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.
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An ED Intensivist from NY.
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Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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great stuff!
I know you dont do peds EM but check this out
http://journals.lww.com/simulationinhealthcare/Abstract/publishahead/Comparison_of_Success_Rates_Using_Video.99814.aspx
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… Read more »
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… Read more »
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.
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… Read more »
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.
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… Read more »
Didn’t understand the out of place ref, Kevin?
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.
Great Podcast. I like Scott’s ultimate approach and reasoning.
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
Yep, it needs to be Mouth-Screen-Mouth-Screen or badness ensues.
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… Read more »
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.
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.
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
Channeled king is a great way to go.
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… Read more »
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… Read more »
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… Read more »
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.
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… Read more »
Correction: the mean to all ends 🙂
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… Read more »
Superior judgment > superior skill > superior equipment.
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… Read more »
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….
Video is the way it is in itunes. If you want audio-only–save to your desktop and drag into your ipod/iphone.
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?
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!
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
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!
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.
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
not sure what you are trying to log in to.
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… Read more »
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… Read more »
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… Read more »
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… Read more »
quite poetic, my friend
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… Read more »
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… Read more »
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… Read more »
@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… Read more »
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.
Thanks for bringing that perspective!
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… Read more »
CMAC with a backup Mac gives me the best of ALL worlds, but I hear you Kat.
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… Read more »
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… Read more »
Frank, I believe I mentioned that very point and I totally agree.
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.
Nice article with Nice Information But I like to mention that a video Laryngoscope can’t beat the direct laryngoscope. Because thousands of users still prefer direct laryngoscope.. We manufacture <a href=” https://www.fizzasurgical.com/laryngoscopes-manufacturer-in-sialkot/“> Laryngoscope </a> and we will keep this in our mind.