• Yuko Shiima, Ting-Chang Hsieh, Andrew Long, and Aaron Donoghue.
• Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan.
• Pediatr Crit Care Me. 2018 Mar 1; 19 (3): e136-e144.

ObjectivesTo examine technical aspects of pediatric tracheal intubation using video recording and to determine the association between tracheal intubation technique and procedural outcomes.DesignProspective observational study.SettingEmergency department resuscitation bay in single tertiary pediatric center.PatientsChildren undergoing emergent tracheal intubation under videorecorded conditions.InterventionsNone.Measurements And Main ResultsA published scoring tool for characterizing patient positioning, intubator kinematics, and adjunctive maneuvers during tracheal intubation was applied to videorecorded pediatric resuscitations when tracheal intubation was performed. Procedural outcomes were measured from video review. Seventy-one children underwent 109 tracheal intubation attempts with an overall first attempt success rate of 69% and a median laryngoscopy duration of 34 seconds (interquartile range, 24-47 s). A significant subset of tracheal intubation attempts were made with the patient's bed at a height below the level of intubator's umbilicus (61%), the patient in a supine position without head elevation (55%), the intubator bent at the waist to greater than 45° (66%), less than 1 cm of mouth opening by the intubator's right hand prior to laryngoscopy (46%), and with the intubator's face less than 12 inches away from the patient's mouth (65%). Adjunctive maneuvers were used in a minority of attempts (cricoid pressure 48%, external laryngeal manipulation 11%, retraction of the right corner of the patient's mouth 26%). On multivariate analysis, including controlling for patient age category and intubator background, retraction of the right corner of the patient's mouth by an assistant showed an independent association with successful tracheal intubation. No other technical aspects were associated with tracheal intubation success.ConclusionsIntubators commonly exhibited suboptimal technique during tracheal intubation such as bending deeply at the waist, having their eyes close to the patient's mouth, failing to widely open the patient's mouth, and not elevating the occiput in older children. Retraction of the right corner of the patient's mouth by an assistant during laryngoscopy and intubation was associated with TI success.

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