Glidescope vs DL

[Groove]

We've got some residents starting soon and I'm sure I'll have to be monitoring their intubations. One thing I've noticed with many of the newer grads is their sole reliance on glide scope. I rarely see anyone using DL anymore and I'm probably one of the "older dinosaurs" that still almost exclusively uses DL and eschews video laryngoscopy unless it's a case where I anticipate difficulty. I certainly recognize the new era and almost standardization of VL but I can't help but feel some of the art and finesse of standard laryngoscopy skills is dying. Our glide scope has hyperangulated blades and curved blades similar to a MAC and I was thinking of having the resident use the standard MAC blade and turning the video monitor around so that I can see but they can't, forcing them to intubate with traditional techniques and line of sight. Am I being unreasonable and should I just forget the old ways and let them intubate with VL exclusively? Are any of you guys involved in residency programs encouraging DL anymore? I don't want to be that unreasonable crotchety attending who's "stuck in the past" but I really do feel these are valuable skills. Thoughts?

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[Fox800]

They need to learn DL. There will be times where the screen is fogged, covered with blood, the light goes out, or it's out of service for maintenance, or they work at some tiny rural place that doesn't have one. Agree with turning the screen around so they can't see it. Trained at a place with the Storz C-MAC with conventional Macintosh blades and this is what we did. Used bougie 100% of the time.

Build good habits and encourage them to become proficient at DL + bougie for every intubation.

 

[bravotwozero]

They need to learn DL. There will be times where the screen is fogged, covered with blood, the light goes out, or it's out of service for maintenance, or they work at some tiny rural place that doesn't have one. Agree with turning the screen around so they can't see it. Trained at a place with the Storz C-MAC with conventional Macintosh blades and this is what we did. Used bougie 100% of the time.

Build good habits and encourage them to become proficient at DL + bougie for every intubation.

What he said.

 

[RustedFox]

They need to learn DL. There will be times where the screen is fogged, covered with blood, the light goes out, or it's out of service for maintenance, or they work at some tiny rural place that doesn't have one. Agree with turning the screen around so they can't see it. Trained at a place with the Storz C-MAC with conventional Macintosh blades and this is what we did. Used bougie 100% of the time.

Build good habits and encourage them to become proficient at DL + bougie for every intubation.

This is the correct answer.

End of thread.

Back to gloom and doom.
Thankyoupleasedrivethru.

 

[turkeyjerky]

No, I'm with you.

The problem with learning VL exclusively, is that the technology and the technique both have a non-zero failure rate, and tend to fail in high-risk, high-stress, time-limited scenarios. DL definitely still has it's place in certain difficult (traumatic airways, UGIB, emesis) and time-dependant (acidotic, critically hypoxic) airways.

I probably use DL in 75% of my airways. Anecodotally, it does seem like I'm an outlier since RT almost always is turning on the glidescope before I tell them to get me a MAC 3/4 (I really wanted to be a Miller guy back in residency, but never felt like I got as good a view).

I would agree that a standard geometry VL blade w/ the screen turned around is probably the best option for learners in this day and age. (The one issue with this is that with the crutch of being able to turn around the screen, they likely won't become as adept in rescue techniques like bimanual laryngoscopy, head elevation, or successfully intubating a grade 3 view). FWIW, I think this is the approach that some programs at the vanguard of airway training take (eg Hennepin).

 

[Apollyon]

In another forum here, I used the word "eschewing" today. Who could have predicted that "eschew" would be used twice in one day on SDN?

 

[NicMouse64]

On my Anesthesia rotation I did probably 90% DLs and 10% VLs. There is something to be said for being "confident" I got it without someone else knowing or being able to see the view. Got scared a couple of times with DL when the sats were dropping and I was able to visualize the cords pretty well and pulled out when I probably shouldn't have. But just a med student so idk how it'll be as a CA-1. I personally was ok with doing DL even though the VL was sitting right outside.

 

[Fox800]

No, I'm with you.

The problem with learning VL exclusively, is that the technology and the technique both have a non-zero failure rate, and tend to fail in high-risk, high-stress, time-limited scenarios. DL definitely still has it's place in certain difficult (traumatic airways, UGIB, emesis) and time-dependant (acidotic, critically hypoxic) airways.

I probably use DL in 75% of my airways. Anecodotally, it does seem like I'm an outlier since RT almost always is turning on the glidescope before I tell them to get me a MAC 3/4 (I really wanted to be a Miller guy back in residency, but never felt like I got as good a view).

I would agree that a standard geometry VL blade w/ the screen turned around is probably the best option for learners in this day and age. (The one issue with this is that with the crutch of being able to turn around the screen, they likely won't become as adept in rescue techniques like bimanual laryngoscopy, head elevation, or successfully intubating a grade 3 view). FWIW, I think this is the approach that some programs at the vanguard of airway training take (eg Hennepin).

Bimanual laryngoscopy is your friend. Use it constantly...not sure if that's a sign that I'm not positioning patients as well as I should, but it's exceedingly effective.

 

[RustedFox]

In another forum here, I used the word "eschewing" today. Who could have predicted that "eschew" would be used twice in one day on SDN?

Bless you.

 

[turkeyjerky]

Bimanual laryngoscopy is your friend. Use it constantly...not sure if that's a sign that I'm not positioning patients as well as I should, but it's exceedingly effective.

Baby jesus cries everytime someone asks if you 'need some cricoid'

 

[skougess]

I’m torn on this. VL is well documented as having a higher success rate and being faster than DL. Should you be reasonably comfortable with DL in case of emergency? Yes. Should you be starting most intubations with a DL attempt? I’d argue that is substandard care. Especially with many patients in the ED getting tubed in tenuous circumstances.

 

[NicMouse64]

I’m torn on this. VL is well documented as having a higher success rate and being faster than DL. Should you be reasonably comfortable with DL in case of emergency? Yes. Should you be starting most intubations with a DL attempt? I’d argue that is substandard care. Especially with many patients in the ED getting tubed in tenuous circumstances.

edit, nvm, didn't read this completely. I still am not sure where you get the idea that a DL attempt is substandard. Whenever I was on airway call with Anesthesia, DL was the go to method. But I admit I don't understand the ER side of things, so know that things can change in that environment.

 

[skougess]

What if you don't know where the VL is (hidden in some room with another doctor or something) and the patient needs to be intubated now?

I feel like you didn’t actually read my post.

 

[GonnaBeADoc2222]

The data is quite clear. In operators who don't do a ton of intubations every day (us), first pass success rates are higher and time to tracheal intubation shorter in VL. I've done maybe one DL intubation in 4 years as an attending. I've worked in many hospitals as a locums and they all had a VL. Not using VL as a first attempt over DL is like MLB teams not using SABRmetrics because "the old times were better."

 

[IMGASMD]

Just realized I was in the EM forum. Thank God.

 

[GassYous]

Another anesthesiologist here, your trainees need to learn DL. I use VL most of the time now because I want to avoid damage to the teeth but I do DLs regularly. Knowing how to do the micromovements, such as rocking back slightly when you see the bottom of the cords without crushing teeth, to optimize your view improves your skills for both DL and VL. Also, DL forces you to look at the anatomy as you go in whereas I feel like a lot of people tend to just shove the VL in and then root around to look for cords. Have them try the miller as well as the mac.

Sometimes the glidescope is just too big for the mouth (not as much of an issue with new generation scopes), you just can't get a good view or you have a great view but can't pass the tube. I remember one covid airway that we got called for because the icu fellow couldn't do it. Airway was all bloody, there were different video scopes all over the bed and the fiberoptic hanging forlornly. We just looked with a mac3 to see what it was, grade 2a view and easy airway. Spent less than 3 minutes in the room.

 

[The Knife & Gun Club]

New PGY2 Recently moved from VL to DL, since we’ve been mandatory VL until recently due to COVID. Tradition at our shop is you start on VL, move to direct around middle to end of intern year.

Holy f***. DL is so much harder. Honestly wish I had moved to direct earlier since I feel like my video tubes are consistently pretty easy, but direct is a whole other, much more complicated beast.

And when you lose the video in a bad GI bleed, there’s no substitute for blade and lightbulb.

 

[Gnarvin]

One thing I would caution is that the Glidescope blade is not the same shape a the Mac blades. The glidescope blade is not necessarily designed to help the operator get a good direct laryngoscopy view, it is designed to get a good video view. If you give your trainees the glidescope blade and take the screen away from them then you are probably not setting them up for success.

I have been told that the CMAC blades are indeed the same shape as real Mac blades so it would make more sense to do your proposed teaching exercise of taking the screen away from the trainee with a CMAC rather than the glidescope. I finished my anesthesiology residency a couple years ago and we never had CMACs where I trained, though.

 

[Kryptocoin]

11 year attending . I use DL 99% of the time. First pass success 98%. Second pass 100%. 85% of my patients are obese . Every ABEM physician should be very proficient in DL. We are airway experts. VL is a good adjunct to learn. I use it when I'm anticipating a very difficult airway (500Ibs+ with no neck and chin). Thank god those are rare.

 

[southerndoc]

One thing I would caution is that the Glidescope blade is not the same shape a the Mac blades. The glidescope blade is not necessarily designed to help the operator get a good direct laryngoscopy view, it is designed to get a good video view. If you give your trainees the glidescope blade and take the screen away from them then you are probably not setting them up for success.

I have been told that the CMAC blades are indeed the same shape as real Mac blades so it would make more sense to do your proposed teaching exercise of taking the screen away from the trainee with a CMAC rather than the glidescope. I finished my anesthesiology residency a couple years ago and we never had CMACs where I trained, though.

I was about to mention the same thing.

DL needs to be mastered during residency. Not every shop has easy access to VL especially in smaller shops.

 

[Franzd'Epinay]

Our glide scope has hyperangulated blades and curved blades similar to a MAC and I was thinking of having the resident use the standard MAC blade and turning the video monitor around so that I can see but they can't, forcing them to intubate with traditional techniques and line of sight.

This is the best of both worlds. Use the video mac blade as DL, then if it's difficult to get a good view, look up to the video.

Turning the video away from the residents is a good teaching strategy (a few of my attendings used to do that to us). The thing that you will need to keep in mind is that your video view will be better than their direct view, so don't get frustrated if they're struggling with what seems to be a good view on the screen.

 

[AlmostAnMD]

On the other end of the spectrum, I've been using the fiberoptic scope more recently. Just adding to skillset. Didn't graduate an expert in it from residency for sure.

Otherwise glide. Did both at once yesterday.

 

[deleted6669]

I’m torn on this. VL is well documented as having a higher success rate and being faster than DL. Should you be reasonably comfortable with DL in case of emergency? Yes. Should you be starting most intubations with a DL attempt? I’d argue that is substandard care. Especially with many patients in the ED getting tubed in tenuous circumstances.

Agree- I did DL for years (since 91) and have used VL exclusively for the last few years because the patients deserve it. Could I do DL, sure. Would it take a bit longer and have a lower 1st pass success rate. Likely. I still practice DL, but it isn't my go to. Also practice fiberoptic, but not my first choice. If I hear ems is bringing in a bad airway I usually lay out all the toys on a side table, including a king LT and a crich kit. I personally hate LMAs.
Can't have too many toys.

 

[deleted6669]

Not every shop has easy access to VL especially in smaller shops.

I have friends who work in the sticks and they buy these for themselves: https://www.boundtree.com/airway-ox...s/vividtrac-video-laryngoscopes/p/group003889
$96 VL last time I checked. And yes, you can clean it and reuse it.

 

[turkeyjerky]

One thing I would caution is that the Glidescope blade is not the same shape a the Mac blades. The glidescope blade is not necessarily designed to help the operator get a good direct laryngoscopy view, it is designed to get a good video view. If you give your trainees the glidescope blade and take the screen away from them then you are probably not setting them up for success.

I have been told that the CMAC blades are indeed the same shape as real Mac blades so it would make more sense to do your proposed teaching exercise of taking the screen away from the trainee with a CMAC rather than the glidescope. I finished my anesthesiology residency a couple years ago and we never had CMACs where I trained, though.

Glide scope has a standard geometry blade now, is it still not suitable for DL? (Granted, I’ve never found any of them to be as good as a regular steel blade).

 

[thegenius]

I have friends who work in the sticks and they buy these for themselves: https://www.boundtree.com/airway-ox...s/vividtrac-video-laryngoscopes/p/group003889
$96 VL last time I checked. And yes, you can clean it and reuse it.

My suspicion with those laryngoscopes where you can pre-load the ET tube is that you are totally at the mercy of the pt's anatomy and just hope that the tube is pointing directly at the true vocal cords with no obstructed path. What if they have big arytenoids? or the angle of the blade is 10 degrees off? It appears you have no flexibility with those devices.

 

[DeadCactus]

You can use a VL MAC to DL and these standard geometry blades are available for most (if not all) VL products. This should be the standard in a teaching hospital where the VL allows better supervision of the DL attempt.

I would argue that it should be the standard in an emergency department because it allows immediate conversion to VL if needed and that the non-VL MAC should be sitting in reserve as a back-up rather than vice versa. Places that intubate frequently have the volume where the improved first-pass success is likely to add up and places that don't should have it as skill atrophy is less of an issue. I view routinely using the metal handled laryngoscopes in the same light as the thousands of arguments about why bedside ultrasound, SpO2, waveform capnography, etc are unnecessary. I accept this second opinion is likely heavily disputed.

And yes you have to practice some self-control and not let yourself or the learner immediately switch to VL for this strategy to be optimal.

 

[dadaddadaBATMAN]

Agree that dl should be practiced regularly for proficiency in residency. I did so as a resident and was probably somewhat unusual in that I was happier with dL than vl when graduating. Which was unfortunate since I graduated in covid times and then had to do exclusively vl last year, but the transition was fairly easy.

I will probably keep starting with vl going forward, or one of the combo blades, mostly because of the consistency of small trial data indicating 4-6% improvement in first pass success and time to first pass success in em docs.

As much as we talk about gi bleeds and vomit in the airway I find the cameras are surprisingly good at clearing with aggressive use of suction.

 

[The Knife & Gun Club]

My suspicion with those laryngoscopes where you can pre-load the ET tube is that you are totally at the mercy of the pt's anatomy and just hope that the tube is pointing directly at the true vocal cords with no obstructed path. What if they have big arytenoids? or the angle of the blade is 10 degrees off? It appears you have no flexibility with those devices.

Our COVID ICU transitioned to these $170 disposable video scopes that function just like normal VL (no tube loading). I used it for a pretty catastrophic “standing on the bed” airway in covid ICU and it worked like a charm.

I know a few people that carry one in their backpack for when they’re moonlighting in the boonies.

i-view Disposable Video Laryngoscope | Bound Tree

i-view Disposable Video Laryngoscope - available online at Bound Tree.

www.boundtree.com

 

[Birdstrike]

Baby jesus cries everytime someone asks if you 'need some cricoid'

Kills two kittens, too.

 

[GassYous]

Those disposable scopes are horrible.

I think the best portable scope is the mcgrath and it's not even close.

 

[NicMouse64]

Those disposable scopes are horrible.

I think the best portable scope is the mcgrath and it's not even close.

Absolutely loved the mcgrath on my anesthesia rotation. Almost more than the VLs the hospital had.

 

[Jabbed]

Just have them do DL with VL on standby unless you're anticipating a rapid decompensation.

VL in general, and the hyperangulated blades specifically, are horrible in that you do not need any sort of optimization in order to get a view and pass a tube for 80-90% of cases. This leads to poor airway skills in general with people not doing airway exams, sniffing position, good scissoring technique, external laryngeal manipulation, etc. These skills are all useful in VL approaches, but you just don't build good technique without doing a ton of DL.

DL with VL blades just feels weird to me. We use the reusable one with the disposable blade attached. The blade just feels too thick and doesn't leverage well in the vallecula.

 

[gamerEMdoc]

As others said, CMAC is ideal for this during training. Very similar to a mac blade, the attending can look at the screen while the resident DL's. Best of both worlds. Resident can get practice with DL, with the video right there and immediately available if no direct view. And at the same time, the attending can see exactly what is going on so they don't keep saying "what do you see" 100 times a minute.

 

[D P356]

As others said, CMAC is ideal for this during training. Very similar to a mac blade, the attending can look at the screen while the resident DL's. Best of both worlds. Resident can get practice with DL, with the video right there and immediately available if no direct view. And at the same time, the attending can see exactly what is going on so they don't keep saying "what do you see" 100 times a minute.

Best solution for training environment.
we did this the first month of my anesthesia residency. Pts getting intubated in ED are an aspiration risk due to them likely not being NPO.

 

[deleted77919]

…

 

[thegenius]

I was very happy to have a glidescope yesterday. Big fat guy with an IPH on eliquis. I even had trouble with the VL but got the tube. I think DL would have been very hard.

 

[AlmostAnMD]

I'm really going the opposite of you guys.

I've been doing mostly glidescope. I've also been working on my fiberoptic skills. We have a nice fiberoptic scope I've been building a good skillset with on non-critical patients (still practicing, albeit on dying people).

I figure any airway can be found with glidescope or fiberoptics. Or at least if it CAN be found, one of those should work.

 

[GassYous]

I'm really going the opposite of you guys.

I've been doing mostly glidescope. I've also been working on my fiberoptic skills. We have a nice fiberoptic scope I've been building a good skillset with on non-critical patients (still practicing, albeit on dying people).

I figure any airway can be found with glidescope or fiberoptics. Or at least if it CAN be found, one of those should work.

I know of two cases where it was tough with glide + fiber. One was unsuccessful (done by two anesthesiologists) and patient was woken up. The other took over ten minutes with a very experienced anesthesiologist on an ecmo patient.

 

[Apollyon]

on non-critical patients (still practicing, albeit on dying people).

Maybe it's just me, but, I thought that dying pts WERE "critical"??

 

[Birdstrike]

It all comes down to what you first learned on.

 

[AlmostAnMD]

I know of two cases where it was tough with glide + fiber. One was unsuccessful (done by two anesthesiologists) and patient was woken up. The other took over ten minutes with a very experienced anesthesiologist on an ecmo patient.

Not convinced a traditional mac blade was gonna get it either

Maybe it's just me, but, I thought that dying pts WERE "critical"??

Yeah but not, like, respiratory dying. Status epilepticus is something I see a lot of (I'm at a tertiary center with a big neuro emphasis). I've got more time to tube them than, say, COPD-related dying lol

 

[Groove]

It all comes down to what you first learned on.

My PD at the time was an anesthesiologist in his first career before doing EM. Glidescope was not necessarily brand new but it hadn't exploded to every ED like it has today. I can still remember him grumbling "What are you gonna do when the power goes out?! You don't need that thing!" Sometimes, I'd get asked what blade I wanted (Me: "Mac 4") (Him: "Mac 4? Here's a Miller 2") Frustrating at the time, but I'm grateful for all the DL experience these days. I'm not convinced all his advice was great though... After all, this is the same guy that made me turn the ultrasound off and do a blind IJ on occasion which I definitely don't think is standard of care these days...

Great advice on here. I see both sides but feel pretty strongly about DL skills along with extra focus on preintubation positioning, bimanual technique and will probably just turn the monitor around. I may even force the upper levels to use a blade with no video at all. After all..."What are you gonna do when the power goes out?!?!"

I wish we had a CMAC but we don't unfortunately.

 

[Groove]

Though I will say VL is preferred during an arrest if there are active compressions going on.

 

[GassYous]

Though I will say VL is preferred during an arrest if there are active compressions going on.

My proudest moment in residency is tubing a guy on the floor during chest compressions using a mac3

 

[Tenk]

Knowing how to use DL is important. If someone has never done it or isn’t used to it and you enjoy it, you’d be the perfect attending to teach it. Definitely teach it.

I would be one of the worst attendings to teach DL because I don’t like it and I think it’s inferior to VL. I’ve still done far more DL intubations than VL because my anesthesiologists in residency were exclusively DL but the second I could choose, I always chose VL. Maybe it’s the 30+ years of being a gamer in me but it just feels more comfortable. I still think it’s important to know both in case you’re in a situation when someone hands you a DL blade but I haven’t used DL in 6 years and I’m doing just fine. 🤷‍♂️

 

[askamsky51]

We've got some residents starting soon and I'm sure I'll have to be monitoring their intubations. One thing I've noticed with many of the newer grads is their sole reliance on glide scope. I rarely see anyone using DL anymore and I'm probably one of the "older dinosaurs" that still almost exclusively uses DL and eschews video laryngoscopy unless it's a case where I anticipate difficulty. I certainly recognize the new era and almost standardization of VL but I can't help but feel some of the art and finesse of standard laryngoscopy skills is dying. Our glide scope has hyperangulated blades and curved blades similar to a MAC and I was thinking of having the resident use the standard MAC blade and turning the video monitor around so that I can see but they can't, forcing them to intubate with traditional techniques and line of sight. Am I being unreasonable and should I just forget the old ways and let them intubate with VL exclusively? Are any of you guys involved in residency programs encouraging DL anymore? I don't want to be that unreasonable crotchety attending who's "stuck in the past" but I really do feel these are valuable skills. Thoughts?

Recent grad here. I learned near 100% DL. We start all of our new interns exactly as you describe. We have CMAC (no glidescope), turn video away from them. After perceived competence then the video completely goes away unless needed as an adjunct. I will say that in the past year we had a tendency to use VL primarily because of COVID.

Just n =1, but a little perspective. CMAC and glidescope obviously have their own learning curves and place but agreed that DL skills come first.

 

[askamsky51]

The data is quite clear. In operators who don't do a ton of intubations every day (us), first pass success rates are higher and time to tracheal intubation shorter in VL. I've done maybe one DL intubation in 4 years as an attending. I've worked in many hospitals as a locums and they all had a VL. Not using VL as a first attempt over DL is like MLB teams not using SABRmetrics because "the old times were better."

What data are you referring to? Most RCT's in the ED I have seen show no difference in first-pass success. There is however delay in intubation with VL, which may be clinically insignificant but is another consideration.

 

[dadaddadaBATMAN]

What data are you referring to? Most RCT's in the ED I have seen show no difference in first-pass success. There is however delay in intubation with VL, which may be clinically insignificant but is another consideration.

Just went on my own literature search after this comment. Had seen several relatively small trials over last few years indicating 96 vs 92%, slightly faster times, etc.

Every large trial, retrospective review and meta analysis I am seeing indicates about 90% success with both on first pass, and no statistical difference. The absolute differences also look small and are a roughly even split between different reviews, trials etc one way or the other.

I didn’t see much on time to intubation but that was also mostly similar.

 

[WildEMDoc]

Anecdotally, I think most people who use DL almost exclusively (myself included) feel they can take an airway so much faster than with VL. Nothing is faster than the direct look with a tube placed immediately. Whether that can be measured or not in a RCT I'm not sure.

I DL for almost every airway, and I'm a relatively recent graduate. My program didn't have any glidescope that was consistently stocked in the ED until I was halfway through 2nd year (county program). Because of that I teach residents now to rely on DL first +/- bougie, typically with a few pass attempts on DL if the situation can tolerate it before switching to VL.

Those "Mac" blades for the glidescope are not quite the same IMO. Not sure if it is handle length or just a touch of hyperangulation, or what, but I feel like a DL with those faux mac blades are not comparable to the real deal. C-Mac is more on target though.