Cite this post as:
Scott Weingart, MD FCCM. A Rant on Video Laryngoscopy. EMCrit Blog. Published on December 27, 2012. Accessed on April 24th 2024. Available at [https://emcrit.org/emcrit/rant-video-laryngoscopy/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: December 27, 2012
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Hi Harold and Scott! what a rant! great stuff! Having used king Vision VL last week on a trauma airway that was Grade 4 CL on DL but 3 with VL, I agree that VL has a role in prehospital airway management! I have tested the Ranger Glidescope for a month now. it has not been met with wild enthusiasm by myself and colleagues mainly because of some of the key points you raise here. Hypercurved indirect bladed VL systems require a distinct technique in both tube delivery and passage. I totally agree with you on standard bougies and VL… Read more »
http://www.ncbi.nlm.nih.gov/pubmed/23231426
check out article above on VL vs DL in critical care transport service.
I’ve used the bougie with virtually no view of anything but the tongue on dozens of patients with 100% success. I find that finding my external landmarks manually with my left hand before I insert the scope, having an assistant then place and hold their fingers exactly where I had them gives me a target and from then it’s pretty easy stuff. I will admit that in the first days of the bougie, it took a couple of attempts a couple of times and I had to abort and re-oxygenate a couple of times as well. But now that I’ve… Read more »
I currently use a McGrath Mac in prehospital (HEMS and ambulance) setting. The Mac has a standard (Macintosh) blade and works really fine with the standard Bougie (just applying a little bend). My tip when I teach VL is: stay a little back with the blade, don’t load the epiglottis, visualize the cords (CL 2 ) so the glottic plan is lower and it’s easier passing the tube (golf stick shaped)
At my fire based gorund service, we have a GlideScope that is our first line equipment. Initially it was a little bit awkward to use with the rigid stylettes, but, with a bit of practice and use on live patients, the bulk of our paramedics have gotten used to it, and can use it without difficulty. I recently was forced to use a standard handle, and mac blade on a cardiac arrest with another service I work for, and it was by far, one of the hardest intubations I’ve done since paramedic school. Not because the view was bad, or… Read more »
Talking of video devices. What do you guys think of this one?
http://arasan.us/VuStik_Video-Stylet.html
This would involve no change in our usual technique. I like the look of the little light weight screen better than the videostylets with eyepieces, or one device I have seen with a bulkier looking screen.
And of course we can still use our usual laryngoscopes.
But I can’t find out much about it online, perhaps because it hasn’t been out long. Have any of you tried this one?
V. nice. It is like a disposable version of our Bonfils and I love the Bonfils.
Our prehospital teams 5 year success rate at intubation using DL and bougie is 100%.
Highest reported success in randomised prehospital trial for VL is less than 50 %.
Currently, I’d consider it unethical for us to change our practice to using VL as first choice technique!
-John
Hi John, I definitely applaud your success rate with DL and the bougie and if that’s what you guys are good at it stick with it. Again my rant was to do with the fact that if you use a DL technique (which you are obviously expert at) with VL (specifically glidescope and the other hyper curved VL scopes it WILL be more difficult. The technique I described for successful VL obviously is not the only trick that works but I just wanted to share this as I find many people like in your shop are having lower success rates… Read more »
Hi John, I totally agree with you about using direct laryngoscopy with a bougie. The comments below including references are what I sent to Harold and Scott. So far no one has sent me any replies or feedback in response to my posted comments. I guess everyone is sold on video laryngoscopy. There are not only issues with it but also it is very expensive. Eric Hi Harold and Scott, I read your “video intubation rant” with great interest. Takenaka and colleagues[1] found that difficult laryngoscopy is not synonymous with difficult intubation. Laryngoscopy was difficult in 17 of the 587… Read more »
Full Disclosure of Conflict of Interest: I own a medical device company that manufactures and markets a video laryngoscope. I’d like to offer my opinion on why I believe everyone is sold on VL and why DL should be relegated to the history books. Science! We now have over a decades worth of data showing that VL is far superior to DL in terms of being able to locate the glottic opening. If you can see where you want to go, its much easier to get there and to do so without causing harm to the patient in the process.… Read more »
Hi Jay, In defense of John, in the Netherlands for example, the average number of endotracheal intubations per paramedic in one year was 4.2 and varied from zero to a maximum of 12[1]. This study found that the incidence of endotracheal intubations performed by Dutch paramedics in one year was low, but endotracheal intubation was successful in 95.2%, which is comparable with findings in international literature. However, you make an important point that just because it is possible to successfully place an ETT without being able to visualize the cords does not mean you should, particularly if it takes a… Read more »
Hi Eric, As you point out, paramedics simply don’t get the experience that we do in the operating room. I may intubate more times in one day than many paramedics intubate in an entire year. So that is one of the main issues. The other is that paramedics have to intubate the worst airways, in the worst conditions. In the OR, we don’t have to worry so much about vomit or blood in the airway. We have plenty of light, equipment, time, help and the ability to properly position the patient. The odds are not stacked in their favor. That’s… Read more »
These are all surrogate markers. The important outcome measure is whether or not harm occurs as a result of process of securing the airway with whatever device you happen to use. My understanding of the data is in locations with rapid access to a trauma centre, pre-hospital intubation has not been proven to alter outcomes. I’d be also interested in real world data with success rates of occasional intubators, not equipment reps with ‘5000 intubations’ other their belt. I’d be concerned if a paramedic was allowing the patient to desaturate significantly before returning to bag-mask ventilation. As Dunfore concludes, good… Read more »
Hi Docxology, Below are the comments I sent in response to the emcrit January 16, 2013 at 17:31 comments “Jay, this whole set of comments have been truly excellent”. My most important point is no matter what airway management skills are taught to Paramedics and EMTs (including manual airway control techniques, the use of alternate airway devices and devices used in endotracheal intubation) they are often going to do a poor job of managing the airway because they aquire, hone, and maintain all their skills with only manikin practice. As I evidenced in my comments this is highly ineffective and… Read more »
of course I agree with John Hinds!
a new car with GPS is a handy thing to have, partic if you are heading to a strange location…but the driving technique is the same regardless of GPS.
and when your GPS fails , yu still need to be able to read a map ..or ask for directions/help.
Hi Harold and Scott, I read your “video intubation rant” with great interest. Takenaka and colleagues[1] found that difficult laryngoscopy is not synonymous with difficult intubation. Laryngoscopy was difficult in 17 of the 587 patients studied; however, in only 4 patients intubation was difficult, but in the remaining 13 patients the trachea was easy to intubate. The size/area of the laryngeal aperture (LA) created during Macintosh laryngoscopy in the difficult group, which they found to be one cause of difficult intubation, was significantly smaller than that in the easy group. In contrast, the LA area provided by jaw thrust during… Read more »
let me start by saying great topic and great comments. we use the C-mac VL and on the left side of the blade is a groove. This is perfect for the introduction of a standard bougie. I do not know if there are people out there who have tested this during training sessions but for me it works every time. I’ll try to email scott pictures to make it clear what I mean.
My apologies for the lesser english.
Pieter,
We have done the same, but for our bougie, we must preload it into the blade groove before placing the blade into the mouth.
same here,
I’ve tried with a second person to load the bougie and this works ok but it does require some getting used to the technique.
Here is a video I made back in the fall describing the technique Pieter and Scott are referring to. Video demonstrates Pocket Bougie preloaded into channel of D Blade of Karl Storz VL system.
http://youtu.be/CwW1cY1Sfuw
Full Disclosure of Conflict of Interest: I own a medical device company that manufactures and markets a video laryngoscope. Harold and Scott, FANTASTIC post covering the technique needed for VL, which is truly different than the technique needed for DL. It can be frustrating to teach VL to an experienced clinician with literally thousands of intubations under their belt because too often, they tend to not listen to the instructions that will help them be successful. Instead, they try to apply the same maneuvers and techniques to VL that they use for DL and invariably end up experiencing failure. Even… Read more »
Jay, this whole set of comments have been truly excellent
Hi Jay and Scott, While I respect your knowledge, experience and expert opinions regarding tracheal intubation, there are important issues that you may not be considering. As you already know, paramedics virtually get no supervised intubation training and experience in patients; they virtually rely entirely on manikin practice to acquire, hone and maintain their skills. However, Yuan and colleagues[1] in their comments on a study of VL training in manikins, cite research in which it was suggested that tracheal intubation is not reliably simulated by manikins due to the use of rigid plastic, lack of collapsible soft tissues, absence of… Read more »
I am a sales rep and have a question. If EMT’s are trained DL with traditional blades, would you be more comfortable using a VL system that has traditional blades so you do not have to learn a new technique and will not lose your “muscle memory”? Also, I am seeing more EMS and Air Rescue services utilizing image capture of tube placement for documentation, then attaching the image to the patient chart. Is this feature a huge benefit, or becoming popular?
Nate
It seems most agree that VL gives a better view but is quite expensive compared to DL so possibly can’t replace it for routine & difficult intubations? If the argument is purely on whether its economical, then a MAC-type standard blade VL with an inexpensive video camera incorporated would be the answer? I wonder why manufacturers can’t go ahead and just create them, the technology to do so exists today. The setup here (albeit proof-of concept stuff) cost me around 40$ US http://link.springer.com/article/10.1007/s10877-013-9522-x
you’re not paying for the device. you are paying for the development, testing, and most of all the liability insurance.