Comparison of conventional laryngoscopy and video supported laryngoscopy techniques in pediatric simulation manikin with normal and difficult airway scenarios

The 'motto' of the Emergency practices is the ABC, meaning the airway protection, and supporting the respiration and the circulation, especially in children. Despite the age, management of every critically ill but not arrested patient in the ED starts in these baselines. Thus, the ED practitioners are expected to be experienced and skillful in airway managements, equipments, procedures and also the alternatives as they are good resuscitators. The pediatric airway has some anatomic and physiologic differences especially in young kids, which sometimes could be a challenge for one who is unfamiliar. A large occiput, relatively small mouth, big tongue and soft tissues, small chin, cephaled and anteriorly located larynx could be potential disadvantages and dangers for a small airway to obstruct and bleed easily. A mild laryngeal irritation even emotional agitation in a mild upper airway infection could improve a serious laryngospasm also bronchospasm. The narrowest point of the pediatric airway, the cricoid ring, may not allow the tube go further, which easily passes through the vocal cords. Although the narrow cricothyroid membran is not large enough, a surgical cricothyrotomy is impossible in children younger than 10 years old. Metabolic events and rates are higher so that makes oxygen consumptions much high with disadvantages of small lungs, relatively decreased residual volumes makes time more vital. Sometimes, but not rare, lack of cooperation and agitation is another difficulty. Rare but the worst scenario is trauma patients with not empty stomachs in a ED which is more chaotic than an operating room. One of the most popular alternative intubation device is videolaryngoscope which provides indirect visualization of larynx. Several recent studies from adult and also pediatric emergency practices with difficult airway situations has reported better laryngeal visualization, intubation success rate, decreased cervical spine mobility, even better intubation times with videolaryngoscopes than direct laryngoscopy,. Even according to some studies videolaryngoscopy is suggested to be the first choice for difficult airway management . The aim of this study is to compare videolaryngoscopic intubation and direct laryngoscopic intubation in normal and difficult pediatric airway scenarios on a 6 year old pediatric simulation manikin. The difficult airway scenario is provided by cervical immobilization with cervical collar. 24 emergency residents working at a tertiary healthcare center ED, attempted totally 144 intubations with direct Macintosh laryingoscope, V-Mac and V-Miller laryngoscope blades. The intubation times, glottic visualization times, glottic visualization degrees with POGO and Cormack-Lehane visual scale, dental pressure and difficulty of intubation with VAS score was collected and evaluated. V-Mac and Mac laryngoscopes did not have a significant difference in the scenarios except for the higher dental pressure with V-Mac in normal airway scenario. This may because V-mac blade was bigger. In normal airway scenario there was no difference between the intubation and glottic visualization times; but visualization degrees was statistically higher with V-Miller laryngoscope than the others and also dental pressure was lower with V-Miller. The significant difference had occurred in difficult airway scenario. The intubation and glottic visualization times, visualization degrees, dental pressures and difficulty were statistically better with V-Miller laryngoscope. V-Miller seems to be more useful especially difficult pediatric airway scenario