Welcome to this month’s edition of Staten Island Corner. The subject of this month’s edition comes from a recent topic on EMRAP. There was an interview with Dr. Ron Walls, who is a well known Emergency Medicine Physician and nationally recognized airway expert. The topic of the discussion was the use of video laryngoscope compared to direct laryngoscopy. Dr. Walls brought up the idea that he believes within the next few years, the standard mode of intubation in the Emergency Department will be via video laryngoscope as compared to the standard direct laryngoscope. This concept met a lot of resistance in the Emergency Medicine world and was a controversial statement. There is a message board on EMRAP that was filled with passionate responses from EM docs around the country. I thought that it would be a good idea to look at the literature comparing the glidescope (what we have in our department) compared to the standard direct laryngoscope.
The first article was a systematic review and meta-analysis of glidescope versus direct laryngoscopy in adult patients. They assessed for the following outcomes: Cormack-Lehane view grade 1 vs grade 2, successful first-attempt intubation, and time to intubate (in seconds). The operators in most of the studies were anesthesiologists who were experienced in both techniques. The glidescope group resulted in improved glottic visualization and the difference in visualization was more pronounced in studies with anticipated or simulated difficulty airways. Intubations were considered difficult in studies that included patients with a known prior difficult intubation, physical examination features suggesting a difficult intubation, or in whom difficult intubation was simulated by providing manual-in-line stabilization. The glidescope increased the success rate of first intubation attempts in non-expert operators, but not in expert operators. The glidescope also decreased time to intubation in the non-expert group, but not the expert group.
The second article looked at the success rate and time to intubation in untrained medical personnel using a MAC blade versus the glidescope. In this study the participants were trained on a manikin on both techniques prior to the study. The intubations were performed in a controlled setting under general anesthesia. The overall time for tracheal intubation for all attempts was significantly shorter for the GlideScope technique versus the Macintosh technique (63 ± 30 s vs. 89 ± 35 s; P < 0.01). The GlideScope technique led to a significant higher success rate (93%) as compared with direct laryngoscopy (51%).
There are previous studies that report the number of intubations required to achieve a success rate of 90% and higher is about 47-56 intubations. This is important because both studies came to the conclusion that the glidescope has more of a benefit in the non-expert group. Although the definition of what makes somebody an expert or not is difficult to define and a completely different discussion, I think that we can all agree that an EM Resident with 30 intubations is not at the same level of an anesthesiologist who has performed hundreds of intubations. Therefore, the question is whether or not the glidescope should be the preferred or initial method of intubation in the “non-expert.”
As EM Residents, we are in a unique position in this debate because we need experience with direct laryngoscopy in order to become “experts.” We are in residency training and therefore we require training on direct laryngoscopy. If the glidescope is used as the initial and preferred method, junior residents will without a doubt get less experience with direct laryngoscopy. Dr. Walls answers this argument with the use of a C-MAC video laryngoscope, which is a device that is similar to a regular MAC blade, but has a video attached to it allowing the attending to directly visualize the view that the resident has. In an Emergency Department based study comparing C-MAC to Direct laryngoscope, the C-MAC was associated with a greater proportion of successful intubations and a greater proportion of Cormack-Lehane grade I or II views compared with a direct laryngoscope.
Where are we at now? I think that it is clear that the glidescope and video laryngoscopes in general do have a role in Emergency Department airway management. It has been shown to improve glottic visualization as compared to direct laryngoscopy which we can assume leads to improved ability to pass the ET tube. In my opinion, the most important use of this technology at this time would be in the patient with the difficult airway. The improvement in visualization is more pronounced in the difficult airway making it a great choice for these patients.
The question that I have for the department is if the glidescope should be used as the initial method of choice in the patient with an anticipated difficult airway or should it be there available as a back up device if unable to successfully intubate via direct laryngoscopy. I would like to hear from the rest of our department on this issue.
References:
1) Braude D, Walls R. Airway management! Time for a change? EMRAP. Sept 2012. https://www.emrap.org/
2) Griesdale DE, Liu D, McKinney J, Choi PT. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: as systematic review and meta-analysis. Can J Anaesth. 2012 Jan;59(1):41-52. Epub 2011 Nov 1.
3) Nouruzi-Sedeh P, Schumann M, Groeben H. Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel. Anesthesiology. 2009 Jan;110(1):32-7.
4) Sackles JC, Mosier J, Chiu S, Cosentino M, Kalin L. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med. In Press, Corrected Proof, 2012 May 4.
basile
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2 Comments
Nikita · January 9, 2013 at 9:16 pm
Good write up and great topic Joe! I think that this is an interesting debate, and there is a good discussion as well on this week’s emcrit website that you can read at this link: http://emcrit.org/blogpost/rant-video-laryngoscopy/. This was a “rank” that one of the listeners sent to Weingart about techniques regarding video and glidescope, and the commentary was also enlightening.
To answer your question Joe – I do think the glidescope should be used in training, there is comfort in knowing what is being visualized.
There is a HUGE caveat though, and i tell this to all of the juniors I work with, and that link / rant addresses it as well. It is a very different technique to intubate with direct vs video.. when I was a junior I only did direct and so I was able to practice the physical maneuvers. But now the current juniors will be using both, if not more video.. and they will have to learn two different techniques, and learn is well. So it may be more difficult to get the hand/eye coordination, physical memory down to complete the task of intubation. I remind all of my juniors to be very wary of this important distinction.
Nikita
jwillis · January 18, 2013 at 1:44 pm
I listened to this podcast recently. It made me think a lot about this issue especially as an upcoming attending. I think we still need to teach residents/juniors how to do direct laryngoscopy.
We have the c-mac device in county (I believe it is still operational) that I feel is not utilized enough and can be a good for direct laryngoscopy skill teaching and video laryngoscopy as described in the EMRAP podcast.
Something I have heard from colleagues in other institutions is the use of glidescope in trauma airways should be standard especially with cspine stabilization. Obviously this is dependent on how bloody the airway is but I think it is something I am trying to incorporate in my practice.
Bottom line I agree with Niki that residents need to learn both skills.