NEED HELP!!! Airway question

[N2b8]

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My attending REAMED me, and I need help with this one. I intubated a difficult airway with a glidescope and in my note I wrote that I had a grade I view. He said that you can't classify the grade of view except under DIRECT laryngoscopy; that the grading system doesn't apply in this circumstance. Is this correct???

Thanks tons for your help!!!

 

[lgher]

correct. that's also what i've been taught. you could visualize the cords from an inch away with a fiberoptic device and also have a "grade 1 view," but it's incorrect to record it as such.

Only under direct laryngoscopy.

 

[Planktonmd]

Your attending is right.
The glidescope view grade does not predict the direct laryngoscopy ease or difficulty.
The goal of the view grade is to provide guidance for future intubations with DL on the patient.

 

[OB1🤙]

This brings up a HUGE silly semantic pet peeve of mine- documenting things like "DLx1 with Glidescope, Grade 1 view..."

By definition, using the Glidescope means the laryngoscopy isn't direct.

I've started charting "VLx1" (for video laryngoscopy obv.) when using the Glidescope, which in my warped brain should be the right way of documenting its use.

 

[IceDoc]

There is a grading system for views obtained via a video laryngoscope. But, it's much more useful as a research tool than purveyor of vital clinical information.

 

[countingdays]

At an airway course recently the glidescope rep told me the view was an average of 1 grade better than DL, implying that you can use grade for a glidescope view and that you can use that information to estimate DL view.

He might not have known what he was talking about though. If you don't trust the rep, then you can also point out that 'the literature' references grades of laryngoscopy view with a glidescope:

"Anesthesia was induced with lidocaine, fentanyl, propofol, and cisatracurium. After 3 min of ventilation via mask, we easily inserted a Glidescope® video laryngoscopy blade and obtained a Grade I view of the vocal cords"
http://www.anesthesia-analgesia.org/cgi/content/full/104/6/1610

"The view of the glottis displayed on the monitor screen of the GlideScope was noted, again using the Cormack and Lehane scale."
http://www.anesthesia-analgesia.org/cgi/content/full/106/5/1495

"The trachea was intubated using direct laryngoscopy (Group DL, n=100) or the GlideScope® (Group GS, n=103). We compared C&L grades for the two views in the same patient, and also the time to intubate for each group."
http://bja.oxfordjournals.org/cgi/content/short/aen234v1

 

[aredoubleyou]

In a rush I took an old lady with a moderately short chin back in a rush, the old anesthesia record stated "grade 1, easy intubation." After barely getting a grade 2 view with a long DL, I saw that later on in the documentation it noted that a glydescope was used 😱. So I totally agree with your attending. Last time I made that mistake, btw.

 

[jennyboo]

So you see cords thru the Glidescope viewer.... now try looking directly into the pt's mouth. Last time I did this the "direct" laryngoscopy view (not the Glidescope viewer) showed NADA (i.e. Cormack-Lehane Grade 4) despite the cords showing up directly on the screen....

So I would describe this as, "Vocal cords visualized on Glidescope screen" and leave it at that....

 

[Licoricestick]

So you see cords thru the Glidescope viewer.... now try looking directly into the pt's mouth. Last time I did this the "direct" laryngoscopy view (not the Glidescope viewer) showed NADA (i.e. Cormack-Lehane Grade 4) despite the cords showing up directly on the screen....

So I would describe this as, "Vocal cords visualized on Glidescope screen" and leave it at that....

If you were attempting that "direct" view using the glidescope then that isn't valid. If you want to compare direct and indirect views in the same patient at the same time then you need to use a device for which direct laryngoscopy is feasible (one look at the curve on the slidscope shows it isn't going to work). I believe the Storz VLS systems use a macintosh blade, inserted just the same way as we do with conventional DL - this would be a feasbile comparison.

In regards to larynx documentation - I agree that documenting C&L grading from VLS view can be unhelpful for future anaesthetists but you still need to document something. There are cases where the view is poor with VLS and if I was going to anaesthetise someone whose last anaesthetic chart stated "Gd III view with glidescope, difficulty passing tube even with glidescope stylet in position" I'd think twice about using the glidescope.

Most of the papers coming out about VLS are using C&L descriptions of laryngeal view obtained with the VLS. So there is a precedent. But with any difficult airway documentation the principle is alwasy to document as much information as you can. You can't be held responsible for the next person's failure to read that information, as long as you have clearly stated how the view was obtained.

 

[Jeff05]

CL view terminology can be applied to any airway visualization device. what your attending may have meant is that you should have specified that the grade I view was obtained with a glide.

the glidescope people refer to the views their product provides in terms of CL:

http://www.verathon.com/PDFs/0900-2132-00-86.pdf

 

[pgg]

My attending REAMED me, and I need help with this one. I intubated a difficult airway with a glidescope and in my note I wrote that I had a grade I view. He said that you can't classify the grade of view except under DIRECT laryngoscopy; that the grading system doesn't apply in this circumstance. Is this correct???

Thanks tons for your help!!!

What kind of ******* dick of an attending "reams" somebody in training for making a simple semantic error?

If he deserved the slightest shred of respect he would have simply corrected you and reminded you that the whole point of grading views is to give future DL'ers an idea of what to expect during DL.

Residency sucks enough without guys like your attending going out of their pompous ways to make it suck more.

 

[tucker27705]

I think the key is to write something that conveys to the reader what you did. Who cares if you use the term grade 1 view, when that view was obtained with a glidescope--as long as you state that the view was obtained with a glidescope. I always state in the record what sort of blade I've used, Mil vs. Mac vs Glidescope etc. and I also state how many pillows, whether cricoid pressure was used to assist the view--i.e. everything that was used to obtain the best view I observed. That way the reader knows what worked for me and can plan accordingly.
This is one case where I really disagree with any other view point. I have never heard that this method of grading is exclusive to using a mac or miller blade.
To further illustrate, I have often had less than a grade one view with a glidescope. What the hell am I supposed to write? I saw one third of the vocal cords? I saw an epiglottis but no vocal cords? We all know this corresponds to grade 2 and 3 views, so why not just say that? AS LONG AS you also say the view was obtained with "insert blade here"!
Thank god I'm not a resident any more. I didn't have many, but those few a-hole attendings were just that.
As a final note, if I've used a glidescope, I would never say the it was an "easy" intubation.
T

 

[BuddhaCanooda]

CL view terminology can be applied to any airway visualization device. what your attending may have meant is that you should have specified that the grade I view was obtained with a glide.

the glidescope people refer to the views their product provides in terms of CL:

http://www.verathon.com/PDFs/0900-2132-00-86.pdf

Look at the original 1984 paper by Cormack. It is not the same. Just because a VL gets a certain view does not predict difficulty. I use a stylet based scope and get a Grade I view with every intubation I achieve. Does that predict difficulty of airway? Absolutely not!

BC

 

[dillpickles]

What kind of ******* dick of an attending "reams" somebody in training for making a simple semantic error?

If he deserved the slightest shred of respect he would have simply corrected you and reminded you that the whole point of grading views is to give future DL'ers an idea of what to expect during DL.

Residency sucks enough without guys like your attending going out of their pompous ways to make it suck more.

I agree completely. Your attending sounds like a very maladjusted individual to get so wound up about the matter. It would be a lot of fun in these residency situations to ask unreasonably freaked out attendings if they have taken their morning happy meds.

 

[inmyslumber]

I would give the attending the benefit of the doubt. I do agree with pgg that the attending should have just explained what DL grades signify. However, in GENERAL, when an attending gives you a hard time about something "minor" it is not the first thing he or she has noticed you need work on. Don't take it personally, just accept the criticism and get it right the next time.

 

[pgg]

However, in GENERAL, when an attending gives you a hard time about something "minor" it is not the first thing he or she has noticed you need work on.

That's a fair point.

 

[SleepIsGood]

I would give the attending the benefit of the doubt. I do agree with pgg that the attending should have just explained what DL grades signify. However, in GENERAL, when an attending gives you a hard time about something "minor" it is not the first thing he or she has noticed you need work on. Don't take it personally, just accept the criticism and get it right the next time.

I agree with you a bit here.

however, I agree with PGG.

Residency is hard as it is. There are unfortunately attendings with short tempers in academics. They really shouldnt be there to begin with. Teaching residents/med students requires patience...for christ sakes they were residents once too that didnt know anything! I'm not saying everything should be peachy, keen...but come on!

now if an attending wants to ream a CRNA....totally OK

 

[inmyslumber]

There are unfortunately attendings with short tempers in academics. They really shouldnt be there to begin with.

Now it is my turn to agree with you!