Head and Neck Alignment for Optimal Glottic view at Paediatric Laryngoscopy: Comparison of two Anatomical Axes

Abstract : Background: Suboptimal head-neck alignment in children, with consequent poor glottic visualisation, results in delayed tracheal intubation cascading to peri-intubation sequelae. Objective: To determine the degree of glottic view achieved in children during direct rigid laryngoscopy for orotracheal intubation with head-neck alignment done keeping the suprasternal notch-auditory meatus (SN-AM) axis versus the sternal angle-auditory meatus (SA-AM) axis, horizontally. Methods: Following ethical clearance and informed parental consent, 68 children aged 1 – 6 years, of American Society of Anesthesiologists (ASA) class I or II, were randomized into two groups of pre-intubation head-neck alignments: group A used horizontal SN-AM axis, while group B adopted horizontal SA-AM axis, for the alignment. Degree of glottic view achieved, tracheal intubation attempts, external laryngeal backward upward rightward pressure (BURP) manoeuvre and grade were recorded. Glottic view achieved and grade of BURP applied were assessed using the Cormack-Lehane grading and three-point Likert scales respectively; the time to orotracheal intubation (TTOTI), defined as the period from removal of preoxygenating face mask to first capnographic evidence of correct tracheal tube placement, and immediate post-intubation arterial Oxygen saturation (SpO2) also were recorded. Results: All 68 children completed the study. The groups were comparable in Cormack-Lehane grades of glottic visualisation, P=0.611, with statistically similar BURP application, P=0.642. The mean TTOTI (26.97±2.58 versus 26.41±2.68) in seconds, and the peri-intubation mean percentage SpO2 (95.08±1.08 versus 94.85±0.957) showed no significant difference, P=0.383 and 0.346, respectively, with zero occurrence of peri-intubation complications, in the groups. Conclusion: In children aged 1-6 years, the degree of glottic visualisation achieved at conventional rigid laryngoscopy for endotracheal intubation, is similar between head-neck alignment done by keeping the SN-AM axis in horizontal plane and head-neck alignment done by keeping the SA-AM axis horizontally.