may reduce these complications, but much of the literature related to tracheal intubation approaches in children with difficult airways is limited to manikin simulations and studies with small sample sizes or single-center data. Identifying techniques with high first pass success rates in a larger population of children with difficult airways is a critical step to improving outcomes for these vulnerable patients.

The Pediatric Difficult Intubation (PeDI) Registry is a data repository of airway management techniques and outcomes in children with difficult airways, with entries from 14 academic children's hospitals in the United States.[3] It was created with the specific aim of categorizing complications and comparing various intubation approaches in children with difficult airways. Being the only repository of its kind makes it the ideal resource to study and compare outcomes of various tracheal intubation approaches in children with difficult airways.

Videolaryngoscopy produces better laryngoscopic views and greater intubation success than conventional direct laryngoscopy in adults and children with difficult airways.[5–7] Videolaryngoscopy has become an important and commonly used tool in the management of pediatric airways.[8] Flexible fiber-optic intubation through a supraglottic airway (FOI-SGA) has been advocated as an alternative for difficult pediatric airways, with certain supraglottic airway devices designed specifically for this use.[9,10] Supraglottic airways allow continuous oxygenation and ventilation while serving as a conduit for fiberoptic intubation.[11] This may be particularly advantageous, as hypoxemia is the most common precursor to intubation-related adverse events in children with difficult airways.[1] Small children (less than 1 yr) are particularly vulnerable to hypoxemia and experience more intubation-related complications than older children.[2,3] Fiber-optic intubation through a supraglottic airway may have unique advantages in this younger population. Supraglottic airways also relieve upper airway obstruction and optimize the laryngeal view with a fiber-optic bronchoscope, therefore requiring less kinesthetic skill than unguided fiber-optic bronchoscopy.[12,13] This may be particularly useful in patients with obstructive upper airway syndromes, such as Pierre Robin Sequence or Treacher–Collins syndrome, where both mask ventilation and tracheal intubation may be difficult.[9]

The primary aim of this study is to compare tracheal intubation success rates of fiber-optic intubation through a supraglottic airway to videolaryngoscopy in children with difficult airways entered in the PeDI registry. We hypothesize that FOI-SGA will have higher first pass success rates than videolaryngoscopy. Our secondary aim is to compare the associated complications of these two techniques. We additionally aim to compare the success rates of these techniques in our a priori defined subgroup, children less than 1 yr of age.

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