Why First Pass Success?
Best review article – first-shot-is-the-best-shot
Each Attempt Makes Things Worse
Hasegawa et al. showed at 3 attempts, things got bad (Ann Emerg Med 2012;60:749)
Sackles JC et al. showed that >1 attempt radically increased complications (ACADEMIC EMERGENCY MEDICINE 2013; 20:71–78)
Mort demonstrated this in the ICU, after two attempts risk of crit desat (70%) is huge and assoc. with cardiopulm arrest (Anesth Analg 2004;99:607)
Mort has further elaboration re: the dangers of intubation in the critically ill (J Inten Care Med 2007;22(4):208)
Heffner et al. showed a 4% cardiac arrest rate in ED intubations (Incidence and factors associated with cardiac arrest complicating emergency airway management. Resus 2013)
Duggan showed >1 attempt = badness
Learning Curve for Laryngoscopy
- Best review of lit is at Openairway
- How many general ED docs do: Ann Emerg Med. 2019 Jun 24. doi: 10.1016/j.annemergmed.2019.04.025.
- How many they need to do: West J Emerg Med. 2019 Jul;20(4):601-609. doi: 10.5811/westjem.2019.6.42946.
VL Teaches DL
This letter has a discussion and pertinent references (BJA 2017;119(4):842–843)
EMCrit Failed Airway Algo V2.0
Bug the ResusTO Folks to Do the Course Again
Blade Views by Nick Chrimes
Now on to the Vodcast…
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- EMCrit Wee – Stop Kneejerk Intubation with the EMCrit Crew - March 30, 2020
- EMCrit Wee – Alternatives to Vent Splitting and the Safest Vent Splitting Methods in COVID19 - March 28, 2020
- COVID Airway Management Thoughts - March 27, 2020
Hey Scott, A couple of thoughts: I am sorry for your most recent negative twitter experience. Unfortunately it can create an environment conducive to visceral poorly thought out responses. I have to say the airway twitter community at least in my experience while at times heated in there dialogue is mostly respectful and often insightful. I appreciated your views on how to achieve competence in high acuity low opportunity procedures such laryngoscopy and intubation. My airway interest began as part of a Masters at University of Illinois Chicago while a resident in EM at Western (Ontario) back in the early 90s. My thesis was on procedural skill maintenance and the skill was DL. Thus was born my passion for airway education (plus a good dose of fear). Despite intubation being a relatively uncommon (compared to the OR) procedure, large EM data sets have had a historical FPS rate of 85%. The Driver et al study had a~95% FPS rate, So what ever we’ve been doing educationally is pretty damn good considering all of our cases are difficult (anatomy, pathology, physiology and psychology). The learning curves are interesting but less important than these markers of patient outcomes. My SMACC talk in… Read more »
WE agree on units od deliberate practice as the real currency of obtaining mastery. That was my whole point on the learning curve and why I find the argument that simple volume indicates the more skilled practitioner to be deeply flawed.
Disagree regarding the MAC not needing pulling back. I have noticed many times the inability of the residents to reach the glottis with a straight bougie or a standardly bent stylet when they have overrun the epiglottis and close to the cords. I think you will find the same at least with the CMAC disposables we use. It is the same problem as with HA, though less extreme.
Perhaps we will agree to disagree but I think this move has the potential to cause more difficulty than benefit with Mac laryngoscopy (CMAC include). Revised anatomy chapter in Infinity edition should clarify what I’ve tried to describe below.
The only way that I can think that would anatomically explain this observation is if they are torking ie rotating the blade resulting an anterior tilt of the larynx resulting in an increase in the primary/secondary curves. The reason a restricted view works with HA blade use is because of over-rotation which visually manifests as too close a view. Pulling back to a grade 2 (50:50view) de-rotates the blade. With a Mac blade laryngoscopy we think the the key is engaging the hyoepiglottic ligament (see our video on a sagital section cadaver we have on you tube ). Too proximal or too distal placement of the blade tip at the base of the vallecula results in a poorly rewarded aggressive lift. Pulling back with a Mac blade risks misplacement of the blade tip engaging the HE ligament.
think you may be being blinded by competence and excellence, my friend. Of course you would never pull back from a properly seated tip in the vallecula. As was mentioned in the comment above, this is when the resident has already overrun the vallecula. They get right up to the cords–occupying whole screen. If the patient is stable, I will have them come all the way out to the base of the tongue and do things the right way. If the pt needs to be intubated now, will just have them pull back until the cords are on the top half of the screen regardless of whether they have pulled back to the epiglottis.
I looked at a lot of these questions in preparation for a debate with Rich Levitan at AAEM 2014; Rich chickened out and didn’t show up (he claimed his flight got canceled). That 10 minute presentation is here:
https://emupdates.com/direct-vs-video-laryngoscopy-in-10-minutes/
I came to essentially all the same conclusions. The reason I have been advocating for trainees to start with SGVL-video and move to DL(SGVL-DL) and HAVL only after mastering SGVL-video is because of Ayoub 2010, which is I think the study you’re calling for, Scott. It’s in this folder, along with a bunch of other studies that make it clear that trainees should start with VL.
https://www.dropbox.com/sh/gojalap0d78siz0/AACZgUnBXiIHy6iiGAjB1jBva?dl=0
Reuben
just listened to your ten minute vid-pod… i’m 3 years late.
It is super-cool. thanks. didn’t realize there are so many different degrees of angulation available on VL.
tom
(maybe i’ll stop into maimo while i’m in brooklyn (see my other comment on this pod.
great find. wish they didn’t suck so bad in both groups, but he VL-trained group def. sucked less.
Great podcast Scott!!! I personally believe you’re doing a great job and definitely should block out all of the ignorance on the social media sites. Hopefully it’s all just misinterpretation.
When it comes to SG-VL…we have been doing this approach at our flight program for quite some time. We utilize the CMAC-SG so that we are able to approach from a DL position but have the ability of VL if necessary. We also use the Bougie(two person technique) on EVERY attempt which has surely helped improve our first time success rate. With this approach, we are in the mid 90% first pass rate as an entire program which I believe it quite impressive seeing we all are Flight Paramedics and Flight Nurses. And with that being said, most of our intubations would be considered “difficult airways” as I’m sure you are aware due to your support of prehospital providers and understanding our environment.
Thanks again for the awesome podcasts! I truly enjoy all of the airway and ventilator discussions, keep them coming!!
[…] https://emcrit.org/emcrit/failed-airway-algorithm-2018/ […]
This is great Scott! Thank you for this and the excellent workshop at ResusTO! I am fully on board with this approach for my environment. Hopefully I can convince others that we should adopt this.
In the workshop you discussed the use of the NRB at flush as one of the best pre-ox devices along with NC. Do you have evidence for this that you can share?
Caputo’s group will be publishing it shortly. Abstract will be at ACEP next week.
This is great. I would like to emphasize trying to, if at all possible, do DL (with the SG-VL) first, before you look at the screen. I see a lot of learners who can see just fine with VL, but then there are about 5 attempts at passing the tube (or bougie…whatever) while the SpO2 drops because they can see fine…they just can’t deliver the tube. They don’t do any more laryngeal manipulation in order to more easily deliver the tube because they can already see. When the SpO2 starts to drop they either keep trying too long because they can see (not a good move) or it turns one attempt into two (only slightly better). I think this was what was seen in the MACMAN trial where there was the same rate of intubation success (including first attempt), but the biggest reason for failure of DL was they couldn’t see, and the biggest reason for failure with VL was they couldn’t place the tube. The VL group had more “severe hypoxemia” (SpO2 < 80%), and my guess is that's because folks could see, but when they couldn't immediately place the tube, they kept trying without the normal larygoscopic manipulation… Read more »
Reuben, many other airway teachers, and I disagree. Learn the video view first. See Reub’s comments above.
Can’t agree. To be clear, i’m not advocating a DL with a DL blade. I’m advocating attempting DL with a VL blade. And I’m not advocating a second pass when you can’t see via DL. I’m advocating looking at the screen and making the same attempt a VL attempt after you have maximized your DL attempt. This was the technique used in the Hennepin bougie trial you mention, where 50% of the attempts used a VL blade, but never looked at the screen. Some (25%) used DL to see, then the screen to deliver the bougie (which I think might be the best way). A minority used the technique you are mentioning, which is look at the screen the whole time (25%). With the technique I’m talking about plus a bougie they had that 98% first attempt success rate, which is super hard to beat. Not sure how you can disagree with that. Again, in my experience and in the MACMAN trial, if you can see via DL you can usually deliver the tube – often not the case in VL. I worry that if folks do what i think you are advocating (which is use the screen primarily for… Read more »
Not sure how I can disagree with what? The Hennepin data does nothing to bolster your point; it was not a comparison of the methods. You would have to find a reanalysis to the success data stratified by method. It just shows the prejudice many residents still retain that there is value to learning direct. My residents still have it, but it just is not true. You have a markedly smaller field of view. There is NO difference in ability to place the tube with standard geo video whether you look direct or at the screen. Key you may be missing is that any time you are passing a tube with a video device. You need to look in the mouth until the tip of the tube or the bougie disappears from view and only then look back at the screen. From your comments it seems your learners are looking at the screen during entire tube placement–this is a path to failure and further a path to posterior pharynx injury. Sequence for any vid device must be: Mouth Screen Mouth Screen for first blade insertion and then tube insertion. This seems to be the root of the issue. I can’t… Read more »
1) ) not sure how a 98% FPS rate can be faulted is what I meant. Totally agree, it wasn’t a study of the technique, but my point is that it’s at least on par with anything reported in the literature that i know of, and they used the “video assisted DL” technique I’m referring to. Even their non-bougie group had a 87% FPS rate, which is on par with or better than many trials. It may be that, with your algorithm, you’re trying to improve on the 85% DASH 1A they had or make the duration of the attempt a little shorter, which would be reasonable goals. But in my view their technique + bougie resultS in the highest FPS, and that fits with my clinical experience. Can’t speak to why they used that technique – could be because they think learning DL is important, they agree with my view on that technique being the best, or because they were worried about blood/vomit/secretions in the airway killing their VL. No idea. But it seemed to have worked. 2) i do and teach the mouth-screen-mouth-screen technique you’re talking about (I also tend to hold the ETT a little higher kind… Read more »
loved this scott. thank you so very much. two quick thoughts : 1. the video at about time 22:18 to 22: 25 is priceless. you brought NYC to toronto, and the rest of the world. you have a clear obvious point. (i hope i am representing this accurately). what we do as ER docs, resuscitationist’s, icu docs, is very different from what many other people do. we are not talking about painting toenails. (not that that is any less dignified or important). we can not slip, err in securing the airway. period. we have an ethical responsibility to be the very best we can possibly be. period. and i think that is part of the anima which informs this lecture/podcast. i loved it. you were loud, and clear. very cool. thanks. 2. in my shop, we do not see enough (is that the correct word?), do not see a great many of intubations in the ER, despite our volume of 72,000/year. i thought i was “good”, have been trying to follow all your, and many of Rich Levitan’s pods, and video lectures, have all my little tricks of O’s up the nose, ap-ox, I even have my free-sample Ducanto catheter… Read more »
why not combining different tecniques togheter in order to achive always a sussesfull intubation on the 1st attemp? I’ll explain myself: it has been quite a while that I am using VL (macGrath, but the tecnique can also be applied to any VL interface is in sale) with fiberoptic broncoscopy with OT tube loaded. The principle of using the FBS is that it simulate a “mobile” bougie that I can direct in a more fine and clean way through the vocal chords in the first attemp, then give trough the FBS some lidocaine to anesthetize the chords and the trachea (so avoiding miorelaxant) then unload and slide the OT tube into trachea and then use it as a normal FBS to place the tube right on the carena.
well can’t be recommended for a few reasons:
1. cost. either of sterilization or replacement of AMBU scope. TOugh to justify as routine rather than reserved for difficult.
2. We cann this the triple setup (Kovac G) and use this quite a bit for a predicted difficult, but at least in my hands, this requires two intubators. In which case there is your second reason. Or have you figured out a way to do this solo (unlikely)
what you might consider instead is something like the new CMAC intubating video stylet. You can use it one handed, it’s tip articulates and the images are AMAZING (don’t take money from them). If you are willing to do the sterilization yourself (no suction channel to worry about) using a cidex bath or similar, it can be cost effective as well.
But I have a serious worry of lack of skill development/retention for standard technique if this was your go-to.
[…] Also Checkout Scott’s Podcast HERE: EMCrit 233 – EMCrit Failed Airway Algorithm 2018 from resusTO […]
Thx Scott. That was super – I think you’re right. The only way to maximize your success in intubation is to focus on one technique and practice it often. I see an analogy to martial arts – you have no time to practice 100 techniques – but if you know the one technique like a master you can win (ok you can loose but then you can always ask for help – it’s not possible in fight). Too many choices makes you slower and sometimes is confusing. That’s a different game than in OR (dojo vs on the street). I’m anesthesiologist now but I was a paramedic in the past and from this point of view I totally agree with you. PS I’m in your tribe. Take care.
My go to has been video laryngoscopy but I have not used the bougie on first pass. Can you recommend best technique for holding/passing the bougie when using standard geometry blade and hyper angulated blade. Reference or links would be fine. Great podcast
Thank you for just about the best damn explanation of managing the sick airway. I am emailing this to my residents TODAY.
[…] To minimize complications of emergent airway management, successful intubation should be achieved on the first attempt: EMCrit Failed Airway Algorithm 2018 from ResusTO […]
Awesome podcast as always, Scott. Such a shame regarding the negative and dismissive comments from the Anaesthetic folk. They took your presentation out of context and clearly couldn’t discern the difference between a trauma and elective patient (1st attempt being paramount in the former). Agree with your comments regarding teaching and VL. Love your work, keep it up mate!
Awesome podcast as always, Scott. Such a shame regarding the negative and dismissive comments from the Anaesthetic folk. They took your presentation out of context and clearly couldn’t discern the difference between a trauma and elective patient (1st attempt being paramount in the former). Agree with your comments regarding teaching and VL. Love your work, keep it up mate!
Great podcast! Im a new anesthesia resident and really appreciated this episode. People in medicine often downplay (b/c of culture?) how much practice (and thoughtful review) is required for skill mastery, airway management included. My EM resident bestie and I were just talking about how crazy it is that EM residents only do a limited amount of required intubations when DL can actually be quite varied and challenging as Ive experienced in the OR (fail, fail, fix, fix, fail again with DL as you described). Thanks again for all of your hard work in education.
[…] Weingart has updated the Emcrit Airway Algorithm. Check out the vodcast and discussion. […]
[…] Weingart has updated the Emcrit Airway Algorithm. Check out the vodcast and discussion. […]
Hi Scott: Fantastic lecture and don’t let the Twitter wankers get you down. : )
I would like to see someone (Scott?) tackle the BIG issue of pre-hospital intubation i.e. should we intubate at all and when? I personally take a look with a scope and a bougie and if I don’t have a clear shot I give up and just place an LMA Supreme (that’s what we have). But maybe I should just go right to the LMA in some patients – I don’t know. All thoughts appreciated. THX! Chip, CCEMT-P. @mainecrit
HA-VL with malleable bougie. Maybe the best method with best first pass success if this becomes our choice for “Single Technique Mastery.” Why go to step 2 of algorithm (optimize or HA-VL) for those occasional really difficult airways when we could make HA-VL with malleable bougie the first, and best attempt?
BTW, I’m FP boarded, and have never done anything but full-time ED medicine toiling on the seamy periphery of medicine, working in under-served, understaffed, and really poorly equipped rural hospitals. I have no residency training in EM, but work hard constantly to stay current and provide good care. Hopefully I am included in your tribe.
I found this rather enjoyable. Thanks for the laughs. Twitter should be converted to Haiku only.
Call for back-up – why not put it in ?
huh?
I am a anesthesiologist working in ICU and EMS, not that it matter.
Call for more experience, is not bad thing, i still do it when i work in house. Also now when i am the one, the others call for.
But when i work, prehospital it other mater, no back there. But your flow chart is for in house.
Sorry i see it there