Effect of cervical spine immobilization technique on pediatric advanced airway management: a high-fidelity infant simulation model

Pediatr Emerg Care. 2008 Nov;24(11):749-56. doi: 10.1097/PEC.0b013e31818c2665.


Objective: Current guidelines recommend cervical spine immobilization during orotracheal intubation when traumatic injury is suspected in infants. We evaluated the effect of cervical spine immobilization techniques on orotracheal intubation performance with a high-fidelity infant simulator.

Methods: A randomized control study with repeated measurement. Nonanesthesia pediatric practitioners certified for intubation performed 6 intubations with 3 different cervical spine immobilization techniques (no physical protection, manual in-line immobilization, and cervical collar: C-collar). Time to accomplish key actions, cervical extension angle, and observed intubation associated events such as mainstem intubation, esophageal intubation with or without immediate recognition were recorded.

Results: Twenty-six practitioners performed 156 successful orotracheal intubation. Time to intubation from end of mask assist ventilation was 29.0 +/- 12.2 seconds in no physical protection, 33.0 +/- 17.4 seconds in C-collar, and 33.0 +/- 17.1 seconds in manual in-line immobilization (P = 0.39). Maximal cervical extension angle in no physical protection (2.39 +/- 2.56 degrees ) and C-collar (2.65 +/- 1.79 degrees ) were significantly greater compared with 0.85 +/- 1.05 degrees in manual in-line immobilization (P < 0.0001). The number of intubation attempts and intubation associated events were not different among 3 techniques. Laryngeal visualization measured by Cormack-LehaneScale was more difficult in C-collar compared with other 2 techniques (P< 0.001).

Conclusions: In this high-fidelity infant simulator model, cervical spine immobilization technique affected cervical extension angle and laryngeal visualization. Tracheal intubation associated events occurred in 33% of intubation attempts but were not different by technique. Time to achieve tracheal intubation, number of intubation attempts needed to succeed, and intubation-associated events were not affected by immobilization techniques. These results support Advanced Trauma Life Support recommendations to perform manual in-line immobilization in infants.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Airway Obstruction / therapy*
  • Cervical Vertebrae
  • Clinical Competence*
  • Emergency Treatment
  • Hospitals, Pediatric
  • Humans
  • Immobilization / instrumentation
  • Immobilization / methods*
  • Infant
  • Intubation, Intratracheal / methods*
  • Laryngoscopes
  • Models, Biological
  • Probability
  • Sensitivity and Specificity
  • Spinal Cord Injuries
  • Spine*