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.
Keywords :
Glottic view, Head-neck alignment, Laryngoscopy.References :
- Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first-pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med, 2013;20(1):71-78. doi: 10.1111/acem.12055.
- Patel R, Lenczyk M, Hannallah HS, McGill WA. Age and the onset of desaturation in apnoeic children. Can J Anaesth. 1994;41(9):771-774 doi:10.1007/BF03011582.
- Carroll CL, Spinella PC, Corsi JM, Stoltz P, Zucker AR. Emergent endotracheal intubations in children: be careful if it’s late when you intubate. Peidatr Crit Care Med. 2010;11(3):343-348 doi:10.1097/PCC.0b013e3181c51426
- Doerges V, Sauer C, Ocker H, Wenzel V, Schmucker P. Smaller tidal volumes during cardiopulmonary resuscitation: comparison of adult and paediatric self-inflatable bags with three different ventilatory devices. Resuscitation. 1999;43(1):31-37. doi: 10.1016/s0300-9572(99)00117-3.
- Berg MD, Idris AH, Berg RA. Severe ventilatory compromise due to gastric distention during pediatric cardiopulmonary resuscitation. Resuscitation. 1998 Jan;36(1):71-73. doi: 10.1016/s0300-9572(97)00077-4.
- Greenland KB, Edwards MJ, Hutton NJ. External auditory meatus-sternal notch relationship in adults in the sniffing position: a magnetic resonance imaging study. Br J Anaesth 2010;104:268-269. https://doi.org/10.1093/bja/aep390
- Lee YK, Shin ES, Shim JY et al. Developing a scoring guide for the Appraisal of Guidelines for Research and Evaluation II instrument in Korea: a modified Delphi consensus process. J Korean Med Sci 2013; 28: 190-194.
- Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA, Association of Pediatric Anaesthetists of Great B, et al. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth 2015;25:346-362
- Kim E-H, Ji S-H, Song I-K, Lee J-H, Kim J-T, Kim H-S. Am J Emerg Med. 2017;35(6): c928-929 https://doi.org/10.1016/j.ajem.2017.01.048
- Katz DL, Jekel JF, Elmore JG, Wild DMG, Lucan SC. Sample size calculation for epidemiological studies. In: Jekel JF Editor. Jekel’s Epidemiology, Biostatistics, Preventive Medicine and Public Health. 4th edition. Philadelphia. Saunders, Elsevier Inc. 2014; p. 155-undefined
- Chun EH, Chung MH, Kim JE, Kim JM, Lee HS, Son JM, et al. Effects of head-elevated position on tracheal intubation using a McGrath MAC videolaryngoscope in patients with a simulated difficult airway: a prospective randomized cross-over study. BMC Anesthesiology 2022;22:166-176. https://doi.org/ 10.1186/s12871-022-01706-5
- Rensis L. A Technique for the Measurement of Attitudes. Archives of Psychology1932; 140: 1–55
- Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984; 39(11):1105-1111 doi: 10.1111/j.1365-2044.1984.tb08932.x.
- Hasan MR, Sharmin T, Rickta D, Sharmin R, Gosh P. Complications of Anesthesia in Children: An Observational Study.EAS J Anesthesiol Crit Care.2025;7(4):60-66. doi: 10.36349/easjacc.2025.v07i04.001
- Henderson JJ, propat MT, Latto IP, Pearce AC. Difficult Airway Society Guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004;59(7):675-694
- Traylor BA, McCutchan A. Unanticipated Difficult Intubation in an Adult Patient. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.
- Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyadi AI, Greeberg RS, Reynolds PI. Airway management complications in children with Difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med. 2016;4(1):37-48. doi: 10.1016/S2213-2600(15)00508-1
- Collins SR. Direct and Indirect Laryngoscopy: Equipment and Techniques. Respiratory Care. 2014;59(6):850-864. doi: 10.4187/respcare.03033
- Li H, Jia X, Ye H, Liang J-W, Zhao W-L, Cui P, et al. Impact of lateral positioning on upper airway morphology in sedated children under five. World J Pediatr. 2025;21:587-596. doi: 10.1007/s12519-025-00910-w
- Thibodeau LG, verdile VP, Bartfield JM, Incidence of aspiration after urgent intubation. Am J Emerg Med.1997;15(6):562-565 doi: 10.1016/s0735-6757(97)90157-1.
- Cook TM, MacDoughall-Davies SR. Complications and failure of airway management. Br J Anaesth. 2012;109(1):i68-i85. doi: 10.1093/bja/aes393.
- Cook TM, Woodall N, Frerk C; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617-631. doi: 10.1093/bja/aer058.
- Dunham CM, Barraco RD, Clark DE, Daley BJ, Davis FE. Gibbs MA, et al. EAST Practice Management Guidelines Work Group. Guidelines for emergency tracheal ntubation immediately after traumatic injury. J Trauma. 2003;55(1):162-169. doi: 10.1097/01.ta.0000083335.93868.2c.
- Akbar A, Ali Z, Hanif S, Ullah I, Akhtar A, Ullar TR, et al. Risk Factors Associated with Aspiration During Rapid sequence Induction. JHWCR [Internet]. 2026;4(3):e1202 doi: 10.61919/h82sh690
- Yemam D, Melese E, Ashebir Z. Comparison of modified Malampati classification with Cormack and Lehane grading in predicting difficult laryngoscopy among elective surgical patients who took general anesthesia in Werabie comprehensive specialized hospital – cross sectional study. Ethiopia, 2021. Ann Med Surg. 2022;24(79):103912. doi: 10.1016/j.amsu.2022.103912
- Yu T, Wu R, Longhini F, Wang B, Wang M, Yang F, et al. The “BURP” maneuver improves the glottic view during laryngoscopy but remains a difficult procedure. J Int Med Res. 2020;48(5). doi: 10.1177/0300060520925325
- Aggo AT, Hart F. Impact of two different head and neck alignment planes on glottic visualization at laryngoscopy in adults. Int J Adv Med. 2025;12:278-284. doi: 10.18203/2349-3933.ijam20251076
- Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31-81. doi: 10.1097/ALN.0000000000004002
- Goto T, Gibo K, Hagiwara Y, Okubo M, Brown DFM, Brown CA, et al. Factors associated with first-pass success in pediatric intubation in the Emergency Department. West J Emerg Med. 2016;17(2):129-134. doi: 10.5811/westjem.2016.1.28685
- Chen DY, Devsam B, Sett A, Perkins EJ, Johnson MD, Tingay DG. Factors that determine first intubation attempt success in high-risk neonates. Pediatr Res. 2023;95(3):729-735. doi: 10.1038/s41390-023-02831-8
- Chanthawatthanarak S, Tangpaisarn T, Kotruchin P, Phungoen P, Lenghong K, Apiratwarakul K. First-pass Success Rates of Endotracheal Intubation Using Ramped versus Supine Positioning in the Emergency Department. Med Assoc Thai. 2020;103(6):51-57.
- Panchal AR, Bartos JA, Cabanas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_Suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916
- Jobe AH. Intubating infants: How long does it take? J Pediatr. 2004;145(1):PA3. doi: 10.1016/j.peds.2004.06.011
- Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP, et al. Part II: Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation. 2010;122(2):S516-538. doi: 10.1161/CIRCULATIONAHA.110.971127
- Marciniak B. growth and development. In: Cote CJ, Lerman J, Todres ID, editors. A Practice of Anaesthesia for Infants and Children. 4th ed. Philadelphia, PA: Saunders Elsevier;2009. p7-21
- Bhammar DM, Wilhite DP, Olojo T, Alagappan K, Jones K, Liu Y-L, et al. Effects of Obesity and Sex on Supine Functional Residual Capacity and ExpiratoryFlow Limitation in Children. Pediatr Pulmonol. 2025;60(4):e71061. doi: 10.1002/ppul.71061
- Harteveld LM, Nederend I, Ten Harkel ADJ, Schutte NM, de Rooij SR, Vrijkotte TGM. et al. Maturation of the Cardiac Autonomic Nervous System Activity in Children and Adol escents. J Am Heart Assoc. 2021;10(4):e017405. doi: 10.1161/JAHA.120.017405.
- Hagen-Poiseuille equation. In: Gooch J.W. (eds) Encyclopedic Dictionary of polymers. 2007; Springer, New York, NY. Available from: https://doi.org/10.1007/978-0-387-30160-0_5664 Accessed March 11, 2026
- Bhammar DM, Jones HN, lang JE.Inspiratory Muscle Rehabilitation Training in pediatrics: What Is the Evidence? Can Respir J. 2022;2022:5680311. doi: 10.1155/2022/5680311
- Singh N, Sawyer T, Johnson LC, Herrick HM, Moussa A, Zenge J, et al. National Emergency Airway Registry for Neonates (NEAR4NEOS). Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol. 2022;42(9):1221-1227. doi: 10.1038/s41372-022-01484-5.

