FACT or CRAP? 1st June 2012 by Dr DuCanto

Effectiveness and safety of the Levitan FPS Scope™ for tracheal intubation under general anesthesia with a simulated difficult airway.

Okay folks. Jimmy D wanted to comment on an article from Canada on the Levitan FPS scope I sent him. He wrote back with a great idea! See below…

Jimmy’s rant starts now:

This gives me an idea for an ongoing intellectual exercise that would benefit all of us, and particularly, physicians in training.  It could periodically become a fixture in your blog, and we could easily rotate the duty of who handles the “heavy lifting” of creating content to feed this feature.  The feature would be based on a popular page-a-day calendar known as “Fact or Crap”.  As you are Australian, we might call it “Fact or Rubish”.  It’s almost as if we are reviewing articles in the same way that media types review movies.

For instance, new movie “Battleship” in movie theaters now—quintesenntial “Guy” movie.  Aliens (not A-lines), huge explosions, naval warfare, decent action…..I give it two thumbs up.

This article?  They evaluated the Levitan for the wrong role.  If they initially stated that the device has been compared to the utility of a bougie (which requires DL), why would they compare against DL alone for efficacy?  That was the WRONG way to evaluate the Levitan–it assess the device’s ability to create space and visualize structures.  It is really bad at creating its own space (all fiberoptic scopes share this same property).  This article gets two thumbs down from me–useless study design provides useless resultants and promulgates medical mis-information.

A better study design may have been to compare the rate at which each device can fall toward the bottom of a 6 meter swimming pool—-chances are, the Mac blade and handle may win (less buoyancy due to the Levitan being made of plastic around the eyepiece).  Think about it and let me know what you think.  I think it’s only natural that we continue our dialogue in multiple different capacities such as this.

Here is the calendar. Enjoy (I looked up the answer on the back of the page and marked it on the front).  I put the Twinkies box in the background for a laugh(with my pager on top of it) .  They are pastries so sugary and awful that urban legend in the United States claims that the lowly cockroach does not recognize it as food.  My kids bought them–I gave them up 30 years ago.

Jimmy’s rant ends now.

Wow, when Jimmy’s buttons get pushed he sure speaks his mind! I wrote back and in general terms, disagreed with him. My own take on the Levitan FPS is that its a fantastic device with good training and practice. You need to work at getting good at it combined with direct laryngoscopy. Its brilliance comes out when you combine it with a SGA/LMA device and use it to tube through the SGA. More videos from DuCanto demonstrating this to follow. Stay tuned. And look forward to more episodes of FACT OR CRAP?

8 thoughts on “FACT or CRAP? 1st June 2012 by Dr DuCanto

  1. Jim, you lost me. I can only get the abstract of this paper, but it seems they were using Levitan with a mac blade. The mac makes the room. This is the way Rich teaches it as well. I don’t know if it was a well performed study or not without seeing the full manuscript, but the methods seem sound. On face, mac + Levitan should have given lower CL than mac alone.

  2. thanks Scott. I agree with you. I find the study design to be reasonable and the question they were seeking to answer was an appropriate one : compared to DL, does using the optical stylet add anything in a simulated difficult airway during elective anaesthesia? I think what this study demonstrates is that like any device the optical stylet has a learning curve and it takes deliberate training and practice before significant improvements in airway performance are noted. A study from Australian anaesthetists comparing the Bonfils and Levitan stylets demonstrated the existence of a learning curve even amongst qualified anaesthetists.
    FACT or CRAP? You decide!

  3. Hi guys–I reacted a bit harshly to this article due to their comparison of this device to a bougie. Approaching a fiberoptic scope from this perspective irks me beyond belief. The abstract does not contain this information, so it may look like I overreacted here. I still leave the question open, of course. I call foul on their comparison of this device to a bougie.

    1. Jim-they did not compare the device to the bougie. That was just in their intro b/c the bougie is one of the predominant devices for difficult airway in the UK and I imagine Canada. They were stating the Levitan is considered good b/c it matches up to the bougie, so let’s see how it compares to macintosh alone without the bougie.

      1. No worries, mate…I am happy to be wrong occasionally! It hampers my learning and my ability to innovate if I am not offered chances to look at things differently. Most of my fanatical support for optical stylets derive from their use through SGA’s. I use the optical stylets to intubate in other ways because, well, I intubate a lot of people and I like to try new ways of approaching airways. What doesn’t often dawn on me is that most endoscopists (including the 42 other anesthesiologists in my department) like predictability, and thus tend to perform routine airway management in the standard, routine manner. I thrive on diversity, so I make it different most of the time I intubate so that I can learn something. Failure has been one of my greatest teachers, and I have seldom failed with the Levitan.

        In the third year student handbook of the Medical College of Wisconsin, the entry regarding the Anesthesiology Rotation I supervise goes something like this…”…Lots of procedures and experience. Expect to intubate a different way every time.” This is probably annoying to the students, but it is helpful to me as a teacher to discover the utility and ease of various techniques in relatively unskilled and uneducated hands. Now to think of it, the only time I let the Med students handle the Levitan is when I video enabled it, so when they got lost, a quick repositioning on my part could get them back on track quickly.

        I have a video demonstrating a patient with a recognized difficult airway in which I utilized a video enabled Levitan alongside a Miller 3 and was unable to create the space necessary to visualize around the epiglottis (I’ll dig it up tommorow). As I needed alternate plans, the Glidescope was there for me to use at a moments notice, and I was able to achieve a grade 1-2 visual with it and complete the intubation with the Levitan. So, perhaps I can change my mind about this topic a bit…….

        With DL, the Levitan may be a tough sell. I have had it work with curved laryngoscope blades, but with straight blades, I have not been able to reliably obtain the advantage it offers.

        With SGA., (and bent properly), the Levitan can deliver the goods.

        With VL, the Levitan can augment the primary VL device, principally because the VL device delivers superior illumination, magnification, look around the corner such that the Levitan can be placed optimally to serve as an endoscopic adjunct to VL. Having the Levitan video enabled is really key here.

        The new Clarus video stylet offers an upgrade on the Levitan, but is half the price of a Glidescope.

        Thanks for the discussion. It’s difficult to discuss these things with Anesthesia colleagues–they mostly believe that they have learned enough, so they are not interested in alternative techniques until after critical events leave them humbled.

  4. Thanks Jim. Its true what you say. Most clinicians like routine and getting good at doing things a limited way. Its easier and our brains dont like too many challenges at once…well at least the male brain..speaking for myself of course. during anaesthetic rotation I got taught RSI a certain way and was told get good at this and you will be fine. Only occasionally I would get an anaesthetic supervisor who would really put you through your paces and test what you thought were adequate routines. Doing a whole anaesthetic using mask ventilation alone, or giving only half the usual dose of propofol for intubation..or tubing from the side position.
    Prehospital and retrieval medicine, nothing is standard and trying to make anaesthetic skills fit into that environment is challenging when you have learnt them in a controlled setting. The only way to manage this is deliberate practice of non routine. Practice your routine but throw in an uncommon problem and troubleshoot. Practice the permutations. Airway management in the critically ill and injured , in the prehospital setting , is like a street fight. If all you ever learnt in unarmed combat was how to deal with punches and kicks and then you get into a situation where someone pulls a knife on you, what good is your training? Its generally true that most of the time, you dont need RSA , DSI or bougie via SGA. But the challenge is when you do need those skills, are you prepared?

  5. My strategy for fights? Run away! You bruisers are welcome to it…

    Sadly not always an option when facing a difficult airway at 3am in Dingo Creek with no backup.

    Minhs comments on training are well made.

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