Direct v Video laryngoscopy: Time to give up the ghost?
Myron Yaster MD, Jamie Peyton MD, and Melissa Brooks Peterson MD
I was privileged to recently give 2 lectures at the annual meeting of the American Society of Dentist Anesthesiologists in Austin, TX. The lectures were based on the best articles we’ve reviewed over the past 2 years in the PAAD. One, the management of the difficult pediatric airway, evoked an enormous amount of audience response. The take home message of the lecture, which was based on many of the articles from SPA’s pediatric difficult airway registry (PEDI-R), was that your first attempt at a difficult intubation should be your best attempt and that attempt should be with video laryngoscopy. 1,2 During the Q&A following the lecture, one member of the audience asked “should we simply give up the ghost and intubate everyone with video laryngoscopy?” My response was that in many pediatric emergency departments, transport systems, and PICUs this has already happened – a resounding “perhaps”. Today’s PAAD by Ruetzler et al. is an ADULT study published in JAMA that strongly suggests that “video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures.”3
Has the time come for us to follow suit? The PAAD’s airway gurus, Drs. Jamie Peyton and Mel Brooks will weigh in with their thoughts. Myron Yaster MD
PS: A warm welcome to our over 140+new dentist anesthesiologist readers!
Original article
Ruetzler K, Bustamante S, Schmidt MT, Almonacid-Cardenas F, Duncan A, Bauer A, Turan A, Skubas NJ, Sessler DI; Collaborative VLS Trial Group. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024 Apr 16;331(15):1279-1286. doi: 10.1001/jama.2024.0762. PMID: 38497992; PMCID: PMC10949146.
Tracheal intubation is an essential component of anesthetic practice. “Failure,” particularly if coupled with an inability to oxygenate and/or ventilate is, as the late UK Prime Minister Margaret Thatcher said, “not an option!” In our daily practice, we face expected and unexpected situations when multiple intubation attempts are required. Those attempts may result in hypoxemia, bradycardia, regurgitation, aspiration, airway trauma, cardiac arrest and even death. Today’s PAAD by Ruetzler et al. is a single center, randomized controlled, clinical cross over trial that “compared video laryngoscopy with direct laryngoscopy on the number of intubation attempts required to correctly position a single-lumen tube. Specifically, the trial tested the primary hypothesis that fewer intubation attempts would be required when initial laryngoscopy was performed with a video laryngoscope rather than a direct laryngoscope in patients being intubated in the operating room for cardiac, thoracic, or vascular surgical procedures. Secondarily, the trial tested the hypotheses that video laryngoscopy would reduce the number of intubation failures and a composite of airway and dental injuries.”3
“Among the 8429 intubations, 3283 (38.9%) were performed by nurse anesthetists, 2514 (29.8%) by residents, 1185 (14.1%) by fellows, 1175 (13.9%) by student nurse anesthetists, 225 (2.7%) by attending anesthesiologists, and 47 (0.6%) by medical students. The median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of −3.7% (95% CI, −4.4% to −3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).
I (MY) have always taught my students and colleagues “that good technique with direct laryngoscopy makes a difficult airway easy, whereas bad technique, makes an easy airway difficult!” How does one develop good technique or, more preferably, become an expert? Becoming an expert in ANYTHING requires a significant amount of deliberate practice. The "10,000-Hour Rule," popularized by Malcolm Gladwell, suggests that it takes approximately 10,000 hours of practice to achieve mastery in a specific field. Josh Kaufman, the author of the Personal MBA: Master the Art of Business, suggests that it takes only 20 hours. I’ve (MY) always been told that it takes 50 successful attempts at a procedure to develop mastery. For many of our colleagues, achieving this level of practice with either direct or video laryngoscopy may be difficult or impossible. For the PAAD’s readership we would urge you to practice with both techniques on a regular basis to achieve and maintain expertise. The time to use video laryngoscopy after a failed direct laryngoscopy will only be effective if the mastery of video laryngoscopy skills have already been achieved.
An advantage of video laryngoscopy in teaching practices is obvious. We can help guide leaners and manipulate their hands, positioning, the larynx and the endotracheal tube under our direct view. With standard laryngoscopy we simply cant see what our students or colleagues are seeing and therefor have limited ability to help.
JP and Mel here – We agree with everything Myron has said. We’ll add that we already have a lot of data supporting the use of video laryngoscopy over direct laryngoscopy in adults, including RCTs, meta-analyses, and a large-scale Cochrane review. This paper specifically looks at only hyperangulated video indirect laryngoscopy vs traditional Macintosh blade direct laryngoscopy. It did not look at Macintosh blade video indirect laryngoscopy, which would be a more interesting comparison and illustrates an important point that we need to consider when thinking about video laryngoscopy, and one I (JP) never miss the opportunity to bang the drum about. This paper falls into the same trap that many of its predecessors did by casting video laryngoscopy as the nemesis of direct laryngoscopy. With modern equipment, indirect video laryngoscopy can be performed at the same time as direct laryngoscopy if you use a video-enabled direct laryngoscope blade. It would be more useful for researchers to look at how the different types of VL blades perform in large RCTs rather than continuing to bring out single-center RCTs that simply confirm what has already been shown. This is important in children because we have data that suggests using Miller or Macintosh blade video laryngoscopes may be associated with higher success rates and fewer complications than using hyperangulated video laryngoscopes, particularly in children who are difficult to intubate. There are also many cases where failed hyperangulated indirect video laryngoscopy has been rescued by standard blade indirect video laryngoscopy or traditional direct laryngoscopy4.
The reasons for this are unclear, it may be due to anatomical differences seen in smaller children that create less space to maneuver the tracheal tube during intubation, or it may be simply that we are not as experienced in using hyperangulated indirect laryngoscopy in our patients. Using a hyperangulated video laryngoscope requires different skills than direct laryngoscopy, and the two should be thought of as complementary techniques rather than opposing ones. I look at it as analogous to teaching mask ventilation and supraglottic airway use, they are techniques that are both vital for us to have expertise in. As Myron says, using video-enabled laryngoscopes allows us to teach and supervise in a fashion we could not in years gone by. All available laryngoscopy techniques should be taught to our trainees, with anesthetic departments increasing the availability of video-enabled laryngoscopy systems to facilitate this. One critical piece of advice I (Mel) always stress is that the most important outcome we should be insisting on obtaining (and then documenting!!) is the direct laryngoscopy view with a standard blade video laryngoscope, followed by the on-screen view of the laryngeal inlet with the standard blade video laryngoscope. This is the way to achieve documentation of a traditional method for locations that do not have access to video equipment, but also offer the added safety and first attempt success of a video blade.
One important aside (from Mel): I stress to my colleagues, trainees, and essentially anyone who will listen that the hyperangulated video laryngoscope is (simply) a crappy device, and if I could have my way, I would put the hyperangulated blade devices in the trashcan! Why? because of the thick, plastic, sticky phlange/blade that is hard to use in an adult normal airway, let alone a smaller oral cavity in infants and neonates. Additionally, it is really a difficult procedure to insert this thick, sticky plastic blade and get a view and then try to insert a properly styletted/curved ETT along that thick, sticky blade. Instead, it requires a different technique which Annery Garcia-Marcinewicz described beautifully in the Fall 2023 SPA meeting during her “what have we learned” airway registry talk: the co-insertion and co-advancing technique of the hyperangulated devices. This involves “insert a little blade, insert a little ETT, advance a little blade, advance a little ETT, and to do this repeatedly until the view is obtained and the ETT is sitting right there” This “co-advance” technique with a hyperangulated blade, I offer to our PAAD readership, should be conceptualized as a totally different technique with a different device than what we have trained with and are accustomed to. I wonder if this accounts for differences we see in the data we see on first attempt success and utility of this hyperangulated blade versus a standard blade videoscope. Therefore, I push my department, colleagues and trainees to invest in and opt for the standard blade videolaryngoscope with the HD camera because it is the blade that is familiar in feel, weight, size, dimensions, “stickiness” and curvature, and offers the major benefit of a high-quality video on the end. The standard blade videolarygoscope is truly the best of both worlds, and I suspect (and hope) future research will tease this device out as the optimal device.
To summarize, we are not at the point where we should be recommending hyperangulated video indirect laryngoscopy in all our patients, that day may come, but the data does not support this in children. However, the data does support the universal use of video laryngoscopy systems, which is a different thing!
Thus, today’s PAAD confirms AND strongly suggests that in ADULT patients, video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures. Should we change our practice as well? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Park R, Peyton JM, Fiadjoe JE, et al. The efficacy of GlideScope® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. British journal of anaesthesia 2017;119(5):984-992. (In eng). DOI: 10.1093/bja/aex344.
2. Burjek NE, Nishisaki A, Fiadjoe JE, et al. Videolaryngoscopy versus Fiber-optic Intubation through a Supraglottic Airway in Children with a Difficult Airway: An Analysis from the Multicenter Pediatric Difficult Intubation Registry. Anesthesiology 2017;127(3):432-440. (In eng). DOI: 10.1097/aln.0000000000001758.
3. Ruetzler K, Bustamante S, Schmidt MT, et al. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. Jama 2024;331(15):1279-1286. (In eng). DOI: 10.1001/jama.2024.0762.
4. Peyton J, Park R, Staffa SJ, Sabato S, Templeton TW, Stein ML, Garcia-Marcinkiewicz AG, Kiss E, Fiadjoe JE, von Ungern-Sternberg B, Chiao F, Olomu P, Zurakowski D, Kovatsis PG; PeDI Collaborative Investigators. A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry. Br J Anaesth. 2021 Jan;126(1):331-339. doi: 10.1016/j.bja.2020.08.010. Epub 2020 Sep 17. PMID: 32950248.