Video Laryngoscopy

[alphaholic06]

So, in this month's episode on EMRAP, Ron Walls says that we should be using video laryngoscopy instead of direct laryngoscopy. So my question to group is how many of you are using a video laryngoscope, specifically those of you in community practice? How many of you want to use video laryngoscopy but don't have access to the technology? How many of you prefer DL?

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[The White Coat Investor]

I use it for half my intubations, about the same as in residency. I think it's important to keep both skills up.

 

[8654Marine]

I took Ron Wall's airway course. In it, the program stressed having a primary and a secondary plan for airways.

Relying on one technology seems like a good way to set yourself for failure.

Airway management is a perishable skill. Ask anyone who's not tubed an adult, let alone an infant, recently.

Getting enamored of the latest gadgetry and not having an alternative is not smart.

I've worked in ED's where power went out.

I use half direct and half video.

 

[Arcan57]

Our glidescope has something wrong with the optics and the picture looks like those mid-90's full motion video games that came out after CD-ROM drives became popular. It's also a 50-50 chance that it will have a stylet and an appropriately sized cover, which makes it not so much my go to intubation device.

I sort of feel about video laryngoscopy the way I do about US. The literature says it's awesome, when I use it at courses it produces awesome images that are clear and understandable, and on the crappy last-gen equipment I have at my shop it's mostly useless.

 

[DannyB]

Just DL with the video blade and only look at the screen if you get into trouble

 

[southerndoc]

I probably use the GlideScope maybe 0.5% of time. I won't give up DL for the near future. The GlideScope takes longer in my opinion.

 

[RustedFox]

I use the GlideScope only if its a TOUGH airway and I need to jam the tube in there. The handle and blade are just waaay different than a good old MAC-4, and give a totally alien feel.

I also echo that there's a slim chance that an appropriately sized GlideScope plastic cover (blade?) will be in with the GlideScope.

MAC-4 and a good sniffing position for the win. If they're in a c-collar, then MAC-4 and GlideScope in case I just can't see it.

 

[joeDO2]

I probably use the GlideScope maybe 0.5% of time. I won't give up DL for the near future. The GlideScope takes longer in my opinion.

I think the infrequent use of video laryngoscopy contributes to it taking longer. A big part of it is not obtaining the view but the actual tube delivery. This takes some practice as it is a bit different technique from when you are doing plain old DL.

I like devices like the storz cmac since you can start off with DL and then use the video if you are having problems getting the view. Its also a good teaching tool. I think it gives the best of both worlds if you don't have a wide variety of devices to play with.

As a side note, I would highly recommend the levitan course for giving these things a try. You will be able to become proficient in all the new devices as well as refine your DL technique. With the availability of fresh cadaveric specimens, you probably do more intubations in the weekend course than you would in the next several years in practice.

 

[RustedFox]

I think the infrequent use of video laryngoscopy contributes to it taking longer. A big part of it is not obtaining the view but the actual tube delivery. This takes some practice as it is a bit different technique from when you are doing plain old DL.

This, too.

You need a serious hook on that ETT to use the glidescope via the screen, and not just as a MAC blade. Its bizarre, for sure.

 

[alphaholic06]

Just DL with the video blade and only look at the screen if you get into trouble

This is actually what we do at my program. I think it gives you the best of both worlds.

 

[Rendar5]

This is actually what we do at my program. I think it gives you the best of both worlds.

I'm sure it can work with some devices, but that would actually make it harder for me to use a glidescope. I don't have great arm strength, and the curvature on that thing makes it so it I visualize better with the video cam than with the direct view. Just gotta use that rigid stylet, hate making a U shape out of my flexible one (which is what anaesthesia did when they used our glidescope). Rigid stylet took about 5-10 patients before I got real comfy with it though.

 

[alphaholic06]

I'm sure it can work with some devices, but that would actually make it harder for me to use a glidescope. I don't have great arm strength, and the curvature on that thing makes it so it I visualize better with the video cam than with the direct view. Just gotta use that rigid stylet, hate making a U shape out of my flexible one (which is what anaesthesia did when they used our glidescope). Rigid stylet took about 5-10 patients before I got real comfy with it though.

Yea, the glidescope is an indirect device. We use the CMAC at our program which allows for DL. It's basically a Mac blade with a video screen. Th screen gives the attendings a little piece of mind as they watch you pass the tube.

 

[southerndoc]

I think the infrequent use of video laryngoscopy contributes to it taking longer. A big part of it is not obtaining the view but the actual tube delivery. This takes some practice as it is a bit different technique from when you are doing plain old DL.

Practice isn't the issue. I've had plenty of it because I used it a lot when we first got it. It's not that hard once you get used to it, but for the first few times you can do some damage with the stylette if you aren't careful. We've had pharyngeal lacerations from inexperienced use.

I work in a 76-bed ED. Respiratory therapy keeps the GlideScope in their office. For them to retrieve it takes a while. I can have someone intubated before the GlideScope is even at the bedside. We don't have enough GlideScopes in our department to have them in each patient care area.

 

[zinjanthropus]

i had an airway today where I just couldn't get the tube to go through the cords using glidescope....switched to DL and had no problem....need to keep both skills up

 

[joeDO2]

Practice isn't the issue. I've had plenty of it because I used it a lot when we first got it. It's not that hard once you get used to it, but for the first few times you can do some damage with the stylette if you aren't careful. We've had pharyngeal lacerations from inexperienced use.

I work in a 76-bed ED. Respiratory therapy keeps the GlideScope in their office. For them to retrieve it takes a while. I can have someone intubated before the GlideScope is even at the bedside. We don't have enough GlideScopes in our department to have them in each patient care area.

I guess that would explain the time difference then! I have seen some departments that just have 1 of them place it in the critical care/trauma area and put it on a wheeled stand so it can be to patient side quickly. Maybe this would be a better solution to just having one in the respiratory office?

As far as the pharyngeal lacerations, I think that is just a matter of training. The first few times using it should be on a sim man. Although it doesn't give you realism per se, its great for avoiding those technical procedural errors.

 

[joeDO2]

i had an airway today where I just couldn't get the tube to go through the cords using glidescope....switched to DL and had no problem....need to keep both skills up

I have run into this occasionally (although I think its much less when you get used to the new tube delivery technique). I find that having a bougie available during VL allows you to place the bougie in and deliver the tube in a single attempt if there is difficulty. This saves you from having to take a second attempt and repeat the laryngoscopy.

 

[zinjanthropus]

good thought - tried it - watched the bougie sit around in the oropharynx and laugh at my attempt to push it through the cords on the screen....

 

[Arcan57]

good thought - tried it - watched the bougie sit around in the oropharynx and laugh at my attempt to push it through the cords on the screen....

If the Glidescope is advanced to far, it will give a perfect image of the cords that there is no physical way to manipulate the ETT through. If the cords fill most (>80%?) of your screen, you're probably too close. If you pull back about an inch, the cords look further away but the ETT tube will be directed right through them by the curve of the stylet.

 

[EM_Rebuilder]

Many of my colleagues are using our CMAC nearly all the time.

Personally, I almost always have it at the bedside but still go direct first. Every once in a while I will use the CMAC just to keep my comfort level with it.

I think using all video is dangerous as there is the chance of the video being down, working somewhere without it, etc. I think we can all agree that direct is a skill that diminshes when not used; I think the video, after doing a few, you can pretty easily go back to it without issue...

 

[ptarmigan]

There are less intubations now than their used to be, and now 2 skills (indirect and direct laryngoscopy) to stay proficient in. That's not to mention the trachlight or machinoscope/bronchoscope.

 

[joeDO2]

There are less intubations now than their used to be, and now 2 skills (indirect and direct laryngoscopy) to stay proficient in. That's not to mention the trachlight or machinoscope/bronchoscope.

this is true. especially in the smaller places. one of the aeromed services up north I know sends their staff to the OR every month to make sure they're getting enough tubes. do you think this might be a viable option for the ED? I think it would be great refresher in places that are low volume but I know competition with students could be an issue as well as some tension with ED taking critiques from the anesthesia folks.

 

[Cerberus]

If the Glidescope is advanced to far, it will give a perfect image of the cords that there is no physical way to manipulate the ETT through. If the cords fill most (>80%?) of your screen, you're probably too close. If you pull back about an inch, the cords look further away but the ETT tube will be directed right through them by the curve of the stylet.

Another tip I give to people who are not as comfortable or learning on the glidescope is to hold the stylelet/tube from the top, like a gear shifter. The tube is much easier to manipulate when you are holding it this way. I've seen several people flounder with an intubation because either the glidescope is too close to the cords, like you stated, or they are manipulating the tube too distally. Also, when inserting the tube, insert at an angle, from the corner of the mouth, not directly through the groove in the blade (this was taught to me by someone who took the difficult airway course).

I'm pretty comfortable with both DL and Glidescope but in a difficult airway, I'll take the glidescope any day of the week.

 

[Cerberus]

this is true. especially in the smaller places. one of the aeromed services up north I know sends their staff to the OR every month to make sure they're getting enough tubes. do you think this might be a viable option for the ED? I think it would be great refresher in places that are low volume but I know competition with students could be an issue as well as some tension with ED taking critiques from the anesthesia folks.

I'm not sure why there would be less tubes now than before. I rarely go an acute care shift without performing or supervising 1+ intubations.

 

[deleted109597]

This is where I get to sound like an old fart.
DL worked just fine (most of the time) for years.
VL works when DL doesn't work (sometimes).

I don't think this is quite the same argument as US(UTZ or whatever they're calling it now) as people aren't arguing to use VL for pelvic exams or whatever else they're using US for.
However, many places don't have any type of glidescope.
If I had infinite money, I would have a Storz or Glidescope Cobalt any day of the week, so I could do DL, and if that failed, turn the monitor around. As an attending, I would love to see what my interns see before they start bagging the esophagus. But the reality is that it isn't always available.

 

[EctopicFetus]

I use it for half my intubations, about the same as in residency. I think it's important to keep both skills up.

I do the same..

 

[WilcoWorld]

I'm not sure why there would be less tubes now than before.

Non-invasive positive pressure ventilation?

 

[Cerberus]

Non-invasive positive pressure ventilation?

Yes, but at the same time the population is aging, which probably evens it out.

 

[Rendar5]

Yes, but at the same time the population is aging, which probably evens it out.

Not sure honestly every old time EM guy I'd worked with in residency always remarked how many fewer tubes we were doing cause of bipap. I'm not old enough to have a perspective, but think how many CHFers and COPDers we avoid these tubes on now who would've been tubed coming in the door

 

[EMPD]

We put our residents through a rigorous signoff process for the Glidescope before allowing them to use it. And frankly I feel residents have a habit of going to it too early. You simply have to be an expert at DL in order to exist in this profession.

Rich Levitan has the best airway course in my opinion and he uses fresh cadavers, and he focuses on DL. Interestingly enough this was the first place I had ever used the German Mac blade and I truly believe that we should scrap all the thick flanged American MAC blades and focus more on DL for residents. The toys are important, but they can be overused.

 

[joeDO2]

Rich Levitan has the best airway course in my opinion and he uses fresh cadavers, and he focuses on DL. Interestingly enough this was the first place I had ever used the German Mac blade and I truly believe that we should scrap all the thick flanged American MAC blades and focus more on DL for residents. The toys are important, but they can be overused.

absolutely the german mac is superior IMO. he also emphasizes the difference in illumination between dull bulbs, bright, and LEDs. it makes more of a difference than you might think.