Will video laryngoscopes become standard of care? Should they?

[nimbus]

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two lacerations of the soft palate both were sutured by ENT doc who was drafted from adjacent OR during same anesthetic. One nasty scrape of the floor of the mouth. Required oral surgeon to repair several days later. In all cases I think the same mechanism of injury. Laryngoscopist had eyes on screen as opposed to the blade being inserted to the mouth. I do agree that the glide scope is usually easier on the teeth than the standard laryngoscope.

That’s a great point about watching the mouth while you’re inserting the blade until you get around the bend.

 

[San Marzano]

The glidescope company actually has a four step technique widely available on their website that tells you exactly how to use it. Step 1, look in the mouth while inserting blade. https://www.verathon.com/assets/0900-4696-xx-60.pdf

 

[DrZzZz]

That’s a great point about watching the mouth while you’re inserting the blade until you get around the bend.

Even more important is watching the ETT go into the oropharynx and not staring at the screen the second it passes the lips. Recipe for skewered tonsillar pillars. Some people just weren't taught how to properly utilize the glidescope and like anything else, the tool is only as good as the operator. Or at least that's what I tell my wife...

 

[deleted126335]

The glidescope company actually has a four step technique widely available on their website that tells you exactly how to use it. Step 1, look in the mouth while inserting blade. https://www.verathon.com/assets/0900-4696-xx-60.pdf

That's awesome. It's a good thing that nobody in human history ever failed to follow standards, guidelines, and directions.

 

[Arch Guillotti]

two lacerations of the soft palate both were sutured by ENT doc who was drafted from adjacent OR during same anesthetic. One nasty scrape of the floor of the mouth. Required oral surgeon to repair several days later. In all cases I think the same mechanism of injury. Laryngoscopist had eyes on screen as opposed to the blade being inserted to the mouth. I do agree that the glide scope is usually easier on the teeth than the standard laryngoscope.

Have also seen a couple of ugly palate injuries as well from VL.

 

[vector2]

Even more important is watching the ETT go into the oropharynx and not staring at the screen the second it passes the lips. Recipe for skewered tonsillar pillars. Some people just weren't taught how to properly utilize the glidescope and like anything else, the tool is only as good as the operator. Or at least that's what I tell my wife...

I wonder why in every other specialty the reps are like the MD’s shadow when they’re learning new equipment/using a new drug, but in anesthesia a new device just appears in the OR and we’re forced to stare at it like the monkeys in 2001 A space odyssey.

 

[Iso4ane]

To keep it simple, yes and yes (in big patients), but with caveats. I’m training with both, and although I’m a big fan of VL (specifically the McGrath), knowing how to do DL is still very beneficial in learning how to do VL.

 

[DM27]

The majority of injuries I could associate with the glidescope were not due to intrinsic flaws in the glidescope itself, but more due to what was mentioned above where the operator was watching the screen instead of the mouth when inserting the blade.

 

[sluggs]

Interloping from CCM: VL is a great tool to improve visualization of a very distal airway. especially using the Lopro blades. No matter how good someone is with DL, it is not possible to get an equal view of a very distal airway that would not be seen with a Mac or miller (these airways do exist). The flip side is that the Lopro can actually position the airway in such a way (anterior and "up") such that it is more difficult even with a good view. Optimal positioning is also different (ramping for DL and more flat for VL). Soft palate injuries are also statistically more common with VL. In 2019, anyone who manages airways has to be good with both. It is very hard, conceptually, to understand that you might need to "rescue" a difficult VL situation with DL, but I have had 2 situations where I could not pass a tube using VL with a good view, but was able to intubate with DL.

 

[fakin' the funk]

Comparison to ultrasound for blocks and central lines is inaccurate. Ultrasound for those is a game changer. A leap in safety and efficiency.

Glidescope is an extension, or an incremental step. Easily defeated by blood or secretions. Doesn't provide much anterior traction. Predisposes to soft tissue injuries. It's an adjunct.

 

[Aether2000]

I disagree. VL makes some otherwise impossible intubations possible, especially if unanticipated difficulty. That to me is a game changer. US, like VL, is not efficient unless the US/VL are in the room. The VL intubation failures I have seen most often involved difficult passage of the ETT through the cords due to the steep anterior curve on the very rigid VL stylet, causing ETT tip impaction upon the anterior trachea or anterior cord commissure.

 

[dhb]

I DL, US for blocks and landmark for CVL...

 

[caveat87]

as a new grad I wouldn't say VAL is my standard, but I have a low threshold to call for it if my first attempt is a grade 3 or 4 view and I cant easily improve with cricoid pressure. my understanding is that once you get beyond 3 attempts the risk of failed intubation goes up substantially and from both a time saving and safety standpoint it just makes sense to me to have video visualization. especially in a bigger person or pregnant patient. aside from planned awake fiberoptic intubations, I've only had maybe 2 situations where I couldn't intubate with a cmac and relied on a fiberoptic scope to get the tube in. impressive technology!

 

[DrZzZz]

as a new grad I wouldn't say VAL is my standard, but I have a low threshold to call for it if my first attempt is a grade 3 or 4 view and I cant easily improve with cricoid pressure. my understanding is that once you get beyond 3 attempts the risk of failed intubation goes up substantially and from both a time saving and safety standpoint it just makes sense to me to have video visualization. especially in a bigger person or pregnant patient. aside from planned awake fiberoptic intubations, I've only had maybe 2 situations where I couldn't intubate with a cmac and relied on a fiberoptic scope to get the tube in. impressive technology!

I'm in a supervision gig. If the CRNA doesn't get a good view on the first look, I call for the glide. While one of the nurses is getting it, I DL myself. Usually, tube is in before the glide arrives or is plugged in. If I don't get a good view, at least it's on its way. If the patient has a history of difficult intubation, I have it in the room set up. But as long as I don't have concerns about masking the patient, I DL first. I like knowing what we're working with. Sometimes someone was listed as difficult in the past purely because a less-skilled provider was managing the airway, poor patient positioning, etc. If I optimize all that and don't get a good view, then someone can just hand me the glide blade and we're good to go.

 

[nimbus]

I'm in a supervision gig. If the CRNA doesn't get a good view on the first look, I call for the glide. While one of the nurses is getting it, I DL myself. Usually, tube is in before the glide arrives or is plugged in. If I don't get a good view, at least it's on its way. If the patient has a history of difficult intubation, I have it in the room set up. But as long as I don't have concerns about masking the patient, I DL first. I like knowing what we're working with. Sometimes someone was listed as difficult in the past purely because a less-skilled provider was managing the airway, poor patient positioning, etc. If I optimize all that and don't get a good view, then someone can just hand me the glide blade and we're good to go.

Seems like a good argument to just start with the glide. Why subject patients to 2 laryngoscopies when one will do?

10 years from now I think it will be common to have VL in every room and many more people using it as option 1.

 

[DrZzZz]

Seems like a good argument to just start with the glide. Why subject patients to 2 laryngoscopies when one will do?

10 years from now I think it will be common to have VL in every room and many more people using it as option 1.

I wouldn't disagree with you. Maybe it's hubris. Maybe it's just a way for me to not let my skills degrade since I'm supervising. If I had to intubate the patient emergently on the floor, I'd feel better if I knew that myself or a colleague was able to intubate via DL as opposed to delaying because of a potentially nebulous history of difficult intubation. Again, I'm not talking about patients who have a seriously recessed mandible or other obvious signs portraying a difficult airway.

 

[dhb]

Seems like a good argument to just start with the glide. Why subject patients to 2 laryngoscopies when one will do?

10 years from now I think it will be common to have VL in every room and many more people using it as option 1.

I've had plenty of grade 3 views on previous laryngoscopies turn into an easy Cormack 2 when i DL.
I agree with the general sentiment on this thread though: VL should be standard of care for some "providers".

 

[Drwine]

Light Wand all day baby.

I am not a fan of a blind technique unless blood obscures the view. However, knowing how to use a light wand obviates over aggressive people from doing "tonsillectomies" with the tube in the blind spot and lifting too much with the Glidescope blade to make tube passage difficult. When I use the Glidescope, I pass the tube first in the same manner as passing the light wand with the goal of palpating the midline and catching the epiglottis if possible. I have someone hold the tube in that position while I carefully peel the tongue away from the tube. Just about always the tube is teed up for easy passage. Sometimes I need a minor adjustment and maybe every 2 to 3 months I need a bougie to replace the stylet to get the tube to pass.
I have a colleague who lifts so much like he is using a Mac blade that he is always using a bougie or bronchoscope to get the tube to pass. Each instrument has subtle differences to use optimally and we should not use the same technique for everything.

To answer the question asked, this will eventually happen if companies improve video scopes to take advantage of the inherent ability to not need a direct line of site. Glidescope has improved their design over the years while Stortz just slapped video on to create the C Mac. As an example take digital cameras. When I bought my first one, I still relied on my traditional SLR. Once I bought a Nikon D 750, I never looked back.

 

[nimbus]

I've had plenty of grade 3 views on previous laryngoscopies turn into an easy Cormack 2 when i DL.
I agree with the general sentiment on this thread though: VL should be standard of care for some "providers".

Me too but why bother?

 

[dhb]

Me too but why bother?

I don't know, in my practice i need a VL maybe once or twice a year so why bother?

 

[IlDestriero]

I would argue that we probably should use a VL, like a Storz VL not a glide, on every attempt because it will improve the likelihood of first attempt success. We don’t do that, but perhaps we should, especially with trainees. We use it for all the babies and it absolutely makes things easier as I can see what’s going on with the intubation attempt. I have a better understanding of the airway and what might be helpful if another attempt is required. I can also make helpful suggestions and/or maneuvers, potentially not stopping a DL attempt to mask vent some more, utilizing the screen to help place the tube on the first attempt.

 

[nimbus]

I don't know, in my practice i need a VL maybe once or twice a year so why bother?

You’re a better man than me. I use it much more than once or twice a year. Sometimes 2-3x/day and basically every male >300lbs.

 

[chocomorsel]

You’re a better man than me. I use it much more than once or twice a year. Sometimes 2-3x/day and basically every male >300lbs.

He's in Europe. They don't have lots of fatties over there like we do. Lol

 

[dhb]

You’re a better man than me. I use it much more than once or twice a year. Sometimes 2-3x/day and basically every male >300lbs.

That's why i said in my practice: we don't get them 300+ pounders very often.

 

[Twiggidy]

This discussion also strikes me a little bit as fear from some anesthesiologists that intubation will become “too easy” and our claim to fame will be devalued somewhat. Anything that makes airways easier for us and everyone else is a win for patients.

The only thing VL sucks for is placing double lumen tubes. But that just requires an engineering solution that isn’t in place yet. It’s not an inherent insurmountable limitation of VL

i mean it does fall a bit into the "Why are you teaching CRNAs" thread. If "everyone" is able to do a skill, then your skill isn't that special anymore, so there is a little bit a truth to the "devaluing" argument, even if just a little.

 

[DM27]

I don't know, in my practice i need a VL maybe once or twice a year so why bother?

I feel that the sentiment of we end up needing something so rarely that why bother using/doing it is the antithesis of most things we do in anesthesia.

 

[kmurp]

No. It's not where things are going. We have 6 video laryngoscope in my hospital for 9 ORs. They are READILY available. And yet, they are only used when there's a reason to. Do I have one in the OR when a patient looks like they might be difficult? Sure. But do I use them on the first look? No. And wow, look at that, I actually rarely need it because I know how to Dl properly and I'm pretty good with a Miller blade.

Are they helpful for residents and those in other healthcare areas who might not be as experienced? Sure. But for those of who actually know how to DL, they're an extra tool, not the standard of care.

And your analogy is terrible. A pulse ox is an essential tool to improve outcomes (and has helped drive anesthesia malpractice way down since it's adoption along with other safety improvements). Does the use of video laryngoscopes on every case improve outcomes vs having one available if needed? No way. Why don't you do a study.

I’m old enough to remember when pulse ox came on the scene. NY state made it a standard of care in the late 80s and there was much bitching by many of my older partners.
There have been few game changers in my career. Pulse ox, etco2, propofol infusions, ultrasound, video laryngoscopy LMAs and maybe sugammadex are the ones I can think of off the top of my head.

 

[nimbus]

I’m old enough to remember when pulse ox came on the scene. NY state made it a standard of care in the late 80s and there was much bitching by many of my older partners.
There have been few game changers in my career. Pulse ox, etco2, propofol infusions, ultrasound, video laryngoscopy LMAs and maybe sugammadex are the ones I can think of off the top of my head.

Damn you’re even older than me.