April 21, 2014

Did video kill the radio star?

Video laryngoscopy has changed the game in in airway management, but has it made direct laryngoscopy obsolete? Anand “The Swami” Swaminathan joins Ercast to discuss the controversy and share some of his research.

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  1. Rob… long time listener, first time typer…Great talk… as always. Have heard this similar discussion over and over again for a long time… same with ultrasound guided central lines or the clinical exam vs imaging. As technologies emerge, we lose traditionally taught clinical skills, whether it be anatomical knowledge required for airway management or vascular access, or the ability to do serial belly exams or cardiac exams. That being said, often, the newer technologies/techniques are safer. Now that US guided central lines are the standard of care and ultrasound machines are near ubiquitous, do we put patients at risk by insisting docs do blind lines? Same with VL… clearly superior and safer. Do we put patients at risk by doing ‘blind’ procedures? Understandably we are at a turning point as these are relatively new devices. In 10 years, VL devices will be as ubiquitous as EKG’s. The evidence is solid… Maybe its time for a position statement by ACEP and/or the ASA, to drive ALL hospitals and ED’s to acquire these machines. As to which device… no brainer. HAS to be a device that uses the same mechanics as DL (CMAC or newer glidescope). As opposed to USGCL’s, in the case of DL vs VL, you can have your cake and eat it to… turn the monitor around and let the resident do DL while safely watching the screen.

    • Matt, totally agree with you on many levels. You need to know how to do both and you need to have the best equipment to protect the patients. Clearly, the VL devices that can be used as DL would be best for training. I like the analogy to US guided lines but I have to tell you that I still think my residents should be able to put in a line without US.

  2. A few comments:
    After being an early adopter of VL, I wondered whether, after 5 yr of almost solely using VL, returning to a more primitive practice with no VL, I would find DL to be tremendously hard. The answer, for me, was NO! I had become more skilled, and accustomed to a really, really good (not sure which number Cormack-Lehane correlates with really, really good) laryngeal view, and much to my surprise found it much easier to duplicate the view with DL than I had experienced prior to my VL experience. My conclusion -- start your learning & training with VL, then after you get skilled, do some DL tubes to complete your experience.
    Regarding the Storz C-Mac: great for residents to do DL -- same blade, better light source -- but, the supervising attending has a ringside supervisory VL seat. Further, using a bougie with a C-mac works fine (and, for any potential tough tube, my opinion is: just start with the bougie). Not so with the Glidescope.
    Finally, don’t forget blind nasotracheal tubes. Back in the 70′s (pre-RSI for ER Docs), perhaps 80% of my tubes were blind naso-tracheal -- even in apnea (I figured that 80% success was better than fighting with an apneic, but not quite dead, jaw locked guy -- I could do that if the blind failed). More recently, NT -blind or visualized -- can be useful for transport -- especially kids- where you really don’t want to lose a tube during flight. Or, when the oral cavity is completely obstructed -- think Ludwig’s (cric is probably better though more intimidating), or ACEI induced angioedema, or burn. But, how to teach? We could do it on some easier cases where RSI would be a good backup, but if we succeed, our ICU colleagues will have a cow over the small tube. i.e., if we do a blind NT for training purposed, and succeed using the usual smaller tube, then we don’t have an adequate tube size for good air flow and for tracheal toilet. Tough call.

Awesome article, I know - please share your erudite thoughts...