Will video laryngoscopes become standard of care? Should they?

[Urzuz]

Read a recent article regarding ultrasound-guided central lines leading to lower complications, and it got me thinking: 1) why the hell are people still studying this since it seems so obvious to me what the results will be, and 2) will I be thinking the same thing about video laryngoscopy in 20 years when costs come down and they have potential to be in every OR/ICU in the country?

Thoughts?

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[abolt18]

Read a recent article regarding ultrasound-guided central lines leading to lower complications, and it got me thinking: 1) why the hell are people still studying this since it seems so obvious to me what the results will be, and 2) will I be thinking the same thing about video laryngoscopy in 20 years when costs come down and they have potential to be in every OR/ICU in the country?

Thoughts?

But why, when 99+% of the time you don't need it?

 

[deleted126335]

Read a recent article regarding ultrasound-guided central lines leading to lower complications, and it got me thinking: 1) why the hell are people still studying this since it seems so obvious to me what the results will be, and 2) will I be thinking the same thing about video laryngoscopy in 20 years when costs come down and they have potential to be in every OR/ICU in the country?

Thoughts?

No they shouldn’t be. Routine use 100% of the time will be a Destroyer of skills. In the case of residents they will prevent them from ever acquiring skills. Also I have seen 3 nasty injuries with the glide scope that I don’t believe would have happened with standard laryngoscopes

Having them Available as a standard of care for General Anesthetics you can make a case for.

 

[ryanjmy]

Video cameras don’t work well when covered in blood.

 

[Urzuz]

But why, when 99+% of the time you don't need it?

I agree with you. However, I would also imagine that 50 years ago, you could bang a central line in using a landmark-based technique 99% of the time without issue either. Why has ultrasound become standard of care?

No they shouldn’t be. Routine use 100% of the time will be a Destroyer of skills. In the case of residents they will prevent them from ever acquiring skills. Also I have seen 3 nasty injuries with the glide scope that I don’t believe would have happened with standard laryngoscopes

Having them Available as a standard of care for General Anesthetics you can make a case for.

Will atrophy of DL skills matter if video laryngoscopes are everywhere? Most graduating residents probably don’t feel comfortable doing landmark-based regional techniques or landmark-based central lines...but no one seems all too concerned? And though ultrasound has become the standard for these two examples, complications still arise.

As I told the other poster, I use a video laryngoscope maybe once every couple weeks, but we recently got them in every OR so in theory I could use it every single day for every single intubation. And actually we do have a partner that does use them for every single intubation. Surprisingly, he is in his late 60s with several decades of experience.

 

[Urzuz]

Video cameras don’t work well when covered in blood.

For elective intubation.

 

[DM27]

I think a lot of the value of video laryngoscopes as a standard would be seen in their use as a first line by people who intubate seldomly (<50 a year we’ll say) but are also the first line intubator (EDs or ICUs where there isn’t a high incidence of airway management) since it will be difficult to develop and maintain traditional DL skills. Another scenario where I think the video laryngoscope has value as a first line are scenarios where proper patient positioning is difficult to achieve in the face of someone on the steep part of the decompensating curve (urgent floor, ICU, and ED intubations), as the video aspect tends to resolve a fair amount of positioning scenarios that would otherwise obstruct the traditional “axes alignment” views for a standard DL.

 

[abolt18]

For elective intubation.

And what about when you get that tonsillar bleed, and your glidescope is useless, and you haven't DL'd in months/yrs. Seems like a great time to suddenly NEED that skill.

 

[Urzuz]

I think a lot of the value of video laryngoscopes as a standard would be seen in their use as a first line by people who intubate seldomly (<50 a year we’ll say) but are also the first line intubator (EDs or ICUs where there isn’t a high incidence of airway management) since it will be difficult to develop and maintain traditional DL skills. Another scenario where I think the video laryngoscope has value as a first line are scenarios where proper patient positioning is difficult to achieve in the face of someone on the steep part of the decompensating curve (urgent floor, ICU, and ED intubations), as the video aspect tends to resolve a fair amount of positioning scenarios that would otherwise obstruct the traditional “axes alignment” views for a standard DL.

Agree completely. I feel that the learning curve for direct laryngoscopy is much steeper, and providers that don’t intubate enough (ICU docs in less busy ICUs, EMTs, maybe some ED folks, etc) may not be able to become proficient in DL.

 

[IMGASMD]

US guided central line. You decrease “real risk” of poking the big red. Video scope you decrease “potential risk” of a difficult intubation. Is how I think of it.

Going back to the point of skill atrophy. I’ve recently worked with a surgeon who struggled 5 hours to do a lap chole. He just kept on struggling when he could have maybe open by hour 3? The reason was, he hasn’t done one since residency. He has been practicing for ~10 years.

 

[facted]

No way on Earth video laryngoscope becomes standard of care. Nor should it be. It's actually amazing to me how people rely on it when DL (often with a Miller) gets the job done. My residency PD looked down on those who used the Glidescope as a crutch and I'm forever grateful for that. It's got a place here and there, but luckily it's a rare place.

 

[Impromptu]

Learn the signs that will commonly trigger a difficult ventilation or intubation experience and eliminate them. Optimize your first attempt.

Obese? Ramp. DL
Small chin? Video laryngoscope.
Goatee? Hiding either a double chin or a small chin. (as opposed to a real beard).

Live in a region of the country where 90% of the population has a small chin? You will get to know your video laryngoscope very well.

 

[cchoukal]

The VA has a national policy that video laryngoscopes be available for out-of-OR emergency airway management. Not exactly saying it's "standard of care," in the sense that there's no policy on routine OR management policy.

 

[GravelRider]

Which one costs more: single-use, disposable laryngoscopes or single-use glidescope/stylet?

 

[dannyboy1]

If it looks even remotely difficult I use VL. Also for every floor/ed intubation. Haven’t regretted it yet.

 

[deleted171991]

There are two skillsets that have really changed my airway game: becoming good at glidescope intubations, and becoming good at using various types and sizes of LMAs. I even do awake looks with the glidescope, when in doubt. There are much fewer airways that make me nervous than before.

DL was created for a different generation, a different BMI. Look at the old movies: people used to have a BMI of 20 or less. A BMI of 25+ was obese. For those patients, DL was enough. For the BMI 50 patient, I will use a videolaryngoscope, while some "my hand is bigger than yours" guy will strugle with an intubating LMA or a bougie. Thanks, but no thanks.

I once made the mistake of working in a place which was too cheap to invest in proper videolaryngoscopes. Never again. Every single obese or difficult patient was hard labor and stress. Let's not mention off-floor intubations. If I can't have a glidescope or C-mac with the proper blades, I don't want to work there.

 

[Urzuz]

For the BMI 50 patient, I will use a videolaryngoscope, while some "my hand is bigger than yours" guy will strugle with an intubating LMA or a bougie. Thanks, but no thanks.

+100.

 

[deleted126335]

Which one costs more: single-use, disposable laryngoscopes or single-use glidescope/stylet?

Wrong question. Single use disposable glide scope + reprocessing of stylet v. reprocessing of metal laryngoscope blade + disposable stylet 50-75% of the time?

 

[Impromptu]

A previous hospital switched to disposable laryngoscope blades, as that was cheaper than processing the multi-use laryngoscope blades.

In residency, we had a journal club article that discussed how first time success rates were higher with disposable blades. This was thought to be due to the fiber optics breaking and the light getting dimmer and dimmer with the reusables, verses a consistently brighter light with the disposables.

Another question to ask the administration. What is cheaper, proper video laryngoscopes, or the lawsuits from hypoxic injuries that didn't need to happen?

 

[nimbus]

Wrong question. Single use disposable glide scope + reprocessing of stylet v. reprocessing of metal laryngoscope blade + disposable stylet 50-75% of the time?

I use a disposable stylet with the disposable glidescope.

 

[Dejavu]

Just like U/s only block training, I foresee the day when a video scope cable will come out of your machine’s monitor screen.

Press a button on the VL handle and your screen becomes a giant VL screen. Place the tube, re-touch the button and your screen returns to monitor mode.

Degradation of skills would be no different than present day residents looking aghast when you say, “Let’s do an hour long mask case.”

This would have been routine for us ancient ones, but totally upsets modern-trainees.

Degradation of skills, when something better comes along, is a time honoured tradition, like abandoning adult caudal blocks, trans-arterial axillary blocks. Although I do wonder what happens in departments with two U/S machines and one is busted and the department head has the other, and your case needs to get started. You gonna tell the surgeon that you aren’t skilled enough to do blocks without $1000’s of dollars of equipment crutches?

Lastly, VL-only skill sets won’t help much when you’re lying on a bathroom floor on the wards, trying to intubate someone who arrested during a BM post-op.

The old ways are the best, I always say.‍⚕️ Anybody can do our job with enough high-tech help.

 

[DM27]

On the receiving end of care, I would personally refuse a regional block done by landmarks.

I do not view ultrasound block training as a proper analogy to the video laryngoscope and DL. This is literally comparing something being done completely blindly and hoping that dumping a lot of local in will make up for the lack of precision to being able to actually visualize the structures.

A more adequate analogy would be to compare the art of digital intubation (blind using one's finger) to that new-fangled fancy metal direct laryngoscope where you can actually see the structures. I sadly cannot think of a better analogy. Landmark vs. u/s IJ central line still has a confirmation method in the landmark approach. Nerve stim vs. u/s block still has a confirmation in the nerve stim approach. I guess landmark has the "ouch you transected part of the nerve" confirmation.

 

[T-burglar]

I DL damn near everyone . And if my view isn’t great I still almost always DL plus bougie.

That said , video laryngoscopy is superior, just like ultrasound guided arterial or venous line placement is superior. You folks saying VL is useless in a drowned airway? Have you ever dipped the lens in water and wiped it clean ? I mean just think about what you’re saying. One of the only situations where I immediately call for a VL is the drowned airway .

I should patent a VL with a wiper and washer fluid system like a car. These problems you are all talking about just require a tiny bit of thought to circumvent.

 

[deleted875186]

I DL damn near everyone . And if my view isn’t great I still almost always DL plus bougie.

That said , video laryngoscopy is superior, just like ultrasound guided arterial or venous line placement is superior. You folks saying VL is useless in a drowned airway? Have you ever dipped the lens in water and wiped it clean ? I mean just think about what you’re saying. One of the only situations where I immediately call for a VL is the drowned airway .

I should patent a VL with a wiper and washer fluid system like a car. These problems you are all talking about just require a tiny bit of thought to circumvent.

I disagree .... patient coughing up blood or other bodily fluid that obscures your view, makes video laryngoscopy very difficult.

 

[chocomorsel]

The VA has a national policy that video laryngoscopes be available for out-of-OR emergency airway management. Not exactly saying it's "standard of care," in the sense that there's no policy on routine OR management policy.

Dude, when I was at the VA, we had six Glidescopes for eight ORs. We were flush with equipment. That's the gubment for you.

 

[Nargosi]

No way on Earth video laryngoscope becomes standard of care. Nor should it be. It's actually amazing to me how people rely on it when DL (often with a Miller) gets the job done. My residency PD looked down on those who used the Glidescope as a crutch and I'm forever grateful for that. It's got a place here and there, but luckily it's a rare place.

You can’t really believe this. Whether or not you think DL is a useful skill (it is), this is where things are going to go. You sound like someone saying that we don’t need pulseox when you can just look and see if the patient is turning blue.

 

[MirrorTodd]

The thing is, those other technologies have all provided an additional and/or "measurable" data points to improve care. Video laryngoscopy provides the same feedback/data points that direct laryngoscopy does. I can't really think of a true difference in something measurable between the two. The only real difference I can think of is that with VL everyone can see.

 

[2.0%]

1) why the hell are people still studying this since it seems so obvious to me what the results will be?

Whether or not it seems obvious what the outcome will be, administrators, insurers, lawyers, laymen, etc... all appreciate the ease of looking at documented proof without actually having to understand the "why" and "how".

 

[nimbus]

No they shouldn’t be. Routine use 100% of the time will be a Destroyer of skills. In the case of residents they will prevent them from ever acquiring skills. Also I have seen 3 nasty injuries with the glide scope that I don’t believe would have happened with standard laryngoscopes

Having them Available as a standard of care for General Anesthetics you can make a case for.

What were the injuries? I think the opposite statement could also be true.

 

[MoMoGesiologist]

There are two skillsets that have really changed my airway game: becoming good at glidescope intubations, and becoming good at using various types and sizes of LMAs. I even do awake looks with the glidescope, when in doubt. There are much fewer airways that make me nervous than before.

DL was created for a different generation, a different BMI. Look at the old movies: people used to have a BMI of 20 or less. A BMI of 25+ was obese. For those patients, DL was enough. For the BMI 50 patient, I will use a videolaryngoscope, while some "my hand is bigger than yours" guy will strugle with an intubating LMA or a bougie. Thanks, but no thanks.

I once made the mistake of working in a place which was too cheap to invest in proper videolaryngoscopes. Never again. Every single obese or difficult patient was hard labor and stress. Let's not mention off-floor intubations. If I can't have a glidescope or C-mac with the proper blades, I don't want to work there.

For your awake glidescopes, do you induce once you see the airway or after ETT is in? What do you do in those situations where you have a good view with glide but difficulty passing the ETT?

 

[deleted171991]

For your awake glidescopes, do you induce once you see the airway or after ETT is in? What do you do in those situations where you have a good view with glide but difficulty passing the ETT?

I generally induce once I see the airway, unless I think I may have trouble placing the tube (like having a ton of tissue in the way). What I basically ask myself is: Do I have an easy short path to the glottis? How much time will I have, if the tube doesn't pass easily? I would probably not give up SV in a really big patient until the tube is in. A bit of unpleasantness can prevent a lot of brain injury.

 

[facted]

You can’t really believe this. Whether or not you think DL is a useful skill (it is), this is where things are going to go. You sound like someone saying that we don’t need pulseox when you can just look and see if the patient is turning blue.

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.

 

[vector2]

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.

If the videolaryngoscope is your “rescue” device, then by definition you would have some kind of improvement in metrics such as time to intubation, airway swelling, development of hypoxia, or other morbidity by just VL’ing on the first attempt every time. It may be a small improvement (and require hundreds of pts to demonstrate statistical benefit) since DL’ing is easy for an experienced operator 99% of the time, but it’s a improvement nonetheless.

 

[DM27]

Out of curiosity, can anyone produce a good study that indicates the pulse oximeter improved outcomes?

 

[abolt18]

Out of curiosity, can anyone produce a good study that indicates the pulse oximeter improved outcomes?

Yeah, right there next to the study that showed that breathing is good for you!

 

[coffeebythelake]

If the videolaryngoscope is your “rescue” device, then by definition you would have some kind of improvement in metrics such as time to intubation, airway swelling, development of hypoxia, or other morbidity by just VL’ing on the first attempt every time. It may be a small improvement (and require hundreds of pts to demonstrate statistical benefit) since DL’ing is easy for an experienced operator 99% of the time, but it’s a improvement nonetheless.

If patient isn't an aspiration risk and appears maskable I always DL first. I only use VL in situations where I perceive difficulty of some sort. Taking a few minutes more to intubate isn't a big deal for vast majority of patients as long as you can mask ventilate.

I think DL by default provides a wealth of information for future anesthetics. Not everyone and not everywhere do people readily have access to VL

 

[Aether2000]

Although I am an ancient anesthesiologist, I will take the contrarian view that videolaryngoscopy will eventually become the standard of care. There is less tissue damage with a carefully placed VL vs DL, less risk of dental damage in my opinion, less torque on the cervical spine, and a much better view of the cords in some cases with a much more rapid intubation x 1 attempt vs. the several attempts that might be needed with an unanticipated difficult airway using DL. Just as other techniques used in medicine, VL should not supplant DL in all situations. Learned skills such as DL do not usually decay to the point of uselessness if they are not regularly practiced. Just as US guidance for CVL placement is becoming the standard, we retain the ability to blindly place these lines when needed. Ultimately cost will drive the use of VL over DL with the cost of fractured teeth, litigation from vocal cord injury or intraoral tissue damage playing heavily into the equation. Costs for DL are escalating given the current standard of care for resterilization of DL blades and handles now making disposable blades preferred in many centers. The costs of VL is steadily decreasing and high quality VL is now available via Glidescope Go and a fraction of the prior price of VL.

 

[GravelRider]

I don’t think the question is how awesome we are with our sweet DL skills. The question is whether or not routine VL will decrease morbidity and mortality enough to become standard of care. I agree that I can successfully DL 99% of patients...including properly positioned obese patients. There is probably a significant percentage of patients where my index of suspicion for difficulty is high, so I go straight to VL, but probably would have been successful with DL. However, a few times a year I get the rogue difficult airway that I did not suspect and now have to call for a glidescope. The question is whether those times present a significant enough risk to make VL standard.

My practice now is that when I am working during the day and there are extra hands around, I almost always DL first even if airway challenge is a possibility. However, at night, when I am alone, I almost always VL...I’m usually tired, there isn’t staffing available to fetch supplies if needed, and it’s just easier. I also always go straight to VL for all ICU, ER, and floor intubations.

I also often wonder if post-intubation sore throat is less with VL compared to DL.

 

[pgg]

I don’t think the question is how awesome we are with our sweet DL skills. The question is whether or not routine VL will decrease morbidity and mortality enough to become standard of care.

Agree. I was just going to post something like this.

Things should become "standard of care" if and only if they have demonstrated reductions in morbidity or mortality. Nebulous real or imagined disadvantages related to skill maintenance aren't really relevant to the discussion.

 

[dabears505]

I have found it's a lit easier to place double lumen tubes with dl rather than glidescope. I think that in the field and out of or, dl is useless compared to video. I have never met a non anesthesiologist that had an easier time with dl than video. If they cant get tube with video, I dont care how much blood is in the mouth, they wont get it with dl.

 

[T-burglar]

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

 

[vector2]

If patient isn't an aspiration risk and appears maskable I always DL first. I only use VL in situations where I perceive difficulty of some sort. Taking a few minutes more to intubate isn't a big deal for vast majority of patients as long as you can mask ventilate.

I think DL by default provides a wealth of information for future anesthetics. Not everyone and not everywhere do people readily have access to VL

My practice is mostly the same (except for ICU and the floor where I go straight to VL if I'm solo) but I'm just playing devil's advocate. I agree with your last paragraph that for the time being DLing does provide a lot of benefit in that a pt doesn't unnecessarily get labeled a difficult airway for future anesthetics simply because you went straight to VL. However, this argument will change with the increasing availability of ultraportable VL like glidescope go and mcgrath. For instance, no one is saying nowadays that doing the IJ line anatomically 'provides a wealth of information' for future central lines.

 

[Twiggidy]

I went "Glidescope For Most" for a while just because I was having issues with lip cuts and lip splits doing DL and we have a population of patients were a small lip cut could outweight any surgical complication. So I was using the glide to try to minimize "wrangling" the airway. I took this time to tell myself slow down and be more careful during even the easiest of airways and I think that has helped me tremendously with my DL technique. I like the glidescope a lot but I do feel there are instances where it can make something that is otherwise easy, more difficult. I've had this odd streak lately where the glide has made intubating people with large tongues difficult only for me to take a look with DL and have a clear view.

I don't think Video will become a standard of care but I think it is making a technique that was otherwise reserved for the very skilled open to anyone who wants to give it a shot (CRNAs, IM-CC doc, ER doc, etc)

 

[Impromptu]

Some people believe that Miller blades are the greatest creation since the original 7 days of creation ended. I have only had one experience where switching to a Miller gave a better view than the Mac, but have rescued many Miller uses with a Macintosh blade. I am sure that some Miller enthusiasts will claim that they rescue Macintosh users with Miller blades. Likely I am just really good at using the Macintosh. Others are really good with the Miller.

If I were a patient, I would want the anesthesiologist to use whatever he/she was best at. I would also hope they had good skill at a back-up or two, whatever their preference may be. In additional to video laryngoscopes, I occasionally use Millers, bougies, and intubating LMAs, just to keep up my skills.

 

[nimbus]

I have found it's a lit easier to place double lumen tubes with dl rather than glidescope. I think that in the field and out of or, dl is useless compared to video. I have never met a non anesthesiologist that had an easier time with dl than video. If they cant get tube with video, I dont care how much blood is in the mouth, they wont get it with dl.

Agree on both points.

I work with a former paramedic who says his goto was the King Vision VL.

 

[Twiggidy]

Agree on both points.

I work with a former paramedic who says his goto was the King Vision VL.

i second

 

[deleted162650]

Light Wand all day baby.

 

[abolt18]

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

Have you used the special glidescope stylet for DL tube? I found out to be exceptionally smooth the 2-3 times I've used the glidescope when placing a DL tube.

 

[pgg]

Light Wand all day baby.

Haven't seen one of those in years.

They were the perfect tool to intubate an easy airway. 🙂

 

[deleted126335]

What were the injuries? I think the opposite statement could also be true.

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.