Video Assisted Laryngoscope Facilitates Intubation Skill Learning in the Emergency Department

The utilization of video laryngoscopy in nasotracheal intubation for oral and maxillofacial surgical procedures: a narrative review

The video laryngoscope is a novel instrument for intubation that enables indirect visualization of the upper airway. It is recognized for its ability to enhance Cormack-Lehane grades in the management of difficult airways. Notably, video laryngoscopy is associated with equal or higher rates of intubation success within a shorter time frame than direct laryngoscopy. Video laryngoscopy facilitates faster and easier visualization of the glottis and reduces the need for Magill forceps, thereby shortening the intubation time. Despite the advanced glottic visualization afforded by video laryngoscopy, nasotracheal tube insertion and advancement occasionally fail. This is particularly evident during nasotracheal intubation, where oropharyngeal blood or secretions may obstruct the visual field on the monitor, thereby complicating video laryngoscopy. Moreover, the use of Magill forceps is markedly challenging or nearly unfeasible in this context, especially in pediatric cases. Furthermore, the substantial blade size of video laryngoscopes may restrict their applicability in individuals with limited oral apertures. This study aimed to review the literature on video laryngoscopy, discuss its clinical role in nasotracheal intubation, and address the challenges that anesthesiologists may encounter during the intubation process.

Endotracheal Intubation of Difficult Airways in Emergency Settings: A Guide for Innovators

Over 400,000 Americans are intubated in emergency settings annually, with indications ranging from respiratory failure to airway obstructions to anaphylaxis. About 12.7% of emergency intubations are unsuccessful on the first attempt. Failure to intubate on the first attempt is associated with a higher likelihood of adverse events, including oxygen desaturation, aspiration, trauma to soft tissue, dysrhythmia, hypotension, and cardiac arrest. Difficult airways, as classified on an established clinical scale, are found in up to 30% of emergency department (ED) patients and are a significant contributor to failure to intubate. Difficult intubations have been associated with longer lengths of stay and significantly greater costs than standard intubations. There exists a wide range of airway management devices, both invasive and noninvasive, which are available in the emergency setting to accommodate difficult airways. Yet, first-pass success rates remain variable and leave room for improvement. In this article, we review the disease states most correlated with intubation, the current landscape of emergency airway management technologies, and the market potential for innovation. The aim of this review is to inspire new technologies to assist difficult airway management, given the substantial opportunity for translation due to two key-value signposts of medical innovation: the potential to decrease cost and the potential to improve clinical outcomes.

Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis

Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees.

Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice.

Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Sub-analysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students.

Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.