Lights, Camera, Action!

!

Dr!J!Peyton!MBChB!MRCP!FRCA!

Society!for!Pediatric!Anesthesia!Annual!Mee;ng!April!2016!

Conflicts!of!Interest!

•  I!have!no!conflicts!of!interest!to!declare!

15!minutes…!

•  Is!there!evidence!to!support!the!use!of!videolaryngoscopy!(VL)!in!children?!

•  What!about!in!children!who!are!difficult!to!intubate?!

•  Should!we!use!it!more!oQen?!•  Are!my!two!opponents!completely!wrong?!

I!aim!to!convince!you!that!VL…!•  Improves!the!laryngoscopic!view!•  Increases!the!chance!of!a!successful!intuba;on!

•  Facilitates!teaching!!•  Enables!real!;me!documenta;on!of!a!fundamental!anesthe;c!procedure!

•  Is!the!natural!successor!to!direct!laryngoscopy!(DL)!

Why!is!DL!so!popular?!•  46%!of!PeDI!registry!cases!had!DL!as!the!first!choice!technique!10!

•  Simple!•  Cheap!•  Been!around!for!a!very!long!;me!•  Very!successful!in!children!(usually!)!

There’s!a!problem!

•  Difficult!intuba;on!has!been!es;mated!to!occur!in!0.5[1%!of!children!10,27,28!

•  May!be!as!high!as!5%!in!children!<1!year!27,28!•  Difficulty!intuba;ng!is!unan;cipated!in!20%!of!cases!10!

•  PeDI!registry!data:!Hypoxia!9%!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Cardiac!arrest!2%!

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Video:!Fly!with!the!Red!Arrows,!The!Science!Museum,!London!

Alignment!is!key!in!DL!

Karsli!C.!Managing!the!challenging!pediatric!airway:!Con;nuing!Professional!Development.!Can$J$Anaesth.$2015;62(9):1000616.!!

VL!improves!laryngoscopic!view!

•  Mul;ple!studies!show!improved!view!compared!to!DL!1[9!

•  Different!VLs!have!different!designs!•  More!work!is!needed!to!establish!which!device,!if!any,!is!beger!

•  It!will!depend!upon!both!device!and!pa;ent!characteris;cs!

VLs!can!see!around!the!corner…!

Glidescope,!Verathon!website!! C[Mac,!Storz!website!

Does!VL!help!you!to!intubate?!

•  PeDI!Registry!data!10:!!•  83%!of!VL!agempts!were!with!the!Glidescope!

DL# VL#

1st!Agempt!Success!

3%! 55%!

Fiadjoe!JE,!Nishisaki!A,!Jagannathan!N,!Hunyady!AI,!Greenberg!RS,!Reynolds!PI,!et!al.!Airway!management!complica;ons!in!children!with!difficult!tracheal!intuba;on!from!the!Pediatric!Difficult!Intuba;on!(PeDI)!registry:!a!prospec;ve!cohort!analysis.!Lancet!Respir!Med.!2016;4(1):37[48.!!

Does!VL!help!you!to!intubate?!

•  May!take!longer!to!insert!the!endotracheal!tube,!3,5[7!but!then!again,!it!may!not!8[12!

•  No!evidence!of!clinically!significant!differences!in!;me!taken!to!intubate!

•  Morbidity!and!mortality!are!associated!with!number!of!agempts!at!laryngoscopy!10,19,20!

Teaching!

•  It!can!be!used!to!teach!laryngeal!anatomy!and!intuba;on!technique!1,13[18!

•  May!also!be!used!remotely!17,18!

Documenta;on!

•  Contemporaneous!documenta;on!of!intuba;on!is!important!20!

•  A!recording!can!be!used!as!a!permanent!record!of!intuba;on!in!the!pa;ent’s!chart!

•  Easily!stored!in!electronic!medical!records!

!All!I!need!is!an!LMA!

All!I!need!is!an!LMA!

•  Great!if!you!don’t!need!to!intubate!!•  Excellent!rescue!devices!•  Good!conduit!for!fibreop;c!intuba;on!whilst!allowing!con;nuous!oxygena;on/ven;la;on!

•  Vital!part!of!modern!anesthe;c!prac;ce!

Supraglooc!airway!devices!can!fail!

•  Failure!rate!≈1%!in!normal!children!22,23!•  Higher!in!children!with!abnormal!airway!anatomy!22,23!(4[5%)!

•  PeDI!registry!data10:!17%!poor!ven;la;on!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!2%!impossible!placement!

All!I!need!is!an!LMA!

Youtube!

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!Fibreop;cs!are!Fun!!

! ! ! ! !!

Some;mes!you!have!no!choice!

Fibreop;cs!are!fun!!

They!can!be!complicated!

Infec;on?!

•  Over!a!42!year!period!(1970[2012),!48!outbreaks!of!bronchoscopy[related!infec;ons!were!reported!23!

•  198!pa;ents!were!cross[contaminated!23!•  P.!aeruginosa!and!Klebsiella!pneumoniae!have!also!been!transmiged!24[26!

!

My!old!rugby!coach!

“It!doesn’t!mager!where!that!ball!has!been.!It!doesn’t!mager!where!it!is!now.!What!magers!is!where!it!will!be…”!

Alvin!Williams,!Penzance!!Pirates!RFC!and!Cornwall!County!

Choose!VL…!

•  It!is!a!beger!technique!than!DL!for!difficult!intuba;on!

•  Gives!you!a!beger!view!and!more!chance!of!success!at!intuba;ng!!

•  It!is!simple!•  Facilitates!teaching!and!learning!•  Allows!real!;me!documenta;on!of!intuba;on!

Picture:!The!Minack!Archive!

References!

VL!improves!the!view!

Time!to!intubate!slower!than!DL!

3.!Fiadjoe!JE,!Gurnaney!H,!Dalesio!N,!Sussman!E,!Zhao!H,!Zhang!X,!et!al.!A!prospec;ve!randomized!equivalence!trial!of!the!GlideScope!Cobalt®!video!laryngoscope!to!tradi;onal!direct!laryngoscopy!in!neonates!and!infants.!Anesthesiology.$2012;116(3):62268.$5.!Vlagen!A,!Aucoin!S,!Litz!S,!Macmanus!B,!Soder!C.!A!comparison!of!the!STORZ!video!laryngoscope!and!standard!direct!laryngoscopy!for!intuba;on!in!the!Pediatric!airway[[a!randomized!clinical!trial.$Paediatr$Anaesth.$2009;19(11):110267.$

7.!Singh!R,!Singh!P,!Vajifdar!H.!A!comparison!of!Truview!infant!EVO2!laryngoscope!with!the!Miller!blade!in!neonates!and!infants.!Paediatr$Anaesth.$2009;19(4):338642.$

6.!Macnair!D,!Baraclough!D,!Wilson!G,!Bloch!M,!Engelhardt!T.!Pediatric!airway!management:!comparing!the!Berci[Kaplan!Video!Laryngoscope!with!direct!laryngoscopy.$Paediatr$Anaesth.$2009;19(6):577680.$

Time!to!intubate!faster!or!no!different!than!DL!

8.!Armstrong!J,!John!J,!Karsli!C.!A!comparison!between!the!GlideScope!Video!Laryngoscope!and!direct!laryngoscope!in!paediatric!pa;ents!with!difficult!airways![!a!pilot!study.!Anaesthesia.$2010;65(4):35367$$$9.!Riad!W,!Moussa!A,!Wong!DT.!Airtraq!versus!Macintoch!laryngoscope!in!intuba;on!performance!in!the!pediatric!popula;on.!Saudi$J$Anaesth.$2012;6(4):33265.$$11.!White!M,!Weale!N,!Nolan!J,!Sale!S,!Bayley!G.!Comparison!of!the!Cobalt!Glidescope!video!laryngoscope!with!conven;onal!laryngoscopy!in!simulated!normal!and!difficult!infant!airways.!Paediatr$Anaesth.$2009;19(11):1108612.$$12.!Rodriguez[Nunez!A,!Oulego[Erroz!I,!Perez[Gay!L,!Cor;nas[Diaz!J.!Comparison!of!the!GlideScope!Videolaryngoscope!to!the!standard!Macintosh!for!intuba;on!by!pediatric!residents!in!simulated!child!airway!scenarios.!Pediatr$Emerg$Care.$2010;26(10):72669.$!

VL!as!a!teaching!tool!1.!Weiss!M,!Schwarz!U,!Dillier!CM,!Gerber!AC.!Teaching!and!supervising!tracheal!intuba;on!in!paediatric!pa;ents!using!videolaryngoscopy.!Paediatr$Anaesth.$2001;11(3):34368!13.!Moussa!A,!Luangxay!Y,!Tremblay!S,!Lavoie!J,!Aube!G,!Savoie!E,!et!al.!Videolaryngoscope!for!Teaching!Neonatal!Endotracheal!Intuba;on:!A!Randomized!Controlled!Trial.!Pediatrics.$2016.!14.!Donoghue!AJ,!Ades!AM,!Nishisaki!A,!Deutsch!ES.!Videolaryngoscopy!versus!direct!laryngoscopy!in!simulated!pediatric!intuba;on.!Ann$Emerg$Med.$2013;61(3):27167.!15.!Lees!M,!Seal!RF,!Spady!D,!Csanyi[Fritz!Y,!Robinson!JL.!Randomized!trial!of!success!of!pediatric!anesthesiologists!learning!to!use!two!video!laryngoscopes.!Paediatr$Anaesth.$2013;23(5):43569.!16.!Low!D,!Healy!D,!Rasburn!N.!The!use!of!the!BERCI!DCI!Video!Laryngoscope!for!teaching!novices!direct!laryngoscopy!and!tracheal!intuba;on.!Anaesthesia.$2008;63(2):1956201.!!17.Berg!BW,!Beamis!EK,!Murray!WB,!Boedeker!BH.!Remote!videolaryngoscopy!skills!training!for!pre[hospital!personnel.!Stud$Health$Technol$Inform.$2009;142:3163.$18.Boedeker!BH,!Berg!BW,!Bernhagen!M,!Murray!WB.!Direct!versus!indirect!laryngoscopic!visualiza;on!in!human!endotracheal!intuba;on:!a!tool!for!virtual!anesthesia!prac;ce!and!teleanesthesiology.$Stud$Health$Technol$Inform.$2008;132:3166.$$

Other!references!10.!Fiadjoe!JE,!Nishisaki!A,!Jagannathan!N,!Hunyady!AI,!Greenberg!RS,!Reynolds!PI,!et!al.!Airway!management!complica;ons!in!children!with!difficult!tracheal!intuba;on!from!the!Pediatric!Difficult!Intuba;on!(PeDI)!registry:!a!prospec;ve!cohort!analysis.!Lancet$Respir$Med.$2016;4(1):37648.$$19.!Mort!TC.!Emergency!tracheal!intuba;on:!complica;ons!associated!with!repeated!laryngoscopic!agempts.$Anesth$Analg.$2004;99(2):607613$20.!Peterson!GN,!Domino!KB,!Caplan!RA,!Posner!KL,!Lee!LA,!Cheney!FW.!Management!of!the!difficult!airway:!a!closed!claims!analysis.!Anesthesiology.$2005;103(1):3369$$21.!Jagannathan!N,!Sequera[Ramos!L,!Sohn!L,!Wallis!B,!Shertzer!A,!Schaldenbrand!K.!Elec;ve!use!of!supraglooc!airway!devices!for!primary!airway!management!in!children!with!difficult!airways.!Br!J!Anaesth.!2014;112(4):742[8.!22.!Mathis!MR,!Haydar!B,!Taylor!EL,!Morris!M,!Malviya!SV,!Christensen!RE,!et!al.!Failure!of!the!Laryngeal!Mask!Airway!Unique™!and!Classic™!in!the!pediatric!surgical!pa;ent:!a!study!of!clinical!predictors!and!outcomes.!Anesthesiology.!2013;119(6):1284[95!23.!Kovaleva!J,!Peters!FT,!van!der!Mei!HC,!Degener!JE.!Transmission!of!infec;on!by!flexible!gastrointes;nal!endoscopy!and!bronchoscopy.$Clin$Microbiol$Rev.$2013;26:2316254.$24.!Schelenz!S,!French!G.!An!outbreak!of!mul;drug[resistant!Pseudomonas!aeruginosa!infec;on!associated!with!contamina;on!of!bronchoscopes!and!an!endoscope!washer[disinfector.!J!Hosp!Infect.!2000;46:23[30.!

Other!references!25.!Sorin!M,!Segal[Maurer!S,!Mariano!N,!Urban!C,!Combest!A,!Rahal!JJ.!Nosocomial!transmission!of!imipenem[resistant!Pseudomonas!aeruginosa!following!bronchoscopy!associated!with!improper!connec;on!to!the!Steris!System!1!processor.!Infect!Control!Hosp!Epidemiol.!2001;22:409[413.!26.!Machida!H,!Seki!M,!Yoshioka!N,!Yabuno!K,!Miyawaki!K,!Yoshida!H,!Yamamoto!N,!Hamaguchi!S,!Tomono!K.!Correla;on!between!outbreaks!of!mul;drug[resistant!Pseudomonas!aeruginosa!infec;on!and!use!of!bronchoscopes!suggested!by!epidemiological!analysis.!Biol!Pharm!Bull.!2014;37:26[30.!27.!Heinrich!S,!Birkholz!T,!Ihmsen!H,!Irouschek!A,!Ackermann!A,!Schmidt!J.!Incidence!and!predictors!of!difficult!laryngoscopy!in!11,219!pediatric!anesthesia!procedures.$Paediatric$anaesthesia.$2012;22(8):729636!28.!Graciano!AL,!Tamburro!R,!Thompson!AE,!Fiadjoe!J,!Nadkarni!VM,!Nishisaki!A.!Incidence!and!associated!factors!of!difficult!tracheal!intuba;ons!in!pediatric!ICUs:!a!report!from!Na;onal!Emergency!Airway!Registry!for!Children:$NEAR4KIDS.$Intensive$Care$Med.$2014;40(11):1659669.$$!$!!!$