Why Video will never kill the direct laryngoscope star!
What follows is a bit of a rant but stay with me as there is some updated airway research evidence to present too!
EMRAP Audio by Dr Mel Herbert is an excellent monthly audio subscription podcast that I happily shell out the annual fee for. IN recent months it has included a segment called ” Airway and underpants” by none other than Dr Darren Braude, who teaches some great airway techniques including one called Rapid Sequence Airway.
On the latest September edition, Darren interviews none other than Dr Ron Walls, who has published more airway research articles than I have had hot breakfasts and runs a great website and program called Airway World.
During the interview, which is on the new edition of the Difficult Airway Manual by Walls, he states
“I will unequivocally state that it is wrong for people to practice direct laryngoscopy in 2012.”
I was a bit irritated by this statement!
Here are the discussion comments since the episode was posted
EMRAP Airway episode with Walls COMMENTS
I personally have great respect for Dr Walls as being a pioneer and great mind in the area of emergency airway management and so it shocked me to hear such a statement spoken by him.
Then I read the OnLine first segment of Canadian Journal of Anaesthesia this month and guess what I found?
Griesdale DE, Chau A, Isac G, Ayas N, Foster D, Irwin C, Choi P
[Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial.] [JOURNAL ARTICLE]
Can J Anaesth 2012 Aug 30.
PURPOSE: Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers.
METHODS: Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures.
RESULTS: Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO(2) (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO(2) of 95% in the DL group [IQR 85-99] (P = 0.04).
CONCLUSIONS: Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on ClinicalTrials.gov number, NCT00911755.
I believe and teach that both VL and DL have a blended role in emergency airway management and are not mutually exclusive. Love to hear your thoughts out there and its worth spending the time and money to hear the original interview with Darren Braude and Ron Walls on EMRAP Audio.
Now I feel better, whew!