Cite this post as:
Scott Weingart, MD FCCM. Two OR Intubation Videos. EMCrit Blog. Published on November 20, 2011. Accessed on April 26th 2024. Available at [https://emcrit.org/emcrit/two-or-intubation-videos/ ].
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: November 20, 2011
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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I enjoy the EtCO2 tracing overlay prior to switching to the intubation.
I’m looking but I’m not seeing what you’re point out
18 seconds in, top left.
Ahh gotchya. I started searching too late in the second clip and couldn’t fathom why you thought a CO2 flatline was interesting. Don’t worry, as usual I just chalked it up to you knowing something I didn’t.
EtCO2 tracing and absolute number is of vital importance not only in Anesthesia, but in Emergency Medicine. How are you guys going to know if your CPR is working? The EtCO2 can be your guide. Consider asking your medical electronics department if you can obtain any of the discarded anesthesia gas analyzers that are being chucked out the window as many medical systems are finding them incompatible with electronic medical record keeping systems. These gas analyzers will give you not only EtCO2, but also end-tidal O2 concentrations (EtO2). EtO2 has become important to me clinically in that I use this… Read more »
Dr. DuCanto, You’ll be happy to hear that waveform EtCO2 is going strong in many EMS systems, and most high performing systems use it on any advanced airway placement (BIAD or ETT). In North Carolina, it’s required in any system utilizing RSI. And as you’ve noted, EMS often uses EtCO2 to benchmark CPR but also as a data-point for discontinuation of resuscitation in the field. Those with nasal cannula monitoring capabilities may use it on COPD/Asthma or even CHF patients. We don’t (yet?) have EtO2 measurements in the field, but that certainly would be helpful during preoxygenation! I’d love to… Read more »
Jim, brilliant demo of the Levitan stylet. I really love your nifty digital camera attachment with the swivelling LCD display..is that custom made adaptor or did you find one off the shelf?
that bending of the stylet I read about in a recent paper on using the Levitan scope as the sole intubating device..it seems to work really well in your hands..how do you do it..bend it into that shape?!
I bow to you master!
Thanks for the generous favorable feedback! If I could have only 1 advanced airway device with me, it would be the Levitan Optical stylet (with an Air-Q). It can intubate 5 different ways, it’s affordable and durable. I could live without video laryngoscopes, but that’s me, I’m an anesthesiologist, not an Emergency Medicine physician. Repetition to the point of exhaustion is needed to gain the skills and confidence to use an optical stylet in an emergency situation, so for those of you out there thinking of getting one, my advice is to use the device with every intubation that comes… Read more »
Like Jim, we bent our bonfils stylet to the exact shape of the AirQ Curve in vivo. We didn’t add the retroverted backwards bend on the prox end to make true sigma. Ours is just a gentle arc that slips down the AirQ like butta’.
Doing the actual bending was petrifying though as the bonfils is even less malleable than Levitan.
Can you show picture of your set up….very interesting. Been try before buy the air-vu for a week now. It is very nice!
thanks Jim! What you use now, the shikani setup with the camera, looks very much like the new Clarus video system? Would you consider that instead now? Also a few years back Greenland from my neck of the woods in Brisbane, did an operative anaesthesia comparison study of the Levitan and the bougie..finding little performance difference? Do you have any comments? do you think that if a patient is deemed to require RSI, you would still consider the technique of placing a sGA and tubing via the sGA? I guess I am hinting at the RSA technique that Darren Braude… Read more »
I actually do own the Clarus Video system. It’s pretty neat, and I used to carry it around with me, but nowadays, I carry the Levitan. Technique-wise, the Levitan is better with DL because of its length and setup with eyepiece. As I DL, I am close to the patient’s face, scoping over the top of the eyebrows. The Levitan swings in, and as it comes around the base of the tongue, the eyepiece falls naturally into line with the eye. With the video system, I need almost 2 1/2 feet between me eye and the viewscreen to use it… Read more »
thanks for the advice on the Clarus Video System..makes sense. I have to ask. How do you go about sterilising the Levitan in between cases? We were recommended using the Starrad technique but I have heard some clinicians just clean it in standard endoscopy sterilising solution. The issue for training with it is how often you can use it during a standard theatre list. You are right in that it requires dedicated practice and deliberate technique with DL to use the Levitan effectively. I agree if you put in the dedicated practice you will be rewarded handsomely. What we have… Read more »
For myself and one of my colleagues, the bonfils is a pleasure and I would agree with Jim if you are in the community where you do your own tubes (rather than supervise residents) the Levitan may be the ultimate device along with an intubating SGA. The moves to use a fiber stylet are radically different than bougie or laryngoscope intubation. If you can intubate with a bronchoscope, stylets are easy. If you are doing stylets for the first time, you need someone to show you the tricks. Stylet through AirQ is dead simple if you lube properly as Jim’s… Read more »
Jim, welcome to EMCRIT. I thank Scott all the time for this internet vehicle he has created in allowing some of us who aren’t in critical care fellowships, to keep on learning how to take care of the sickest of the sick patients. I can’t wait for you to show some videos regarding the Oxylator that you use.
Jim-I’m willing to post any good videos you send my way.
thanks for the advice You both have reinvigorated my enthusiasm to research and teach advanced techniques with the Levitan stylet. There is no doubt in my mind that cost wise, you could easily afford both a lEvitan stylet and king vision video laryngoscope and still have spare change compared with other video systems out there like GLidescope, Pentax and CMAC. intubation via SGA using an optical stylet is potentially a very resilient technique in the ED and even prehospital. Attention has been diverted away from it in recent years with the whole range of video laryngoscopes spewing out onto market.… Read more »
Exactly. Bonfils or Levitan are a useful adjunct to the armamentorium and Minhs argument is well reasoned
Made my decision to go with KingVision and Levitan some weeks ago…the discussion on this thread reinforces it
Sorry for the delay in getting back to you guys—home, holidays and call duties built up over the past 2 weeks. Minh, your ideas are spot on. If DL doesn’t work, going to an SGA for ventilation, then using that SGA as a guide for optical stylet driven intubation attempts is a very sound plan. This is the usual progression for me in my practice. The King Vision is a good endoscope—-as good as any other out there, and is now reasonably priced. The high prices of the videolaryngoscopes are related to the systems they have been traditionally competing with… Read more »
Jim, I missed you mate! I was searching online for where to buy a box of the new AIr Q blockers so what a coincidence! Can you post a link to where you bought your AIrQ blockers..I can’t find anywhere to spend my money on getting them! I managed to get a spare Levitan FPS, bend it into that sigma shape and practice with an IGel, so I now want to try it out with the AirQ blockers I have an idea I want to work up in regard to aeromedical retrieval of agitated patients using what we have discussed.… Read more »
I will get the name of the rep in Australia and get back to you in the next couple days–I know the people who make and distribute the product here in the US, and they’ll get back to me shortly. Most certainly you do not need paralytics to place and ventilate through the Air-Q or any other SGA, and that can be an advantage, as it permits spontaneous ventilation, which decreases the impact on hemodynamics that often accompanies positive pressure ventilation. Transport on SGA alone is reasonable with a second generation SGA. The US military has this in their transport… Read more »
OK I figured out MICU. Intubating only on propofol (controlling hemodynamics to offset the hypotension)? What is needed here is either a collossal dose of propofol to know out the brain and the spinal cord reflexes (think gag, laryngospasm), or the concomitant administration of an analgesic to provide proper anesthesia for the procedure (like ketamine). I think that (propofol alone) is a technique for anesthesiologists—we know the effects of the medication at different doses, and can anticipate how to limit those side effects, like with pressors for instance. Too many variables for a non-anesthesiologist. A more reasonable approach is a… Read more »
Jim,
At least my opinion is that such a work would be enormously useful. Especially on the specifics of the AirQ rather than the fasttrach.
If you added in some videos from your archives it would be amazing. Happy to put it up here on the blog if you’d like.
is the Pope a Catholic? Absolutely would love to see a monograph from you Jim on tubing via the AirQ blocker using the Levitan FPS! Its good to hear you write on how transporting with second generation SGA is reasonable and the US military have a plan for this. This has been my conclusion for a while based on some cases and it aligns with what Dr Darren Braude teaches and has published on. I trained extensively with the Fastrach ILMA and I love it but must admit it is not intuitive at all for many. Exploring the AirQ blocker… Read more »
Jim, Scott. I managed to get a box of 4.5 AirQ ILA from US. I have been testing it on the Trucorps mannikin today using the Levitan FPS. I agree, at least on the mannikin , its a pretty smooth technique. I tried intubating using the Levitan with a Fastrach silicone tip wire reinforced 7.0 ETT loaded on, with the connector removed. It makes it the right length for the Levitan with the tip of the stylet just emerging from the end of the ETT. Nice you don’t have to cut the ETT length. I must admit it seems to… Read more »
Super news it is definitely. My girlfriend has been awaiting for this update.