Videolaryngoscopy for difficult tracheal intubation in critically ill children

Critically ill children present unique challenges for tracheal intubation during stabilisation. Planning for induction of anaesthesia involves preparation for all potential airway management consequences, including a ‘cannot intubate, cannot oxygenate’ scenario.

The Difficult Airway Society (DAS) guidelines for children prescribe a step‐wise approach including direct laryngoscopy (≤ 4 attempts) and suggest the use of a bougie, a straight blade and smaller tracheal tube in difficult cases [1]. However the role of videolaryngoscopy is not clearly defined. The availability and expertise in the use of videolaryngoscopy has improved globally and there are a range of paediatric size blades available now.

Limiting direct laryngoscopy (≤ 2 attempts) and quickly transitioning to an indirect technique such as videolaryngoscopy would enhance patient safety [2]. A recent editorial goes one step further stating that regardless of clinical specialty or patient location to ‘make the first attempt at tracheal intubation your best attempt’ [3] using all available aids.

Delays during tracheal intubation and multiple attempts are associated with increased complications in 20% and cardiac arrest in 2% of children presenting with difficult airway [2]. In addition, there is a lag in response time to capnography, and auscultation can be challenging if lung compliance is poor. Hence, the use of early videolaryngoscopy provides maximum opportunity for successful tracheal intubation and allows visual confirmation by more than one individual.

The DAS guidelines for critically ill adults recommends videolaryngoscopy and preparation for front‐of‐neck airway after the first failed attempt at tracheal intubation [4]. Clinicians should consider a videolaryngoscope early in critically ill children similar to the adult algorithm.