A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department

A prospective, pragmatic non-inferiority study of emergency intubation success with the single-use i-view versus standard reusable video laryngoscope

INTRODUCTION

Video laryngoscope (VL) technology improves first-pass success. The novel i-view VL device is inexpensive and disposable. We sought to determine the first-pass intubation success with the i-view VL device versus the standard reusable VL systems in routine use at each site.

METHODS

We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i-view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator-initiated interim analysis was performed. Our primary outcome was a first-pass success with a non-inferiority margin of 10% based on the per-protocol analysis.

RESULTS

There were 93 intubations using the reusable VL devices and 81 intubations using the i-view. Our study was stopped early due to futility in reaching our predetermined non-inferiority margin. Operator and patient characteristics were similar between the two groups. The first-pass success rate for the i-view group was 69.1% compared to 84.3% for the reusable VL group. A non-inferiority analysis indicated that the difference (-15.1%) and corresponding 90% confidence limits (-25.3% to -5.0%) did not fall within the predetermined 10% non-inferiority margin.

CONCLUSIONS

The i-view device failed to meet our predetermined non-inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i-view month.

Airway registries in primarily adult, emergent endotracheal intubation: a scoping review

BACKGROUND

Emergency Department (ED) airway registries are formalized methods to collect and document airway practices and outcomes. Airway registries have become increasingly common in EDs globally; yet there is no consensus of airway registry methodology or intended utility. This review builds on previous literature and aims to provide a thorough description of international ED airway registries and discuss how airway registry data is utilized.

METHODS

A search of Medline, Embase, Scopus, Cochrane Libraries, Web of Science, and Google Scholar was performed with no date limitations applied. English language full-text publications and grey literature from centres implementing an ongoing airway registry to monitor intubations performed in mainly adult patients in an ED setting were included. Non-English publications and publications describing airway registries to monitor intubation practices in predominantly paediatric patients or settings outside of the ED were excluded. Study screening for eligibility was performed by two team members individually, with any disagreements resolved by a third team member. Data was charted using a standardized data charting tool created for this review.

RESULTS

Our review identified 124 eligible studies from 22 airway registries with a global distribution. We found that airway registry data is used for quality assurance, quality improvement, and clinical research regarding intubation practices and contextual factors. This review also demonstrates that there is a great deal of heterogeneity in definitions of first-pass success and adverse events in the peri-intubation period.

CONCLUSIONS

Airway registries are used as a crucial tool to monitor and improve intubation performance and patient care. ED airway registries inform and document the efficacy of quality improvement initiatives to improve intubation performance in EDs globally. Standardized definitions of first-pass success and peri-intubation adverse events, such as hypotension and hypoxia, may allow for airway management performance to be compared on a more equivalent basis and allow for the development of more reliable international benchmarks for first-pass success and rates of adverse events in the future.

First-Attempt Intubation Success Among Emergency Medicine Trainees by Laryngoscopic Device and Training Year: A National Emergency Airway Registry Study

STUDY OBJECTIVE

We compare intubation first-attempt success with the direct laryngoscope, hyperangulated video laryngoscope, and standard geometry video laryngoscope among emergency medicine residents at various postgraduate years (PGY) of training.

METHODS

We analyzed prospective data from emergency department (ED) patients enrolled in the National Emergency Airway Registry from January 1, 2016 to December 31, 2018 using mixed-effects logistic regression to assess the association between PGY of training and first-attempt success by the device.

RESULTS

Among 15,204 intubations performed by emergency medicine trainees, first-attempt success for PGY-1, PGY-2, and PGY3+ residents, respectively were: 78.8% (95% CI, 75.0 to 82.2%), 81.3% (79.4 to 83.0), and 83.6% (95% CI, 82.1 to 85.1) for direct laryngoscope; 87.2% (95% CI, 84.2 to 89.7), 90.4% (95% CI, 88.8 to 91.9%), and 91.2% (95% CI, 89.8 to 92.5%) for hyperangulated video laryngoscope; and 88.7% (95% CI, 86.1 to 90.9), 90.2% (95% CI, 88.7 to 91.5%), and 94.6% (95% CI 93.9 to 95.3%) for standard geometry video laryngoscope. Direct laryngoscope first-attempt success improved for PGY-2 (adjusted odds ratio [aOR],1.41; 95% CI, 1.09 to 1.82) and PGY-3+ (aOR, 1.76; 1.36 to 2.27) trainees compared to PGY-1. Hyperangulated video laryngoscope success also improved for PGY-2 (aOR, 1.51; 1.1 to 2.05) and PGY-3+ (aOR, 1.56; 1.15 to 2.13) trainees compared to PGY-1. For the standard geometry video laryngoscope, only PGY-3+ (aOR, 1.72; 1.25 to 2.36) was associated with improved first-attempt success compared to PGY-1.

CONCLUSION

Each laryngoscopy device class was associated with improvement in first-attempt success as training progressed. The video laryngoscope outperformed the direct laryngoscope for all operator groups, and PGY-1 trainees achieved higher first-attempt success using a standard geometry video laryngoscope than PGY-3+ trainees using a direct laryngoscope. These findings support the conjecture that in adult patients, a direct laryngoscope should not be routinely used for the first intubation attempt unless clinical circumstances, such as the presence of a soiled airway, would favor its success. These findings need to be validated with prospective randomized clinical trials.

The use of video laryngoscopy outside the operating room: A systematic review

This study aimed to describe how video laryngoscopy is used outside the operating room within the hospital setting. Specifically, we aimed to summarise the evidence for the use of video laryngoscopy outside the operating room, and detail how it appears in current clinical practice guidelines. A literature search was conducted across two databases (MEDLINE and Embase), and all articles underwent screening for relevance to our aims and pre-determined exclusion criteria. Our results include 14 clinical practice guidelines, 12 interventional studies, 38 observational studies. Our results show that video laryngoscopy is likely to improve glottic view and decrease the incidence of oesophageal intubations; however, it remains unclear as to how this contributes to first-pass success, overall intubation success and clinical outcomes such as mortality outside the operating room. Furthermore, our results indicate that the appearance of video laryngoscopy in clinical practice guidelines has increased in recent years, and particularly through the COVID-19 pandemic. Current COVID-19 airway management guidelines unanimously introduce video laryngoscopy as a first-line (rather than rescue) device.

A comparison of endotracheal intubation characteristics between Macintosh, CMAC and Smart Trach laryngoscopes; A randomized prospective clinical trial

BACKGROUND

In this study, we compared the performance characteristics of Macintosh laryngoscope, CMAC videolaryngoscope with a recently developed videolaryngoscope called Smart Trach.

RESEARCH DESIGN AND METHODS

: Three hundred seventy-five patients belonging to mixed population without having anticipated difficult airways undergoing elective surgeries were randomly allocated to be intubated using either of the three laryngoscopes (Macintosh, CMAC or Smart Trach). Time needed for successful intubation, number of attempts, Cormack Lehane's (CL) grading, optimisation maneuverers, intubation difficulty score (IDS), subjective ease of intubation (VAS), subjective lifting force and complications were recorded.

RESULTS

: Demographic and anthropometric measurements (sex, height, weight and body mass index) among the groups were comparable. CL grades, lifting force, IDS, VAS and intubation times (seconds) were significantly different whereas need for maneuver, attempts and complications were similar. (p>0.05 each). Intubation times (seconds) were significantly different between Macintosh [36(29-43) seconds] CMAC [30(24-37)] and Smart Trach [35(30-42] groups. (p<0.001). Subjective ease of intubation based on VAS score was lowest in Smart trach group [1(1-2)] (p<0.001).

CONCLUSION

Shortest intubation times were achieved with CMAC with least use of lifting force. First attempt success rates of were similar. Intubation was easiest subjectively using Smart Trach as manifested by lowest VAS and IDS.

TRIAL REGISTRATION

Clinical Trial registry of India (CTRI/2019/09/021279 dated 17/09/2019).

Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review

OBJECTIVE

Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization.

METHODS

We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization.

RESULTS

We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies.

CONCLUSIONS

Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.

Improving first-pass success rates during emergency intubation at an academic emergency department: a quality improvement initiative

BACKGROUND

Airway management is a high-stakes procedure in emergency medicine. Continuously monitoring this procedure allows performance improvement while revealing safety issues. We instituted a quality improvement initiative in the emergency department to improve first-pass success rates in the emergency department.

METHODS

This was a quality improvement initiative at an academic emergency department from 2018 to 2020. We developed a rapid sequence intubation guideline for procedure standardization and introduced an intubation procedure note for performance monitoring. Data were entered directly by the primary physician and nurse during intubation. The quality improvement team thereafter collected the data retrospectively and entered into a local airway database. More importantly, we introduced a culture of quality improvement and safety in airway management via regular education and feedback.

RESULTS

We included a total of 146 intubations. The first-pass success rate started at 57.1% and increased to 80.0% during the study period (P < 0.01). Fifty-six percent were male, and the mean age (±SD) was 55.56 (±17.64). Video laryngoscopy was used in 101 (69.2%) patients, while direct laryngoscopy was used in only 44 (30.8%) patients. A logistic regression analysis was conducted to determine the independent factors associated with first-pass success. These factors included the use of video laryngoscopy (odds ratio (OR) 2.47 95% confidence interval (95% CI) [1.62-3.76]) (adjusted OR 3.87 [1.13-13.23]) and good Cormack-Lehane views (grades 1-2) (OR 2.71 95% CI [1.74-4.20]) (adjusted OR 7.88 [2.43-25.53]).

CONCLUSION

Our study shows that implementing and maintaining an airway quality improvement program improves first-pass intubation success. Moreover, the use of video laryngoscopy and obtaining good Cormack-Lehane views (grades 1-2) are independently associated with improved first-pass success.

Comparison of Endotracheal Intubation Skills With Video Laryngoscopy and Direct Laryngoscopy in Providing Airway Patency in a Moving Ambulance

BACKGROUND

Early and successful management of the airway in the prehospital and hospital settings is critical in life-threatening situations.

OBJECTIVE

We aimed to perform endotracheal intubation (ETI) by direct laryngoscopy (DL) and video laryngoscopy (VL) on airway manikins on a moving track and to compare the properties of intubation attempts.

METHODS

Overall, 79 participants with no previous VL experience were given 4 h of ETI training with DL and VL using a standard airway manikin. ETI skill was tested inside a moving ambulance. The number of attempts until successful ETI, ETI attempt times, time needed to see the vocal cords, and the degree of convenience of both ETI methods were recorded.

RESULTS

Overall, 22 of 79 individuals were men; mean age was 30.3 ± 4.5 years. No difference was found in the comparison of the two methods (p = 0.708). Time needed to see the vocal cords for those who were successful in their first attempt were between 1 and 8 s in both methods. In the VL method, time needed to see the vocal cords (p = 0.001) and the intubation time (p < 0.001) in the first attempt were shorter than in the DL method. The VL method was easier (p < 0.001). The success rate was 97.5% in DL and 93.7% in VL.

CONCLUSIONS

The VL method is rapid and easier to see the vocal cords and perform successful ETI. Therefore, it might be preferred in out-of-hospital ETI applications.

A manikin study comparing the performance of the GlideScope®, the Airtraq® and the C-MAC® in endotracheal intubation using suction-assisted laryngoscopy airway decontamination techniques in a simulated massive haematemesis scenario by emergency doctors

Background:

The suction-assisted laryngoscopy and airway decontamination (SALAD) techniques (level 1, SALAD-1 and level 2, SALAD-2) are newly proposed airway management skills to facilitate endotracheal intubation in patients with massive haematemesis. A pilot study using GlideScope® demonstrated the superior performance of SALAD-1 technique in massive haematemesis simulation.

Objectives:

To compare the performance of three different video laryngoscopes (the GlideScope®, the Airtraq® and the C-MAC®) in endotracheal intubation using SALAD techniques by emergency doctors in a manikin simulating massive haematemesis.

Methods:

Forty-eight emergency doctors were recruited. The participants’ performance of endotracheal intubation using the GlideScope®, the Airtraq® and the C-MAC® with the conventional and the two SALAD techniques in a manikin simulating massive haematemesis was evaluated. The time for intubation, number of attempts, rate of failed intubation, amount of aspirated fluid and the subjective ease of different devices and techniques were compared.

Results:

The C-MAC® had shorter intubation time compared with GlideScope® when using conventional (mean intubation time: 28.48 vs 47.00 s, p = 0.018) and SALAD-1 technique (mean intubation time: 29.35 vs 43.25 s, p < 0.039). The intubation time of all three video laryngoscopes was similar in SALAD-2 technique. There was no significant difference in the number of attempts and failed intubation rate among different video laryngoscopes in using different techniques. Intubation with the C-MAC® resulted in the least mean amount of aspiration in all the conventional (35.63 mL), SALAD-1 (14.06 mL) and SALAD-2 (18.13 mL) techniques. However, the results were not significantly different from the GlideScope® and the Airtraq®. The C-MAC® was rated the most favourable video laryngoscope for the SALAD-1 technique (p < 0.001). There was no significant preference for different video laryngoscopes in using the SALAD-2 technique (p = 0.111).

Conclusion:

All the video laryngoscopes have similar intubation performance with the SALAD-1 and SALAD-2 techniques. The C-MAC® performed better than GlideScope® in terms of intubation time. The C-MAC® was the most favourable video laryngoscope for the SALAD-1 technique.

A randomised crossover comparison of two endotracheal tube introducers: the FROVA and the Flexible Tip Bougie for GlideScope intubation of a difficult airway manikin by infrequent intubators

BACKGROUND

This unblinded randomised crossover study compares two endotracheal tube introducers (ETIs): the FROVA and the "Flexible Tip Bougie" (FTB), in an airway manikin mimicking difficult intubation with a percentage of glottic opening view of 30%. Participants were Emergency Medicine and Anaesthesia trainees with recent experience of less than twenty patient intubations. The primary outcome was time to intubation, further divided into time taken to pass the ETI and time to railroad the endotracheal tube (ETT) over the ETI. The secondary outcome was the difficulty of intubation.

RESULTS

The median total time to ETT placement was significantly shorter with the FTB (37.5 s) compared with the FROVA ETI (63.0 s), P = 0.0006. The median difficulty reported (scores 0-10 with 0 being no difficulty) with the FTB was 2 compared with 5 for the FROVA, P < 0.0001.

CONCLUSIONS

The FTB enabled significantly faster and easier placement of the endotracheal tube compared with the FROVA in inexperienced hands intubating a difficult intubation manikin.

Comparing Emergency Department First-Attempt Intubation Success With Standard-Geometry and Hyperangulated Video Laryngoscopes

STUDY OBJECTIVE

It is unclear whether laryngoscopy using a standard-geometry blade shape, able to obtain both direct and indirect views, is associated with different first-attempt success or adverse events during emergency intubation compared with using a hyperangulated blade capable of indirect laryngoscopy only. We sought to compare first-attempt intubation success between patients intubated with a standard geometry video laryngoscope versus a hyperangulated video laryngoscope.

METHODS

We analyzed data from the National Emergency Airway Registry from January 2016 to December 2018. Patients aged 14 years or older were included if the first attempt at oral intubation was performed with a standard-geometry or hyperangulated video laryngoscope. We used multiple logistic regression to determine whether blade shape was independently associated with first-attempt intubation success.

RESULTS

During the study period, 11,927 of 19,071 intubation encounters met inclusion criteria, including 7,255 (61%) with a standard blade and 4,672 (39%) with a hyperangulated blade. Unadjusted analysis revealed higher success with a standard-geometry blade, 91.9% versus 89.2% (absolute difference 2.7% [95% confidence interval 1.6% to 3.8%]; odds ratio for standard-geometry laryngoscope compared with hyperangulated laryngoscope 1.37 [95% confidence interval 1.21 to 1.55]). The logistic regression model, however, demonstrated no association between blade shape and first-attempt success (adjusted odds ratio for standard-geometry laryngoscopy compared with hyperangulated laryngoscopy 1.32 [95% confidence interval 0.81 to 2.17]).

CONCLUSION

In this large registry of patients intubated with video laryngoscopy in the emergency department, we observed no association between blade shape (standard-geometry versus hyperangulated laryngoscope) and first-attempt intubation success after adjusting for confounding variables.

Videolaryngoscopy for Physician-Based, Prehospital Emergency Intubation: A Prospective, Randomized, Multicenter Comparison of Different Blade Types Using A.P. Advance, C-MAC System, and KingVision

BACKGROUND

Videolaryngoscopy is a valuable technique for endotracheal intubation. When used in the perioperative period, different videolaryngoscopes vary both in terms of technical use and intubation success rates. However, in the prehospital environment, the relative performance of different videolaryngoscopic systems is less well studied.

METHODS

We conducted this prospective, randomized, multicenter study at 4 German prehospital emergency medicine centers. One hundred sixty-eight adult patients requiring prehospital emergency intubation were treated by an emergency physician and randomized to 1 of 3 portable videolaryngoscopes (A.P. Advance, C-MAC PM, and channeled blade KingVision) with different blade types. The primary outcome variable was overall intubation success and secondary outcomes included first-attempt intubation success, glottis visualization, and difficulty with handling the devices. P values for pairwise comparisons are corrected by the Bonferroni method for 3 tests (P[BF]). All presented P values are adjusted for center.

RESULTS

Glottis visualization was comparable with all 3 devices. Overall intubation success for A.P. Advance, C-MAC, and KingVision was 96%, 97%, and 61%, respectively (overall: P < .001, A.P. Advance versus C-MAC: odds ratio [OR], 0.97, 95% confidence interval [CI], 0.13-7.42, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001; C-MAC versus KingVision: OR, 0.043, 95% CI, 0.0088-0.21, P[BF] < 0.001). Intubation success on the first attempt with A.P. Advance, C-MAC, and KingVision was 86%, 85%, and 48%, respectively (overall: P < .001, A.P. Advance versus C-MAC: OR, 0.89, 95% CI, 0.31-2.53, P[BF] > 0.99; A.P. Advance versus KingVision: OR, 0.24, 95% CI, 0.055-0.38, P[BF] = 0.0054; C-MAC versus KingVision: OR, 0.21, 95% CI, 0.043-.34, P[BF] < 0.003). Direct laryngoscopy for successful intubation with the videolaryngoscopic device was necessary with the A.P. Advance in 5 patients, and with the C-MAC in 4 patients. In the KingVision group, 21 patients were intubated with an alternative device.

CONCLUSIONS

During prehospital emergency endotracheal intubation performed by emergency physicians, success rates of 3 commercially available videolaryngoscopes A.P. Advance, C-MAC PM, and KingVision varied markedly. We also found that although any of the videolaryngoscopes provided an adequate view, actual intubation was more difficult with the channeled blade KingVision.

The Impact of Video Laryngoscopy on the Clinical Learning Environment of Emergency Medicine Residents: A Report of 14,313 Intubations

BACKGROUND

The introduction of video laryngoscopy (VL) may impact emergency medicine (EM) residents' intubation practices.

METHODS

We analyzed 14,313 intubations from 11 EM training sites, July 1, 2002, to December 31, 2012, assessing the likelihood of first-attempt success and likelihood of having a second attempt, by rank and device. We determined whether direct laryngoscopy (DL) first-attempt success decreased as VL became more prevalent using a logistic regression model with proportion of encounters initiated with VL at that center in the prior 90 and 365 days as predictors of DL first-attempt success.

RESULTS

First-attempt success by PGY-1s was 71% (95% confidence interval [CI] = 63% to 78%); PGY-2s, 82% (95% CI = 78% to 86%); and PGY-3+, 89% (95% CI = 85% to 92%). Residents' first-attempt success rate was higher with the C-MAC video laryngoscope (C-MAC) versus DL, 92% versus 84% (risk difference [RD] = 8%, 95% CI = 4% to 11%), but there was no statistical difference between the GlideScope video laryngoscope (GVL) and DL, 80% versus 84% (RD = -4%, 95% CI = -10% to 1%). PGY-1s were more likely to have a second intubation attempt after first-attempt failure with VL versus DL: 32% versus 18% (RD = 14%, 95% CI = 5% to 23%). DL first-attempt success rates did not decrease as VL became more prevalent.

CONCLUSIONS

First-attempt success increases with training. Interns are more likely to have a second attempt when using VL. The C-MAC may be associated with increased first-attempt success for EM residents compared with DL or GVL. The increasing prevalence of VL is not accompanied by a decrease in DL success.

Use of Polarized Sunglasses During Video Laryngoscopy: A Cause of Difficult Prehospital Intubation

BACKGROUND

In the prehospital setting, many providers advocate for video laryngoscopy as the initial method of intubation to improve the likelihood of a successful first attempt. However, bright ambient light can worsen visualization of the video laryngoscope liquid crystal display (LCD).

CASE REPORT

A patient involved in a motor vehicle accident was evaluated by an Emergency Medical Services (EMS) crew. Initial endotracheal intubation attempt using video laryngoscopy was aborted after the patient desaturated. The primary reason for the failure was poor visualization of the video laryngoscope LCD, despite attempts to block direct sunlight. Debriefing revealed that the intubating provider was wearing polarized sunglasses.

DISCUSSION

Because LCDs emit polarized light, use of polarized sunglasses may cause the display to appear dark. Thus, the purpose of this Case Report is to raise awareness of a potential safety issue that is likely under-recognized by prehospital providers but can be easily avoided.SmithAJ, JackimczykK, HorwoodB, ChristensonD. Use of polarized sunglasses during video laryngoscopy: a cause of difficult prehospital intubation.Prehosp Disaster Med. 2019;34(1):104-107.

Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template

Background

Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset.

Methods

We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process.

Results

The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described.

Conclusions

Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management.

Trial registration

The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260).

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0509-y) contains supplementary material, which is available to authorized users.

[Polytrauma following a truck accident : How to save lives by guideline-oriented emergency care]

BACKGROUND

Identification and immediate treatment of life-threatening conditions is fundamental in patients with multiple trauma. In this context, the S3 guidelines on polytrauma and the S1 guidelines on emergency anesthesia provide the scientific background on how to handle these situations.

CASE STUDY

This case report deals with a seriously injured driver involved in a truck accident. The inaccessible patient showed a scalping injury of the facial skeleton with massive bleeding and partially blocked airway but with spontaneous breathing as well as centralized cardiovascular circulation conditions and an initial Glasgow coma scale (GCS) of 8. An attempt was made to stop the massive bleeding by using hemostyptic-coated dressings. In addition, the patient was intubated via video laryngoscopy and received a left and right thoracic drainage as well as two entry points for intraosseous infusion.

DISCUSSION

In modern emergency medical services, treatment based on defined algorithms is recommended and also increasingly established in dealing with critical patients. The guideline-oriented emergency care of patients with polytrauma requires invasive measures, such as intubation and thoracic decompression in the preclinical setting. The foundation for this procedure includes training in theory and practice both of the non-medical and medical rescue service personnel.

Current evidence for the use of C-MAC videolaryngoscope in adult airway management: a review of the literature

The C-MAC videolaryngoscope is the first Macintosh-typed videolaryngoscope. Since the advent of its original version video Macintosh system in 1999, this device has been modified several times. A unique feature of C-MAC device is its ability to provide the 2 options of direct and video laryngoscopy with the same device. The available evidence shows that in patients with normal airways, C-MAC videolaryngoscope compared with direct laryngoscopy can provide comparable or better laryngeal views and exerts less force on maxillary incisors, but does not offer conclusive benefits with regard to intubation time, intubation success, number of intubation attempts, the use of adjuncts, and hemodynamic responses to intubation. In patients with predicted or known difficult airways, C-MAC videolaryngoscope can achieve a better laryngeal view, a higher intubation success rate and a shorter intubation time than direct laryngoscopy. Furthermore, the option to perform direct and video laryngoscopy with the same device makes C-MAC videolaryngoscope exceptionally useful for emergency intubation. In addition, the C-MAC videolaryngoscope is a very good tool for tracheal intubation teaching. However, tracheal intubation with C-MAC videolaryngoscope may occasionally fail and introduction of C-MAC videolaryngoscope in clinical practice must be accompanied by formal training programs in normal and difficult airway managements.

A comparison between the GlideScope® classic and GlideScope® direct video laryngoscopes and direct laryngoscopy for nasotracheal intubation

DESIGN

Prospective, randomized, clinical trial.

SETTING

University hospital operation room.

PATIENTS

104 patients scheduled for elective dental or maxillofacial surgery were randomized to two groups: GlideScope® classic (GSc) and GlideScope® direct (GSd).

INTERVENTIONS

We compared the video laryngoscopes GSc and GSd with each other and with direct laryngoscopy (DL) for nasotracheal intubation with regard to visualization of the glottis, intubation success rate, and required time for and ease of intubation. The aim of the study was to determine whether the use of the video monitor alone reduced the difficulty of nasotracheal intubation, and also to investigate whether the GSc, with its blade designed for difficult airways, had an additional advantage over the video-assisted Macintosh blade (GSd). In both groups the investigators first performed laryngoscopy using the GSd blade, first with the monitor concealed and then with it visible. In the GSd group the tube was then inserted into the trachea with the video monitor screen visible. In the GSc group, the GSd blade was exchanged for the GSc blade, which was then used when inserting the tube with the screen visible.

RESULTS

The success rates and the times required for the video-assisted nasotracheal intubation did not differ significantly between the groups. A better view was obtained more often in the GSc group. In both groups there was a significant difference between direct laryngoscopy and the video-assisted intubation technique. Overall, using the video monitor improved the C-L scores by one grade in 52% and by two grades in 11% of the patients.

CONCLUSIONS

Video laryngoscopes increase the ease of nasotracheal intubation. The GSc blade might provide a better view of the laryngeal structures in case of a difficult airway than the GSd blade. Video laryngoscopy per se gives a better view of the glottis than direct laryngoscopy.

Comparison of the C-MAC video laryngoscope to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED

Objectives

We aimed to compare the performance of the C-MAC video laryngoscope (C-MAC) to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED.

Material and methods

This was a prospective randomized study. The primary outcome measure is overall successful intubation. Secondary outcome measures are first attempt successful intubation, Cormack–Lehane (CL) grade, and indicators of the reasons for unsuccessful intubation at the first attempt with each device. Adult patients who suffered from blunt trauma and required intubation were randomized to video laryngoscopy with C-MAC device or direct laryngoscopy (DL).

Results

During a 17-month period, a total of 150 trauma intubations were performed using a C-MAC and DL. Baseline characteristics of patients were similar between the C-MAC and DL group. Overall success for the C-MAC was 69/75 (92%, 95% CI 0.83 to 0.96) while for the DL it was 72/75 (96%, 95% CI 0.88 to 0.98). First attempt success for the C-MAC was 47/75 (62.7%, 95% CI 0.51 to 0.72) while for the DL it was 44/75 patients (58.7%, 95% CI 0.47 to 0.69). The mean time to achieve successful intubation was 33.4 ± 2.5 s for the C-MAC versus 42.4 ± 5.1 s for the DL (p = 0.93). There was a statistically significant difference between the DL and C-MAC in terms of visualizing the glottic opening and esophageal intubation in favor of the C-MAC (p = 0.002 and p = 0.013 respectively).

Discussion and conclusion

The overall success rates were similar. The C-MAC demonstrated improved glottic view and decrease in esophageal intubation rate.

Advances in Laryngoscopy

Recent technological advances have made airway management safer. Because difficult intubation remains challenging to predict, having tools readily available that can be used to manage a difficult airway in any setting is critical. Fortunately, video technology has resulted in improvements for intubation performance while using laryngoscopy by various means. These technologies have been applied to rigid optical stylets, flexible intubation scopes, and, most notably, rigid laryngoscopes. These tools have proven effective for the anticipated difficult airway as well as the unanticipated difficult airway.

Evaluation of Karl Storz CMAC Tip™ device versus traditional airway suction in a cadaver model

Introduction

We compared the efficacy of Karl Storz CMAC Tip™ with inline suction to CMAC with traditional suction device in cadaveric models simulating difficult airways, using media mimicking pulmonary edema and vomit.

Methods

This was a prospective, cohort study in which we invited emergency medicine faculty and residents to participate. Each participant intubated 2 cadavers (one with simulated pulmonary edema and one with simulated vomit), using CMAC with inline suction and CMAC with traditional suction. Thirty emergency medicine providers performed 4 total intubations each in a crossover trial comparing the CMAC with inline suction and CMAC with traditional suction. Two intubations were performed with simulated vomit and two with simulated pulmonary edema. The primary outcome was time to successful intubation; and the secondary outcome was proportion of successful intubation.

Results

The median time to successful intubation using the CMAC with inline suction versus traditional suction in the pulmonary edema group was 29s and 30s respectively (p=0.54). In the vomit simulation, the median time to successful intubation was 40s using the CMAC with inline suction and 41s using the CMAC with traditional suction (p=0.70). There were no significant differences in time to successful intubation between the 2 devices. Similarly, the proportions of successful intubation were also not statistically significant between the 2 devices. The proportions of successful intubations using the inline suction were 96.7% and 73.3%, for the pulmonary edema and vomit groups, respectively. Additionally using the handheld suction device, the proportions for the pulmonary edema and vomit group were 100% and 66.7%, respectively.

Conclusion

CMAC with inline suction was no different than CMAC with traditional suction and was associated with no statistically significant differences in median time to intubation or proportion of successful intubations.

Do emergency medicine residents receive appropriate video laryngoscopy training? A survey to compare the utilization of video laryngoscopy devices in emergency medicine residency programs and community emergency departments

BACKGROUND

Video laryngoscopy (VL) has emerged as a critical tool in the "difficult airway" armamentarium of emergency physicians. The resultant increase in the types of available VL devices has made Emergency Medicine Residency (EMR) training in VL increasingly challenging. Additionally, the prevalence of VL devices in the community is unknown. Because Emergency Medicine (EM) residents go on to work in diverse settings, many in non-EMR emergency departments (EDs), it is preferable that they receive training on the airway modalities they will encounter in practice.

OBJECTIVE

To compare the prevalence and type of VL devices in EMR programs to non-EMR EDs.

METHODS

This was a survey study conducted from July 2012 to October 2012 of Accreditation Council for Graduate Medical Education-accredited, MD EMR programs in the United States and non-EMR EDs in New York State. A chi-squared test was performed to determine whether the difference in VL prevalence was significant.

RESULTS

There were 158 EMR programs and 132 non-EMR EDs surveyed; 97.8% of EMR and 84.3% of non-EMR EDs reported having some form of VL in their departments. The difference in proportion of EMR vs. non-EMR EDs that have VL was χ(2) = 13 (p < 0.001). The Glidescope® device (Verathon Medical, Bothell, WA) was present in 87.7% of EMR programs and 79.3% of non-EMR EDs.

CONCLUSIONS

The majority of EMR programs trained residents in VL. The Glidescope device was used most frequently. Non-EMR EDs in New York State had a lower presence of VL devices, with the Glidescope device again being the most common. These results demonstrate that VL is pervasive in both practice environments.

Techniques, success, and adverse events of emergency department adult intubations

STUDY OBJECTIVE

We describe the operators, techniques, success, and adverse event rates of adult emergency department (ED) intubation through multicenter prospective surveillance.

METHODS

Eighteen EDs in the United States, Canada, and Australia recorded intubation data onto a Web-based data collection tool, with a greater than or equal to 90% reporting compliance requirement. We report proportions with binomial 95% confidence intervals (CIs) and regression, with year as the dependent variable, to model change over time.

RESULTS

Of 18 participating centers, 5 were excluded for failing to meet compliance standards. From the remaining 13 centers, we report data on 17,583 emergency intubations of patients aged 15 years or older from 2002 to 2012. Indications were medical in 65% of patients and trauma in 31%. Rapid sequence intubation was the first method attempted in 85% of encounters. Emergency physicians managed 95% of intubations and most (79%) were physician trainees. Direct laryngoscopy was used in 84% of first attempts. Video laryngoscopy use increased from less than 1% in the first 3 years to 27% in the last 3 years (risk difference 27%; 95% CI 25% to 28%; mean odds ratio increase per year [ie, slope] 1.7; 95% CI 1.6 to 1.8). Etomidate was used in 91% and succinylcholine in 75% of rapid sequence intubations. Among rapid sequence intubations, rocuronium use increased from 8.2% in the first 3 years to 42% in the last 3 years (mean odds ratio increase per year 1.3; 95% CI 1.3 to 1.3). The first-attempt intubation success rate was 83% (95% CI 83% to 84%) and was higher in the last 3 years than in the first 3 (86% versus 80%; risk difference 6.2%; 95% CI 4.2% to 7.8%). The airway was successfully secured in 99.4% of encounters (95% CI 99.3% to 99.6%).

CONCLUSION

In the EDs we studied, emergency intubation has a high and increasing success rate. Both drug and device selection evolved significantly during the study period.

The C-MAC® video laryngoscope is superior to the direct laryngoscope for the rescue of failed first-attempt intubations in the emergency department

OBJECTIVE

To compare the effectiveness of the C-MAC® video laryngoscope (CMAC) to the direct laryngoscope (DL) when used to rescue a failed first attempt intubation in the emergency department (ED).

METHODS

Data were prospectively collected on all patients intubated in an academic ED center over a five-year period from February 1, 2009 to January 31, 2014 when both the CMAC and the DL were available. Following each intubation the operator completed a continuous quality improvement (CQI) form documenting patient, operator and intubation characteristics. All orotracheal intubations attempted by emergency physicians (EPs) on adult patients with a failed first intubation attempt, and in which the CMAC or the DL was used for the second attempt, were included. The primary outcome was successful intubation on the second attempt using either the CMAC or the DL. A multivariate logistic regression analysis was performed to adjust for potential confounders.

RESULTS

During the five-year study period, there were 460 adult orotracheal intubation attempts by EPs which were not successful on the first attempt. In 398 (86.5%) of these cases the same operator performed the second attempt. The CMAC was utilized for the second attempt in 141 cases and was successful in 116 (82.3%; 95% CI 75.0%-88.2%) and the DL was utilized in 94 cases and was successful in 58 (61.7%; 95% CI 51.1%-71.5%). In a multivariate logistic regression analysis the CMAC was associated with an increased odds (adjusted OR 3.5; 95% CI 1.9-6.7) of a second attempt success compared to the DL.

CONCLUSIONS

After a failed first intubation attempt in the ED, regardless of the initial device used, the CMAC was more successful than the DL when used for the second attempt. This suggests that the CMAC is the preferred rescue device after an initial intubation attempt in the ED fails.

Learning curves for direct laryngoscopy and GlideScope® video laryngoscopy in an emergency medicine residency

INTRODUCTION

Our objective is to evaluate the resident learning curves for direct laryngoscopy (DL) and GlideScope® video laryngoscopy (GVL) over the course of an emergency medicine (EM) residency training program.

METHODS

This was an analysis of intubations performed in the emergency department (ED) by EM residents over a seven-year period from July 1, 2007 to June 30, 2014 at an academic ED with 70,000 annual visits. After EM residents perform an intubation in the ED they complete a continuous quality improvement (CQI) form. Data collected includes patient demographics, operator post- graduate year (PGY), difficult airway characteristics (DACs), method of intubation, device used for intubation and outcome of each attempt. We included in this analysis only adult intubations performed by EM residents using a DL or a standard reusable GVL. The primary outcome was first pass success, defined as a successful intubation with a single laryngoscope insertion. First pass success was evaluated for each PGY of training for DL and GVL. Logistic mixed-effects models were constructed for each device to determine the effect of PGY level on first pass success, after adjusting for important confounders.

RESULTS

Over the seven-year period, the DL was used as the initial device on 1,035 patients and the GVL was used as the initial device on 578 patients by EM residents. When using the DL the first past success of PGY-1 residents was 69.9% (160/229; 95% CI 63.5%-75.7%), of PGY-2 residents was 71.7% (274/382; 95% CI 66.9%-76.2%), and of PGY-3 residents was 72.9% (309/424; 95% CI 68.4%-77.1%). When using the GVL the first pass success of PGY-1 residents was 74.4% (87/117; 95% CI 65.5%-82.0%), of PGY-2 residents was 83.6% (194/232; 95% CI 76.7%-87.7%), and of PGY-3 residents was 90.0% (206/229; 95% CI 85.3%-93.5%). In the mixed-effects model for DL, first pass success for PGY-2 and PGY-3 residents did not improve compared to PGY-1 residents (PGY-2 aOR 1.3, 95% CI 0.9-1.9; p-value 0.236) (PGY-3 aOR 1.5, 95% CI 1.0-2.2, p-value 0.067). However, in the model for GVL, first pass success for PGY-2 and PGY-3 residents improved compared to PGY-1 residents (PGY-2 aOR 2.1, 95% CI 1.1-3.8, p-value 0.021) (PGY-3 aOR 4.1, 95% CI 2.1-8.0, p<0.001).

CONCLUSION

Over the course of residency training there was no significant improvement in EM resident first pass success with the DL, but substantial improvement with the GVL.

Improvement in GlideScope® Video Laryngoscopy performance over a seven-year period in an academic emergency department

To evaluate the outcomes in first pass success (FPS) of GlideScope (GVL) intubations over a seven-year period in an academic ED. Data were prospectively collected on all patients intubated in an academic ED with a level 1 trauma center over the seven-year period from July 1, 2007 to June 30, 2014. Following each intubation, the operator completed a standardized data collection form that included information on patient, operator and procedure characteristics. The primary outcome was first pass success, defined as successful intubation with a single laryngoscope blade insertion. The secondary outcome was the Cormack-Lehane (CL) view of the airway. To adjust for important confounders, a logistic regression model was used to determine the association between academic year and first pass success. In the first year of the study, the first pass success with the GVL was 75.6% (68/90; 95% CI 65.4-84.0%) and the percentage of patients with CL I/II views was 95.6% (86/90; 95% CI 89.0-98.8%). By the seventh year of the study, the first pass success with the GVL increased to 92.1% (128/139; 95% CI 86.3-96.0%) and the percentage of patients with CL I/II views was 94.2% (131/139; 95% CI 89.0-97.5%). In the logistic regression model, first pass success improved during the seven-year period (aOR 3.1; 95% CI 1.3-7.1; p = 0.008). Over the seven-year period, there was significant improvement in the first pass success of the GVL, without any change in the Cormack-Lehane view, suggesting that there was improvement in the skill of tube delivery with use of the GVL over time.

Management of the anticipated and unanticipated difficult airway in anesthesia outside the operating room

PURPOSE OF REVIEW

The number of diagnostic and interventional procedures outside the operating room has dramatically increased over the last years. However, providing well tolerated anesthesia with the same standard of care in these locations is often challenging to the anesthesiologist. The remote locations include different organizational aspects and hazards. Airway management in general is still confronted with scenarios of difficult intubation and ventilation and often leads to significant morbidity and mortality. Continuous awareness of the potential complications is urged when providing anesthesia for remote procedures.

RECENT FINDINGS

Recent studies have poorly addressed the issue of airway management by trained anesthesiologists outside the operating room. The majority of evidence is provided in the field of emergency medicine and intensive care settings. However, when dealing with difficult airway management in the remote setting, careful assessment and preparation is even more important than in the operating room. New evidence concerning prediction of ventilation and intubation must be incorporated in algorithms of airway management. Different anesthetic regimens using remifentanil and avoiding the use of neuromuscular blockers have to be carefully considered since they might change the scenario of intubation conditions. The new era of video laryngoscopes offers important potential to increase the tools for airway management. These new devices have the perfect design to be incorporated in remote settings. However, studies mainly focus on the emergency department and ICU. Also, there is currently a lack of consensus among professionals about their use and the large number of different devices seems to avoid careful comparisons.

SUMMARY

Airway management outside the operating room is challenging and needs the implementation of algorithms including the new airway devices. The recent update of the practice guidelines about difficult airway management of the American Society of Anesthesiologists remains the standard reference guide.

Comparison of the reusable standard GlideScope® video laryngoscope and the disposable cobalt GlideScope® video laryngoscope for tracheal intubation in an academic emergency department: a retrospective review

OBJECTIVES

The objective was to compare the first-pass success and clinical performance characteristics of the reusable standard GlideScope® video laryngoscope (sGVL) and the disposable Cobalt GlideScope® video laryngoscope (cGVL).

METHODS

This was a retrospective analysis of prospectively collected data recorded into a continuous quality improvement database at an urban academic emergency department (ED). The intent of the database is to evaluate operator performance and to track practice patterns used for intubation in the ED. Between July 1, 2007, and June 30, 2013, operators recorded all consecutive intubations performed in the ED. The database included patient demographics and detailed information about each intubation, such as device(s) used, reason for device selection, method of intubation, difficult airway characteristics, number of intubation attempts, and outcome of each attempt. The operator also evaluated the presence of lens fogging and extent of lens contamination. The primary outcome measure was first-pass success. Secondary outcome measures were ultimate success, Cormack-Lehane (CL) view of the airway, presence of lens fogging, and extent of lens contamination. Only adult patients age 18 years or older intubated with the sGVL or cGVL using a stylet, and who had data forms completed at the time of intubation, were included in this study.

RESULTS

A total of 583 intubations were included in the study, 504 with the sGVL and 79 with cGVL. First pass success was achieved in 81.0% (95% confidence interval [CI]=77.3% to 84.3%) of patients in the sGVL group and in 58.2% (95% CI=46.6% to 69.2%) of patients in the cGVL group. In a multivariate logistic regression analysis, the sGVL was associated with a higher first pass success than the cGVL (odds ratio [OR]=3.3, 95% CI=1.9 to 5.8). The ultimate success of the sGVL was 92.1% (95% CI=89.4% to 94.3%) and the cGVL was 72.2% (95% CI=60.9% to 81.7%). A CL grade I or II view was obtained in 93.2% (95% CI=90.7% to 95.3%) in the sGVL group and 86.1% (95% CI=76.5% to 92.8%) in the cGVL group. Lens fogging occurred in 33.3% (95% CI=29.2% to 37.6%) of the cases in the sGVL group and 59.5% (95% CI=47.9% to 70.4%) of the cases in the cGVL group. Significant lens contamination occurred in 5.0% (95% CI=3.2% to 7.2%) of the sGVL group and 21.5% (95% CI=13.1% to 32.2%) of the cGVL group.

CONCLUSIONS

In this observational study, the sGVL had higher first pass and overall success than the disposable cGVL. The cGVL had significantly higher incidence of lens fogging and contamination, which may partially account for its lower success. A prospective randomized trial is needed to confirm these findings.

Postoperative sore throat after laryngoscopy with macintosh or glide scope video laryngoscope blade in normal airway patients

Background:

The Glide Scope videolaryngoscope provides a suitable view for intubation, with less force required.

Objectives:

The present study was conducted, to compare postoperative sore throat and hoarseness after laryngoscopy and intubation, by Macintosh blade or Glide Scope video laryngoscope in normal airway patients.

Patients and Methods:

Three hundred patients were randomly allocated into two groups of 150: Macintosh blade laryngoscope or Glide Scope video laryngoscope. The patients were evaluated for 48 hours for sore throat and hoarseness by an interview.

Results:

The incidence and severity of sore throat in the Glide Scope group, at 6, 24 and 48 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. In addition, the incidence of hoarseness in the Glide Scope group, at 6 and 24 hours after the operation, were significantly lower than in the Macintosh laryngoscope group. The incidence and severity of sore throat in men, at 6 and 24 hours after the operation, were significantly lower than in the women.

Conclusions:

The incidence and severity of sore throat and hoarseness after tracheal intubation by Glide Scope were lower than in the Macintosh laryngoscope. The incidence and severity of sore throat were increased by intubation and longer operation times.

Retrospective analysis of etomidate versus ketamine for first-pass intubation success in an academic emergency department

OBJECTIVES

The objective of this study was to compare first-pass intubation success between patients who received etomidate versus ketamine for rapid sequence intubation (RSI) in the emergency department (ED).

METHODS

This was a retrospective analysis of prospectively collected data recorded in a quality improvement database between July 1, 2007, and December 31, 2012. The study was conducted in an academic ED in the United States. All patients who received etomidate or ketamine as part of RSI were included. The primary outcome measure was first-pass success. A multivariate analysis was conducted to determine if sedative type was associated with first-pass success, after adjusting for potential confounders and baseline differences.

RESULTS

The final cohort consisted of 2,098 RSI procedures using either etomidate (n = 1,983) or ketamine (n = 115). First-pass success occurred in 77.0% of patients in the etomidate group and 79.1% of patients in the ketamine group (difference = -2.1%; 95% CI = -5.5% to 9.8%). In the multivariate analysis, after adjusting for potential confounders, sedative type was not associated with first-pass success (odds ratio = 0.89; 95% CI = 0.5 to 1.5; p = 0.632).

CONCLUSIONS

Etomidate and ketamine are associated with equivalent first-pass success when used in RSI. Ketamine may be an appropriate alternative to etomidate for RSI in the ED.

Comparative analysis of airway scope and Macintosh laryngoscope for intubation primarily for cardiac arrest in prehospital setting

STUDY OBJECTIVE

This study sought to determine and compare the utility of the Airway scope (AWS; Pentax Corporation, Tokyo, Japan) and the conventional Macintosh laryngoscope (MLS) for intubation in the prehospital setting.

METHODS

In this randomized controlled trial in the prehospital setting, the primary outcome was time required for intubation, and the secondary outcomes were ultimate success, first attempt success, and difficulty of intubation. The intent-to-treat principle was used to analyze time to intubation. Ultimate success was defined as intubation completed within 600 s regardless of the device ultimately used.

RESULTS

A total of 109 patients, primarily with cardiac arrest, were randomly assigned to the AWS or MLS arms. Median time (interquartile range) to intubation was 155 (71-216) s with the AWS versus 120 (60-170) s with the MLS (P = .095). Ultimate success rate was slightly lower with the AWS (96.4%) than with the MLS (100%) (P = .496), while the first attempt success rate was significantly lower (46% and 75%, respectively; P = .002). There was no significant difference in difficulty of intubation (P = .066). Multivariate logistic regression analysis revealed that cervical immobilization and oral contamination, such as vomit, was associated with first attempt success (odds ratio [95% confidence interval]: 0.11 [0.01-0.87] and 0.43 [0.18-0.99], respectively).

CONCLUSION

Despite its many advantages seen in other settings, the AWS did not show superior efficacy to the MLS in relation to time required for intubation, ultimate or first attempt success rate, or difficulty level of intubation in the prehospital setting.