Podcast 94 – Has Video Laryngoscopy Killed the Direct Laryngoscope?

Paul Mayo and I seem to have established a tradition of debating each other at the annual Greater NY Hospital Association Critical Care Controversies Conference.

Last year, we debated whether paralytics should be used for emergent intubations.

This year, the topic was Should All Intubations be Performed with Video Laryngoscopy?

I think you will enjoy the debate, because we don’t mind attacking our opponent.

If you enjoyed this podcast and the others on the EMCrit site, please consider supporting the show at CME.EMCrit.org.

Need an audio-only version?

Right click here and choose save-as

Now, on to the debate…

 

You finished the 'cast,
Now get CME credit

Already an EMCrit CME Subscriber?
Click Here to Get CME Credit for the Episode


Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , published 1 year ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. Minh Le Cong says:
    • Scott Gallagher says:

      Minh Le,

      Thank you for your insightful contributions to this website. I always appreciate reading your perspective.

      The article you attached demonstrated reduced success with VL for ped intubation. Wondering if in the study this was the residents’ first exposure to VL. As discussed previously, VL is a separate skill set from DL – particularly with hyperangulated devices. If first exposure, then delay in intubation times is not surprising.

      As related question, have you found that a specialized stylet is helpful for ped intubation with hyperangulated VL devices? I find the GlideScope Rigid Stylet extremely helpful with adults (down to ETT size 6) when using the GlideScope.

      Was very disappointed at difficulty I had passing tube around curvature of GlideScope with recent emergent pediatric intubation without benefit of soecialized rigid stylet.

      • Minh Le Cong says:

        Scott, If you are going to use the Glidescope you should use the custom stylet that it comes with or at least know how to shape your stylet in the manner of that custom one. I tested a Glidescope ranger for a full month and ran it pass my colleagues. Lets be honest, at my shop, we all trained in DL on anaesthesia rotations. The minimum rotation time is 6 months here in Oz for anaesthesia relevant to specialties like EM, ICU and rural GP. Most do a full 12 months.
        Its fairly obvious that those who are experienced at DL will find it challenging transitioning to using a VL like the Glidescope. Its a totally different mindset in tube delivery.
        You need that stylet, plain and simple with an indirect VL like the Glidescope.
        I am a bit surprised GLidescope have not gone down the design route of channeled blades like the King Vision, Airtraq or Pentax, where tube delivery is easier with the guide channel. This is why in my opinion the King Vision is better than the Glidescope. But unfortunately it does not come in pediatric sizes..yet, whereas the Glidescope does. But I hear Glidescope will soon come in standard MAC blade designs. There will be a price war this year and standoff between Glidescope and CMAC across the world. I dont know who will win but hopefully the market will get more affordable as result of the competition and we the intubators will all be the winners..along with our patients.

        • I know all of the glidescope tricks and have no problem with this device. The problem with these tricks are every one of them is the exact opposite of what you should do with DL. So it builds bad habits.

      • A main factor is due to the 60 degree curve of Glidescope blades. In pediatrics (especially infants and neonates), the anatomy is very different from Adults. A Miller 0 or 1 blade or Mac 2 is ideal for these patients because there is no or limited curve (Mac 2). The CMAC has Miller 0,1 and Mac 2 blades that are ideal for these patients and require no special stylet to get “around”the curve.

        • DocXology says:

          So is the Glidescope VL technique same as conventional pads intubation where one flips the large, floppy epiglottis up with the tip of the straight Miller blade?

          • Glidescope is designed for the vellecula but you never know if the tip is there because you cannot see the tip on their screen. The CMAC MAC and DBlade are also designed for the vellecula but you know where the tip is at all times because you can see the tip of the CMAC blades, which helps you see where the blade is positioned at all times. This is very advantageous over Glide because it allows the user to know where they are placing the blade. It also is safer for the patient because the user is not putting unnecessary pressure in soft tissue areas which may cause injury. The CMAC has a Miller 0 and 1 size which is perfect for neonates and infants because it does not change the technique of the user but gives them great visual since the camera is at the tip of the blade. The Glide pediatric blade is curved and can be very difficult to insert. Thank you.

  2. Haven’t listened to the podcast yet but this study is food for thought for the VL only crowd

    http://www.ncbi.nlm.nih.gov/m/pubmed/22429970/

    Cadaver study DL vs glidescope- DL much more successful at removing a similated foreign body. One could argue that this wouldn’t apply to the C-MAC but that makes another good point- you can’t lump all VL devices into the same category (although I think glidescope has a much larger market share).

    • Again, the acute 60 degree curve of the Glidescope blade hinders the success of extracting foreign bodies from the airway because it is extremely difficult to get rigid forceps around the corner of the Glidescope blade. This is not the case with the CMAC because it has standard Mac blades, making it easier to maneuver the forceps into the airway to remove the matter.This is important in the prehospital/ED setting.

  3. Kevin M says:

    I’m sorry but this debate is somewhat out of place to begin with. What in Heaven’s name does this have to do with the Emergency Department?

    In any case, there if this were a criminal trial, the attorney for defense of Dl could argue after the prosecution’s case for immediate dismissal based on the arguments made don’t meet minimal level of proof of the case.

    I’d like to tackle the common argument that Dr. Mayo makes regarding argument #2, VL as a bailout. His argument is why would you use DL as a bailout?

    I’d argue somewhere along the lines that those who are great with VL are great with intubating under a variety of circumstances including having virtually no view of the airway or airway structures at all.

    I’ve had many intubations, on first pass, within 30 seconds, using DL and a bougie where I only knew where my scope was, where the larynx was and where the airway most likely was. I doubt someone who uses DL only will ever get to that point. And THAT is the point we all should get to.

    So yeah, I have used DL once, in over 2000 intubations, only in a person who had a severe throat cancer whose surrounding tissue and chords looked like a cervix with a very small opening. I used the Glidescope to make sure I didn’t see any other likely airway and then I stuck my bougie where I would have had I not had a glidescope in the first place and the patient had an airway.

    • Didn’t understand the out of place ref, Kevin?

      • Kevin M says:

        Just joking about my impression that Dr. Mayo may be comparing apples to oranges when he extrapolates critical care fellows to Emergency Medicine residents and attendings.

  4. Kevin M says:

    Great Podcast. I like Scott’s ultimate approach and reasoning.

  5. Great debate. Thanks for addressing the fact that VL is a different skill from DL and it can serve as a great educational tool. I have read that the blade should not be inserted too far when using VL, look where you place the tube in the posterior pharynx, etc. If you allow your trainees to use the VL as it was meant to be used (using the screen to intubate), what is the most difficult part of the procedure for them?

    Thanks

  6. Matt S says:

    Great debate. I wish all residency programs made sure they were using a traditional geometry/direct blade for their VL devices. I’ve been trained on the Glidescope (indirect blade) and it’s clearly a very different skill set from DL. I’ve had the opportunity to use a CMAC once or twice and it’s superiority seemed obvious to me. So all that being said…

    Does anyone have any thoughts on why the Glide seems to be so popular in training/residency programs? I think Scott brings up great points on why a direct VL device would make much more sense and I’d love to see more residency programs utilizing it.

    • Minh Le Cong says:

      MAtt, I have a thought on why Glidescope is so popular in USA. Marketing. plain and simple. It has enjoyed the early adopter phenomenon of first generation systems. It was marketed well.
      It was never meant to completely replace DL but I understand the temptation for many centres to consider this. Dr Mayo has articulated some excellent points as to why this should be. Sadly this is not a holistic approach.

      • Agree with Minh. Glidescope did a phenomenal marketing job. Matt, have your residency buy some traditional-mac-shape glidescope blades.

        • Matt S says:

          Wish it were that easy to have them switch course after 6+ years of using the Glide. Couldn’t hurt to try and talk with a few key folks to see what they think, though. On the plus side I graduate in a few months and move on to my CCM fellowship. Hopefully they’ve moved from the dark side of Glide.

          • Glide was first to Market with a portable solution. Karl Storz was first to market with a Video Laryngoscope system called the VMAC but it was not as portable and needed a light source. The CMAC was launched in 2009. There has been a lot of hospitals, especially residency programs utilizing the CMAC because it allows teaching with a standard MAC or Miller (0,1) blades.

  7. Travis says:

    I with 911, we are a critical care paramedic service vs standard paramedic. What are your thoughts on the king VL device? In EMS would you teach only the VL vs standard blade or a combination of both? Thank you

  8. Where are the anesthesiologists in this discussion? By graduation, a CA-3 anesthesia resident has more (difficult) intubations under his belt than most ER/ICU attendings in 10 years. I must admit I stopped watching after 10 minutes; the arrogant sarcasm was just too much to take. Seriously, Dr. Mayo, when we have trouble intubating a patient in the OR, it’s easy because we could just wake him up???

    For an anesthesiologist, the debate about the “1943 tools” is just laughable. You know why? Because all you need to kill the view during your precious video and fiberoptic intubation is a drop of saliva. Let’s not talk about blood.

    I agree that your trainees will have an easier time learning to intubate with a video laryngoscope, and will probably be more successful than with a direct laryngoscope. It’s also more enjoyable and produces less harm to the patient in the wrong hands. But you are approaching the problem from the wrong end; what your trainees and the EM and non-gas ICU attendings in general need to learn first is airway management, starting from properly VENTILATING the patient, down to the difficult airway algorithms and scenarios an anesthesiologist is trained for. They might learn that you do not keep trying to intubate a patient and call anesthesia after you bloodied him up, transforming an easy to ventilate situation in a difficult to both ventilate and intubate one. Or that proper airway management is not always (rapid sequence) intubation. Or that you should have not one, but many backup plans READY. Or that there are very few truly emergent intubations, most of them being just urgent. (What makes them emergent, most of the time, is a non-gas provider who does not know how to properly mask-ventilate a patient.) And the list could go on…

    The best advice a non-gas attending could give to his trainee is to go learn airway management from the best: the anesthesiologists, especially the ones doing ENT cancer cases every day. And then invest in a few nights with the on call anesthesia team, intubating coding patients on the floor, without stopping CPR. Those are the real emergencies we train for, using “1943 tools” (and a LOT of others the average ICU/EM attending has no idea about).

    I enjoy this blog a lot on the critical care side, but a little knowledge is a dangerous thing. Mine included.

    • DocXology says:

      I suspect this is the key point. A novice is likely to benefit more using a VL than DL. The VL technique is relatively crude and easier to learn. Without a doubt the VL is the superior instrument for all operators but it’s marginal utility is smaller for the expert. The comes the important question, aside from surrogate markers such as greater number of first pass intubation or improved C-L grades, I wonder how much it influences important outcomes e.g. patient morbidity/mortality from prolonged hypoxic brain injury, increased LOS from aspiration etc.

      These are quite expensive tools to place in the hands of every pre-hospital worker, ED or ICU across a country. One could even argue that there is less of a need for these instruments in high-volume centres and should be deployed to more remote settings.

      Securing an airway is only one step in the whole management of critically ill or traumatised patients and perhaps money could be better spent on other components of the system to actually produce more substantive benefits for the population.

    • Craig Bates says:

      While there is a lot of overlap, it is important to bear in mind that airway management in the operating room vs. other settings is not exactly the same thing. Some anesthesiologists have significant experience functioning outside the OR and some do not. Just like some EM docs have significant experience functioning in more austere environments while many only practice in a warm, dry, well lit ED with lots of backup and toys.

      Some of the devices and skills in OR airway management are not often relevant in the ED or field environment and I’m sure the flip side is true. For example, retrograde intubation is not often going to be a great option in EM practice. Doesn’t mean you can’t use it of course but the value is less for our patient population.

      Many of the anesthesiologists I have encountered have little experience or confidence executing a surgical cric. They may be able to wield a percutaneous cric kit but the issues with those are fairly well documented. This is a skill that EM docs are almost all quite ready to perform.

      On the flip side, many of the EM docs I know (myself included) have little experience or confidence using fiberoptics for a difficult airway. Maybe they could blunder through it but almost every single anesthesiologist I know can perform this skill very well.

      I have an anesthesia colleague who flies as a flight physician in our flight program. I’ve really enjoyed comparing and contrasting how things can be very different (not just airway management either) and also very similar. Instead of making assumptions about different specialities we need to learn to communicate and exchange ideas better and be able to grow from the experience.

      And for Ervin who has a nice little vignette to demonstrate how ED docs can be stupid – I’m sure that everybody here can bring up some stories about profoundly stupid things done by all specialities. In the last week alone my flight crews have encountered anesthesiologists at smaller hospitals giving paralytics without sedation for intubation (“don’t want to alter her sensorium…” as a reason), another used paralytics as part of procedural sedation to reduce a shoulder, yet another did RSI on a 100 kg patient with versed 2 mg, SCh 100 mg and wondered by they had a difficult intubation. Those individual experiences don’t tell us anything about the state of anesthesia in the U.S. today though.

      Buy me a beer and I’m sure that I could shred every specialty on the planet…

    • Old School says:

      Ervin, don’t you know that we only do easy intubations in the OR? As soon as it gets tough we just “wake them up and send them home”.

      I agree with you about the arrogant sarcasm.

  9. This is what your trainees should know (and usually don’t): http://pdfs.journals.lww.com/anesthesiology/2013/02000/Practice_Guidelines_for_Management_of_the.12.pdf (at least the difficult airway algorithm in Fig.1). You guys think that intubating is the end to all means.

    I will never forget the genius ED attending who induced a well-saturating spontaneously-breathing ACEI angioedema with propofol and sux, because she had a videolaryngoscope and she was too dumb to wait 3 more minutes for a crike kit to arrive at bedside. There were about 10 other anesthesia and ENT providers patiently waiting for the kit, but she had to demonstrate her “skills” and total lack of judgement.

    • Ervin, You may want to finish the podcast at least until you get to my part. : )

      As to your assertions, I have found generalizations based on specialty to be just about as useful as generalizations about race, creed, religion etc.–not useful at all. I have found horrible airway operators in both anesthesia and emergency medicine, just as I have found excellent ones. I could easily debate either side of the issue as to who is the ideal intubator in an emergency as I have delicious anecdotes for both sides.

      Not sure if you are trolling for the sake of response, but you are just skirting the border of inflammatory and I try to avoid that kind of thing on the site.

  10. Correction: the mean to all ends :-)

  11. Minh Le Cong says:

    Ervin, you make some excellent points but anaesthesia doctors can be just as guilty of task fixation and repeated intubation attempts as those you have cited. I am aware of elective OR cases which have turned into tragically avoidable fatalities, where waking the patient up was a perfectly valid strategy that was somehow not entertained by the anaesthesiologist.
    I totally agree with your point that its not the tool you pick up, but the mind of the wielder that determines safety and success in difficult airway management.
    For the record, here in Australia, our airway management training is predominantly learnt during anaesthesia rotations. I find this notable as it is in contrast apparently to the North American paradigm where I believe little time is spent in anaesthesia rotations for EM /ICU training and airway skills are taught on the ED or ICU floor.
    Our rationale in Australia, is that in anaesthesia you manage airways every day of your work, so you get the numbers done.
    This is good but it can be bad. Things become automatic, which is good, but once again this can be not so helpful when unexpected stuff occurs. You get so good at managing a range of airway scenarios that rarely you come across the feared CICV situation. And this is where I have seen anaesthesia colleagues get unstuck. Even in the animal wet lab training, I have seen colleagues hesitate or become unnerved..and this is on an anaesthetised sheep! They have to get really forced to cut the neck i.e ETT clamped shut and saturation allowed to drop to 70%!
    The other thing I find not so helpful of anaesthesia airway training is the reliance on the skills of a sole operator. There is less of a team approach to emergency airway management. Less use of checklists.
    So whilst I agree with you that anaesthesia rotations are useful training in airway management, my own experience is that they will get you to a point of competency then no further. I know few anaesthesia colleagues who have performed a successful surgical airway in an emergency, but I know a number of prehospital and retrieval physicians who have.
    I agree the criticism levelled at anaesthesiologists was unfair but hopefully it was in light humour for the debate.

  12. Mathias Tschopp says:

    Sorry to pollute the comment thread with a technical question, but there’s something in the format of this particular episode that renders it unreadable by my old iPhone 3G (stuck with iOS 4.2.1). The podcast app says the video is incompatible.

    Now I understand that I have crappy hardware that I need to upgrade, but that’s the phone I use to listen to podcast on my car. While I can understand the benefits of video, it seems that watching you speak in the mike on video doesn’t really add anything to the party, while rendering old hardware incapable of playing the rest of the audio podcast.

    I didn’t have issues with other episodes and I just thought I’d give this feedback to alert you that having a video instead of an audio podcast cuts a bit in your reachable fanbase.

    Sorry to complain on the format of an otherwise fantastic episode.

    • Mathias Tschopp says:

      As an addendum: I know you provide a link for audio-only, but the subscription of the podcast I have on iTunes only downloads and transfers to the device the video version….

    • Me speaking in the mic lasts 70 seconds, the entire rest of the video consists of the slides, which may or may not be helpful to you. 90% of the episodes are audio only. The videos have the audio-only versions available on the show notes for the episode. There are free programs like handbrake that will convert the videos to use on a 3G. Mathias, how else can I help?

      • Mathias Tschopp says:

        Episode 93 has video that plays on my device (as most of your previous video episodes), the point of my message was to indicate that something in this episode’s video settings prevented it from being compatible with older devices. If this is out of your control, then I guess it’s just planned obsolescence doing its trick and I should upgrade. You’re indeed right that slides are part of the videos and do help!

  13. Excellent.
    This was a great and extremely entertaining.
    The argument between DL and VL is very similar to the argument made in the past in Aviation regarding analog or Digital displays in the cockpit. The difference is NTSB has much better and bigger studies to prove this.I will be glad to expand in the future.
    EB

  14. Jeremy M says:

    Anyone have any thoughts on VL and being harder to learn for the older generation vs those from the video game era? I am still hoping Minh convinces someone to make a cmac blade that will hook on to our current handles and connect to our phones. Would be a money maker!

  15. Gannon D says:

    Great debate. Thank you. I was wondering if anyone have been able to purchase the “Standard geometry blades” for the GlideScope? I called up Verathon today and the rep had no knowledge of the blades. We use the AVL model in my shop with the disposable blades.

    • Yes, and I saw them again with Glide again this weekend. It is called the training blade. Disposable mac geometry still pending.

  16. for some reason your system responds to my trying to log in with “this address is banned”>>>>

    I learn a lot that helps me work in the difficult siguations here.

    Thank you

  17. DocXology says:

    Thanks to emcrit for drawing my attention to the Sakles paper comparing C-MAC VL with Mac blades vs DL Mac blades

    http://www.ncbi.nlm.nih.gov/pubmed/22560464

    Although an observational study it showed a 10% increase in successful intubations and 5% increase in Grade I-II views (despite CMAC group containing a significantly larger number of clinically determined potential ‘difficult intubations’) amongst supervised US EM residents.

    Questions I have:

    Is the magnitude of absolute benefit of VL over DL affected by:

    1) Experience of operator in DL versus VL
    2) Presence of expert clinician assistance
    3) Confirmed cases of ‘difficult intubation’ (versus predicted cases)
    4) Geometry of blade (standard Macintosh versus hyper-acute)
    5) Other design factors of the VL

    There does seem to be some

  18. Hermann says:

    In my experience if is precisely the altered geometry of the Glide Scope blade vs. that of the “standard” Mac geometry – that offers an advantage in those cases whose airway anatomy does NOT conform to that of the “standard” blade. Where the airway anatomy is comparable either/any of the devices ( Glide Scope, C Mac or DL MAC ) will be effective. The advantage of the Glide Scope is in those cases where the airway anatomy is not “standard” In using the device, obviously one needs to be familiar with the options regarding stylet curvature and angulation- as one needs to be familiar with the precise technique when using ANY medical device. Facile use of all airway devices is not achieved easily. It behooves the operator to become trained before he/she intervenes in the care of his/her patient. Anything less than accepting that degree of responsibility is negligent.

    • DocXology says:

      And would be the main reason why I would have a VL with hyper-acute blade (e.g. GlideScope blade, C Mac D blade) as my back up tool.

      If I can’t get the tube in with direct visualisation by standard Mac blade and bougie, then I want something radically different to visualise the anterior larynx.

      But one must be absolutely familiar with the completely different technique of using these blades and the stylet curve required.

      I have seen a few examples already where the use of a VL by expert operators has resulted in failure due to their unfamiliarity with the equipment and technique. I made exactly the same mistakes when I first attempted using them at a trade stall.

      My advice, listen to the advice of the VL rep – unlearn everything you thought you knew about intubation, and watch the supplied instructional videos.

  19. Dave Weber, Esq., FP-C says:

    Do love the debate. I’m just an old ground pounder that now works under the rotor disk. The Glide-scope, and VL in general, is a game changer. This is without question. I can think back on scores of pediatric cases where this device would have saved me valuable seconds on those rare pediatric, and seemingly not so rare, difficult airway scenarios. All present may well recite the multitude of physiological and anatomical nuances presenting advantageous solutions and disastrous potentialities. The point of dictating a given approach as a must first try is fraught with peril. I very much appreciate the new addition (new to me) of VL to the bag of tricks. Schmutz within the various regions of the airway take on a whole new meaning when viewed remotely; the intimately known anatomy and friendly landmarks are now strangers for whom I must meet anew. Hands-on matters, both for the student as well as the crowned professional. One should never employ a device or technique that is not intimately known to them. There should be no rust on the tools, nor distrust of patina. I love the new toys, and will spend the time to learn their potential and limitations. So far, I have seen a few blood obscured optical views of airways – following the ‘first use’ directive. I for one, am happy to have VL available. Even more grateful for all of you present for sharing and adding to my cache of stray thoughts and in-the-moment beacons of out of body guidance.

  20. DocXology says:

    Just an outline of differences between Glidescope and conventional technique
    to show how radically different they are:

    Conventional (non-trauma with stylet)

    1) Prepare ETT with stylet and arbitrary ‘hockey-stick’ curvature at end
    2) Place patient in SNIFFING position
    3) Slide blade down RIGHT side of mouth
    4) Carefully DISPLACE tongue leftward to improve aperture of view
    5) Find epiglottis (blade should be advanced far enough but not too far)
    6) Insert tip of blade exactly in vallecula (this has to be precise)
    7) Lift towards ceiling and feet of patient
    8) Visualise cords
    9) Insert tube under direct vision between cords
    10) Remove stylet

    Glidescope

    1) Prepared tube with stylet shaped to curvature of blade
    2) Have head in NEUTRAL position
    3) Insert blade down MIDLINE (tongue does not have to be displaced to side)
    4) Visualise epiglottis/laryngeal inlet (do not attempt to advance blade tip into vallecula, do not apply lifting force)
    5) Insert tube in mouth under direct vision until tip disappears into pharynx
    5) Turn eyes to video monitor and identify tip of tube
    6) Advanced tube under video surveillance until tip passes cords
    7) Hold by scope and tube with left hand and disengage stylet with right thumb
    8) Switch tube to right hand and remove scope with left hand
    9) Remove stylet with left hand whilst steadying tube with right hand (using a curving manoeuvre moving up and forward)

    Common mistakes with Glidescope (per the rep)

    1) Advancing blade too far and coming too close to laryngeal inlet (you want a ‘bird’s eye view’)
    2) Advancing tube too far before moving eyes to video screen (tip of tube is no longer in vision, tube is obscuring cords and too late to manipulate the trajectory of the tube )
    3) Not getting tip of tube past cords before disengaging stylet (and extubating the patient)
    4) Stylet ‘sticking’ because the operator is trying to pull it straight out rather than following the curvature of the tube

  21. Anne Smith says:

    Thanks for an interesting debate. I am a senior EM registrar in Cape Town, South Africa and found this talk helpful in preparing an opinion for potential questions for upcoming final exams. I thought I would just share the South AFrican perspective.

    The SA training system is very different to the States/Canada in that we are trained at medical school(6 years), internship (2 years) and community service (compulsory 1 year) with a more general approach – thus intubation is taught in final year med school, internship requires at least 40 intubations to be done under supervision and most community service docs do not have the privelige of having an EM consultant/attending or anesthetist in the hospital. We only start specialising after those 9 years of ‘basic training’ and then need in our setting is definitely slanted towards docs who can ‘do it all’.

    All my training thus far has been on DL, and I would estimate in my 8 years of clinical practise I have probably performed well over 800 intubations. VL devices have only recently made an appearance in our ECs (although most ORs have had them for some time) and it has been great learning to use them and having that option. Using a video laryngoscope certainly is a totally new skill and one that requires a patient teacher and a keen student!

    I am looking forward to the day when I will have a choice of which device I would like to use for every intubation. Until then, realistically in South Africa, DL is still very much the ‘essential skill’ that doctors need to know.

    Thanks for a great talk!

  22. Eric Chase M.D. says:

    Emergent endotracheal intubation is different than the management of the difficult airway in the operating room. Although this comparison is often drawn as if they are similar groups. Not only are patients presenting to the emergency department (and in the ICU) in extremis and not prescreened for their airways but are also under significant physiologic stress. For these reasons the most optimal tool for the job should be one where the task can be completed effectively, quickly, and without harm coming to the patient.

    It has been my experience and has been documented well in the literature that the effect of video laryngoscopy over direct laryngoscopy has been profound in the management of the emergency airway. VL has been shown to have better first pass success and ultimate success when compared to DL in this patient population (Sakles, J.C., et al., A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med, 2012. 60(6): p. 739-48.) Not only is the success rate higher for all comers but the significant complication rate is lower as well. Dr. Mayo demonstrated this in his presentation where he was able to lower the esophageal intubation rate from 19% to 0%. This is of significant importance as esophageal intubation has been linked to other complications such as hypoxemia, aspiration, bradycardia and even death. While the rate of 19% may seem quite high it is not that different than Dr. Mort described for first year Anasthesia residents performing emergent endotracheal intubation (CA-1 with at least 6 months clinical training, 17.5%; CA-2, 13.3%; CA-3, 10.3%; and staff 7.5%) (Mort, T.C., Esophageal intubation with indirect clinical tests during emergency tracheal intubation: a report on patient morbidity. J Clin Anesth, 2005. 17(4): p. 255-62).

    The concern also that those who are trained with VL will not be proficient with the skill of DL also seems to be unfounded. It has shown at least twice in the literature that novices who are trained on VL perform DL better than those received DL training alone (Herbstreit F et al. Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students. Anesth Analg 2011 Sep; 113:586., Ayoub CM et al. Tracheal intubation following training with the GlideScope® compared to direct laryngoscopy. Anaesthesia 2010 Jul; 65:674.). So having DL on the “crash carts” may still be a suitable choice even for operators who have been trained on VL. However, with advent of smaller more portable devices such as the King Vision VL that could easily be kept on a crash cart this may no longer be an issue.

    There has been surprising considerable resistance and fear in widely adapting this new technology. Much of which seems to be founded in tradition, pride, and dogma that perpetuate in the halls of medicine and not on the current evidence.

    • DocXology says:

      @eric chase MD

      I would hope that the baseline rate of oesophageal intubations in our department is nowhere near 19%. Those operators sound pretty green. Perhaps they should get the skills up first and then see how much an expensive bit of kit will improve their intubation success.

      My take on the Herbstriet article is that VL teaches you the anatomy to apply DL. Apart from that it doesn’t tell you anything how good your DL technique will be to perform difficult intubations.

      Good technique (expert taking over from novice) can improve airway C-L grades by one to two as well.

  23. with training you can minimize time and improve skill to intubate by VL, but DL remaines essential skill. It is the fastest way to intubate. It is available every where. Here in Egypt, VL costs much, and it will not be availabe, so our trainee should be well trained on DL. Thank you for amazing podcast.

  24. I’m a 3rd year EM resident and feel that I’ve done a fair amount of both VL and DL considering my level of training. Where, I train, my first year we did most of our intubations with DL and I did probably 2/3 MAC and 1/3 Miller just to get a feel for both blades. My second year, we did all the trauma intubations and were encouraged to do all with the VL for C-spine purposes (unless there was a reason not to). We had a one on one training session with one of our attendings prior to our first 2nd year shift specifically working with the glidescope to have a little familiarity with it. I’ve used both a CMak and the Glidescope. I actually prefer the glidescope because I feel it is easier to put together and I think I’m just more familiar with it.

    As a 3rd year, I will typically use my glidescope for my initial attempt. In my own experience, I have had great and speedy first pass success with this. I feel very comfortable with the glidescope and typically reach for it first……. even with some of my attendings who are less comfortable with it.

    However, there have been at least 3 occasions this year where there is NO WAY I would have been successful with the VL technique. 2 of these involved facial trauma or hematemesis with blood in the airway. The other involved our glidescope malfunctioning. Yes, it happens and we only have one in the ED.

    In my limited experience, I would say I really like the way I learned. Initially with the DL, then incorporated the VL and finally use both depending on the situation. Why limit yourself? When I set up for an airway, I’m completely paranoid. I have my bougie, my glidescope, my mac, miller, at least 2 tube sizes and an LMA (and I know where my cric kit is) Unlike US and CL, I don’t think you can reasonably argue that VL should be standard of care or should ever completely take the place of DL. I LOVE the VL but there are times when VL is absolutely not possible.

  25. Adam L. says:

    Great podcast. I love and appreciate the DL/VL debate. I think it’s interesting how the propagation of these devices has opened-up a whole new channel of airway management thoughts and techniques for us to develop and to prove…
    Honestly though, I’m really not worried about DL (ever) going away completely and I’m not even sure that I really believe anyone thinks that’s actually going to happen.
    Yes “DL skills” will deteriorate as VL proliferates, but – as I reminded myself only this morning – there will ALWAYS remain a number of commonly-enough encountered emergent situations where direct visualization of the larynx is the only option that does not involve a percutaneous airway.
    (Any blood or emesis in the airway and you may as well be holding a shoehorn as a Glidescope in the hypopharynx.)

    Yes DL rescued VL last night.

    Stranger things have already happened.

  26. frank meissner says:

    I am suprised from the perspective of a trainer that the principal advantage of VL with respect to seeing what the trainee is seeing, and being able to help contemparenously with the initial intubation attempt if the trainee is having a difficult time with intubation has not been mentioned. I think this is a real advantage to the technique. And a significant reason for its popularity in the training environment.

    But like all things there is a learning curve, and for my own part the VL system is a backup rather than primary intubation technique except in the setting of trauma and Cspine immobilization.

  27. Excellent discussion. As has been pointed out in the discussion, VL does not mean Glidescope; but I think it deserves restating. The problems with the Glidescope, good vision of the target but difficulty placing the ETTube and damage to the nearby tissues with the rigid stylet, are not those of the video-empowered standard Mac blade VLs.

Speak Your Mind (Along with your name, job, and affiliation)