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Introduction: Classical teaching in pediatric laryngoscopy advocates the use of straight blades to be placed underneath the epiglottis, whereas curved blades are placed in the vallecula. Anesthesia studies suggest that straight blade positioning in the vallecula may be a satisfactory technique for small children. We sought to assess laryngoscope blade tip position during pediatric tracheal intubation (TI) and its association with intubation success. Methods: Observational single center study. Children undergoing TI from November 2017 until December 2018 in a pediatric emergency department (ED) and pediatric intensive care unit (PICU) using a CMAC video laryngoscope with recorded images available for review were eligible for inclusion. Patient and provider characteristics were obtained from quality improvement database. Each video was independently reviewed, and the blade tip position was determined by study personnel as ‘in vallecula’ or ‘under epiglottis’. TI success was defined as observation of the tube entering the trachea on video. Univariate analysis between blade tip position and success, as well as potential confounders, was performed by chi 2 testing. Multivariable logistic regression to determine the independent association between blade tip position and success while controlling for relevant confounders. Results: 95 TI attempts were analysed. 58% of attempts were successful (14/35 in infants, 8/15 in 1-7 yr old, 33/45 in 8+ yr, p=0.01). Blade tip position was in the vallecula for 20/31 (65%) attempts with curved blades and 23/64 (36%) with straight blades. In univariate analysis, TI attempts with blade tip position ‘in vallecula’ were significantly more successful than attempts with ‘under epiglottis’ (37% vs. 84%, p Conclusion: During pediatric TI, laryngoscope blade tip position in the vallecula was independently associated with success when compared with placement under the epiglottis.

OBJECTIVES To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. DESIGN Prospective pre/post observational study. SETTING A large single-center noncardiac PICU in North America. PATIENTS All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018. INTERVENTIONS Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement. MEASUREMENTS AND MAIN RESULTS Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34-0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31-0.96) while adjusting for tracheal intubation indications and device. CONCLUSIONS Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children.

Introduction: Classical teaching in laryngoscopy advocates the use of Miller (Straight) blades to be placed underneath the epiglottis and lift it, whereas for Macintosh (Curved) blades the tip is positioned in the vallecula. Published studies in anesthesia suggest that straight blade positioning in the vallecula may be a satisfactory technique for small children. However, there is no clear evidence of consistent implementation of this methodology in practice and associated intubation success. Objectives: To assess laryngoscope blade tip position during pediatric tracheal intubation in the emergency department (ED) and its association with intubation success and time of laryngoscopy. Methods: Single center retrospective observational cohort study. Children undergoing tracheal intubation in a tertiary pediatric ED under video-recorded conditions were eligible for inclusion. A CMAC video laryngoscope was used as first line device with the video feed recorded for review. Videos were reviewed and the blade tip position during intubation recorded by study personnel. Blade tip position was categorized as ‘Correct’ if the curved blade was in the vallecula or straight blade was lifting the epiglottis; otherwise the position was categorized as ‘Incorrect’. Time of laryngoscopy was defined as time from blade insertion to removal. Univariate analysis between covariates was done by Fisher’s exact testing for intubation success and by nonparametric methods for laryngoscopy time. Results: A total of 17 complete videos were included in the study. Mac blade was used correctly in 8/10 cases (80%); Miller was used correctly in 1/7 cases (14%). Among infants (≤ 12 months), the Miller was used incorrectly in 3/4 cases (75%). Intubation was successful in 9/9 cases (100%) with correct blade position and in 5/8 cases (63%) with incorrect position (p=0.04). There was no significant difference in mean calculated laryngoscopy time for correct versus incorrect blade tip position (37.90 ± 26.80 sec vs. 44.33± 15.22 sec, p=0.12) Conclusion: Correct position of the laryngoscope blade tip is associated with higher intubation success. There was no significant difference in the laryngoscopy time for both correct and incorrect blade position.