Why Video will never kill the direct laryngoscope star!

Hi folks!

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!

Minh

4 Comments
  1. Like so many tech assistance devices, I think they have definite potential to improve patient safety and outcomes. However, there is always the issue of what one does on the day the US machine does not work, or the video laryngoscope packs up etc. Therefore, it is essential that one has the skills, knowledge and experience to insert CVCs blind based on anatomical principles or to intubate via direct laryngoscopy for the occasion when needs must. The great advantage that video devices bring is the ability of a supervisor to also visualise, and guide, the novice in order to improve their intubation techniques etc.

  2. Thanks Mark
    Folks , Dr Seth Trueger of MDAware blog and a favourite of mine, emailed me with the following comments on this issue as well as some other things that sounded cool. He permitted me to share his words with you all! QUOTE BEGINS NOW….

    Minh,

    Great discussion, as always! Sorry I was both muted and had to leave early.

    2 things I wanted to discuss a little more with you (although sadly I had to leave) and will probably post on my site at some point.

    1) (DL vs VL) vs (landmark vs US for IJ & femoral lines)

    It is not lost on me that these are very similar questions, and I come down on different sides with each. I do not want to simply explain myself out of some Jungian desire to resolve my cognitive dissonance (in fact, I don’t even think Jung had anything to do with cognitive dissonance and simply used him here because he’s the psychology giant whose name I know aside from Freud. Wikipedia states that Festinger coined the term). Instead, I want to explain why I see 2 similar situations and come to different conclusions.

    With respect to US in CVC, I think that it is clear that the landmarks are simply not reliable. I don’t have hard references (although people who taught me assure me they exist) but the Sinai US guru Bret Nelson loved to take junior residents, show them the nice “NAVEL” shot and then scan up and down and show how the anatomy changes. I have done this on nearly every fem line and it is shocking. Similarly, Scott has shown data on the IJ just not being reliably related to the carotid.

    I think Marik is possibly (probably?) correct and in the era of monitoring CLAB, space-suit CVC placement, and DVT prophylaxis, the infection & DVT rates might be less of a problem.

    But the placement issues — bleeding, neck hematoma, RP hemorrhage, pseudoaneurysm, fistula, or just not being able to place the line — do still exist.

    Plus, IJs and femoral veins both collapse during many types of hypotension, making blind placement even more difficult. In cardiac arrest, the femoral vein might have the pulse.

    Further, once you get over the learning hump (maybe 5 lines in someone who is remotely savvy?) I think that it is easier AND faster to place the lines under US.

    And lastly, Scott put it very well today: people don’t immediately die if I can’t get the line in.

    With central lines, the blind approach works very well most of the time. However, Marty Tobin put it very well:

    “But here’s the rub. The challenge of clinical medicine is not about taking care of the great majority of patients who do well irrespective of the methods employed by their physicians. Instead, the goal is to take feasible steps that have a high likelihood of circumventing a catastrophe in a small number of instances….Taking simple steps to prevent infrequent occurrences that lead to a clinical catastrophe should dictate the practice of medicine, rather than employing approaches that are convenient to physicians and successful in most patients.”

    http://pulmccm.org/main/2012/critical-care-review/tobin-minimal-peep-and-pressure-support-during-sbt-kills-some-patients-ajrccm/

    Compare with DL vs VL. As I mentioned earlier, the key points are that DL skills are translatable to VL; VL is easily defeated by a speck of blood, vomit, or mucus; equipment issues; and whatever the other thing I said was. VL will get us the view in a higher percentage of cases (although you may not always be able to deliver the tube) but DL isn’t as far behind as landmark lines are behind US lines. The gap is very different.

    And I also agree that the combo VL/DL devices are very different than the angulated devices, and allow for training of both juniors and skill maintenance over time. During my chief year I think I used the CMAC on nearly every tube but never looked at the screen unless I ran into trouble (insert joke about how often that was).

    2) VL as a lightsaber

    Your analogy is way off. While the lightsaber is the weapon of the Jedi, it is not the source of the Jedi’s power. For whatever reason, some people are just force sensitive (to varying degrees) and may be trained to hone those skills. (I do not believe the prequels to be canonical so we can ignore the microbiologic explanation of force sensitivity.)

    Giving a monkey a MacGrath MAC doesn’t make him an anesthesiologist just as Luke didn’t become a Jedi the moment Obi-Wan handed him his father’s lightsaber.

    Seth


    Seth Trueger, MD
    Health Policy Fellow
    Emergency Medicine

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s