Reader response and news you can use
Myron Yaster MD
From anonymous
Regarding your Dec 4 PAAD Video laryngoscopy is becoming omnipresent – Should we worry about the future?, this is a continuing discussion in many departments and as far as I can tell, it is generation based. Interestingly the answer is right in front of us (or more accurately, far behind us) in the inaugural experience using the Bullard laryngoscope. Data from that era showed that the operators who found the Bullard useful were far more likely to be inexperienced at direct larygoscopy. I think that a “big picture” view of the current debate re VL is much the same, except it now includes the opinions of trainees and non-anesthesiologist intubating persons.
I think the far more important question is how we can in this era of trainees advance the skills of DL in our junior colleagues as well as trainees. Airway complications in normal neonates and infants as well as those who could be deemed to be “difficult” still present in our M and M conferences where the Plan B is too often to call ENT to intubate with a rigid telescope. Honestly if the vocal aperture can be seen with a rigid scope, failure to see it with DL represents a technical shortcoming in performing DL. The use of ENT support in a difficult airway should be for the rare need for a surgical airway.
The real challenge is “How do we better teach DL to our trainees?”, “How do we maintain superior technical competency among experienced practitioners?” and even more interestingly, “Should we support our ICU and ER colleagues best by making sure they have access to a VL, or making sure that they have access to Anesthesiology support”?
From Jamie Peyton, Mary Lynn Stein, Stephen Flynn, Ray Park, Pete Kovatsis, Boston Children’s Hospital Airway Research Group
We read the latest PAAD with interest and thought it might be useful to share our experiences as a group within Boston Children’s Hospital who now almost exclusively use video-enabled laryngoscopes to teach direct laryngoscopy to our trainees when they are intubating infants. Our use of standard blade (Miller) video laryngoscopes (predominantly Storz CMAC reusable blades) has increased from around 3% of infants in 2017 to about 80% of cases now, with a corresponding increase in intubation success and a decrease in complications1
We understand the concerns expressed about the use of indirect laryngoscopy degrading direct laryngoscopy skills. We maintain that direct laryngoscopy remains an essential skill for us to teach and for our residents and fellows to master. However, concerns about skill degradation could be addressed by more intentionally teaching direct laryngoscopy with video-enabled standard-blade laryngoscopes, a technique we commonly refer to as Video-Assisted DL (VADL). Thus, the issues stem not from an inherent problem with the devices themselves but from poor oversight of how standard VL blades are used. Photos from a previous PAAD show a poor direct view with the CMAC Miller blade, but they also demonstrated poor laryngoscopy technique2. Coaching on applying direct laryngoscopy technique correctly would improve the direct view and facilitate tracheal tube placement. Some clinicians on social media also complain that they cannot sweep the tongue effectively with CMAC blades during direct laryngoscopy due to the blades’ design. This came as a surprise to us, as we teach the tongue sweep with the CMAC blade as a key laryngoscopy skill. While there are subtle differences in technique with the CMAC Miller blade relative to a traditional Miller blade to gain the best direct view, this is no different from adjusting technique to use a Mac blade, or a Wis-Hippel blade, which we have been doing and teaching for decades. There are a multitude of manufacturers that make Miller blades, and no two are exactly alike, so the provider must also make subtle adjustments to their technique to best fit the blade.
It is also clear that changing the paradigm of airway management away from an over-reliance on traditional laryngoscopes has benefited our patients3, particularly those who are difficult to intubate4. In our teaching and practice, we aim to foster a culture where comprehensive airway management is taught, safety is paramount, and airway techniques are viewed as complementary rather than in opposition. We focus on oxygenation, emphasizing the role of pre-oxygenation, supplemental oxygenation during the intubation attempt, particularly in patient groups at high risk of hypoxemia or when a junior trainee is involved, the use of muscle relaxation to obtain optimal mask ventilating and intubating conditions, video-enabled laryngoscopes to teach and perform direct laryngoscopy, allowing for guided instruction and teaching that is not possible with a traditional laryngoscope, and just-in-time coaching sessions with residents before they intubate infants. Even when using VL systems, just-in-time coaching immediately before this high-stakes procedure increases first-attempt success by 10%, improves technical skills, and significantly decreases the cognitive load of the trainee5. Laryngoscopy skills improve when attendings and trainees share a real-time mental model, enabling more impactful iterations rather than having a novice laryngoscopist describe a less familiar learning encounter via DL to an attending. VADL eliminates guesswork when seconds count.
The focus we see in the literature, which is reflected in the PAAD, on ‘VL vs DL’ detracts from the more important, bigger picture of improving safety and ensuring access to care that we have seen develop within the world of pediatric airway management over the past decade.
References
1. Abstracts of International Anesthesia Research Society & Society of Critical Care Anesthesiologists 2025 Annual Meetings. Anesthesia & Analgesia 140(5S):p 1-1247, May 2025. | DOI: 10.1213/ANE.0000000000007736
2. https://open.substack.com/pub/ronlitman/p/reader-response-9c8?utm_campaign=post&utm_medium=web
3. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, Gonzalez A, Kanmanthreddy S, Gálvez JA, Franz AM, Peyton J, Park R, Kiss EE, Sommerfield D, Griffis H, Nishisaki A, von Ungern-Sternberg BS, Nadkarni VM, McGowan FX Jr, Fiadjoe JE; PeDI Collaborative investigators. First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet. 2020 Dec 12;396(10266):1905-1913. doi: 10.1016/S0140-6736(20)32532-0. PMID: 33308472.
4. Stein ML, Sarmiento Argüello LA, Staffa SJ, Heunis J, Egbuta C, Flynn SG, Khan SA, Sabato S, Taicher BM, Chiao F, Bosenberg A, Lee AC, Adams HD, von Ungern-Stejoe JE, Kovatsis PG; PeDI Collaborative Investigators. Airway management in the paernberg BS, Park RS, Peyton JM, Olomu PN, Hunyady AI, Garcia-Marcinkiewicz A, Fiaddiatric difficult intubation registry: a propensity score matched analysis of outcomes over time. EClinicalMedicine. 2024 Feb 14;69:102461. doi: 10.1016/j.eclinm.2024.102461. PMID: 38374968; PMCID: PMC10875248.
5. Flynn SG, Park RS, Jena AB, Staffa SJ, Kim SY, Clarke JD, Pham IV, Lukovits KE, Huang SX, Sideridis GD, Bernier RS, Fiadjoe JE, Weinstock PH, Peyton JM, Stein ML, Kovatsis PG. Coaching inexperienced clinicians before a high stakes medical procedure: randomized clinical trial. BMJ. 2024 Dec 16;387:e080924. doi: 10.1136/bmj-2024-080924. PMID: 39681397; PMCID: PMC11648086.
From Peter Wu, MD MBA FASA, Chair, Department of Anesthesiology and Perioperative Medicine – USF Morsani College of Medicine, Assistant Facility Medical Director/Director of Quality and Safety, Anesthesia – Tampa General Hospital
Thanks for tackling one of my favorite topics…to what extent should we even be teaching direct laryngoscopy anymore?
Back in the dark ages when I trained at Brigham and Women’s/Boston Children’s, video laryngoscopy was still experimental, so I became proficient in a variety of techniques including the Miller blade, the Wisconsin blade, fiberoptic bronchoscopy (awake and asleep), the lightwand, the seeing optical stylet, the Bullard scope, and the intubating LMA. When I started my first attending job at Inova Fairfax Hospital in Virginia, call nights were interesting but allowed for little sleep because I was the only person in the building with advanced airway skills, and the phone was constantly ringing as I went from one emergent intubation to another.
When video laryngoscopy came along, it was like a miracle, as it rapidly improved the intubation skills of many different types of non-anesthesia clinicians. The phone calls went down dramatically, call nights temporarily became more peaceful (the hospital soon found other cases to keep us busy), and anesthesia got called only rarely when the first three attempts at intubation failed. I don’t have a case log of these, but it was rare for any of these to resolved by the use of direct laryngoscopy. It was much more likely that solving the problem involved some combination of repositioning the patient or reshaping the stylet to facilitate intubation.
Fast forward 20 years and we have started a new residency at Tampa General Hospital, where we are having a lively debate about the teaching of direct laryngoscopy vs video laryngoscopy. We have made video laryngoscopy universally available in every anesthetizing location (mostly McGrath but Glidescope is available). I am in the camp that trainees should master VL first, only followed by DL after they have mastered VL. Having processed many dental claims over the course of my career in quality and safety roles, I favor VL because the technique results in fewer attempts. In my role as a teaching pediatric anesthesiologist, I favor the straight VL blade on the Glidescope for teaching trainees, as it allows me to coach them to obtain an optimal view and reduces the amount of chest pain I have as the patient is less likely to desaturate! We do teach FOB intubation as well, starting with task trainers and progressing to asleep patients to optimize technique before progressing to awake patients.
I think this debate is analogous to the use of ultrasound for central venous line placement. This is another technology that was in its infancy when I trained, and I was curious but skeptical when it was suggested that I use it after having placed over 1000 central lines using landmark techniques. As with many anesthesiologists of my vintage, I agreed to use it only for the challenging placements, which changed over time to using it for every insertion. Many institutions, including mine, now require ultrasound for every central line insertion, and I am on the verge of using it from the start for every arterial line placement. Both practices are well supported by the literature.
The literature also supports the superiority of video laryngoscopy over direct laryngoscopy, and arguments for teaching direct laryngoscopy seem mainly related to finding yourself in some situation in which VL is unavailable. This is rational (although I do tell our trainees I would advise against taking a job in any facility that did not want to spend the money on VL), but even so, I can’t think of any reason why you should teach DL prior to teaching VL. I have had a hard time convincing all of my colleagues about this concept, and am greatly looking forward to reading other reader responses to your post.
From Elizabeth Leweling M.D., C.E.O., Elizabeth Leweling M.D. PLLC
In 2015, after completing my pediatric fellowship, I worked in a physician only private practice in Montana. I did all of my pediatric T&As over the next 10 years with sevo induction and propofol maintenance. All patients were extubated in the operating room. The incidence of PACU emergence delirium and PRAEs did not disappear, but it became so much less common that the veteran PACU RNs became concerned that newer grads would be unfamiliar, if a PRAE arose.
Propofol maintenance made my practice better & safer, but it does require vigilance to time emergence well. Very worth the effort though! I frankly, wouldn’t perform a pediatric T& A any other way.
From Slava Sher MD, Rambam medical center, Haifa Israel
It is our practice to start and finish (extubate) tonsillectomies and adenoidectomies in the operating room. We do not extubate in the PACU. The anesthetic technique used in today’s PAAD would require a radical culture change in our practice and operational workflow. Thus, many of the recommendations in the article by Shen et al. would simply not work in our practice. Although we don’t use a standardized protocol in our practice, most of us primarily attempt to extubate our patients awake in the OR by downward titration of sevoflurane as the case comes to an end. Additionally, we add 0.5-1 mcg/kg IV fentanyl to smooth things out and to provide analgesia postoperatively. Additionally, I personally always give lidocaine IV at induction and during emergence prior to extubation.
From Nancy S. Cunningham, MMSc Emory University
I am a retired anesthesiologist assistant and I discovered a cache of vintage monitoring equipment that I had stored thinking I might someday return to a low resource country for teaching. My bag contains several sizes of precordials, a stethoscope with the end modified to connect to the precordials and some extension tubing in case I couldn’t be close to the patient’s chest. I also found a twitch monitor and many sizes of hemostats plus bandage scissors. I guess I planned to leave many of these pieces in the hands of the local staff with whom I might be working, and one hopes, teaching a little bit about non-electrical/non-computer monitoring.
I’m afraid that many or most of our colleagues today are not learning about a finger on the pulse or listening to breath and heart sounds. Their eyes are glued to the monitors, not the patient. If any younger anesthetists and anesthesiologists are lucky enough to visit a low resource country to teach or help out they might be in a sea of anxiety when they see how little monitoring is done.
Anyway I don’t know what I will do with my cache as I certainly won’t be traveling to teach anesthesia (a Nile cruise is more my idea of a vacation now). I am speaking at the April meeting in Denver of the American Academy of Anesthesiologist Assistants about the path AAs have followed from new profession to familiar provider. Maybe I will take my cache to the meeting and give away the hardware as door prizes to those to choose to attend my talk (simultaneous sessions so the audience might be thin).
I always preferred a precordial to an esophageal esp in peds...those thin chest walls were perfect resonators. If any of you are interested in obtaining this cache of supplies please email me: nancy cunningham <nancysc@yahoo.com>
From Juan Pablo Zapata: In a recent PAAD you discussed some myths/bubbameisas involving NPO guidelines and preoxygenating with 100% FiO2 (rather than 80%) Could you provide the links?
From Myron: here are a couple: July 19, 2021 NPO GUIDELINES are they “bubbameisters”? November 21, 2023 Supplemental Oxygen Therapy