title: Assessment of technique during pediatric direct laryngoscopy and tracheal intubation: a simulation-based study.
abstract: OBJECTIVE
  This study aimed to assess the feasibility of characterizing direct laryngoscopy (DL) and tracheal intubation (TI) technique based on videographic review and to determine the association between technical aspects of DL and TI with successful completion of intubation.
  
  
  METHODS
  Physicians in pediatrics, emergency medicine, pediatric emergency, pediatric critical care, and neonatology performed TI on simulators (newborn, infant, and adult). A video laryngoscope was used without a display (ie, as a direct laryngoscope), and video recordings were reviewed. A scoring instrument characterized technical aspects of DL and TI; outcomes related to procedural performance were recorded. Interrater reliability of the instrument was assessed by weighted κ; collinearity was assessed by a correlation matrix. Univariate analysis determined technical aspects of DL and TI associated with outcomes.
  
  
  RESULTS
  Seventy-three subjects performed 206 intubations. Significant differences existed between simulators with respect to the first-attempt success (newborn, 63%; infant, 80%; adult, 42%; P < 0.001), laryngoscopy time (27 seconds vs 31 seconds vs 42 seconds, P < 0.001), and percentage of glottic opening score (68% vs 65% vs 35%, P < 0.001). Interrater reliability for the instrument was good (κ = 0.68); no significant collinearity existed between data points. Position of the tip of the laryngoscope blade in the vallecula and under the proximal epiglottis was associated with improved first-attempt success.
  
  
  CONCLUSIONS
  Pediatric intubation technique can be reliably assessed using videography and video laryngoscopy. Future studies should examine video-based characterization of DL and TI technique in real patients outside the operating room, as well as whether technical aspects of intubation are associated with improved outcomes.
authors.affiliation: Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. donoghue@email.chop.edu
authors.forename: Aaron
authors.initials: A
authors.lastname: Donoghue
authors.forename: Anne
authors.initials: A
authors.lastname: Ades
authors.forename: Akira
authors.initials: A
authors.lastname: Nishisaki
authors.forename: Huaqing
authors.initials: H
authors.lastname: Zhao
authors.forename: Ellen
authors.initials: E
authors.lastname: Deutsch
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005240:Feasibility Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007442:Intubation, Intratracheal / Q000379:methods*; D007828:Laryngoscopy / Q000379:methods*; D016544:Patient Simulation; D011446:Prospective Studies; D015203:Reproducibility of Results; D016896:Treatment Outcome; D014741:Video Recording / Q000379:methods*