Question 2: During pediatric intubations, how much does a shoulder roll (or equivalent) help intubation success?

We admit that we’ve made the mistake of complicating a pediatric intubation by not using a shoulder roll (or an equivalent means of elevating a child’s shoulders). But how much does it really matter? Two separate studies in 2019 alone re-emphasize the importance.

A study by Koylu Gencay et al prospectively randomized 96 elective surgery pediatric patients younger than 2 years of age to intubation with a C-MAC Miller video laryngoscope either with or without a folded towel under the shoulder to better align the oral-pharyngeal and laryngeal axes.¹ The primary outcome was the percent of glottis opening (POGO). Secondary outcomes included time to intubation and number of intubation attempts. POGO scores were assessed by a party blinded to presence/absence of shoulder elevation by a towel.

Of 48 total patients with a towel (Group 1), the POGO score was 100 percent in 37 children and 90 percent in the other 11. For the 48 children without a towel (Group 2), the POGO was 100 percent in 26 children, 90 percent for 16 children, and 80 percent in the remaining six children. The differences were statistically significant (P=0.004). The time to intubation was also significantly faster in the group with a towel (24.83 ± 3.82 seconds versus 31.67 ± 11.91 seconds). A single child in the group without a towel required a second attempt at intubation.

Another article by Ahn et al prospectively evaluated children younger than 36 months of age requiring intubation who were undergoing elective surgery. Exclusion criteria included head/neck malformations, possible lung aspiration, current/recent upper respiratory infection, emergency surgery, and hemodynamic instability. Primary outcomes were POGO, mouth opening, and laryngoscopy handling score (LHS). LHS consisted of an assessment of mouth opening, teeth contact, sternum contact, and resistance to laryngoscope advancement. Outcomes were measured before and after a procedural assistant performed a maneuver called hand-assisted elevation and caudal traction of the shoulder (HA-ECTS)—a maneuver nearly identical to placement of a shoulder roll.

In 37 children ages 0–36 months, the median POGO score was significantly better (30 percent versus 60 percent) after performing HA-ECTS. LHS was also significantly easier after HA-ECTS (P<0.001). Subgroup analysis of 18 children ages 0–12 months demonstrated an easy (nine patients), moderate (five patients), and difficult (four patients) LHS prior to HA-ECTS. After HA-ECTS, laryngoscope handling in all 18 children became easier. LHS scores in older children (ages 12–36 months) did not reach statistical significance (P=0.08) after HA-ECTS.

Conclusion

During endotracheal intubation in children, shoulder elevation to align the oral-pharyngeal and tracheal axes significantly improves visualization and time to intubation.

References

1. Koylu Gencay Z, Begec Z, Ozgul U, et al. The effect of placement of a support under the shoulders on laryngeal visualization with a C-MAC Miller video laryngoscope in children younger than 2 years of age. Paediatr Anaesth. 2019;29(8):814-820.
2. Ahn JH, Kim D, Gil NS, et al. Improvement of laryngoscopic view by hand-assisted elevation and caudal traction of the shoulder during tracheal intubation in pediatric patients. Sci Rep. 2019;9(1):1174.