The Effects of a Shoulder Roll During Laryngoscopy in

Infants: A Randomized, Single-Blinded, Crossover Study

Presenter: Hamza Abou Alchamat M.D, PGY-2
Moderator: Dr. Samar Taha, M.D, Phd

5, Nov, 2020
 Introduction

 The use of a shoulder roll to view the glottic opening during direct
laryngoscopy in infants has been recommended but is not evidence based.
 Hypothesis: the presence of a shoulder roll reduces the vertical distance from
the angle of the laryngoscopist’s eye to the operating room (OR) table
compared with no shoulder roll and may change the view of the glottis.
 primary outcome: the vertical distance from the angle of the laryngoscopist’s
eye to the top of the OR table with and without a shoulder roll.
 secondary outcomes: the differences in the percent of glottis opening
(POGO) scores with and without a shoulder roll and the corresponding
cardiorespiratory changes.
Background
 Methods
 Study population:
 20 infants of both sexes
 Inclusion Criteria:
 0–12 months of age
 (ASA) physical status I–III
 undergoing elective urogenital surgery
 requiring oro-tracheal intubation under general anesthesia
 at Oishei Children’s Hospital (Buffalo, NY)
 Exclusion Criteria:
 Emergent surgery
 difficult airway anticipated
 obese infants ([BMI] > 95 percentile for age)
 untreated gastroesophageal reflux, full stomach
 history of muscle disease (including malignant hyperthermia)
 20 sequential numbers were randomized (using www.random.com) into 2
equal size groups: shoulder roll present first and then no shoulder roll (N =
10), or no shoulder roll first then a shoulder roll present (N = 10).
 The group assignment determined whether a gel roll (semicircular, 2-inch
[5cm] vertical height [AliMed, Dedham,MA]) was placed under the shoulders
for the first set of measurements and then removed for the second set or vice
versa.
 After consent was obtained, anesthesia was induced using a standard
inhalational induction, Standard monitors were then applied, and ventilation
was assisted as needed.
 Once anesthesia was induced, one of the investigators manually anchored a
24-inch right angle carpenter T-square against the side of the OR table to
measure the distance from the angle of the eye of the laryngoscopist to the
tabletop.
 The investigator who measured the vertical distance with the T-square was
blinded to the presence or absence of the shoulder roll by an opaque drape
that was affixed to the head of the T-square.
 With the zero marking at the top of the square aligned with the angle of the
laryngoscopist’s eye, the numerical reading on the T-square at the level of
the tabletop was the vertical distance.
 Before performing laryngoscopy, the height of the table was adjusted by the
laryngoscopist so it was an appropriate height for him to perform direct laryn-
goscopy without a shoulder roll. The height of the table was unchanged for
the remainder of the study.
 The randomization sequence was then revealed and an assistant either
inserted a shoulder roll or did not place a roll under the infant’s shoulders for
the first set of measurements.
 Direct laryngoscopy was performed using a size 1 Miller blade via the
paraglossal approach, The view of the glottis was optimized by externally
manipulating the larynx as needed.
 The laryngoscopist adjusted his height to achieve the best glottic view by
bending his knees while maintaining an erect spine (eg, changing his height by
moving vertically rather than by leaning forward, by bending his knees or
stooping).
 Once the best glottic view was achieved, the vertical distance from the angle
of the left eye of the laryngoscopist to the OR table was recorded and a photo
of the glottic opening was taken using a high-quality digital hand-held camera
 A second set of measurements was then performed with the alternate
shoulder roll position.
 Once the recordings were completed, the trachea was intubated, surgery
proceeded, and the study was concluded. Demographic data including sex,
age, weight, height, ASA physical status, and type of surgery were recorded.
 Cardiorespiratory data (heart rate, systemic blood pressure, oxygen
saturation, and end-tidal partial pressure of carbon dioxide [Pco2]) were all
recorded immediately before and within 60 seconds of tracheal intubation.
 At the conclusion of the enrollment period, the pairs of photos of the glottis
were deidentified, optimized using Photoshop and randomized individually.
 An investigator who was blinded to the study hypothesis then reviewed the
photographs to measure the POGO score, in 10% increments between 0% and
100%.
Results
Conclusions
Critique