Video Laryngoscopy 100% of the time… every time.

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I'm not near 100% but I have a very low threshold for VL. Used to DL the difficult ones for ego, the same way I'd avoid U/S for art lines. But now all I care about is safety and efficiency. Eventually if you damage a tooth, vocal cord, C-spine, etc the first question will be if you had access to VL. If you're playing airway warrior while glidescopes sit unused in the hallway, that's inexcusable. Different situation for trainees and those who don't have ready access to VL.

VL is a skill just like anything else and those that are using it frequently are better at it. They're going to be worse at DL over time, but that's the tradeoff. I'm ok with that tradeoff -- when it hits the fan, there are plenty of situations where high level VL skills are more useful than DL skills.
 
There is still a learning curve with VL as well. People who don't intubate as often make grave mistakes like putting the glidescope too deep as to not have the necessary angle to place the tube, having bad hand eye coordination, etc. Definitely less difficult than DL of course.
 
Great question. I struggle with the VL vs. DL and US for a-line questions all the time. I can honestly say this:
1. If I have a say about someone intubating me, I would want they to go straight to VL.
2. It's nice to know how to use a paper map, but how many of you still drive to a new place without some GPS navigation on your phone/car? Do you ever worry that your phone breaks down? Glidescope, US?

With that said, I still make my residents:
1. Do a-line with palpation in ASA1-2 patients
2. Start with DL as CA1

Also, I don't know the monetary and environmental cost of cleaning laryngoscopes vs. disposables blades.
 
The "you can't use VL in a contaminated airway" line is *mostly* nonsense. I've stopped counting the number of bloody airways I've taken over from the ED where I still used their CMAC to secure the tube, or the number of code intubations on the floor in a vomiting pt where I still used the McGrath.

My biggest pet peeve watching others VL is many just shove the blade into the mouth haphazardly thinking that whenever they stop a great view is going to magically appear, which is just not the case. Same goes for oral fiberoptic, where if you advance too fast without deliberately "steering" around secretions and staying away from the mucosa, your lens is gonna get smudged.

In the contaminated airway, if one actually suctions beforehand, scissors the mouth, inserts yankauer again and leaves it in the pharynx (or better yet double suctions), and then inserts the VL carefully trying to stay anteriorly and away from where gravity dependent blood/vomit is going to pool, you will get a good view at a high enough rate to question the traditional teaching about VL and contaminated airways.

Here's an OMFS case from earlier this year where after extubation I got called to a colleagues room to assist. Some suture line had opened up in the pharyx. Guy is satting 60 and blood is coming out the yankaeur in the mouth at a good clip. OMFS about to cut the neck. I still elected to glidescope the guy, and of course the epiglottis/glottis looked like swollen hamburger, however I managed to get a tube in. But with the right approach and yankauer in place the blood on the screen situation wasn't too bad (just that bit of pooling around 7,8 oclock of the ETT.

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I love video laryngoscopes and they have helped me nearly eliminate awake FOIs. However, way overkill to use it 100% of the time. It adds a little bit of cost. Probably adds a little bit of time. Not needed terribly often, though I do not hesitate whatsoever to have standing by or switch to if needed. The incidence of complication from DL by an experienced person is exceedingly low and the complications that do happen are extremely minor. The incidence of complications from VL is also not zero as I have seen a few nice lacerations in the pharynx from the rigid stylet tube being placed in the oropharynx.

Also not really similar to the use of U/S for CVP placement because complication rate of CVPs by landmark is significantly higher than that of direct laryngoscopy and the severity of the complications is much higher as well. A single pneumothorax or carotid injury probably greatly outweighs every tooth ever chipped by a laryngoscope.
 
I find myself grabbing the McGrath with an x-blade attached when running on a code, but DL with a slim mac 4 gets me there almost every time,and is my first choice.

To me, a contaminated airway with a McGrath is not a good time, as the image quality, compared to a direct or cmac view is pretty dark and grainy. Light intensity for DL with a mac blade attached is really poor, as outlined by others. The curvature of the mac4 blade is slightly more acute than that of a german or english mac, so if I get a grade 2a/b view in the monitor, looking inside the OC might get me a grade 3. Don't know if the american mac is the same angle as the mcgrath one, though.

We also have a CMAC with the cart monitor, and while I love it for teaching (with the mac4, display in my view only), and bring it out for a bunch of elective OR intubations with fat males and poor mouth openings, neither my attendings or nurse anesthetist colleagues ever bring it over to the ED or ICU, as it is a hassle.

The CMAC (mac4 and d-blade) and DL blades are freely used in our dept, as they're cleaned alongside clamps, masks, etc. McGrath stuff, while not more expensive than an LMA, still costs us a bit to use.
 
VL is the standard of care for babies where I’m working, has been for years. Under 6 months or under 5kg. Why, because bad things happen, babies have no reserve on a good day, and we have trainees. If you don’t need/want to look at the screen and you have a view, don’t. Though you can still look up after advancing the tube to confirm you’re in.
PICU, NICU, and ED are all VL all day, every day.
I want the tube in on the first attempt, I don’t care what it costs. That’s what all those ridiculous facility fees are for.
 
pgg said:
If the day comes that I need to be intubated, I honestly DGAF what the tube jockey uses to visualize my vocal cords.
Click to expand...
I'll make sure to relay this to the 1st month SRNA who's just dying to try out that shiny Miller 2 for the first time





:smuggrin:
 
People who are good at DL pick up the McGrath pretty quickly. People who never learned DL and start with the McGrath are mediocre with the VL and worse with DL. You didn't start off driving the Tesla S Plaid, you worked up to it,
 
FWIW, I use the Mcgrath or Glidescope about 1/3 of the time these days. That is a lot for an senior attending trained with a Miller 2 and bougie. I feel the combination of daily DL and VL is ideal. Now, is 50/50 the right combination? I am fine with that as well. I just don't believe in extremes because the DL is still a valuable skill which must be maintained IMHO.

If you NEVER do trauma or high risk cases then by all means shift to the VL. But, if you want to maintain those skills you must continue to do DL.

I also stand-by my statement that a very skilled provider won't chip your tooth or cause much trauma from a DL. Over time, I have perfected my technique to be extremely careful with the blade and use the minimum force necessary to intubate the patient. If the airway is difficult or Class 4 I won't even attempt DL these days. But, everyone knows that the majority of airways are Class 1 or 2 and should be easily intubated with DL. That said, I think 1/3 or 1/2 of the time to use VL makes sense to keep that skill up as well.
 
Interesting discussion. As a fellow, I would say that I have a formula:

-No concerns: MAC 4. No matter what. It's the best. Period.

-C-spine concerns in C-collar but no other issues: CMAC D-blade with inline stabilization.

-Legit airway concern: fiberoptic

-Code situation: MAC 4. The GOAT.

-ICU garbage: CMAC D-blade (would carry around this in my backpack with portable screen).

-Looks reallllllll gnarly: retrograde wire.


Glidescope is flimsy cheap junk and mcgrath is for posers.


MAC4/CMAC D-BLADE/fiberoptic covers it all.
 
BlueRug said:
Interesting discussion. As a fellow, I would say that I have a formula:

-No concerns: MAC 4. No matter what. It's the best. Period.

-C-spine concerns in C-collar but no other issues: CMAC D-blade with inline stabilization.

-Legit airway concern: fiberoptic

-Code situation: MAC 4. The GOAT.

-ICU garbage: CMAC D-blade (would carry around this in my backpack with portable screen).

-Looks reallllllll gnarly: retrograde wire.


Glidescope is flimsy cheap junk and mcgrath is for posers.


MAC4/CMAC D-BLADE/fiberoptic covers it all.
Click to expand...

I genuinely can't tell if you're joking. This is one of the worst takes I have seen re: airway equipment.
 
Glide scope is the superior video scope, the hyper angulated blade optimized the view for difficult patients, but makes it hard to pass the tube at times.

For any anticipated airway I use a VL, hence it is the better method.

DL is easier to pass a tube in many situations.

The CPR pulmonary edema vomit and other fluids obscuring view in video laryngoscopy is real, which means DL skills are mandatory.

I see no harm in DL for an easy airway. It is faster, and it maintains the skills.
 
BlueRug said:
Interesting discussion. As a fellow, I would say that I have a formula:

-No concerns: MAC 4. No matter what. It's the best. Period.

-C-spine concerns in C-collar but no other issues: CMAC D-blade with inline stabilization.

-Legit airway concern: fiberoptic

-Code situation: MAC 4. The GOAT.

-ICU garbage: CMAC D-blade (would carry around this in my backpack with portable screen).

-Looks reallllllll gnarly: retrograde wire.


Glidescope is flimsy cheap junk and mcgrath is for posers.


MAC4/CMAC D-BLADE/fiberoptic covers it all.
Click to expand...

huh... and you are a fellow in anesthesia?
 
MalloryWeiss said:
If you have a decked out 2021 Tesla Model S Plaid in your driveway… why drive the 1989 Honda Civic?

Once upon a time the only way to place a central line was by doing it “blind” aka using landmarks. Today, not using an ultrasound is considered to be below the standard of care (unless it’s an emergency).

How many of you have similarly evolved your practice to using a video laryngoscope 100% of the time (McGrath)?

- optimizes first attempt success (therefore you’re reliably faster, fewer attempts, makes you consistently more slick in private practice)
- nobody is forcing you to look at the screen, so if you’re feeling proud that day then just use the McGrath as a regular mac blade and look directly
- less torque required therefore less sympathetic response and less traumatic to oropharynx/epiglottis/tongue/etc. (I see some people barbarically crank and contort the patient’s head to get a good view… YIKES! Guys… there is a better way, and you can bet that if I’m going in for a lap appy, I’ll be kindly requesting Video)
- less risk of dental injury

Sure there is some marginal upfront cost (3-5k I think, not including the disposal blades)… but who cares? That’s a drop in the bucket compared to the SAFETY benefits that video provides.

I use it 100% of the time, and I think one day it will become the standard of care (similar to ultrasound for lines). In my house, we have one McGrath in every OR. Anyone else out there who is proud to be on the video train?

(To clarify: not suggesting we wheel in a Glidescope for every case. I’m talking handheld devices)
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That’s where we are headed. Thinking otherwise is being a troglodyte.

It’s fine as long as you don’t go working in missions where there is no equipment.
 
urge said:
That’s where we are headed. Thinking otherwise is being a troglodyte.

It’s fine as long as you don’t go working in missions where there is no equipment.
Click to expand...


We have glidescopes on our missions. Our medical director who has over 30yrsexperience believes it is superior. Our100% pediatric colleagues are true believers too.
 
Just published in JAMA

Screenshot_20211213-171211_Chrome.jpg

Key Points
Question In critically ill adult patients undergoing tracheal intubation, does use of a tracheal tube introducer (“bougie”) increase the incidence of successful intubation on the first attempt, compared with use of an endotracheal tube with stylet?

Findings In this randomized clinical trial that included 1102 critically ill adults, successful intubation on the first attempt was 80.4% with use of a bougie and 83.0% with use of an endotracheal tube with stylet, a difference that was not statistically significant.

Meaning Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

Abstract
Importance For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer (“bougie”) increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.

Objective To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.

Design, Setting, and Participants The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.

Interventions Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).

Main Outcomes and Measures The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.

Results Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, −2.6 percentage points [95% CI, −7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, −1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.

Conclusions and Relevance Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

-------


What's crazy to me is that in this (presumably non-anesthesiologist) study the first pass success rate was only ~80%. That's with use of VL in about 70-75% of pts in both the bougie and stylet cohorts. I feel like I'd have assassinated so many people with no pulmonary and/or cardiac reserve in the ICU if my first pass rate was that low.
 

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vector2 said:
Just published in JAMA

View attachment 346766
Key Points
Question In critically ill adult patients undergoing tracheal intubation, does use of a tracheal tube introducer (“bougie”) increase the incidence of successful intubation on the first attempt, compared with use of an endotracheal tube with stylet?

Findings In this randomized clinical trial that included 1102 critically ill adults, successful intubation on the first attempt was 80.4% with use of a bougie and 83.0% with use of an endotracheal tube with stylet, a difference that was not statistically significant.

Meaning Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

Abstract
Importance For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer (“bougie”) increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.

Objective To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.

Design, Setting, and Participants The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.

Interventions Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).

Main Outcomes and Measures The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.

Results Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, −2.6 percentage points [95% CI, −7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, −1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.

Conclusions and Relevance Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

-------


What's crazy to me is that in this (presumably non-anesthesiologist) study the first pass success rate was only ~80%. That's with use of VL in about 70-75% of pts in both the bougie and stylet cohorts. I feel like I'd have assassinated so many people with no pulmonary and/or cardiac reserve in the ICU if my first pass rate was that low.
Click to expand...
I believe there was a ED study a couple years ago showing better first pass success with boogie … same criticism of that paper
 
To the OP,

I think you are right. We will use some sort of video assisted intubations on all intubations. What technology or form that takes, who knows.

To argue otherwise, I think, is like arguing that back-up cameras are not useful and won't become standard.

I am not that great with VL - I try to practice it probably in a 1:3 ratio. I am still much faster with DL, and it feels much smoother for me.

I can get a great view with VL - it is the tube delivery that slows me down a bit. I'd like to get as fast and facile with VL as I am with DL.
 
vector2 said:
Just published in JAMA

View attachment 346766
Key Points
Question In critically ill adult patients undergoing tracheal intubation, does use of a tracheal tube introducer (“bougie”) increase the incidence of successful intubation on the first attempt, compared with use of an endotracheal tube with stylet?

Findings In this randomized clinical trial that included 1102 critically ill adults, successful intubation on the first attempt was 80.4% with use of a bougie and 83.0% with use of an endotracheal tube with stylet, a difference that was not statistically significant.

Meaning Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

Abstract
Importance For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer (“bougie”) increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.

Objective To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.

Design, Setting, and Participants The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.

Interventions Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).

Main Outcomes and Measures The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.

Results Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, −2.6 percentage points [95% CI, −7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, −1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.

Conclusions and Relevance Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

-------


What's crazy to me is that in this (presumably non-anesthesiologist) study the first pass success rate was only ~80%. That's with use of VL in about 70-75% of pts in both the bougie and stylet cohorts. I feel like I'd have assassinated so many people with no pulmonary and/or cardiac reserve in the ICU if my first pass rate was that low.
Click to expand...

80% is terrible. Can't believe these people publish these horrible studies. "Hey our appy center of excellence has a 40% mortality compared to the 50% at da u so academics sux"
 
dipriMAN said:
I believe there was a ED study a couple years ago showing better first pass success with boogie … same criticism of that paper
Click to expand...

GassYous said:
80% is terrible. Can't believe these people publish these horrible studies. "Hey our appy center of excellence has a 40% mortality compared to the 50% at da u so academics sux"
Click to expand...
My god….I’m going through the full paper:

“Patients were eligible if they were undergoing tracheal intubation with the planned use of sedation and a nonhyperangulated (eg, Macintosh [curved] or Miller [straight]) laryngoscope blade. Patients were excluded if they were pregnant, were incarcerated, had an immediate need for tracheal intubation without time for randomization, or if the clinician performing the intubation procedure (referred to as the “operator”) determined that use of a bougie or a stylet was either required or contraindicated.”

This study didn’t even include c-collar/c-spine injuries or no-chin morbidly obese Mal 4 airway disasters (since presumably they would’ve been using hyperangulated blades there from the get-go and thus would’ve been excluded)……………..and their success rate was still barely 80%.
 
vector2 said:
Just published in JAMA

View attachment 346766
Key Points
Question In critically ill adult patients undergoing tracheal intubation, does use of a tracheal tube introducer (“bougie”) increase the incidence of successful intubation on the first attempt, compared with use of an endotracheal tube with stylet?

Findings In this randomized clinical trial that included 1102 critically ill adults, successful intubation on the first attempt was 80.4% with use of a bougie and 83.0% with use of an endotracheal tube with stylet, a difference that was not statistically significant.

Meaning Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

Abstract
Importance For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer (“bougie”) increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.

Objective To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.

Design, Setting, and Participants The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.

Interventions Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).

Main Outcomes and Measures The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.

Results Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, −2.6 percentage points [95% CI, −7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, −1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.

Conclusions and Relevance Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

-------


What's crazy to me is that in this (presumably non-anesthesiologist) study the first pass success rate was only ~80%. That's with use of VL in about 70-75% of pts in both the bougie and stylet cohorts. I feel like I'd have assassinated so many people with no pulmonary and/or cardiac reserve in the ICU if my first pass rate was that low.
Click to expand...

Garbage. Who the hell js doing these intubations?
 
coffeebythelake said:
Garbage. Who the hell js doing these intubations?
Click to expand...
Non anesthesiologists.

I went to an ICU airway page with my resident last week. They were attempting to mask ventilate a person who self-extubated. Total flail of a two person, two-handed mask, barely moving air, finally induced paralyzed and stuck a VL in there and couldn't get a view, couldn't do it. My resident stepped in, masked the patient back up with one hand, VL'd the patient like a boss and stuck the tube in like it was easy.

Just the way it is.

To their credit, they hit up the airway pager to get backup to the bedside as soon as the patient extubated herself.
 
Those studies are so friggin pointless. Waste of money from the get go- who in their right mind believes they’re saving lives by using a bougie over a stylet or vice versa.
 
Radetzky said:
Those studies are so friggin pointless. Waste of money from the get go- who in their right mind believes they’re saving lives by using a bougie over a stylet or vice versa.
Click to expand...
I do think routine bougies are helpful for non-anesthesiologist operators who frequently have trouble engaging the glottis smoothly or directly with the tip of the ETT, and who have little troubleshooting ability if the bevel hangs on the anterior subglottic trachea and won't advance smoothly, etc
 
If you were at the PGA…pretty much the only thing vendors prattled on about were the disposable laryngoscopes which also come with an attached monitor. You’d think the future was 100% VL.
 
FiO2@21 said:
But the stylet shouldn't be extending past the tube anyway.
Click to expand...

the tube on a rigid stylet can really slice up some tissue if you are not careful. The stylet doesn't need to extend past the tube to help cause some damage by making the tube hold a rigid shape.
 
Mman said:
the tube on a rigid stylet can really slice up some tissue if you are not careful. The stylet doesn't need to extend past the tube to help cause some damage by making the tube hold a rigid shape.
Click to expand...

Heard of a perf into the esophagus from intubation. Think it was a dlt though
 
nimbus said:
From another thread.

Dead toddler=no bueno

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Terrible. I’m actually sad and nauseated after reading that.
Don’t recommend a read.
Take home lesson, if the patient is having a hypoxemic arrest after intubation, before going down some rabbit holes, confirm the tube is in the trachea.
Which you would already know if you used VL and saw it go between the cords and down into the trachea before removing the blade.
 
IlDestriero said:
Terrible. I’m actually sad and nauseated after reading that.
Don’t recommend a read.
Take home lesson, if the patient is having a hypoxemic arrest after intubation, before going down some rabbit holes, confirm the tube is in the trachea.
Which you would already know if you used VL and saw it go between the cords and down into the trachea before removing the blade.
Click to expand...


With VL everyone in the room knows where the tube went.
 
I’ll never forget arriving on the scene of an infant code in the OR as a resident. An extremely experienced senior anesthesiologist was coding a baby after induction and intubation. No O2 sat, asystole, no ETCO2. Epi, compressions, etc. Chaos. The same time I arrived a pediatric anesthesiologist ran in as well and went to the head of the bed.
“Arrested on induction” was the story.
1st question. Could you ventilate before you put the tube in? -Yes.
2nd question. Was it a difficult intubation? (Kid looked normal) -No.
Tube out, oral airway in, proper jaw lift, easy mask ventilation. ROSC.
Unfortunately that didn’t happen in time to avoid catastrophe.
I think he actually pulled the tube after the first question, but you get the point.
 
IlDestriero said:
Terrible. I’m actually sad and nauseated after reading that.
Don’t recommend a read.
Take home lesson, if the patient is having a hypoxemic arrest after intubation, before going down some rabbit holes, confirm the tube is in the trachea.
Which you would already know if you used VL and saw it go between the cords and down into the trachea before removing the blade.
Click to expand...

When I read about her life and her smile, I thought of my own kid. So sad.
 
IMGASMD said:
19mos for a finger surgery, terrible.

I didn’t know you can ventilate if the tube was in the upper esophagus….
Click to expand...
I also didn’t realize you could get some ventilation and repeating ETCO2 waveform from an esophageal tube with a leak in a child. If the sat came up to 95% with bagging, and two separate anesthesiologists had intubated, I can see how the picture becomes confusing.

I agree VL probably avoids all this.
 
dipriMAN said:
I also didn’t realize you could get some ventilation and repeating ETCO2 waveform from an esophageal tube with a leak in a child. If the sat came up to 95% with bagging, and two separate anesthesiologists had intubated, I can see how the picture becomes confusing.

I agree VL probably avoids all this.
Click to expand...

Lots of things could have avoided all this. VL is one possible thing.
 
GassYous said:
Sounds like they had small tracing on etco2 but not the actual waveform like you would typically see
Click to expand...
I am certainly not well versed in their academic rankings. Registrar, then consultant? But regardless, at some point there were four anesthesiologists in the room….. kind of scary, that we become so focus on one thing and forgot the basics. Also they multiple people checked breath sounds.

Yes if it was a VL then everyone can actually “see.”
 
IMGASMD said:
I am certainly not well versed in their academic rankings. Registrar, then consultant? But regardless, at some point there were four anesthesiologists in the room….. kind of scary, that we become so focus on one thing and forgot the basics. Also they multiple people checked breath sounds.

Yes if it was a VL then everyone can actually “see.”
Click to expand...
Yes my understanding is with a small patient and enough positive pressure, the esophageal tube with a closed mouth was allowing for some ventilation of the lungs, so breath sounds and ETCO2 may have been present, but tube still misplaced.

And they did remove the tube and intubated again with a different intubator , just put it in the esophagus again.
 
IMGASMD said:
I am certainly not well versed in their academic rankings. Registrar, then consultant? But regardless, at some point there were four anesthesiologists in the room….. kind of scary, that we become so focus on one thing and forgot the basics. Also they multiple people checked breath sounds.

Yes if it was a VL then everyone can actually “see.”
Click to expand...
Registrar= resident, consultant= attending
 
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