• Preston Dean, Katherine Edmunds, Ashish Shah, Mary Frey, Yin Zhang, Phillip Thomas, Stephanie Boyd, Gary Geis, and Benjamin T Kerrey.
• Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH. Electronic address: preston.dean@cchmc.org.
• Ann Emerg Med. 2023 Jun 1; 81 (6): 658666658-666.

Study ObjectiveOur study objective was to determine if the location of laryngoscope blade tip placement is associated with clinically important tracheal intubation outcomes in a pediatric emergency department.MethodsWe conducted a video-based observational study of pediatric emergency department patients undergoing tracheal intubation with standard geometry Macintosh and Miller video laryngoscope blades (Storz C-MAC, Karl Storz). Our main exposures were direct lifting of the epiglottis versus blade tip placement within the vallecula and median glossoepiglottic fold engagement versus not when the blade tip was placed in the vallecula. Our main outcomes were glottic visualization and procedural success. We compared measures of glottic visualization between successful and unsuccessful attempts using generalized linear mixed models.ResultsProceduralists placed the blade tip in the vallecula (indirectly lifting the epiglottis) during 123 (71.9%) of 171 attempts. When compared with indirectly lifting the epiglottis, directly lifting the epiglottis was associated with improved visualization-by percentage of glottic opening (POGO) (adjusted odds ratio [AOR], 11.0; 95% confidence interval [CI], 5.1 to 23.6) and modified Cormack-Lehane (AOR, 21.5; 95% CI, 6.6 to 69.9). When in the vallecula, engagement of the median glossoepiglottic fold was associated with improved POGO (AOR, 3.6; 95% CI, 1.9 to 6.8), modified Cormack-Lehane (AOR, 3.9; 95% CI, 1.1 to 14.1), and success (AOR, 9.9; 95% CI, 2.3 to 43.7).ConclusionsEmergency tracheal intubation can be performed in children at a high level by directly or indirectly lifting the epiglottis. If indirectly lifting the epiglottis, median glossoepiglottic fold engagement is helpful in maximizing glottic visualization and procedural success.Copyright © 2022 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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