Advanced Practice: Airway Mastery Series! DL vs VL for Airway Management in the ED

 

Note: EMDaily has no financial disclosures in relation to the manufacturers of any airway devices!

 

Improved First Pass Success (FPS)

  • 93% FPS with VL vs 51% FPS with DL in untrained medical personnel (think residents!)
  • 10-15% FPS improvement with VL over DL in ED patients with 0, 1, 2 or 3 predictors of difficult airway
  • 93% FPS with VL vs 84% with DL in OR patients with predicted difficult airway intubated by experienced anesthesiologists
  • 74% FPS with VL vs 40% FPS with DL in Intensive Care Unit patients

 

Complication rates

  • Critical desaturation 26% DL vs 18% VL in ICU patients
  • Esophageal intubation 6.6% vs 2.1% in ICU patients
  • Esophageal intubation rates 5.5% vs 1% in ED patients
  • >2 attempts 22% DL vs 7% VL in ICU patients

 

Success after failed intubation attempt

  • Second pass success 82% vs 62% in ED patients (switching to DL or sticking with DL both had worse rates than going with VL)

 

Conclusion

 

  • Video laryngoscopy should become the primary airway device for orotracheal intubation in the ED and ICU. Direct laryngoscopy skills, while important, should be relegated to a backup role.

 

  • In order to reap the benefits of VL while not losing the skills of DL, consider using a hybrid device such as the Storz CMAC device; the technique for intubation is identical to DL, with the added benefit of the video monitor if needed to improve your view.

 

References:

Parichehr NS, Schumann M, and Groeben H. Laryngoscopy via Macintosh blade versus glidescope: success rate and time for endotracheal intubation in untrained medical personnel. Anesthesiology 2009; 110(1):32-7.

Aziz M, Dillman D, Fu R, Brambrink A. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology 2012; 116(3):629-636.

Silverberg MJ, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. Critical Care Medicine 2015; 43(3): 636-641.

Sakles JC, Javedani PP et al. The use of a video laryngoscope by emergency medicine residents is associated with a reduction in esophageal intubations in the emergency department. Academic Emergency Medicine 2015; 22(6):700-7.

Sakles JC, Patanwala AE, Mosier JM, and Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department.

Sakles JC, Mosier JM, Patanwala AE, Dicken JM, Kalin L and Javedani PP. The C-MAC video laryngoscope is superior to the direct laryngoscope for the rescue of failed first-attempt intubations in the emergency department.