An approach to difficult airway in infants: Comparison of GlideScope® Spectrum LoPro, GlideScope® Spectrum Miller and conventional Macintosh and Miller blades in a simulated Pierre Robin sequence performed by 90 anesthesiologists

Abstract

Background Airway management can be challenging in neonates and infants. The Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis and airway obstruction. The airway management of these patients poses great challenges for anesthesiologists and pediatricians alike. To date, there has been no direct comparison of the hyperangulated GlideScope® Spectrum LoPro (GLP), the straight GlideScope® Spectrum Miller (GSM), a conventional Macintosh (MC) and a conventional Miller blade (ML) in patients with PRS. Methods For this purpose, 90 anesthesiologists (43 with limited experience, 47 with extensive experience) performed orotracheal intubation on an Air-Sim® Pierre Robin X manikin using GLP, GSM, MC and ML in randomized order. ‘Time-to-vocal-cords’, ‘time-to-intubate’, ‘time-to-ventilate’, the severity of oral-soft-tissue-trauma and the subjective evaluation of each device were recorded. Results A significantly faster and better view of the vocal cords and lower oral-soft-tissue-trauma was achieved using the GLP (p<0.001). Though, there were no significant differences in the ‘time-to-intubate’ or ‘time-to-ventilate’. The highest intubation success rate was found with GSM and the lowest with GLP (GSM 100%, ML 97.8%, MC 96.7%, GLP 93.3%). When using the videolaryngoscopes, there were no undetected esophageal intubations but in six cases prolonged attempts of intubation (>120s) with the GLP. In the sub-group with extensive experience, we found significantly shorter intubation times for the GSM and ML. The GLP was the tool of choice for most participants, while the conventional MC received the lowest rating. Conclusions Videolaryngoscopy leads to increased safety for the prevention of undetected esophageal intubation in the airway management in a PRS manikin. Hyperangulated blades may ensure a good and fast view of the vocal cords and low oral-soft-tissue-trauma but pose a challenge during the placement of the tube. Specific skills and handling seem to be necessary to ensure a safe tube placement with this sort of blades.

Airway management in a two‐year‐old child with a tongue tumor using video laryngoscope‐assisted flexible bronchoscopic nasotracheal intubation (hybrid technique)

“…11 Irouschek and colleagues, found in a study using a Pierre Robin Manikin, that curved video laryngoscope blades provided a significantly faster and better view of the vocal cords and reduced oral soft tissue trauma compared to standard video and conventional blades. 12 Our young patient's tumor was so unfavorably located that direct laryngoscopy would have put pressure on the tumor. Even a video laryngoscope with a standard straight blade would have been likely to cause pressure injury to the tumor.…”

“…They concluded, that the GlideScope® required less force to obtain similar or better laryngoscopic views 11 . Irouschek and colleagues, found in a study using a Pierre Robin Manikin, that curved video laryngoscope blades provided a significantly faster and better view of the vocal cords and reduced oral soft tissue trauma compared to standard video and conventional blades 12 …”

“…If an adequate view is obtained with video laryngoscopy, but the tracheal tube cannot be successfully maneuvered through the glottic opening, the flexible bronchoscope can be used as a steerable stylet to facilitate tracheal intubation 9 . This situation can occur during video laryngoscopy especially with hyperangulated blades, where the view is usually better, but the intubation is sometimes technically more difficult 9,12,20 . In these cases, the flexible bronchoscope could be a rescue option 9 .…”

“… 9 This situation can occur during video laryngoscopy especially with hyperangulated blades, where the view is usually better, but the intubation is sometimes technically more difficult. 9 , 12 , 20 In these cases, the flexible bronchoscope could be a rescue option. 9 Another advantage of the hybrid technique are the two different cameras.…”

Airway Management in a Pediatric Patient Presenting with Pierre-Robin Sequence

“…The Spectrum Miller blade showed the highest intubation success rate, though no significant differences were demonstrated in time to intubate and time to ventilate among blades. 8 A 2022 case report advocates for the use of hyperextension and cricoid pressure in combination with video laryngoscopy as a means of improving vocal cord visualization; however, this was performed in a four-year-old patient and not in a neonate. 9 Another recent case report even described the use of a video ureteroscope for endoscopic airway visualization to facilitate the placement of an oral endotracheal tube in a patient undergoing mandibular distraction.…”