Difficult Pediatric Airway Management: A Randomized Trial Comparing Laryngeal Mask Airway, Video-Assisted, and Direct Laryngoscopy

Abstract

Objectives: Compare advanced airway placement (1) success rate and (2) time taken between direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult infant airway simulator. Methods: Prospective, randomized trial in an cademic, tertiary medical center. Twenty-two pediatric residents, interns, and medical students were tested between November 2013 and January 2014. Participants were provided a single training session by faculty from the subspecialties of pediatric otolaryngology, pediatric critical care medicine, and pediatric anesthesiology using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of Pierre-Robin sequence including features of micrognathia, glossoptosis, and cleft palate. Success was defined as a confirmed endotracheal intubation or correct LMA placement by the testing instructor in 120 seconds or less. Results: Direct laryngoscopy demonstrated significantly higher placement success rate (77.3%) than video-assisted laryngoscopy (36.4%, P = .0117) and LMA (31.8%, P = .0039). Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds, 95% confidence interval [CI] 59.4, 110.1), when compared with direct laryngoscopy (44.9 seconds, 95% CI 33.8, 55.9) and LMA placement (36.6 seconds, 95% CI 24.7, 48.4). Conclusions: Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway model of Pierre-Robin. Video-assisted laryngoscopy users took significantly more time to establish a successful advanced airway. Given the potential life-saving implications of advanced airway adjuncts including video laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for in this population.