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WHY VIDEO WILL NEVER KILL THE DIRECT LARYNGOSCOPE STAR! by Dr Rob Bryant

Minh,

Let me preface this case by saying that whenever any of our excellent 2nd year Emergency Medicine residents cannot get a tube, I get a little (a lot) nervous.

Here is the case:

84 year old male, MVC rollover arrives via life flight following needle decompression of left pneumo en route. Normotensive.

Mild increased work of breathing, very tender left chest wall, sats 94% NRB, he had additional soft tissue extremity injuries requiring operative debridement, CXR showed multiple left sided rib fractures, no visible pneumo on CXR)

Pre-oxygenation:

Pt placed in reverse Trendelenburg 15 degrees head up, NRB flow rate 30L/min, nasal cannula on, and turned up to 15L after sedative and paralytic meds pushed.

200mcg of fentanyl given en route, another 50 mcg given on initial assessment.

Ketamine 1mg / kg, Roccuronium 1.25 mg/kg

Initial attempt by resident with glidescope (due to C-spine immobilization) gave a grade 2 view of the larynx. His mucosa was very tacky, and there was a moderate amount of tenacious saliva that cleared with suction. Despite multiple attempts at repositioning the tip of the ETT, tube delivery was unsuccessful. There was an estimated 2 minute safe apnea duration on the VL attempt prior to sats hitting 90%, when the glidescope was withdrawn, and he was BVM ventilated back up to sats of 98%, (this took about one minute)

On DL, I had a grade 1 view, bougie was used due to the grade 2 view on VL, ETT tube passed over bougie without difficulty.

Post intubation fentanyl 1 mcg/kg bolus and fentanyl drip for sedation.

This case illustrates the difficulties with tube delivery using VL. There was a reasonable view of the larynx, but do to the tackiness of his mucosa, tube delivery was extremely challenging, even in the setting of great pre-oxygenation, and a lengthy safe apnea duration.

I would still try VL first in c-spine immobilized patients, however would switch to DL earlier next time.

I believe we need to be proficient at both DL and VL, and this is a case that demonstrates this point well.

I attached my idiots guide to apneic oxygenation.

Apneic_oxygenation_slideshare  (pdf)

Apneic_oxygenation_slideshare (ppt)

Rob

Rob Bryant MD

Utah Emergency Physicians

801 633 8453

@robjbryant13

(Editor’s comment (Minh) – Note to self. Don’t throw direct laryngoscope just yet. Might still be useful)

15 Comments Post a comment
  1. I’ll make a few queries and comments
    The glidescope has a learning curve to its use, so was the operator versed in it’s use?

    Was a gliderite stylet used?

    Was the problems with the tube catching on the anterior wall of the trachea or manipulating the tube to the inlet?

    Some potential solutions include withdrawing the glidescope a little bit to give a great field of view, gentle rotation of the tube and stylet to bring the tip into the correct plane or in the case of anterior wall issues , gentle withdrawing the stylet and advancing the ETT or reverse loading the tube so when the stylet is removed it tends to follow the curve of he anterior wall.

    On a different note there is good evidence from the anaesthetic literature that direct laryngoscope is easier than videolaryngoscope with a difficult type blade( as compared with a mac type blade) in a straight forward intubation. The reverse is generally seen when the Cormack and Lehane grade is 3 or 4.

    On final note it is important to highlight clearly as you have done, that a videolaryngoscope is being used when documenting the view obtained: As it can be dangerous for someone to assume direct laryngscopy has been performed if tn reality a vl has been used
    ie using your information
    POGO scoring system: POGO 75% Glidescope
    Fremantle scoring system : P3 Glidescope
    modified C&L scoring system as proposed by Dr Phillip Allen (QLD): Grade 2V Glidescope
    which one you use all depends on whether you want to use the information for research purposes or just simple practical documentation.

    Cheers
    Pierre

    October 13, 2012
    • Thanks Pierre for the helpful comments
      Nice reference to the Fremantle proposed classification . That was an interesting article they published on airway classification system and indirect laryngoscopes

      October 13, 2012
    • Rob Bryant #

      Experienced operator, our EM2′s are typically more facile w the glidescope than most attendings.
      We were using the gliderite stylet, tip of ETT was catching on posterior edge of larynx.
      There was ample time to reposition both glidescope and rotate the tube, without success.

      October 14, 2012
  2. Seth Trueger #

    1) Rob, you know I agree with you, BUT:

    2) Why no bougie on the first attempt?

    October 14, 2012
    • Rob Bryant #

      Great point about the bougie, I have not used a regular blue bougie with the glidescope previously, partly from being lucky and not having to go to plan B, and the other times the glidescope has failed me it has been a secretion/blood issue, not a tube delivery issue. Once I get my hands on a pocket bougie I plan to use it more.

      October 14, 2012
    • Seth ,I think no bougie was used on first attempt was because the glide rite stylet is the optimal initial piece of kit to use with the Glidescope due to its angulation.

      October 14, 2012
      • have to agree here. The hyperangulated bladed indirect devices do not do all that well with standard bougie. Waiting on a Pocket bougie from the states to test this.

        October 14, 2012
      • Seth Trueger #

        I agree that if you have the Gliderite stylet it’s the best shot. But if it doesn’t work, a bougie is certainly an option. There are a number of techniques to help a regular bougie work with an angulated VL — the “most likely to be successful” is probably to emulate the Gliderite (http://crashingpatient.com/wp-content/images/part4/PA280010.jpg). Similarly, in a pinch I will just curve the entire bougie into a circle about the size of a stored central line wire, hold it for a second or two, and it gives a great curve. With the combination of Gliderite shape, coude tip, and flexibility (to duck into the trachea despite hyperangulation) it can be quite helpful!

        October 15, 2012
  3. Jimmy D #

    The Glidescope requires a ‘working around the corner’ mode of use. Video enabled MAC blades alleviate much of that difficulty, even when piloting the ETT by video alone (not trying to strictly DL with the device). This is due to the less extreme angle for working around the corner. I own and use the McGrath MAC, and I can get about 2/3rds done with this device as I can get done with a Glidescope, but the Glidescope still outperforms it.

    From the point of view of video enabled MAC blades, try this point of view on for size:

    Video enabled MAC blades offer the illumination, magnification and clarity of image to perform a time sensitive (and critical) procedure. Surgical microscopes (and laparoscopic/arthroscopic equipment) offer the surgeon the same improvement in their primary sense of sight–illumination, magnification and clarity.

    I once had an email exchange with Jack Pacey, the inventor of the Glidescope, about this issue. I forwarded him an article out of Canada regarding the substantial benefits that laparoscopic technology offers the aging surgeon because of the the unfortunate tendency of the aging physicians’ eye sight to deteriorate over time. It was hypothesized that assistive aids such as laparoscopic cameras can effectively extend the quality (and working life) of aging surgeons.

    I don’t need reading glasses (yet), but in as short as 3 or 5 years, as I cross the 50 year barrier, I suspect I will need reading glasses to successfully perform DL.

    One other issue to consider with the video enabled blades is something related to me by an ED physician from SUNY Downstate–that the strength of the Glidescope is the connection between the camera position on the blade and the approach used with insertion in the mouth:
    ——If the blade is maintained in close proximity to the tongue as it is wrapped around the tongue base, the camera-optics do not get dragged through the blood/vomit/goo pooling in the posterior pharynx This keeps the camera-optics clear. The devices that get fouled more easily in this scenario are devices like the Levitan optical stylet, and the channeled video laryngoscopes (Airtraq, Pentax, King) because they take a more posterior approach around the base of tongue. This is the phenomena that likely drove Scott at EMCRIT to concoct his suction apparatus for the Bonfils stylet, so that he can deal with fouling more readily. That ‘s all from me for now.

    October 14, 2012
    • thanks Jim. Must get you back on the podcast for our online airway training program!
      Never thought about the presbyopia issue and advantages of VL for the aging intubator!

      its a very good point!
      but equally maybe ability to blindly intubate may come full circle for those of us who trained a long time ago in the art of Jedi Force related intubation skills…nasal blind tubes, Fastrach ILMA blind tubes. Digital intubations…as we all get older and our eyes are not so good!

      Maybe that is why Ron Walls likes VL so much! Thats a joke, Ron, well intended Aussie humour!

      October 14, 2012
  4. All good points. Whilst I have a Bullard-type VL with hyperangulated lade, this bit of kit was made more on cost compared to the Mac-type blades. With that comes a whole different technique.

    ‘Hang up’ on the R arytenoid seems quite common – if noone has mentioned it yet, then I’d suggest using a Parker tip ETT to reduce this risk.

    October 14, 2012
    • or some decent cricoid pressure or to be politically correct, generous posterior laryngeal manipulation..even BURP! it all helps with these Bullard type VLs, Airtraq, King Vision, Pentax AWS, Vividtrac

      October 14, 2012
      • Seth Trueger #

        Minh- I know we have our differences on the use of CP, which is fine. But please don’t conflate CP with laryngeal manipulation!

        October 15, 2012

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