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

Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period

OBJECTIVE

There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED.

METHODS

This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age.

RESULTS

During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]).

CONCLUSIONS

In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.

Study on the effect of a cold environment on the quality of three video laryngoscopes: McGrath MAC, GlideScope Ranger, and Pentax Airway Scope

Objective

Several environmental factors influence the prehospital use of video laryngoscopes (VLs). For example, fogging of the VL lens can occur in cold environments, and the low temperature can cause the VLs to malfunction. As relevant research on the effect of environment on VLs is lacking, we aimed to study the effect of a cold environment on three commonly used VLs.

Methods

McGrath MAC, Pentax Airway Scope (AWS), and GlideScope Ranger were exposed to temperatures of -5°C, -10°C, -20°C, and -25°C for 1 hour each and then applied to a manikin in a thermohydrostat room 5 times. Immediately after turning on the power and inserting the blade, the time until an appropriate glottic image appeared on the screen was measured.

Results

McGrath MAC was able to accomplish immediate intubation regardless of the temperature drop. However, GlideScope Ranger required an average of 4.9 seconds (-5°C to -20°C) and 10.1 seconds (-25°C) until appropriate images were obtained for intubation. AWS showed adequate image acquisition immediately after blade insertion despite slight fogging at -20°C, but at -25°C, images suitable for intubation did not appear on the screen for an average of 4.7 minutes.

Conclusion

All three devices appear to be usable without any limitations up to -20°C. However, GlideScope Ranger and AWS may not produce images immediately at temperatures below -25°C. Thus, medical practitioners performing VL in a cold environment should be aware of the characteristics of the VL devices in advance.

Endotracheal tube-mounted camera-assisted intubation versus conventional intubation in intensive care: a prospective, randomised trial (VivaITN)

BACKGROUND

For critically ill patients, effective airway management with a high first-attempt success rate for endotracheal intubation is essential to prevent hypoxic complications during securing of the airway. Video guidance may improve first-attempt success rate over direct laryngoscopy (DL).

METHODS

With ethics approval, this randomised controlled trial involved 54 critically ill patients who received endotracheal intubation using a tube with an integrated video camera (VivaSight™-SL tube, VST, ETView Ltd., Misgav, Israel) or using conventional intubation under DL.

RESULTS

The two groups did not differ in terms of intubation conditions. The first-attempt success rate was VST 96% vs. DL 93% (not statistically significant (n. s.)). When intubation at first attempt failed, it was successful in the second attempt in all patients. There was no difference in the median average time to intubation (VST 34 s (interquartile range 28-39) vs. DL 35 s (28-40), n. s.). Neither vomiting nor aspiration or accidental oesophageal intubation were observed in either group. The lowest pulsoxymetric oxygen saturation for VST was 96 (82-99) % vs. 99 (95-100) % for DL (n. s.). Hypotension defined as systolic blood pressure < 70 mmHg occurred in the VST group at 20% vs. the DL group at 15% (n. s.).

CONCLUSION

In this pilot study, no advantage was shown for the VST. The VST should be examined further to identify patient groups that could benefit from intubation with the VST, that is, patients with difficult airway conditions.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02837055 . Registered on 13 June 2016.

Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials

Background

There is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients.

Methods

We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only randomized controlled trials comparing video and direct laryngoscopy for tracheal intubation in emergency department, intensive care unit, and prehospital settings were selected. The primary outcome was the first-attempt success rate. Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of evidence for all outcomes.

Results

Twelve studies (2583 patients) were included in the review for data extraction. Pooled analysis did not show an improved first-attempt success rate using video laryngoscopy (relative risk [RR], 0.93; P = 0.28; low-quality evidence). There was significant heterogeneity among studies (I² = 91%). Subgroup analyses showed that, in the prehospital setting, video laryngoscopy decreased the first-attempt success rate (RR, 0.57; P < 0.01; high-quality evidence) and overall success rate (RR, 0.58; 95% CI, 0.48–0.69; moderate-quality evidence) by experienced operators, whereas in the in-hospital setting, no significant difference between two devices was identified for the first-attempt success rate (RR, 1.06; P = 0.14; moderate-quality evidence), regardless of the experience of the operators or the types of video laryngoscopes used (P > 0.05), although a slightly higher overall success rate was shown (RR, 1.11; P = 0.03; moderate-quality evidence). There were no differences between devices for other outcomes (P > 0.05), except for a lower rate of esophageal intubation (P = 0.01) and a higher rate of Cormack and Lehane grade 1 (P < 0.01) when using video laryngoscopy.

Conclusions

On the basis of the results of this study, we conclude that, compared with direct laryngoscopy, video laryngoscopy does not improve intubation outcomes in emergency and critical patients. Prehospital intubation is even worsened by use of video laryngoscopy when performed by experienced operators.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1885-9) contains supplementary material, which is available to authorized users.

Use of the GlideScope Ranger Video Laryngoscope for Emergency Intubation in the Prehospital Setting: A Randomized Control Trial

OBJECTIVES

We sought to assess whether the GlideScope Ranger video laryngoscope may be a reliable alternative to direct laryngoscopy in the prehospital setting.

DESIGN

Multicenter, prospective, randomized, control trial with patient recruitment over 18 months.

SETTING

Four study centers operating physician-staffed rescue helicopters or ground units in Austria and Norway.

PATIENTS

Adult emergency patients requiring endotracheal intubation.

INTERVENTIONS

Airway management strictly following a prehospital algorithm. First and second intubation attempt employing GlideScope or direct laryngoscopy as randomized; third attempt crossover. After three failed intubation attempts, immediate use of an extraglottic airway device.

MEASUREMENTS AND MAIN RESULTS

A total of 326 patients were enrolled. Success rate with the GlideScope (n = 168) versus direct laryngoscopy (n = 158) group was 61.9% (104/168) versus 96.2% (152/158), respectively (p < 0.001). The main reasons for failed GlideScope intubation were failure to advance the tube into the larynx or trachea (26/168 vs 0/158; p < 0.001) and/or impaired sight due to blood or fluids (21/168 vs 3/158; p < 0.001). When GlideScope intubation failed, direct laryngoscopy was successful in 61 of 64 patients (95.3%), whereas GlideScope enabled intubation in four of six cases (66.7%) where direct laryngoscopy failed (p = 0.055). In addition, GlideScope was prone to impaired visualization of the monitor because of ambient light (29/168; 17.3%). There was no correlation between success rates and body mass index, age, indication for airway management, or experience of the physicians, respectively.

CONCLUSIONS

Video laryngoscopy is an established tool in difficult airway management, but our results shed light on the specific problems in the emergency medical service setting. Prehospital use of the GlideScope was associated with some major problems, thus resulting in a lower intubation success rate when compared with direct laryngoscopy.

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.