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The Importance of Median Glossoepiglottic Fold Engagement on Laryngeal View and Tracheal Intubation Success in Children - 18/05/23

Doi : 10.1016/j.annemergmed.2022.12.027 
Preston Dean, MD, MS a, b, , Katherine Edmunds, MD, MEd a, b, Ashish Shah, MD, MEd c, Mary Frey, MSN a, Yin Zhang, MS d, Phillip Thomas, MD a, Stephanie Boyd, PhD a, Gary Geis, MD a, b, Benjamin T. Kerrey, MD, MS a, b
a Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 
b Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 
c Division of Emergency Medicine, Rady Children’s Hospital, San Diego, CA 
d Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 

Corresponding Author:

Abstract

Study objective

Our study objective was to determine if the location of laryngoscope blade tip placement is associated with clinically important tracheal intubation outcomes in a pediatric emergency department.

Methods

We conducted a video-based observational study of pediatric emergency department patients undergoing tracheal intubation with standard geometry Macintosh and Miller video laryngoscope blades (Storz C-MAC, Karl Storz). Our main exposures were direct lifting of the epiglottis versus blade tip placement within the vallecula and median glossoepiglottic fold engagement versus not when the blade tip was placed in the vallecula. Our main outcomes were glottic visualization and procedural success. We compared measures of glottic visualization between successful and unsuccessful attempts using generalized linear mixed models.

Results

Proceduralists placed the blade tip in the vallecula (indirectly lifting the epiglottis) during 123 (71.9%) of 171 attempts. When compared with indirectly lifting the epiglottis, directly lifting the epiglottis was associated with improved visualization—by percentage of glottic opening (POGO) (adjusted odds ratio [AOR], 11.0; 95% confidence interval [CI], 5.1 to 23.6) and modified Cormack-Lehane (AOR, 21.5; 95% CI, 6.6 to 69.9). When in the vallecula, engagement of the median glossoepiglottic fold was associated with improved POGO (AOR, 3.6; 95% CI, 1.9 to 6.8), modified Cormack-Lehane (AOR, 3.9; 95% CI, 1.1 to 14.1), and success (AOR, 9.9; 95% CI, 2.3 to 43.7).

Conclusions

Emergency tracheal intubation can be performed in children at a high level by directly or indirectly lifting the epiglottis. If indirectly lifting the epiglottis, median glossoepiglottic fold engagement is helpful in maximizing glottic visualization and procedural success.

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Plan


 Please see page 659 for the Editor’s Capsule Summary of this article.
 Supervising editor: Steven M. Green, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors.
 Author contributions: PD, BK, KE, AS, GG, PT, MF, YZ, and SB conceived and designed the study. PD, KE, and AS performed, and PD and BK supervised data collection. YZ provided statistical advice and analyzed the data. PD drafted the manuscript, and all authors contributed substantially to its revision. PD takes full responsibility for the paper as a whole.
 All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
 Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have no conflicts of interest to declare. The study received no funding.
 Readers: click on the link to go directly to a survey in which you can provide BDHK985 to Annals on this particular article.


© 2022  American College of Emergency Physicians. Publié par Elsevier Masson SAS. Tous droits réservés.
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Vol 81 - N° 6

P. 658-666 - juin 2023 Retour au numéro
Article précédent Article précédent
  • First-Attempt Intubation Success Among Emergency Medicine Trainees by Laryngoscopic Device and Training Year: A National Emergency Airway Registry Study
  • Samuel I. Garcia, Benjamin J. Sandefur, Ronna L. Campbell, Brian E. Driver, Michael D. April, Jestin N. Carlson, Ron M. Walls, Calvin A. Brown
| Article suivant Article suivant
  • The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children
  • Matthew E. Prekker, Ashley R. Bjorklund, Carrie Myers, Lauren Harvey, Gabriella B. Horton, Jack Goldstein, Sarah C. Usher, Robert F. Reardon, Aaron Robinson, Ashley M. Strobel, Brian E. Driver

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