Videolaryngoscopy in neonates
A narrative review exploring the current state of the art
Trends in Anaesthesia and Critical Care
June 2023 by Dr Ashton Speed
This article is a narrative review exploring the utility, benefits and pitfalls of the use of videolaryngoscopy in children with a specific focus on the current practice of neonatal tracheal intubation. The authors conducted a Medline search on all published articles between 2010 and 2022 and ultimately included 20 articles in their narrative review including randomised control trials, observational studies, review articles, meta-analyses and editorials.
The authors concluded that in neonates and or children with expected difficult intubation the routine use of a videolaryngoscope (VL) compared to standard direct laryngoscopy (SDL) as first device for tracheal intubation is associated with higher first attempt tracheal intubation and reduced intubation related complications. This conclusion is supported by data from the Paediatric Difficult Intubation registry (PEDI) and the multicentre RCT Videolaryngoscopy in Small Infants (VISI) trial:
• The PEDI trial found initial tracheal intubation success rate in <18yo paediatric patients with a suspected difficult intubation to be 53% with VL group compared to 4% w SDL
• The VISI trial found that VL compared with SDL improved first pass intubation in neonates and infants <6.5kg by 5%.
The Neonate and Children adult of Anaesthesia practise in Europe (NECTARINE) observational cohort study of critical events during anaesthesia in neonates and infants found that two-thirds of difficult intubations were unexpected and that the use of VL as first device for tracheal intubation was only used when difficult intubation was expected. In that study, VL was associated with reduced intubation attempts, improved first pass tracheal intubation and reduced intubation related complications. Hence, Bonfiglio and Grief have asked the question as to whether anaesthetic clinicians should be using VL as first devices for tracheal intubation in all neonates and infants less than 1yo of age – especially given the majority of difficult intubations are unexpected and VL improves first pass intubation in both neonates and children with difficult intubation.
However, the authors’ contention has not been reflected in Cochrane reviews by Lingappan et al (2018) and Abdelgadir et al (2017) which concluded that there is insufficient evidence to support the routine use of VL for neonatal intubation. Bonfiglio and Grief surmise that these findings are likely due to the heterogeneity of studies included in the Cochrane reviews and that more recent evidence in the PEDI, NECTARINE, VISI and OPTIMISE studies favour the use of VL to improve tracheal intubation management in neonates and infants with difficult intubations. This study further recommends that routine VL use might accelerate the laryngoscopy learning curve to improve clinician skillset when conducting both routine and difficult VL neonatal intubation.
There is a paucity of evidence for recommending specific VL brands and blade type when performing neonatal intubation. In children with difficult intubation, the PEDI trial found that the use hyper-angulated blades were associated with a high tracheal intubation success rate compared with VL standard blades (Miller or MAC). However, after multi-variable logistic regression analysis in patients <5kg without an expected difficult intubation, the PEDI trial found that the use of standard VL blades (MAC, MILLER) resulted in improved initial tracheal intubation success. Hence, Bonfiglio and Grief recommend the use of standard VL blades (MAC/MILLER) over hyper-angulated blades for routine neonatal tracheal intubation.
Due to lack of evidence and recommendations from paediatric and neonatal difficult airway societies the authors have not provided specific suggestions with regards to what specific VL brand should be used when conducting both routine and difficult neonatal and infant intubation. This narrative review has highlighted the potential benefit of video-laryngoscopy when managing neonatal and infant intubation and children with a difficult intubation. The authors have discussed the potential benefits of routine use of VL for neonatal intubation, namely:
• Improved first pass tracheal intubation
• Reduced intubation related complications
• Improved safety when training novice intubators
• Improved airway team situational awareness and performance