How many times a month do you use the Glidescope?

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The amount of replies in the Glidescope tips thread surprised me.

Seems like people put a lot of thought on their Glidescope technique.

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The amount of replies in the Glidescope tips thread surprised me.

Seems like people put a lot of thought on their Glidescope technique.


Maybe 10-20.

Then again I'm directing multiple rooms in a busy place full of gigantically fat people and bad traumas. I mean when you do a stat c-section on somebody with a BMI of 80...
 
I would say about 25 times a month but I cover a LOT of rooms with CRNAs in them. Hence, I ask for the glidescope upfront at least 5 times a week.

Once you do this specialty long enough you learn to leave your ego at home... so just get the glidescope and move on. The point is to intubate the patient ATRAUMATICALLY and SMOOTHLY on the first attempt so for many CRNAs that means using the glidescope. I can't count how many times I cringe at the sight of a CRNA trying to intubate a slightly anterior airway (forget about a Grade 3 airway). Again, do the patient a favor and use the glidescope.

Sure, there is the rare superstar CRNA with A+ intubating skills out there. However, that is the exception and not the norm with most in the "B through C-" skill level in my area. I've never had the privilege of working with any of these so called superstar CRNAs and even the Ex-military trained CRNAs (graduates of the so called top CRNA program and years of active duty) aren't in that camp with most about "B+" or so.

The patients will thank you for putting down your ego and getting the glidescope especially if you are supervising midlevels.
 
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Wow.
Hardly ever.
MD only.
MD only, 1-2 times a week probably. I am of the same mindset as Blade that it isn't about ego, it's about getting the job done safely. If I expect it will be challenging based on my exam I just opt for the technique with which I will most expeditiously and least traumatically be able to intubate the patient. Also, I will say my attitude on this has changed since I became an attending and am now carrying all the risk.

It also helps we have several and they are rarely all in use.

I also use the intubating wedge for super morbid obese patients maybe once or twice a month too. I do it for the same reason. Why make things harder than they need to be?
 
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Rarely. Some of the clinically weaker attendings will push for it but I usually ask if I I can DL first. I mainly use it for unstable C-spines. I've been meaning to use it more frequently to hone my skills since its frequently used as a rescue device. The only time I remember not being been able to pass the tube was in an anterior larynx/unstable cspine. I was moonlighting on a weekend and we had a pyxis failure so we couldn't get a fiberoptic scope. After my attending and I tried a several attempts including nasal, I suggested a retrograde wire which worked out well. We now have an emergency feature in the pyxis so hopefully we won't get stuck in that situation again.


Edit: I agree with okayplayer, I use a blaket ramp or wedge several times a month. In my limited experience, proper positioning virtually eliminates traumatic lifting and cranking on the delicate tissues. If I find I can't get a good view gently I'll stop and remove the blade to reposition rather than cranking/lifting to railroad it in. On a side note, i'm especially careful with double lumens, I cringe when I see people railroad them in with or without a tube exchanger. For some reason a lot of our attendings are rough with DLETT's and the tubes are covered in blood on extubation, it pisses me off.
 
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Now a ramp I will use... often. On the obese, the patients chin needs to be around the level of the sternum or higher. If not, then I ramp.

Good positioning, BURP, RTburg and a boogie gets me ETCO2 almost always.

Glidescope for GD IV views where all I see is pink beefy tissues. Unless they are a known difficult AW or have Pierre-robin syndrome or some other funk I always DL first.
 
MD only, 1-2 times a week probably. I am of the same mindset as Blade that it isn't about ego, it's about getting the job done safely. If I expect it will be challenging based on my exam I just opt for the technique with which I will most expeditiously and least traumatically be able to intubate the patient. Also, I will say my attitude on this has changed since I became an attending and am now carrying all the risk.

It also helps we have several and they are rarely all in use.

I also use the intubating wedge for super morbid obese patients maybe once or twice a month too. I do it for the same reason. Why make things harder than they need to be?

I'm covering a minimum of 4 rooms per day or 4 times your case volume. Hence, you can multiple your weekly use by 4 (or by 5 since I have crnas) and thus we are about the same percentage.
 
Wow.
Hardly ever.
MD only.

I use the glidescope 25 times per month but I actually need it about once or so per month. I use it to minimize trauma to the patients' airways and facilitate a rapid induction/intubation technique.

With a busy neurosurgical service I use the Glidescope for quite a few neck cases.
 
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I would reread Blades posts. There is no "shame" in electing to not DL a patient you think may be difficult. Using the VL or Glide may make your intubation less traumatic. Traumatic doesn't have to mean bloody mess or broken teeth, it can mean edema or excessive sore throat.
The nice thing about the VL is that you can see what they are seeing and offer suggestions or laryngeal manipulation as needed.
 
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Solo MD, once every 2-3 months.

I have it in the room a little more often than that.
 
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Only about half of my clinical time is doing my own cases, the rest is supervising. I use the glidescope maybe once or twice a month, and recommend to the CRNA/SRNA use it another one or two times a month. I think my patients may be a bit smaller, and I do fewer cases, on average, than many of you PP guys.

Since we have one in every room, and I used it regularly in residency, I have no qualms about using it, if I think it'd be beneficial
 
MD only practice.

Once or twice a month.

One of the last things we learn I feel are what our limitations are. I learned the hard way. I still see people DL x 3, crank the head, BURP to no end, and I think "Why?" We have technology. Use it. Drop the machismo.

I can tell pretty quickly now if I need a VL and many times will put the blade in, take a quick gentle look, and immediately go with the VL.
 
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I use it about 4 times a year. But, I only do about 2-3 cases a day. Our surgeons are too slow to do more than that.

I have nothing against using the Glidescope. My only reservation with using it before trying a DL is that the patient might get labeled as a difficult airway by PACU/ICU people. These people are crazy.
 
I use it about 4 times a year. But, I only do about 2-3 cases a day. Our surgeons are too slow to do more than that.

I have nothing against using the Glidescope. My only reservation with using it before trying a DL is that the patient might get labeled as a difficult airway by PACU/ICU people. These people are crazy.

If we intubate somebody with the glidescope without a DL first, I only label them difficult if they were difficult to mask ventilate. If they were easy to ventilate and we just used the Glidescope to make life easier on everybody, they do not get labeled as a difficult airway. If they are truly difficult to the point where I have concern for their safety in the future (back of ambulance, etc) then I have a long talk with them and their family postop and suggest they get a Life Alert bracelet.
 
I used to care about making sure the patient could be intubated with the traditional manner in order to classify them as potentially difficult throughout their hospitalization but now, every ICU, offsite location has one so I err on the side of an easy atraumatic intubation. I also use then for tube exchanges.

I have had 2 times where the the old fashioned DL was easier than the glidescope
 
If we intubate somebody with the glidescope without a DL first, I only label them difficult if they were difficult to mask ventilate. If they were easy to ventilate and we just used the Glidescope to make life easier on everybody, they do not get labeled as a difficult airway. If they are truly difficult to the point where I have concern for their safety in the future (back of ambulance, etc) then I have a long talk with them and their family postop and suggest they get a Life Alert bracelet.
Once somebody puts Glidescope intubation on their report it just gets replicated over and over in the chart without an explanation. You cannot get rid of it. A month later when you are intubating at 2AM the Glidescope thing will pop up. You better be sure you can get the tube in without it, or go back and get the Glidescope, because otherwise you will be collecting unemployment insurance.

People talk a lot about those alert bracelets but I have never seen one. In fact, the website for Life Alert does not mention selling any sort of Med Alert bracelets. You can imagine how many of those patients you counseled to get one, actually got one.
 
I err on the side of an easy atraumatic intubation. I also use then for tube exchanges.

What % of difficult DL intubations do you end up traumatizing?

I don't think that should ever happen. Don't you know when to back off?
 
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Once a day when supervising seems right. Personally, when doing cases maybe 5%. Although we dont use glidescope, we use McGrath. Have glidescopes all over, but the McGrath is just easier to grab. Those newer ones are fairly slick.

I dont see much reason not to use them other than fear of degrading DL skills on "difficult" intubations. Our ICU uses these exclusively, ED is 75+% (not often with blood/puke). The only thing preventing us from just switching over completely in the OR last time we updated equipment was the assumption the replacement rate would be higher, and the fear of losing DL skills for when airways fill with assorted fluids. Outright cost was similar or even initially in favor of video scopes. Technology and progress doesnt need to be feared.

I know, controversial...
 
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They are money for tube exchanges. I use it once or twice a week on the morbidly obese pt with a MIV and receding chin. I prefer to live drama free.
 
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Once a day when supervising seems right. Personally, when doing cases maybe 5%. Although we dont use glidescope, we use McGrath. Have glidescopes all over, but the McGrath is just easier to grab. Those newer ones are fairly slick.

I dont see much reason not to use them other than fear of degrading DL skills on "difficult" intubations. Our ICU uses these exclusively, ED is 75+% (not often with blood/puke). The only thing preventing us from just switching over completely in the OR last time we updated equipment was the assumption the replacement rate would be higher, and the fear of losing DL skills for when airways fill with assorted fluids. Outright cost was similar or even initially in favor of video scopes. Technology and progress doesnt need to be feared.

I know, controversial...

Your ER is using it 75% of the time?? That's wild. Is there an EM residency? If so, I think they are doing their residents a disservice. A lot of the little community ERs don't have any type of VL.

We have the C-MAC in our ER and a glidescope in our community ER affiliate. I would guess we use it in about 10% of our intubations (including trauma), unless known or suspect c-spine fracture.

We have interns intubate using the C-MAC as a DL with the screen turned towards the attending fairly frequently until they become proficient. I always have the VL at bedside when I intubate, if for no other reasons than to ward off the difficult-airway demons. If I fail to obtain a view with which I can successfully intubate (and there's not an obvious reason why), I go straight to VL - agree that it's not about pride, it's about safely getting the tube in.

As an aside, thanks to all you guys for bailing us out when we need help and not being douchy. I had a guy with a c-spine fracture recently that needed emergent intubation. It went real bad. Ended up able to oxygenate with an LMA after a very stressful couple mins. Anesthesia resident came down with a few toys we don't have in the ER and was able to successfully intubate - he was super cool. Anyways, thanks to all of you for being there when we need you - we appreciate it.
 
I consider any intubation which results in a chipped tooth, a slightly dinged tooth, cut to the lip, blood in the oropharynx, etc a diservice to the patient. I can intubate 99% of the patients I encounter with a Miller 2 or Miller 3 combined with a bougie. I trained in an era pre-LMA where we had to get the airway even if it meant some trauma.

These days things are very different. Patients deserve a smooth, atraumatic intubation if possible. The Glidescope allows this to occur on a routine basis. FYI, I often do a DL with my trusty Miller 2 blade after a supposed anterior airway by the CRNA; the result is that most these anterior airways can be successfully intubated by me on the first attempt without a bougie. A few need the bougie and the rest (1%) actually need the Glidescope,
 
I consider any intubation which results in a chipped tooth, a slightly dinged tooth, cut to the lip, blood in the oropharynx, etc a diservice to the patient. I can intubate 99% of the patients I encounter with a Miller 2 or Miller 3 combined with a bougie. I trained in an era pre-LMA where we had to get the airway even if it meant some trauma.

These days things are very different. Patients deserve a smooth, atraumatic intubation if possible. The Glidescope allows this to occur on a routine basis. FYI, I often do a DL with my trusty Miller 2 blade after a supposed anterior airway by the CRNA; the result is that most these anterior airways can be successfully intubated by me on the first attempt without a bougie. A few need the bougie and the rest (1%) actually need the Glidescope,
Totally agree.

I don't agree with the notion that DL comes with trauma, and Glidescope does not. It's all in the operator. Those who like to push and shove with DL, will push and shove with the Glidescope also.

One additional tip, as you're putting the tube into the mouth, make sure you're watching the tube, not the screen. There are reports in the literature (and at my insitution) of people ramrodding the tube through the tonsilar pillars. Remember, intubation is not a loss-of-resistance technique.
As mentioned in the glidescope tips thread, Glidescope has a track record of upper airway injury. We have a decent number of unreported injuries here too.
 
Totally agree.

I don't agree with the notion that DL comes with trauma, and Glidescope does not. It's all in the operator. Those who like to push and shove with DL, will push and shove with the Glidescope also.


As mentioned in the glidescope tips thread, Glidescope has a track record of upper airway injury. We have a decent number of unreported injuries here too.


Over 1,000 Glidescope intubations supervised or performed by me with zero injuries to the patient. Failure rate of the Glidescope is about 2% in my practice. Injury to the patient from the glidescope is due to poor technique and/or lack of experience.
 
Anesthesiology. 2011 Jan;114(1):34-41. doi: 10.1097/ALN.0b013e3182023eb7.
Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions.
Aziz MF1, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM.
Author information

Abstract
INTRODUCTION:
The Glidescope video laryngoscope has been shown to be a useful tool to improve laryngeal view. However, its role in the daily routine of airway management remains poorly characterized.

METHODS:
This investigation evaluated the use of the Glidescope at two academic medical centers. Electronic records from 71,570 intubations were reviewed, and 2,004 cases were identified where the Glidescope was used for airway management. We analyzed the success rate of Glidescope intubation in various intubation scenarios. In addition, the incidence and character of complications associated with Glidescope use were recorded. Predictors of Glidescope intubation failure were determined using a logistic regression analysis.

RESULTS:
Overall success for Glidescope intubation was 97% (1,944 of 2,004). As a primary technique, success was 98% (1,712 of 1,755), whereas success in patients with predictors of difficult direct laryngoscopy was 96% (1,377 of 1,428). Success for Glidescope intubation after failed direct laryngoscopy was 94% (224 of 239). Complications were noticed in 1% (21 of 2,004) of patients and mostly involved minor soft tissue injuries, but major complications, such as dental, pharyngeal, tracheal, or laryngeal injury, occurred in 0.3% (6 of 2,004) of patients. The strongest predictor of Glidescope failure was altered neck anatomy with presence of a surgical scar, radiation changes, or mass.

CONCLUSION:
These data demonstrate a high success rate of Glidescope intubation in both primary airway management and rescue-failed direct laryngoscopy. However, Glidescope intubation is not always successful and certain predictors of failure can be identified. Providers should maintain their competency with alternate methods of intubation, especially for patients with neck pathology.
 
Verathon recommends the insertion of the GlideScope® blade via the midline of the tongue to the epiglottis. This should be done under vision control.
- The GlideScope® may be used like a Macintosh laryngoscope to indirectly lift the epiglottis or produce a Miller’s lift.

- The use of the ETT stylet is recommended. A malleable stylet with a 60–90 degree curvature may be used. GlideRite® Rigid Stylet produced by Verathon is also available.

- Introducing the ETT close to the side of the blade helps to avoid blind, traumatic insertions as the space created by the presence of the blade allows direct visualisation of the styletted ETT, until its tip is seen on the monitor.

- To aid the passage of the ETT, once the tip is at the vocal cords, withdraw the stylet slightly, about 2–3 cm, before further ETT advancement. This avoids trauma to the vocal cords by the rigid stylet. Withdrawal of the laryngoscope or reduction of the lifting force allows the glottis to drop, which may also aid the passage of ETT.

- Always ensure that the tip of the ETT is observed during advancement– initially via direct vision, and then via the monitor when the tip disappears from direct view after further advancement. Avoid blind advancement of the ETT. This will reduce the risk of injury in the oral structures caused by the rigid stylet.

- After intubation, as the GlideScope® is withdrawn, attention should be paid to the path of the ETT and possible injury to the oral cavity.

- The use of soft-edge ETT (such as the Parker Flex-Tip™) may avoid trauma to the pharynx.

- Insert the ETT with the bevelled tip facing against the blade of the GlideScope®.
 
I got good with the GS during residency. Had some great teaching. But once I was good, I would always ask the attending if I could first try with a Mac or miller first on a suspected difficult airway. They were cool with it almost every time.

Now that I'm an attending I just want to get the case started as safety as possible.
 
I got good with the GS during residency. Had some great teaching. But once I was good, I would always ask the attending if I could first try with a Mac or miller first on a suspected difficult airway. They were cool with it almost every time.

Now that I'm an attending I just want to get the case started as safety as possible.


Of course, your technique of looking once or twice with a DL makes perfect sense; but, after that point if the arytenoids are not visualized the logical course is to proceed to the glidescope for an atraumatic intubation.
 
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How many times do I use the Glidescope? Never.

I use a McGrath.
 
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Once somebody puts Glidescope intubation on their report it just gets replicated over and over in the chart without an explanation. You cannot get rid of it. A month later when you are intubating at 2AM the Glidescope thing will pop up. You better be sure you can get the tube in without it, or go back and get the Glidescope, because otherwise you will be collecting unemployment insurance.

People talk a lot about those alert bracelets but I have never seen one. In fact, the website for Life Alert does not mention selling any sort of Med Alert bracelets. You can imagine how many of those patients you counseled to get one, actually got one.

Well I've had a patient come back in wearing the bracelet alerting for difficult intubation, so it does happen. And they needed it as they were an awake fiberoptic.

Also, just because somebody used a glidescope in the past does not require them to be a glidescope in the future. At least here it doesn't. We probably do 25 lap gastric bypasses a week so we have a large number of patients that come back later weighing 100-200 lbs less and are then much easier to intubate later.

It's an important tool in the toolbox that can help make things easier for us at times and help cause less trauma to the patient's airway.



(that said I have seen injuries, usually from the ETT being passed while the user is looking at the screen and just shoving in till the tube shows up on the screen lacerating the posterior pharynx in the process. it's rare and can be avoided)
 
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What % of difficult DL intubations do you end up traumatizing?

I don't think that should ever happen. Don't you know when to back off?

Not me but when I am supervising you dont know what they can and cant see or how hard they are pushing the envelope until you take a look
 
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Watch out for those soft palate injuries.

The one big design flaw with the glidescope is its bulk. Cant fit much else in the mouth and hence where the soft palate injuries come from.
 
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Watch out for those soft palate injuries.

The one big design flaw with the glidescope is its bulk. Cant fit much else in the mouth and hence where the soft palate injuries come from.

Agree. The 2 most common areas for injury with the glidescope:

1. Initial placement of the ETT into the mouth/oropharynx. The ETT has a super rigid stylet in it so CAUTION must be exercised when placing the ETT blindly into the oropharynx. The Provider must be GENTLE and aware of possible injuries to soft tissue until he/she sees the ETT on the screen. Hence, a light tight with caution is required initially.

2. When lining up the ETT with RIGID stylet to the cords caution must be used along with a gentle touch. Forceful movements, rough jabbinng motions should make you cringe. Instead, gentle movements with your right hand at the upper part of the tube/stylet handle is how you direct the ETT into the glottic opening. Once the ETT is lined up with the glottic opening the tube is advanced while pulling back the stylet. The rigid stylet should never go through the vocal cords. If the ETT isn't lining up well with the cords try laryngeal pressure (assistant helps out) or turn the ETT in a clockwise direction. The "Parker tube" really does make glidescope intubation safer and easier but adds additional cost so most just use a standard ETT.

The amount of force required to do a Glidescope intubation vs a DL intubation is significantly less. The Glidescope is more about finesse than force.
 
A Randomized Comparison of a Parker Endotracheal Tube and a Standard Tube Oriented 90˚ Counterclockwise

Wade A. Weigel, Thomas C. Dean

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Department of Anesthesiology, Virginia Mason Medical Center, Seattle, USA.

Email: [email protected], [email protected]

Received August 10th, 2012; revised September 11th, 2012; accepted September 21st, 2012

Keywords: Endotracheal; Intubation; Parker; Mallinckrodt; Fiberoptic

ABSTRACT

Purpose: During oral fiberoptic intubation, advancement of an endotracheal tube (ETT) into the trachea is occasionally impeded by laryngeal structures. The curved flex tip Parker ETT has been shown to improve the likelihood of successful advancement as opposed to a standard ETT that is advanced in neutral orientation. However, a Parker tube has not been compared to a standard ETT oriented 90˚ counterclockwise from the neutral position. We hypothesize that fiberoptically-guided advancement of an ETT into the trachea will be more successful when using a Parker tube than a 90˚ counterclockwise-oriented standard ETT. Methods: This unblinded, randomized controlled trial compares the rate of successful advancement of a fiberoptically-guided endotracheal tube into the trachea. Two groups of randomly assigned patients with non-difficult airways are compared: a Parker flex-tip tube (Parker Group; n = 57) versus a standard ETT oriented 90˚ counterclockwise (Standard Group; n = 58). Our primary outcome is the first pass success rate of advanceing the ETT into the trachea. Results: First pass success occurred in 48 of 57 (84%) patients in the Parker Group vs. 39 of 58 (67%) of patients in the Standard Group (p = 0.0497). Conclusion: When advancing an ETT over an oral fiberoptic scope and into the trachea, a Parker curved flex tip ETT is statistically more likely to be placed successfully on the first pass than is a standard ETT oriented 90˚ counterclockwise.
 
I use a glidescope frequently, but not necessarily for difficult airways. Two common reasons - when our surgeon wants a NIMS ETT for neuromonitoring, we want them to see the tube placement. Sure it's CYA, but if they want it, they watch it. The other is for patients we induce on the bed (hips, trauma, etc) that are hard to reach. I can intubate from the side of the bed and save my back.
 
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