A novel publication goes to enrich the long-living debate on direct laryngoscopy (DL) vs video laryngoscopy (VL) efficacy in emergency intubation.
The recent article, pubblished on JEMS and titled “Deploying the Video Laryngoscope into a Ground EMS System” ,compares the success rate beetwen DL vs VL in a ground EMS Service. The device used was the King Vision with channeled blade. The partecipants had a prior training on the divide, consisting in didactic orientation and practical skills on manikins.
The result of the study shown that “Within the first 100 days of the study, the video laryngoscope utilizing the channeled blade has shown to be at least as effective as DL in relation to first-attempt success” and considering that “the mean experience in our group with DL is nine years, yet the success rate remains unacceptable” “It’s time to consider transition from a skill that’s difficult to obtain and maintain to one that appears to have a quicker learning curve and will likely result in decreased episodes of multiple attempts at intubation and associated complications.”
So is direct laryngoscopy dead?( Or will be so in a few years)
Here are some considerations
There are some fundamental differences in VL tecnique respect the DL tecnique, that makes the DL more intuitive to pass the tube trough the cords.
We have basically 3 main axis in the airways
When we manage the airways we first put the head in “sniffing position” aligning the pharyngeal axis with the laryngeal one
Then we use the laryngoscope to align the mouth axis having so a direct view of the cords. This view coincide with the way to pass the tube, making this step intitive and easy.
When using the videolaryngoscope we take our eyes right in front of the larynx, having a perfect “video” view of the vocal cords, but also minimally modifying the axis of the mouth.
For this reason passing the OTT is not straight forward, so we need the stylet, the Bougie/Froban or the external glottic maneuvers, to facilitate the intubation.
This difference in tecnique makes the VL not so intuitive due to the contrast between the perfect laryngeal view and the not intuitive passage of the tube trough the cords.
In fact the available evidences almost accordingly demonstrate an equivalent success first pass rate beetwen traditional laryngoscope an video but a prolonged intubation time in VL groups.
As the previously cited article demonstrate the learning curve for VL is short and easy to perform, and this make this tecnique surely suitable for emergency intubation.
But for emergency professionals well trained and familiar with DL I think this has to be the first choice approach when managing an emergent airway.
Emergency field is not the place to make trianing or experience with novel devices or drugs.
The still not widely availability of video-laryngoscope makes this device a perfect alternative in all the casess when is not possible to obtain a good laryngela view with DL, but still not the gold standard tecnique.
In the future the increasingly diffusion of videoleryngoscopes (due mostly to more affordable prices), will chenge the airway management scenario. Novel emergency medicine operators will grown up parallel experience wid DL and VL so the latter will be more suitable as first choice device.
Wich way you prefer to go home?
The quickest and the shorter one for sure!
Do you use the GPS to go home?
Agree, me neither!
And when you use it?
Right! When you are lost!
So that’s why Direct Laryngoscope il still my Plan A
My straight way home!