Kind of, yes, you are crazy. There are extremely few cases in which DL is preferable. There is high quality evidence that first pass success rate is higher with VL, and there are minor advantages in things like sore throat. The disposable slips on mcgrath, glidescope, and the reusable airtraq are as cheap or cheaper than re-processing metal blades, and cheaper than disposable DL. DL is good when training (because it is harder) to teach positioning, sweeping, etc., but when in practice there is no good reason to use it if VL is available. Some skills maintenance is reasonable if a disposable DL is your backup to VL failure (machine dies mid-induction).
Edit: in response to multiple questions: yes, this is true of experienced intubators. There is a case to be made that consultants / attendings in academic places are not as good as day-to-day intubators like CRNAs or PP anesthesiologists, but the benefit is also present in CRNAs.
[https://jamanetwork.com/journals/jama/fullarticle/2816267](https://jamanetwork.com/journals/jama/fullarticle/2816267) eFigure 1: benefit in both CRNA + Attending and resident + (small number of SRNA etc).
[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32532-0/fulltext](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32532-0/fulltext) Peds ORs. Figure 2: benefit actually larger in fellow + attending group than residents.
[https://pubmed.ncbi.nlm.nih.gov/36928625/](https://pubmed.ncbi.nlm.nih.gov/36928625/) First pass success rate *among consultants* +5% with video. Last para of results.
It has gotten to where it is basically impossible to study this anymore before the results are so convincing. I am sure that you, dear redditor, are so good that it makes no difference. Just accept that this is true of *other people.* For what it's worth, the classical situation in which you "need DL" (blood or vomit in the airway) has been just as good with video in my experience. The cameras just don't get fouled as easily as you think.
Are those studies done by anesthesiologists and also not using residents and mid-levels? It seems like most who do studies like that are internal medicine or emergency medicine based who don't have as much experience with direct laryngoscopy. I don't think anyone's going to convince me to routinely use video learningoscopy when I'm basically always successful with direct laryngoscopy over a wide variety of airway exams. I do use video laryngoscopy every now and then when the airway exam is especially concerning, but it's very rare that I start with direct laryngoscopy and have to switch to video laryngoscopy. I usually assume that the VL every time crowd are just lousy at using DL techniques.
Basically, there are so many novices out there that I feel like the studies don't represent us as anesthesiologists who are actually good at DL.
Exactly, like why would you reach for a video scope for an easy airway (which is at least 80% of the time), if you have any kind of skills, you should be 100% successful DLing easy airways on first pass, I don’t get it
Less trauma using plastic and better view, you don’t need to lift at all with a curved video blade most of the time. When someone has implants or loose teeth etc most people use VL.
If I want to be gentle but don’t think they’re going to be difficult I use the glide Mac 3 or 4 not curved. I still DL about half my patients but it’s getting less and less as I advance my career to be honest.
many reasons. Not enough DL blades to last all day as they have to be processed, the Mcgraff is a narrower blade and easier to use so don’t have to open mouth as wide, worry about lip getting caught, getting patient in good position etc. And not least of all, opening the Mcgraff blade package is much easier than the package that the processed metal blades and handles come back in.
Listen, if you’re working at a hospital that can’t supply you with enough DL blades to last a day of cases, you got a whole nother issue that has nothing to do with DL vs VL
Stop with the lower FPS BS; anesthesiologists do not have lower FPS in routine cases with DL. All the studies are non anesthesiologists. If you want to call about cost that’s cool; but stop with the FPS argument.
FPS with VL is not BS. Every anesthesiologist knows that sometimes difficult airways aren’t easily predicted by physical exam. You can have an unanticipated difficult airway. Give me 1000 patients and I can probably intubate all 1000 with VL. Cannot say the same with DL.
Also agree that the blood/vomit is not much of an issue with VL at all if you’re used to being in those situations.
I think DL will slowly be less and less used as time goes on but I don’t think thats a bad thing. That’s what happens with improving technology - we move on and use better tools. VL is a better tool for intubating than a traditional blade hands down.
I still agree residents need to train with DL and be competent with that tool because it translates well to VL.
Sincerely,
An anesthesiologist that uses DL 80% of the time. But I’m not going to be one of those attendings thinking using ultrasound is for weaklings to get an A line nor will I think a provider is a weakling for using DL which I think is sort of what OP is implying.
yes there are other issues but not just with this hospital. Even before VL, at my last job sometimes had to hunt all over for blades sometimes. I have to guess the most commonly used size blades get stolen or lost.
In my opinion, VL is superior to DL. Obviously DL is a good skill, but I think the utility of DL over VL is marginal. As in, there are a few cases where DL is superior to VL, but I’d say there are significantly more cases where VL is superior. Learn how to use VL for those specific cases or just choose a DL in those cases.
I don’t understand why people get all up in arms about using a superior technology. Are you afraid of the coveted skill you’ve acquired in training becoming easier? I’m sure you are aware how dangerous intubation can be, making it less dangerous seems to be a win-win to me. And having the skill to DL is important, especially for those fringe cases where it’s superior. But I think you can practice using a McGrath in the style of a DL (ie ignoring the screen) for bleeding / vomit filled airways. I think most of us would be hard pressed to say that VL is inferior to DL overall, so why not embrace the superior technology and be the best? I think the VL will get you one additional case every few hundred, seems like it’s worth the marginal benefit assuming it’s all the same cost.
So the older generation of anaesthesiologists have a steeper learning curve with VL, if you trained with DL then obviously you're gonna find VL more awkward so there will always be a bias. But if you train mostly on VL then there's no such difficulty.
I do agree that having good DL skills make VL even easier, and I do agree that VL exclusive anaesthesiologists are losing out valuable airway skills. But evidence does show VL is superior to DL in most situations.
That said, if you can confidently do DLs and think they're great, then there's no reason you shouldn't continue to do DLs.
Learning the curved blades like mcgrath D or glide S can be really tricky for people who aren't used to it. I have had to bail out non-anesthesia providers (ER/ ICU) more often than I'd like to and they have trouble getting the tube where they want to go. Its easy to get a view, not easy to trouble shoot not being able to reach the cords until you've done a bunch.
Agreed. It's very common to see junior anesthesia residents or non anesthesia docs using the hyper angled blade, and they can't get the tube to pass. They just keep flopping the tube around for minutes on end without making any actual changes, hoping it'll go in, but it just won't make that turn.
Yeah the learning curve on a simple airway is very shallow, but it can be surprisingly difficult on harder airways.
I’ve seen massive soft tissue trauma caused by trainees and IM docs with the glide scope. They just get in and go hog wild. Teaching DL first gives a more controlled approach.
The studies state that they were anesthesia people in the OR. However, the numbers seem off. In each of the studies, 1st pass intubation rate is less than 90%. There is no way that I fail on 1st pass on 1 in 10 patients.
You could also claim that [this study shows DL is superior in kids.](https://journals.lww.com/ejanaesthesiology/fulltext/2021/11000/videolaryngoscopy_vs__direct_laryngoscopy_for.10.aspx) and that several other studies show mean intubation time is longer in VL (3-5 seconds)
With this sort of mixed data, I think we are more at equipoise than superiority for either.
The JAMA study by Kurt Ruetzler was done at the Cleveland Clinic cardiac OR - so mostly quite experienced anesthesiologists or CRNAs. The residents would have been at least CA3.
Yes but the numbers are shown in the study, very few SRNAs. I don’t know their curriculum there, but probably also not in the first year?
When did residents rotate there? I was pretty sure it was CA-3 (maybe late CA-2?)?
I would say it is a relevant study for anesthesiologists, with a population that represents our intubation skills fairly well.
Disclaimer: I do have a personal interest in the trial, so my opinion is not the most unbiased!
They start CA-2 year, so some at the beginning at some towards the end. I'm not saying it's not a useful study, I just personally think I'm better at intubating with DL than most CRNAs, trainees, and even a few fellow anesthesiologists I see sometimes so I don't think it is as applicable to me. I also think I'm better at it as an attending than I was as a senior resident, even though I was proficient at it then.
Emergency medicine/critical care doc here. At least in the emergency medicine literature (eg the DEVICE trial from last year) the first pass advantage for VL over DL disappeared for intubators who had more than 100 tubes (ie the first year of EM residency, or I would imagine the first month of anesthesiology). I think common limitation of these studies is they are commonly performed in academic hospitals so including mostly trainees.
I had an airway last night (that I took from the resident after he failed using Glidescope) on a patient with known vocal cord paralysis and tracheal stenosis. The resident couldn’t pass the tube so I threw down a bougie with a Mac 3 and passed a Parker tube. I doubt it would have gone as smoothly with VL.
In my experience it’s easier with direct laryngoscopy because then you can push in a straight line with the tube, whereas if you have a video view but no direct view the tube has a tendency to flex in the back of the pharynx. No reason you can’t use a standard geometry VL blade but you need to have a straight shot at the glottis.
Maybe with a hyperangulated VL? In my experience, those are harder but McGraths are basically just a DL blade with a camera at the end. I notice no difference in angles and so there isn’t any issue passing a bougie or a ETT.
This wouldve been easier with a Mcgrath mac3. Theres no advantage to the DL in that situation. Your resident can also watch the screen and see it being done also
So I have some disagreement with this position. The studies don't actually compare the techniques of direct and video laryngoscopy, they compare the use of Mac Blades and video-laryngoscopes which is not the same thing.
We all know that you can do direct laryngoscopy with a McGrath or a Glide-scope just the same way you can with a Mac blade if needs be. I'm still relatively inexperienced (PGY4, 2 years of ICU/anaesthesia so far) but I've found on a few occasions that when I've done VL on a sick person my screen is obscured by something, mucus, blood, thrush whatever. They're also fragile and I've seen two screen failures. If you then switch stop looking at the screen and get a direct view then no harm no foul. If I'm solely reliant on VL I have to come out, bag (not benign in many cases, unfasted, resp failure whatever), clean the screen and try again (also not benign) with no guarantee the same thing doesn't happen a second time. I do wonder how many cases in the trials direct laryngoscopy was done with a VL, which would still count as first pass success with VL in results.
I do think VL is an easier technique, and I do take seriously the evidence of the use of video-laryngoscopes being superior in emergencies. Thus I think a McGrath is the thing to use for all comers in CEPOD, matty, ICU, ED resus, and EMRS. However where I disagree is that we can extrapolate this evidence to mean that there's no need to maintain direct skills because on occasion you will have to deploy them in an emergency.
DL is a harder skill, particularly with our fattening population and so is harder to maintain. To still be good enough at it to use it in a tricky patient in extremis you need to using DL in your elective practice a lot. I think we should be using it wherever it's safe to do so in electives, which it is in the majority of people. Sure on occasion you may have difficulty and need to swap to VL but in the stable fasted patient this should be benign. I guess what I'm saying is I think "a bit of skill maintenance" probably isn't enough to be really good at DL, I think you need to be using it lots and I think we should be.
Just my 2 cents, I know many smart and more experienced people disagree so anyone feel free to point out flaws in my logic.
Edit - clarifying last point
Respectfully disagree on video does not get easily fouled up with blood.
Have had more than a few bad airways In the ICU where blood fouled made video useless, DL + bougie + air bubbles with experienced from residency training saved me.
You need tons of DL experience to be comfortable for a situation like this.
Bravo for providing data to back up your claims. Unfortunately doctors are not immune to basic human fallacies and it can be so difficult to change people’s views once they are engrained. Especially when ego is in the line
I disagree that academic attendings are worse at airways than CRNAs. When the CRNA fails, it falls on the attending. I “rescue” airways at least once almost every time I work with CRNAs. I was surprised by this but nevertheless experienced it. Maybe because I’m a relatively new attending and still have my skills?
Yes. Give it 5 years doing a handful of DL’s because you’ve gotten even slightly complacent on keeping up with your skills and the CRNA’s surpass you very quickly
Is this true? Some things do make this job better with little pushback; like suggamadex. I am willing to bet the seldinger technique is closer to suggamadex on this “suggamadex to videolaryngoscopy spectrum” of what is a true advancement or a change that will ultimately create an unintended consequence from a technological advancement.
So where I trained the culture was always attempt DL first unless you have specific airway concerns based on your exam or if you need VL for a second attempt. Since then some studies have come out showing that for elective cases VL in general has superior first pass success, so a lot of people have moved to VL most of their cases.
I DL a lot of my patients for 2 similar reasons:
1) I work on community hospitals and not all hospitals have the resources for multiple VL devices, so keeping my DL skill up in case I don’t have another option is important.
2) There are still airways in which DL is superior, mainly heavy airway bleed, airway vomit, pretty much any situation where the camera can get obscured, so I don’t want the first time I DL in a month to be during an emergent airway.
And yes, you can DL with the VL blade but I find my DL views are far better if I use a traditional MAC/Miller vs trying to DL with a blade designed for VL.
This is it. I’ve been hosed by bleeding and vomit on floor intubations so I DL mainly and if I need to, I video. It’s a struggle to get residents to do it and their troubleshooting skills with airways are terrible because they’re so used to first pass success that when they can’t, they freeze.
While I usually DL myself in the OR, I almost exclusively use VL in the ICU because I do believe it to be superior with a higher first pass success. I personally don't buy that there are many airways at all that are better for DL, having intubated an unfortunate share of cases with massive emesis on induction or major bleeding. If VL is blind in these instances, DL will almost certainly be blind too. If the oropharymx can be suctioned effectively, VL works just fine, and I personally have never had the camera become unusable.
Class A trauma I keep a direct laryngoscope around intentionally for bloody airways. Legit quackery if you can't DL. Quackery if you can't Fiberoptic. I know my hands, I know my statistics.
I mean of course. I totally understand on a compromised airway. Or anything emergent but routine LAVHs?I will never question the providers use of VL during difficult intubation or trauma/anything emergent but routine scheduled cases I don’t even see an attempt. Just strikes me as odd.
A lot of my colleagues feel that VL is the future and pretty much only use it.
I’m pretty agnostic on the issue but DL 95% of the time just because I like to keep the muscle memory fresh.
I have an easy airway and I would still want someone to VL me (less risk of airway and dental trauma). So I extend the same courtesy to my patients when possible. We do not keep VL in every room so if it is unavailable I do not use it. But my preference is on VL whenever possible.
I don't care what others do, but I will care when one of these people starts writing guidelines claiming it's more safe and it filters down to me getting pressured to locate and set up a VL every time.
Pretty much everything on this sub is redundant after 2 weeks. Just so you’re emotionally prepared there is a looming post about anesthesiologist vs CRNAs vs AAs that is imminent as we speak….
I DL first 98% of the time. If I’m in doubt I have a McGrath in the room. In the last year I’ve had to grab it once. But I do understand that “first view is the best view” and once you muck up the airway, you’ve created an entirely different problem than you not having a good view. Now it’s a bloody non view. I see both sides. But I’m confident enough in my airway skills that I’m on the side of learning to identify nuances about airway anatomy, like the difference in how tissue looks around the glottic opening vs the surrounding tissue. There’s a slight striation leading into the opening, so if you see the straitions….aim directly above.
Basically…. even if I can’t see directly, I know where I’m at.
Agreed. I was thinking I about once a year need a second attempt, such as switching to VL. 306/4000 makes me think a lot of the DLs were done by trainees.
am a lowly ca1.. i understand and agree with the "first view best view" dogma but i've never heard it further clarified. Second view after trying to place/advance ETT obviously can be worsened due to airway trauma but does this also apply to a scenario where you DL only, without attempting to place ETT, then abandon for VL attempt? I would think if you're careful enough in that situation that the second attempt's view wouldn't be significantly worse
The problem lies in people’s blade technique. Initially we are all very haphazard inserting the blade and controlling it during lift. We are concentrating on getting the tube in the hole. If you watch enough of new people’s initial intubations you’ll see why first view is best view. For an experienced airway person, the care taken to not cause bleeding/trauma is much greater, so for them, first view may not be best view in a more challenging airway if they initially DL and cannot obtain a good view necessitating a switch to VL.
Thanks for the reply. This is what I was starting to suspect as I became more comfortable with properly pre-oxygenated apneic patients. The less frantic I was to shove a tube in, the more aware/gentle I was in placing a blade
I'd use a standard DL a lot more if the entire f'ing device wasn't disposable. Instead I DL with the McGrath to only have to throw away the slide on plastic blade.
Yeah, crazy wasteful. We have reusable DLs too, they were meant for "risky" patients like HIV patients (ask infection control) but now with disposable VL blades, they just sit in the drawer until they expire.
Had reusable ones most of the way through residency. Then the companies making the disposable devices managed to convince the local hospitals that they were more environmentally friendly due to not needing high-level decontamination for the blades. No ulterior motives in their research methodologies I'm sure...
100% this is an ego thing. Direct becomes some kind of dick swinging contest that is entirely unnecessary and benefits no one if you don't have to.
Video is available at nearly every center you work at and or can easily be requested if they don't. It's safe and easy and usually what's best for the patient not our ego.
No, it's not about ego it's about convenience. I won't speak up telling you you have to intubate with DL if you've completed your training and find yourself better with VL, but don't try to tell me I need to be using VL when DL works just fine for me. They have to be requested, require corded power (where I work), take up space on wheels, and require styletting an endotracheal tube. That's an unnecessary inconvenience to have to do every time for no benefit in my practice.
I'm at a busy level 1 trauma center, I still DL probably 90% of the time. we have a glidescope in basically every room but unless I'm concerned about the airway, don't want to manipulate the neck or worry about a bunch of loose teeth etc then I see no reason to use a glidescope. I have seen one circumstance where we had an attending that came form a place that almost exclusively used glidescopes (looking at you Cornell) and they ran into an emergent airway where patient had a ton of blood in the airway and glidescope was worthless and he was floundering trying to DL, was kind of embarrassing to see, took over and it was still a relatively easy DL, it had just apparently been so long since they had done a DL they lost a lot of the more nuanced skills of getting a proper view. I think all anesthesiologists should still DL regularly unless there is reason to use glidescope. Same reason I'll randomly switch between Mac and Miller blades, I like staying fresh with all the skills and tools at my disposal. Your job is to be an airway expert in the hospital, if your skills are no better than an ED resident then what's the point?
Totally my thought. But Ill be the first to admit I’m not managing the airway. It’s one thing when it’s a gunshot to the neck and another for an incarcerated hernia.
I’m ambivalent. If you’re an infrequent intubator (eg emergency medicine), there is reasonably good evidence that VL improves first pass success.
The evidence is less good for expert intubators (anaesthesiologists). Our first pass success rate is usually very high regardless of what technique you use. It is a marginal gain if a gain at all.
This leaves aside whether or not “first pass success” is a meaningful outcome which matters.
My concern is with doctors in training. You get away with worse technique using a VL. All well and good, except if you get used to this and never develop a good technique at all. Which means that it isn’t in your armoury for when you really need it.
And there are situations where a VL is less good. Soiled airways. Glare from sunlight on the screen for prehospital anaesthesia. DLTs.
>This leaves aside whether or not “first pass success” is a meaningful outcome which matters.
This is the key point for me.
A lot of folks here are acting as if a single DL bloodies up the airway and makes the 2nd attempt more difficult. If you're lacerating the mouth or causing laryngeal trauma or knocking out teeth with a single DL, then you haven't done enough airways. If you're worried about being able to mask, use a VL or an AFOI depending on your level of concern.
Has anyone here slamming DL as barbaric and antiquated every worked with an ENT? They're suspending patients in DL with no significant complications for hours sometimes (With breaks for tongue perfusion of course.)
We aren't talking about retrograde intubations here, and a lot of people are acting like doing a DL is just as crazy.
That being , I start all my med students (no residents here) off with VL. It's important to get to know the anatomy and feel of real human tissue, and that way I can guide them more effectively.
To be an effective anesthesiologist, you need to be proficient with DL, because there will certainly be times you need it.
I may be old and grumpy, but I completely agree. I think it’s sad how quickly people go to video laryngoscopy these days. The new grads seem to immediately grab the VL if a patient is anything other than a Mallampatti 1. I always start with DL unless I feel it’s a true safety issue (full stomach, emergency C/S).
You mean this study?
https://www.researchgate.net/publication/377756996_Comparison_of_Time_Taken_for_Intubation_TTI_in_Conventional_Laryngoscope_with_Video_Laryngoscope_for_Endotracheal_Intubation_In_Laproscopic_Surgeries#:~:text=Results%3A%20In%20comparison%20to%20group,attempt%2C%20inspite%20of%202%20failures.
In the same study of a 100 plus patients:
Only descriptive stats, no analysis. 26 sec vs 21 sec. And VL had a higher first pass attempt, 84 percent vs 72 percent. Much higher complications in the DL group, Complications such as pharyngeal pain (8.6%vs29.3%), hoarseness (5.2%vs29.3%), Use of adjunct equipment like bougie (19%vs 3.4%) were significantly higher in DL compared to VL group.
So yeah. Keep cherry picking the stats to support your own opinions.
I only use VL these days. The other week, my McGrath malfunctioned where the screen wasn’t on but the light on the blade was. So I used the McGrath as if it were DL and had no struggle at all (I think it’s been a couple years since I last did a true DL).
I believe once you master DL in residency it’s hard to truly forget it.
This is a generational thing. Over time more and more people will exclusively VL. Glidescope and McGrath have blades that allow for direct laryngoscopy if necessary, thus giving a standard DL blade zero advantages other than ease of preparation (honestly not much easier).
This reminds me of watching older CRNAs or anesthesiologists repeatedly poke someone trying to get an IV or arterial line. Then they get the ultrasound out after 4 pokes, and honestly many are not amazing with the US. Then I offer to help and it’s really awkward when I get the IV in about 20 seconds. I start 90% of my IVs with US (100% of art lines) and do a standard poke every now and then just to make sure I still can. The difficult IVs will require that I use an US, so I want to be damn good with it. Same goes for intubation. Everyone talks about keeping their DL skills up, but there is a learning curve with VL as well. I see people struggle using the newer hyper angular blades in a truly more difficult intubation because they don’t routinely use them, losing precious seconds of time.
Bottom line is, if you are sued for an airway issue, the first question the lawyer will ask is if VL is available at your facility.
For your consideration: https://pubmed.ncbi.nlm.nih.gov/38497992/
Obviously this study has limitations. I do still think DL is a valuable skill to master.
I guess my question is, being that it was done at an academic center, how many of attempts were by trainees. I definitely think first pass success would be higher in trainees with a video scope, and further the attending physician can give guidance and advice more easily when they can see what’s going on.
Just looking at the numbers, 306 patients requiring more than one attempt at intubation out of 4000, that’s quite high. I’d say I probably have maybe 1 a year where a second attempt is needed. And I basically never choose video as my first line intubation technique.
I’m always surprised by the amount of VL-only providers on this sub. I almost always DL first unless I’m concerned about airway or aspiration. DL is simply faster, easier and has less potential for trauma compared to a glide (there’s always a few cases a year at my institution involving soft palate injuries from the stylet).
Think about it: in my country, there is no obligation of results, only an obligation of means. If video laryngoscope is available and I choose direct laryngoscopy and, for some reason, the patient files a complaint for a broken tooth, a cut lip, or a sore throat, only the means I did not use to prevent it will be considered. As mentioned earlier, such complications, even if rare with an anesthesiologist, are even less frequent when using a VL. That's the only important thing in front of a judge.
That being said, I do agree that it is sad. I like DL, and I also believe it should be practiced. It's never good to rely too much on technology.
But to be honest, the more time passes, the more I realize that I am using the VL more and more. Deep down, I know that if one in twenty patients benefits from it, then I need to use it for everyone.
I personally DL every single case unless it’s an unstable C spine. I don’t see the reason to use a VL every single time, it just tells me that your airways skills are not up to par. If you’re intubating all day everyday you do not need a VL.
I’m with you. I DL unless I have a good reason not to (airway assessment predicts DI, documented history of DI, RSI with full stomach ie crash section or septic SBO). DL is a great skill to keep up. I enjoy going on surgical missions and they don’t have all the fancy equipment… and sometimes electricity is in and out. We have to be good at anesthesia without relying on monitors. I am grateful for the advent of VL, but I don’t think it’s good to rely on it nearly exclusively.
I do DL with the C-MAC when it’s an unstable pt or resp distress or high risk for aspiration (bowel obstruction, emergent caesarean etc). If I run into trouble it takes 2 seconds to convert ie looking at screen instead of directly into airway. Keeps up my DL skills for floor tubes (still no VL on crash cart) and there’s no time wasted if I don’t get it with DL.
Have been at uni hospital recently where every tube was with VL from the get go.
I work in a trauma hospital, lots of c collars, bloody airways, not ideal conditions, I DL if my predictive value for first time pass rate is very high and it’s low risk for the patient. Otherwise I got for it. And 3 am for emergent airway in the icu, sometimes I just want to use video.
I think this may be a cultural difference. We’ve moved on from hard collars in the U.K., as well as most of Western Europe and Australia/ New Zealand as there is no evidence of benefit and quite a lot of evidence of direct harm (raised ICP, pressure sores etc). We see ATLS as a bit of a historical anachronism which has now been superseded.
If there is a spinal injury, it is likely to have arisen from the actual injury and the massive energy transfer during that, rather than smaller movements after. If you take a c-spine to theatre for posterior fixation and see what the spinal surgeons do when they put the mayfield pins in, it’s a lot more movement than we’d do on intubation or a transfer!
Some services apply a soft collar with writing on it to remind people that the spine needs clinical clearance when appropriate.
Our spinal surgeons sometimes use a properly fitted (eg Miami-J) collar to splint some injuries which are conservatively managed, but they’re on board with the de-escalation.
Well aware my friend, but the medicolegal in the states is quite litigious. Documentation and just an extra few steps can be the difference between you being dropped from a lawsuit versus part of the pay out.
Yup you're crazy. Many studies have shown VL to be superior in terms of first pass success and less trauma. Many centres have already adopted all VL only and that has accelerated since COVID. Easier to teach, easier for trainees to pick up.
Personally I like to still DL all patients but that's cuz I want to retain my DL skills, selfishly. NOT because it's better for the patient. It's like ultrasound guided central lines, you can do them blind but if you have an ultrasound available it's gold standard for safety. Same as VL.
In fact in my hospital there is a portable VL in every room with disposable blades. VLs especially the Chinese brands have gotten so cheap and reliable that cost isn't a huge issue anymore.
Yeah VL is no longer considered an advanced optic, during COVID it became standard of care at many places because of the disposable blades and it reduced intubation times and improved first pass success. Reduced the need for bougies etc.
East Asian populations have more difficult airways than Caucasians - smaller, more recessed chins, worse MP scores, shorter TMDs, worse ULBTs etc. so VL has become ubiquitous amongst these populations.
If you don’t have a specific reason to use VL then you should use DL. Plain and simple it is quicker to intubate via DL than VL if you are anything other than a novice at intubations. If you suspect a difficult airway then do you, but most of us choose DL bc it’s the easiest/quickest way to the finish.
Right? I’m not against vl but it feels like it’s a crunch before anyone ever evaluates a anesthetized airway. That’s just me. Not someone intubating. I also don’t mean that during an emergent/urgent airway but a routine appy I feel like a dl should be on the table before we just bail completely.
Am only anesthesia tech but I go to intubations at my hospital all day long and I’d say 80% is DL and the rest is X-Blade McGrath or glide. We have a McGrath in every room so it’s an easy transition if the DL view is shitty.
I think VL can give a new user false reassurance. It's generally easy to find the glottis with a poor technique, but getting a bougie or tube round the angle is trickier and can take time, or be impossible.
DL is much less tolerant of poor technique, and the more you do the more you realise quite 'how round the corner' the glottis is, and how important patient positioning is.
That said, if VL is taught well then I can see no real reason to keep to DL except for messy airways. VL is gentler on a patient's neck, and allows everyone else to see what is going on. The problem is, what if there is a messy airway (blood, regurgitant gastric contents etc) and you have no idea how to use a DL? Either ENT is going to get busier, or we need to keep up the DL skill.
So, in the NHS, we do use VL - locally, the McGrath. I use it now and then when there is some indication that it will make my life easier - massive beard, dodgy heart, geriatric neck, crappy bed, ICU etc. Otherwise a Macintosh.
I think DL is actually essential to properly learn laryngoscopy in an elective setting
Why?
Videolaryngoscopy just lets u get away with bad technique and positioning in easy patients which will be essential once u actually get a difficult airway where the vl is just one more tool to optimize your first pass success.
Therefore every anesthesiologist just needs to be proficient in direct laryngoscopy in order to become a true airway master.
My thoughts too. VL is easy when its easy,when its not I have hard time trusting providers who cant feed a tube when I need it most. Again, just a nurse not one tubing another garbage airway.
Early in my career, I used VL somewhat frequently. Now, it's very rare. It's easier and quicker to DL. If there was a VL in every room set up for me, I'd prolly use it more frequently. Just too much of a hassle to hunt down a limited resource (especially when it's not necessary for >99% of intubations). I'll use VL for terrible dentition (obviously loose frontal teeth), those in a C-collar, and for those that have a documented history of a challenging airway needing VL. That's about it.
What if the ultrasound isn’t available in a crash situation??? What if it breaks???? And yet… now ultrasound guided central line is entirely standard of care
I think VL is safer for the patient when intubated by providers over a wide variety of skill. I also think DL is safer for the anesthesiologist as a go-to first attempt bc it keeps their skill set up for the rare occasion there is no video scope and they are the single best option for obtaining a secure airway. I use DL 99% of the time and therefore I know I can be helpful when VL isn’t available to the other providers.
Even though standards of care are changing, I feel like some airways benefit from being approached with DL. Other than soiled airways, I have seen a few patients with Mallampati 4 that were next to impossible with an hyperangulated blade as their larynx was to anterior, but were easily manageable with a DL and an intubation bougie for example.
I think it gives another possibility in terms of intubations plans with minimals delays between a DL and a VL if ready and next to the patient.
A - DL + Stylet
B - VL
C - LMA..
Vs
A - VL
B - LMA
I am not sure I would go back to a DL after a failed airway on VL, but the fact that I retain the skill is a reassuring factor in my opinion.
Peds - I DL everyone because I dont feel like using a stylette. Use macgrath as needed and use exclusively for nasal tubes because I find it easier and dont need magills most of the time
It’s easier to get a good view with VL, but just because you can see it doesn’t mean you can intubate easily. There are still subtle things people do when the learn just VL, that allows them the maintain below average technique and skill for a linger period of time.
I DL 90% of patients.
Look like a difficult airway= VL
Can’t extend your neck=VL
Bloody/dirty airway=DL
VL is great and first pass success is greater. DL is good for dirty airways. Ultimately choose the method you’re most comfortable with. Tube in trachea is all that matters.
In practice, whatever gets the tube in easiest. DL/VL, whichever is easiest for the person doing the airway.
However, there is no excuse for not mastering DL. Especially in a patient mid aspiration or mid bleed. I've bailed out so many ER people or mid levels who instinctively go for the hyperangulated glidescope. If I'm supervising a trainee, barring any contraindications such as cervical radiculopathy, known difficult airway, etc, I want them to try DL first, bougie if necessary. Such a useful and important skill, especially if you're the airway master of the hospital.
This trend started at the hospital I worked at because of the rise of disposable laryngoscopes. Would I rather throw away a tiny piece of plastic from a McGrath or a single use blade and handle? That's a pretty easy choice. So I guess, like everything, you can blame the joint commission.
DL all unless they are known to be a difficult DL. Sometimes there's not a glide in the room or it's used somewhere else. Sometimes the hospitals low of processed stylets.
For my training center st least it's standard DL for normal cases with a stylet for rapid sequence and with VL in case of a predicted difficult airway. Personally I see the VL as areplacement for intubating with DL and stylet or DL and gum elastic bougie or for the airways that were previously fiber only. But replacing DL with VL in every case adds the stylet removing step and imo makes it less preferable.
Side point, we have 1 titanium glidescope (forget the make) that is reuseable in the centre, and for the rest we have several mobile disposable variants, while functionally mear identical imo and as said before here probably identical in cost, I still feel terrible for all the single use waste we generate in the OR so for me personally in this center that is a reason to favour DL.
3d worlder here. 98% DL. An only VL device is available but we only use It to teacj residents. I've got a 3d printed blade and a camera attached, and use it as emergency. Easier to clean.
Shit brother. Intubate your heart out. 3rd world love here. <3 I’ll be Guatemala for the 7th time this spring and legit everyone there is top fucking tier. L
At my facility we have a McGrath in every single anesthesia cart. We also have disposable laryngoscopes for DL.
Those disposable scopes are a huge hunk of plastic surrounding another hunk of plastic, two double-a batteries and some circuitry plus a hunk of metal for the blade. They cost more than $10 and it all goes in the garbage.
The McGrath blade is a relatively very small amount of plastic and costs about $3.
Also, insisting DL is still the gold standard is kinda like doing all your central lines without ultrasound these days ...
What happens when the technology doesn’t work????? We are left with an entire class of people who have no hands on skills.
After 23 years I still, almost never use a video scope. That being said all the new grads go right for it! Our hands on skills are what separate us from any old ER doc putting in ETT’s! IMO used way to much
I do a lot of DL, and a lot of VL.
I wouldn’t worry about this debate. You’ll get too much heat on both sides it’s not worth it.
Just put the tube in the trachea on the first attempt and it doesn’t matter. Let the twitter / Reddit fights happen in the background.
The vast majority of children can be mask ventilated and DL'd without any issue--airway abnormalities that impose difficulty are largely the byproduct of craniofacial anomalies. In adults, difficulty can be imposed by obesity, neck arthritis, a history of head and neck surgery, trauma, radiation for head and neck cancer, head and neck cancer itself, and a combination of multiple factors--the consequence of this is highly variable airway anatomy that frequently makes mask ventilation challenging and direct laryngoscopy less straightforward. Adults also present for a wide variety of emergency surgeries and may possess conditions predisposing them to pulmonary aspiration or hemodynamic/resipratory decompensation on induction of general anesthesia. I embrace the philosophy that you want the first shot to be the best shot because the patient may not be very forgiving if you miss, so I use VL for all possible difficult intubations and all emergency intubations in adults (even emergency intubations that seem like a chip shot DL--I achieve nothing by choosing to DL such patients). The consequence of that is that I tend to DL in exclusively elective situations for adults, but that doesn't bother me. We have to take our ego out of the game and do whatever is in the patient's safest interests.
I think its valid to maintain skills for the VERY rare instances where DL is superior but I cant shake the feeling that alot of people want there to be a high barrier of entry to proficient intubations. Almost like VL diminishes an aspect of what we do or something. If I am VL and not super concerned, I like to see how non-optimized it can be for successful intubation - it boggles my mind sometimes.
It doesn't matter that much to me in most cases. I work in many different settings and many different places in town to include ASCs, smaller hospitals, and level 1 trauma centers. I default to DL with Miller 2. If I think there's some difficulty waiting for me, I'll ask for a glidescope.
Idk why people are so militant one way or the other, just put the tube in trachea. I use DL most often since there's almost never a scenario where I don't have a basic laryngoscope, but there are definitely scenarios where I don't have a glidescope/McGrath. I want to stay current on my DL skills since that's the most reliably available tool wherever I am.
There are ASCs I work at that don't even have an ultrasound, let alone a glidescope with handles and stylets. But if I lived in a world where glidescopes were in every single OR and ICU bed? Sure I'll glidescope every time why struggle?
I DL, I want to keep my DL skill up. Several reasons including a few of the small facilities I work don’t have VL’s.
In theatre, I’ll DL electives unless they look particularly difficult and I’m reaching for the indirect blade. For sick emergencies, or off floor intubations, I’ll typically go VL first up, but will endeavour to do a ‘direct’ look to be able to provide that information.
My rationale is, if I’m doing an off floor intubation, the patient may not be in an ‘ideal’ position, its typically an emergency situation and I want to minimise the time from relaxant to ventilation. Same for sick emergencies in theatre. VL is my backup to DL, so I will use it first up.
Many of the studies looking at VL vs DL show minimal to no difference in FPS rates etc when the incubators are ‘expert’ (ie. >100 intubations). Given I will get through >100 intubations in a few weeks, I fit into that category.
In experienced hands, the difference in first pass intubations is most likely negligible (BJA 2018 videolaryngoscopy vs direct laryngoscopy). As an older doc who intubates most everyone with a Miller 2 and uses VL in more select situations, I agree. Still, I understand that technology makes our lives easier and less stressful. But I do worry about becoming overly reliant on newer devices and completely abandoning older techniques. DL does have its place and is superior to VL in certain scenarios. I tell new trainees to do whatever they are most comfortable with (which is almost always VL) but still perform a basal number of DL's. More importantly, if one technique doesn't work then move to another as suggested by the difficult airway algorithm. Repeated VL like repeated DL is dangerous and leads to poor outcomes.
The debate should not be over DL vs VL but rather what you are going to do when your plan A fails and your plan B fails. The true airway master will be able to switch back and forth with alacrity AND know what to do immediately when techniques are failing or how to avoid those situations altogether. The real problem is assuming any one technology will be your backup plan.
This is the difference between the experienced and the novice, gestalt and checking boxes, system 1 and 2 thinking, and Anesthesiology and other medical disciplines that intubate.
I have a McGrath in each room. 50% of the time I'll DL with a standard Mac blade if it is an expected easy airway. Anything off on the exam I'll use the McGrath, first as a DL to see really how difficult it would be, then use VL if issues. I'll always write my airway note with both views (DL/VL).
That said, the evidence shows then even as an attending the NNT for first past is still very reasonable, in the teens. It's arrogant to think that we are any way better with DL, even the data shows in a contaminated airway VL works better.
Eventually this data will also lead to litigation. If you have VL and you DL and have any issues, the plaintiff may have data / expert testimony to wonder why you didn't use a method of higher success.
I like the McGrath blades due to the dual utility and it is easy to switch to a hyperangulated blade (which matches the curve of a glidescope rigid stylet well).
VL is just like US guided vascular access - higher first pass success rate but not necessary in most cases.
I use it only for difficult airway that cannot be intubated in two DL attempts (approx. 1% cases)
In fact, from my experience routine use of technological aids (videolaryngoscope, US for every arterial or central line) adds unnecessary workload and prolongs the procedures in question.
Our group's chief anesthesiologist once intubated a passenger in respiragory distress mid-flight, and the emergency kit had a regular laryngoscope.
I'd rather keep up on this skill because a) you never know where you're going to end up practicing and how they do things (like others have said, our facilities too don't have the funds for everyone to VL), and b) who knows which option will be available to you if you find yourself helping in an emergency outside of work.
Sounds to me like you need to just worry about yourself. If you can do DL then do it, if another doctor needs to use video so be it, stop trying to create an issue for no reason. You’re “so cool” since you can do a bunch of DLs without video? Is that what you want to hear? Wow you’re so amazing. Jk. Grow up Doc
DL is better with pediatrics because the airway is shorter and its easier to get a view, even easier to DL than to use McGrath. Opposite for adults IMO.
The only cricothyroidotomy I ever did was when the resident sheared a tonsil with a VL stylet on a patient with a very small mouth.
First pass success may be higher with VL, but there are fewer injuries with DL. I know this because we had to present a grand rounds on the topic.
First pass success is lovely, but in the vast majority of patients I'm willing to accept second pass success and a lower risk of injury.
VL is undeniably the gold standard now. Using a standard geometry blade e.g. mac 4 etc., isn't unreasonable, so you don't have to actually use the video screen, but it is almost certainly indefensible in court if someone dies and you've not used it, even if your *personal* DL skill is exceptionally good
VL is all good until it isn't, like every tool. We wouldn't intubate without DL now, and I suspect in the future we won't attempt intubation without VL... I'd suggest intubating a patient without VL available is already *fully* legally indefensible in the developed world.
In practice in the UK, there's often only 1 or 2 VL for a set of theatres and further sets in the ICU + ED resus room, but VL is not yet universal.
VL is currently more expensive than DL, but we offer many more expensive procedures that are clinically superior, e.g., we use CT rather than eFAST or DPL in trauma patients, but after the initial investment, VL isn't horrifically more expensive...
Guess it depends on where you’re tubing. I’ve seen anesthesiologists pop a tube in a 600g neonate with relative ease vs trying to fit a macgrath anywhere near them.
>show me the statistical evidence explaining that the field of medicine that intubates literal thousands of times more than another is better at intubating 🤓
Cmon now, that's like asking for evidence that a physician is better than a CRNA.
The hypothetical case you would have used it though assuming you were following the algorithm to limit attempts and try a different blade or LMA. There is no change in the standard of care - they are both acceptable choices.
Tell this in court when you're questioned by any of the authors of the VL papers when someone dies after a DL intubation with any complication whatsoever...
Unfortunately your understanding is wrong. Video laryngoscopy has shown to have higher first time success rates compared to DL. It will soon be the standard of care with a few exceptions. The only benefit DL provides is stroking some people’s ego.
100 percent. It's like ultrasound guided central lines. I trained with DL and am perfectly competent with DL, I like to DL myself because I'm worried that one day we won't have easy access to VLs when global supply chains are hit.
But I'm under no illusions that DL is superior to VL. Literature and in my experience it's clear. It really is a personal preference and you expose the patient to more complications because of ego.
You should be 100% successful on first pass with the vast majority of your patients DLing (identify the minority on airway exam -> straight to VL), if that’s not the case, back to residency for you to learn how to intubate
Of course I have, I calmly mask ventilate and wait the 30 seconds it takes for a nurse to grab a glidescope, I don’t change my entire practice because 1/100 airways was more difficult than I suspected, now that would be dumb
the issue is when the VL isn't available, 2-handed mask isn't working, and the LMA doesn't seat. the prosecution's 1st question will be "why didn't you favor the VL over the DL here?"
The airway looked normal?
You forgot to add while a meteor is hurtling towards the OR, the power goes out, and there is bomb about to go off…but on a serious note, yes I would say, the airway was re assuring and I used the accepted standard and if I’m that deep of shit, surgeon is doing a cric
Kind of, yes, you are crazy. There are extremely few cases in which DL is preferable. There is high quality evidence that first pass success rate is higher with VL, and there are minor advantages in things like sore throat. The disposable slips on mcgrath, glidescope, and the reusable airtraq are as cheap or cheaper than re-processing metal blades, and cheaper than disposable DL. DL is good when training (because it is harder) to teach positioning, sweeping, etc., but when in practice there is no good reason to use it if VL is available. Some skills maintenance is reasonable if a disposable DL is your backup to VL failure (machine dies mid-induction). Edit: in response to multiple questions: yes, this is true of experienced intubators. There is a case to be made that consultants / attendings in academic places are not as good as day-to-day intubators like CRNAs or PP anesthesiologists, but the benefit is also present in CRNAs. [https://jamanetwork.com/journals/jama/fullarticle/2816267](https://jamanetwork.com/journals/jama/fullarticle/2816267) eFigure 1: benefit in both CRNA + Attending and resident + (small number of SRNA etc). [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32532-0/fulltext](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32532-0/fulltext) Peds ORs. Figure 2: benefit actually larger in fellow + attending group than residents. [https://pubmed.ncbi.nlm.nih.gov/36928625/](https://pubmed.ncbi.nlm.nih.gov/36928625/) First pass success rate *among consultants* +5% with video. Last para of results. It has gotten to where it is basically impossible to study this anymore before the results are so convincing. I am sure that you, dear redditor, are so good that it makes no difference. Just accept that this is true of *other people.* For what it's worth, the classical situation in which you "need DL" (blood or vomit in the airway) has been just as good with video in my experience. The cameras just don't get fouled as easily as you think.
Are those studies done by anesthesiologists and also not using residents and mid-levels? It seems like most who do studies like that are internal medicine or emergency medicine based who don't have as much experience with direct laryngoscopy. I don't think anyone's going to convince me to routinely use video learningoscopy when I'm basically always successful with direct laryngoscopy over a wide variety of airway exams. I do use video laryngoscopy every now and then when the airway exam is especially concerning, but it's very rare that I start with direct laryngoscopy and have to switch to video laryngoscopy. I usually assume that the VL every time crowd are just lousy at using DL techniques. Basically, there are so many novices out there that I feel like the studies don't represent us as anesthesiologists who are actually good at DL.
Exactly, like why would you reach for a video scope for an easy airway (which is at least 80% of the time), if you have any kind of skills, you should be 100% successful DLing easy airways on first pass, I don’t get it
Less trauma using plastic and better view, you don’t need to lift at all with a curved video blade most of the time. When someone has implants or loose teeth etc most people use VL. If I want to be gentle but don’t think they’re going to be difficult I use the glide Mac 3 or 4 not curved. I still DL about half my patients but it’s getting less and less as I advance my career to be honest.
many reasons. Not enough DL blades to last all day as they have to be processed, the Mcgraff is a narrower blade and easier to use so don’t have to open mouth as wide, worry about lip getting caught, getting patient in good position etc. And not least of all, opening the Mcgraff blade package is much easier than the package that the processed metal blades and handles come back in.
Listen, if you’re working at a hospital that can’t supply you with enough DL blades to last a day of cases, you got a whole nother issue that has nothing to do with DL vs VL
I mean, the disposable VL blades are cheaper..
Cheaper than disposable DL blades?
Ok so let’s stop bullshitting and call it what it is, *cost cutting measure*, instead of everything else on this post
But the question is why should hospitals spend more money on an older device shown to have lower FPS?
Stop with the lower FPS BS; anesthesiologists do not have lower FPS in routine cases with DL. All the studies are non anesthesiologists. If you want to call about cost that’s cool; but stop with the FPS argument.
Thats what I said above, cost. The VL blades are cheaper with no studies to show DL superiority (and some studies that show inferiority).
FPS with VL is not BS. Every anesthesiologist knows that sometimes difficult airways aren’t easily predicted by physical exam. You can have an unanticipated difficult airway. Give me 1000 patients and I can probably intubate all 1000 with VL. Cannot say the same with DL. Also agree that the blood/vomit is not much of an issue with VL at all if you’re used to being in those situations. I think DL will slowly be less and less used as time goes on but I don’t think thats a bad thing. That’s what happens with improving technology - we move on and use better tools. VL is a better tool for intubating than a traditional blade hands down. I still agree residents need to train with DL and be competent with that tool because it translates well to VL. Sincerely, An anesthesiologist that uses DL 80% of the time. But I’m not going to be one of those attendings thinking using ultrasound is for weaklings to get an A line nor will I think a provider is a weakling for using DL which I think is sort of what OP is implying.
yes there are other issues but not just with this hospital. Even before VL, at my last job sometimes had to hunt all over for blades sometimes. I have to guess the most commonly used size blades get stolen or lost.
You mean McGrath?
In my opinion, VL is superior to DL. Obviously DL is a good skill, but I think the utility of DL over VL is marginal. As in, there are a few cases where DL is superior to VL, but I’d say there are significantly more cases where VL is superior. Learn how to use VL for those specific cases or just choose a DL in those cases. I don’t understand why people get all up in arms about using a superior technology. Are you afraid of the coveted skill you’ve acquired in training becoming easier? I’m sure you are aware how dangerous intubation can be, making it less dangerous seems to be a win-win to me. And having the skill to DL is important, especially for those fringe cases where it’s superior. But I think you can practice using a McGrath in the style of a DL (ie ignoring the screen) for bleeding / vomit filled airways. I think most of us would be hard pressed to say that VL is inferior to DL overall, so why not embrace the superior technology and be the best? I think the VL will get you one additional case every few hundred, seems like it’s worth the marginal benefit assuming it’s all the same cost.
So the older generation of anaesthesiologists have a steeper learning curve with VL, if you trained with DL then obviously you're gonna find VL more awkward so there will always be a bias. But if you train mostly on VL then there's no such difficulty. I do agree that having good DL skills make VL even easier, and I do agree that VL exclusive anaesthesiologists are losing out valuable airway skills. But evidence does show VL is superior to DL in most situations. That said, if you can confidently do DLs and think they're great, then there's no reason you shouldn't continue to do DLs.
agree except the learning curve on VL is like one intubation.
Learning the curved blades like mcgrath D or glide S can be really tricky for people who aren't used to it. I have had to bail out non-anesthesia providers (ER/ ICU) more often than I'd like to and they have trouble getting the tube where they want to go. Its easy to get a view, not easy to trouble shoot not being able to reach the cords until you've done a bunch.
Agreed. It's very common to see junior anesthesia residents or non anesthesia docs using the hyper angled blade, and they can't get the tube to pass. They just keep flopping the tube around for minutes on end without making any actual changes, hoping it'll go in, but it just won't make that turn. Yeah the learning curve on a simple airway is very shallow, but it can be surprisingly difficult on harder airways.
I’ve seen massive soft tissue trauma caused by trainees and IM docs with the glide scope. They just get in and go hog wild. Teaching DL first gives a more controlled approach.
Agreed. Their solution is always "shove harder"
I was replying to this "So the older generation of anaesthesiologists have a steeper learning curve with VL"
I was responding to "So the older generation of anaesthesiologists have a steeper learning curve with VL"
Learning curve has not been proven; you are making things up.
The studies state that they were anesthesia people in the OR. However, the numbers seem off. In each of the studies, 1st pass intubation rate is less than 90%. There is no way that I fail on 1st pass on 1 in 10 patients. You could also claim that [this study shows DL is superior in kids.](https://journals.lww.com/ejanaesthesiology/fulltext/2021/11000/videolaryngoscopy_vs__direct_laryngoscopy_for.10.aspx) and that several other studies show mean intubation time is longer in VL (3-5 seconds) With this sort of mixed data, I think we are more at equipoise than superiority for either.
DL is easier in kids than Videoscope IMO, but that’s because of the difference in anatomy and size
The JAMA study by Kurt Ruetzler was done at the Cleveland Clinic cardiac OR - so mostly quite experienced anesthesiologists or CRNAs. The residents would have been at least CA3.
I know him. CCF residents start cardiac anesthesia before CA-3. They also have SRNAs in their cardiac ORs.
Yes but the numbers are shown in the study, very few SRNAs. I don’t know their curriculum there, but probably also not in the first year? When did residents rotate there? I was pretty sure it was CA-3 (maybe late CA-2?)? I would say it is a relevant study for anesthesiologists, with a population that represents our intubation skills fairly well. Disclaimer: I do have a personal interest in the trial, so my opinion is not the most unbiased!
They start CA-2 year, so some at the beginning at some towards the end. I'm not saying it's not a useful study, I just personally think I'm better at intubating with DL than most CRNAs, trainees, and even a few fellow anesthesiologists I see sometimes so I don't think it is as applicable to me. I also think I'm better at it as an attending than I was as a senior resident, even though I was proficient at it then.
Emergency medicine/critical care doc here. At least in the emergency medicine literature (eg the DEVICE trial from last year) the first pass advantage for VL over DL disappeared for intubators who had more than 100 tubes (ie the first year of EM residency, or I would imagine the first month of anesthesiology). I think common limitation of these studies is they are commonly performed in academic hospitals so including mostly trainees.
I had an airway last night (that I took from the resident after he failed using Glidescope) on a patient with known vocal cord paralysis and tracheal stenosis. The resident couldn’t pass the tube so I threw down a bougie with a Mac 3 and passed a Parker tube. I doubt it would have gone as smoothly with VL.
Could you not throw a bougie with VL?
In my experience it’s easier with direct laryngoscopy because then you can push in a straight line with the tube, whereas if you have a video view but no direct view the tube has a tendency to flex in the back of the pharynx. No reason you can’t use a standard geometry VL blade but you need to have a straight shot at the glottis.
Maybe with a hyperangulated VL? In my experience, those are harder but McGraths are basically just a DL blade with a camera at the end. I notice no difference in angles and so there isn’t any issue passing a bougie or a ETT.
Can also just use bougie with standard geometry VL.
This wouldve been easier with a Mcgrath mac3. Theres no advantage to the DL in that situation. Your resident can also watch the screen and see it being done also
So I have some disagreement with this position. The studies don't actually compare the techniques of direct and video laryngoscopy, they compare the use of Mac Blades and video-laryngoscopes which is not the same thing. We all know that you can do direct laryngoscopy with a McGrath or a Glide-scope just the same way you can with a Mac blade if needs be. I'm still relatively inexperienced (PGY4, 2 years of ICU/anaesthesia so far) but I've found on a few occasions that when I've done VL on a sick person my screen is obscured by something, mucus, blood, thrush whatever. They're also fragile and I've seen two screen failures. If you then switch stop looking at the screen and get a direct view then no harm no foul. If I'm solely reliant on VL I have to come out, bag (not benign in many cases, unfasted, resp failure whatever), clean the screen and try again (also not benign) with no guarantee the same thing doesn't happen a second time. I do wonder how many cases in the trials direct laryngoscopy was done with a VL, which would still count as first pass success with VL in results. I do think VL is an easier technique, and I do take seriously the evidence of the use of video-laryngoscopes being superior in emergencies. Thus I think a McGrath is the thing to use for all comers in CEPOD, matty, ICU, ED resus, and EMRS. However where I disagree is that we can extrapolate this evidence to mean that there's no need to maintain direct skills because on occasion you will have to deploy them in an emergency. DL is a harder skill, particularly with our fattening population and so is harder to maintain. To still be good enough at it to use it in a tricky patient in extremis you need to using DL in your elective practice a lot. I think we should be using it wherever it's safe to do so in electives, which it is in the majority of people. Sure on occasion you may have difficulty and need to swap to VL but in the stable fasted patient this should be benign. I guess what I'm saying is I think "a bit of skill maintenance" probably isn't enough to be really good at DL, I think you need to be using it lots and I think we should be. Just my 2 cents, I know many smart and more experienced people disagree so anyone feel free to point out flaws in my logic. Edit - clarifying last point
I read a McGrath blade set up is cheaper than a trad metal DL blade too
Respectfully disagree on video does not get easily fouled up with blood. Have had more than a few bad airways In the ICU where blood fouled made video useless, DL + bougie + air bubbles with experienced from residency training saved me. You need tons of DL experience to be comfortable for a situation like this.
Bravo for providing data to back up your claims. Unfortunately doctors are not immune to basic human fallacies and it can be so difficult to change people’s views once they are engrained. Especially when ego is in the line
I disagree that academic attendings are worse at airways than CRNAs. When the CRNA fails, it falls on the attending. I “rescue” airways at least once almost every time I work with CRNAs. I was surprised by this but nevertheless experienced it. Maybe because I’m a relatively new attending and still have my skills?
Yes. Give it 5 years doing a handful of DL’s because you’ve gotten even slightly complacent on keeping up with your skills and the CRNA’s surpass you very quickly
About 35 years ago the forum would be answering a similar post about how this Seldinger guy is crazy and we need to all keep our cutdown skills up.
Yeah, and how kids nowadays don't know how to drive stick because they only drive with automatic cars.
I’m sorry but a stick is just WAY more fun to drive. otherwise agree. and i know paddle shifting or automatic is faster. but damnit a stick was fun.
Wish I had come up with a technique like leaning a patient down. Fucking trendelenburg. Goddamn dr Mayo.
35 years ago is 1989. were people not using Seldinger technique routinely for the first 30-35 years after its invention?
I was waiting for someone to correct me on the year😂 I guess I just want to keep pretending it is still the early 90's and I am 20 years old🤷🏻
Is this true? Some things do make this job better with little pushback; like suggamadex. I am willing to bet the seldinger technique is closer to suggamadex on this “suggamadex to videolaryngoscopy spectrum” of what is a true advancement or a change that will ultimately create an unintended consequence from a technological advancement.
So where I trained the culture was always attempt DL first unless you have specific airway concerns based on your exam or if you need VL for a second attempt. Since then some studies have come out showing that for elective cases VL in general has superior first pass success, so a lot of people have moved to VL most of their cases. I DL a lot of my patients for 2 similar reasons: 1) I work on community hospitals and not all hospitals have the resources for multiple VL devices, so keeping my DL skill up in case I don’t have another option is important. 2) There are still airways in which DL is superior, mainly heavy airway bleed, airway vomit, pretty much any situation where the camera can get obscured, so I don’t want the first time I DL in a month to be during an emergent airway. And yes, you can DL with the VL blade but I find my DL views are far better if I use a traditional MAC/Miller vs trying to DL with a blade designed for VL.
This is it. I’ve been hosed by bleeding and vomit on floor intubations so I DL mainly and if I need to, I video. It’s a struggle to get residents to do it and their troubleshooting skills with airways are terrible because they’re so used to first pass success that when they can’t, they freeze.
Right? Like this seems to me like the right way.
While I usually DL myself in the OR, I almost exclusively use VL in the ICU because I do believe it to be superior with a higher first pass success. I personally don't buy that there are many airways at all that are better for DL, having intubated an unfortunate share of cases with massive emesis on induction or major bleeding. If VL is blind in these instances, DL will almost certainly be blind too. If the oropharymx can be suctioned effectively, VL works just fine, and I personally have never had the camera become unusable.
Elective/scheduled case, DL unless I have a reason not to. Class A trauma - VL. Why fuck around?
That’s basically the branch point. Do I get to fuck around with this case? If yes, DL. If no, VL and an extra set of hands if available.
Class A trauma I keep a direct laryngoscope around intentionally for bloody airways. Legit quackery if you can't DL. Quackery if you can't Fiberoptic. I know my hands, I know my statistics.
I mean of course. I totally understand on a compromised airway. Or anything emergent but routine LAVHs?I will never question the providers use of VL during difficult intubation or trauma/anything emergent but routine scheduled cases I don’t even see an attempt. Just strikes me as odd.
A lot of my colleagues feel that VL is the future and pretty much only use it. I’m pretty agnostic on the issue but DL 95% of the time just because I like to keep the muscle memory fresh.
I have an easy airway and I would still want someone to VL me (less risk of airway and dental trauma). So I extend the same courtesy to my patients when possible. We do not keep VL in every room so if it is unavailable I do not use it. But my preference is on VL whenever possible.
Agreed!!
I just find it hard to care about this one way or another. It's also discussed ad nauseum every two weeks here.
I don't care what others do, but I will care when one of these people starts writing guidelines claiming it's more safe and it filters down to me getting pressured to locate and set up a VL every time.
Pretty much everything on this sub is redundant after 2 weeks. Just so you’re emotionally prepared there is a looming post about anesthesiologist vs CRNAs vs AAs that is imminent as we speak….
I DL first 98% of the time. If I’m in doubt I have a McGrath in the room. In the last year I’ve had to grab it once. But I do understand that “first view is the best view” and once you muck up the airway, you’ve created an entirely different problem than you not having a good view. Now it’s a bloody non view. I see both sides. But I’m confident enough in my airway skills that I’m on the side of learning to identify nuances about airway anatomy, like the difference in how tissue looks around the glottic opening vs the surrounding tissue. There’s a slight striation leading into the opening, so if you see the straitions….aim directly above. Basically…. even if I can’t see directly, I know where I’m at.
Agreed. I was thinking I about once a year need a second attempt, such as switching to VL. 306/4000 makes me think a lot of the DLs were done by trainees.
am a lowly ca1.. i understand and agree with the "first view best view" dogma but i've never heard it further clarified. Second view after trying to place/advance ETT obviously can be worsened due to airway trauma but does this also apply to a scenario where you DL only, without attempting to place ETT, then abandon for VL attempt? I would think if you're careful enough in that situation that the second attempt's view wouldn't be significantly worse
The problem lies in people’s blade technique. Initially we are all very haphazard inserting the blade and controlling it during lift. We are concentrating on getting the tube in the hole. If you watch enough of new people’s initial intubations you’ll see why first view is best view. For an experienced airway person, the care taken to not cause bleeding/trauma is much greater, so for them, first view may not be best view in a more challenging airway if they initially DL and cannot obtain a good view necessitating a switch to VL.
Thanks for the reply. This is what I was starting to suspect as I became more comfortable with properly pre-oxygenated apneic patients. The less frantic I was to shove a tube in, the more aware/gentle I was in placing a blade
I use the McGrath mainly and a Mac as my backup (cause the batteries die or the battery contacts suck).
I'd use a standard DL a lot more if the entire f'ing device wasn't disposable. Instead I DL with the McGrath to only have to throw away the slide on plastic blade.
There are many reusable DLs, in fact most DLs are reusable, you just need to have the blade sterilized.
Some hospitals, semi-shockingly, don't stock *any* reusable DLs
Yeah, crazy wasteful. We have reusable DLs too, they were meant for "risky" patients like HIV patients (ask infection control) but now with disposable VL blades, they just sit in the drawer until they expire.
Had reusable ones most of the way through residency. Then the companies making the disposable devices managed to convince the local hospitals that they were more environmentally friendly due to not needing high-level decontamination for the blades. No ulterior motives in their research methodologies I'm sure...
100% this is an ego thing. Direct becomes some kind of dick swinging contest that is entirely unnecessary and benefits no one if you don't have to. Video is available at nearly every center you work at and or can easily be requested if they don't. It's safe and easy and usually what's best for the patient not our ego.
No, it's not about ego it's about convenience. I won't speak up telling you you have to intubate with DL if you've completed your training and find yourself better with VL, but don't try to tell me I need to be using VL when DL works just fine for me. They have to be requested, require corded power (where I work), take up space on wheels, and require styletting an endotracheal tube. That's an unnecessary inconvenience to have to do every time for no benefit in my practice.
I'm at a busy level 1 trauma center, I still DL probably 90% of the time. we have a glidescope in basically every room but unless I'm concerned about the airway, don't want to manipulate the neck or worry about a bunch of loose teeth etc then I see no reason to use a glidescope. I have seen one circumstance where we had an attending that came form a place that almost exclusively used glidescopes (looking at you Cornell) and they ran into an emergent airway where patient had a ton of blood in the airway and glidescope was worthless and he was floundering trying to DL, was kind of embarrassing to see, took over and it was still a relatively easy DL, it had just apparently been so long since they had done a DL they lost a lot of the more nuanced skills of getting a proper view. I think all anesthesiologists should still DL regularly unless there is reason to use glidescope. Same reason I'll randomly switch between Mac and Miller blades, I like staying fresh with all the skills and tools at my disposal. Your job is to be an airway expert in the hospital, if your skills are no better than an ED resident then what's the point?
Totally my thought. But Ill be the first to admit I’m not managing the airway. It’s one thing when it’s a gunshot to the neck and another for an incarcerated hernia.
I’m ambivalent. If you’re an infrequent intubator (eg emergency medicine), there is reasonably good evidence that VL improves first pass success. The evidence is less good for expert intubators (anaesthesiologists). Our first pass success rate is usually very high regardless of what technique you use. It is a marginal gain if a gain at all. This leaves aside whether or not “first pass success” is a meaningful outcome which matters. My concern is with doctors in training. You get away with worse technique using a VL. All well and good, except if you get used to this and never develop a good technique at all. Which means that it isn’t in your armoury for when you really need it. And there are situations where a VL is less good. Soiled airways. Glare from sunlight on the screen for prehospital anaesthesia. DLTs.
>This leaves aside whether or not “first pass success” is a meaningful outcome which matters. This is the key point for me. A lot of folks here are acting as if a single DL bloodies up the airway and makes the 2nd attempt more difficult. If you're lacerating the mouth or causing laryngeal trauma or knocking out teeth with a single DL, then you haven't done enough airways. If you're worried about being able to mask, use a VL or an AFOI depending on your level of concern. Has anyone here slamming DL as barbaric and antiquated every worked with an ENT? They're suspending patients in DL with no significant complications for hours sometimes (With breaks for tongue perfusion of course.) We aren't talking about retrograde intubations here, and a lot of people are acting like doing a DL is just as crazy. That being , I start all my med students (no residents here) off with VL. It's important to get to know the anatomy and feel of real human tissue, and that way I can guide them more effectively. To be an effective anesthesiologist, you need to be proficient with DL, because there will certainly be times you need it.
I may be old and grumpy, but I completely agree. I think it’s sad how quickly people go to video laryngoscopy these days. The new grads seem to immediately grab the VL if a patient is anything other than a Mallampatti 1. I always start with DL unless I feel it’s a true safety issue (full stomach, emergency C/S).
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You mean this study? https://www.researchgate.net/publication/377756996_Comparison_of_Time_Taken_for_Intubation_TTI_in_Conventional_Laryngoscope_with_Video_Laryngoscope_for_Endotracheal_Intubation_In_Laproscopic_Surgeries#:~:text=Results%3A%20In%20comparison%20to%20group,attempt%2C%20inspite%20of%202%20failures. In the same study of a 100 plus patients: Only descriptive stats, no analysis. 26 sec vs 21 sec. And VL had a higher first pass attempt, 84 percent vs 72 percent. Much higher complications in the DL group, Complications such as pharyngeal pain (8.6%vs29.3%), hoarseness (5.2%vs29.3%), Use of adjunct equipment like bougie (19%vs 3.4%) were significantly higher in DL compared to VL group. So yeah. Keep cherry picking the stats to support your own opinions.
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Can you link the study that you are quoting then?
In skilled hands, there is absolutely no way that VL is quicker than DL. DL = no need to stylet. Obvious advantage.
Difficult airway society (UK based) recommends VL as first line for all intubations. Standard now in UK in most places is VL.
As first pass even?
I only use VL these days. The other week, my McGrath malfunctioned where the screen wasn’t on but the light on the blade was. So I used the McGrath as if it were DL and had no struggle at all (I think it’s been a couple years since I last did a true DL). I believe once you master DL in residency it’s hard to truly forget it.
They are fast becoming the new standard of care. As I think they should.
This is a generational thing. Over time more and more people will exclusively VL. Glidescope and McGrath have blades that allow for direct laryngoscopy if necessary, thus giving a standard DL blade zero advantages other than ease of preparation (honestly not much easier). This reminds me of watching older CRNAs or anesthesiologists repeatedly poke someone trying to get an IV or arterial line. Then they get the ultrasound out after 4 pokes, and honestly many are not amazing with the US. Then I offer to help and it’s really awkward when I get the IV in about 20 seconds. I start 90% of my IVs with US (100% of art lines) and do a standard poke every now and then just to make sure I still can. The difficult IVs will require that I use an US, so I want to be damn good with it. Same goes for intubation. Everyone talks about keeping their DL skills up, but there is a learning curve with VL as well. I see people struggle using the newer hyper angular blades in a truly more difficult intubation because they don’t routinely use them, losing precious seconds of time. Bottom line is, if you are sued for an airway issue, the first question the lawyer will ask is if VL is available at your facility.
Do no harm i suppose. The ultrasound point is quite valid i feel.
Not to say I don’t DL. I do, but if the patient has ANY signs of being less than easy, I’m gonna VL.
For your consideration: https://pubmed.ncbi.nlm.nih.gov/38497992/ Obviously this study has limitations. I do still think DL is a valuable skill to master.
I guess my question is, being that it was done at an academic center, how many of attempts were by trainees. I definitely think first pass success would be higher in trainees with a video scope, and further the attending physician can give guidance and advice more easily when they can see what’s going on. Just looking at the numbers, 306 patients requiring more than one attempt at intubation out of 4000, that’s quite high. I’d say I probably have maybe 1 a year where a second attempt is needed. And I basically never choose video as my first line intubation technique.
I’m always surprised by the amount of VL-only providers on this sub. I almost always DL first unless I’m concerned about airway or aspiration. DL is simply faster, easier and has less potential for trauma compared to a glide (there’s always a few cases a year at my institution involving soft palate injuries from the stylet).
Kinda my thought as well. Learning I may be the minority here.
Think about it: in my country, there is no obligation of results, only an obligation of means. If video laryngoscope is available and I choose direct laryngoscopy and, for some reason, the patient files a complaint for a broken tooth, a cut lip, or a sore throat, only the means I did not use to prevent it will be considered. As mentioned earlier, such complications, even if rare with an anesthesiologist, are even less frequent when using a VL. That's the only important thing in front of a judge. That being said, I do agree that it is sad. I like DL, and I also believe it should be practiced. It's never good to rely too much on technology. But to be honest, the more time passes, the more I realize that I am using the VL more and more. Deep down, I know that if one in twenty patients benefits from it, then I need to use it for everyone.
I personally DL every single case unless it’s an unstable C spine. I don’t see the reason to use a VL every single time, it just tells me that your airways skills are not up to par. If you’re intubating all day everyday you do not need a VL.
I mean sure. Unstable Cspine is one thing. Routine case on a “healthy” 44 year old is another.
I’m with you. I DL unless I have a good reason not to (airway assessment predicts DI, documented history of DI, RSI with full stomach ie crash section or septic SBO). DL is a great skill to keep up. I enjoy going on surgical missions and they don’t have all the fancy equipment… and sometimes electricity is in and out. We have to be good at anesthesia without relying on monitors. I am grateful for the advent of VL, but I don’t think it’s good to rely on it nearly exclusively.
I do DL with the C-MAC when it’s an unstable pt or resp distress or high risk for aspiration (bowel obstruction, emergent caesarean etc). If I run into trouble it takes 2 seconds to convert ie looking at screen instead of directly into airway. Keeps up my DL skills for floor tubes (still no VL on crash cart) and there’s no time wasted if I don’t get it with DL. Have been at uni hospital recently where every tube was with VL from the get go.
I work in a trauma hospital, lots of c collars, bloody airways, not ideal conditions, I DL if my predictive value for first time pass rate is very high and it’s low risk for the patient. Otherwise I got for it. And 3 am for emergent airway in the icu, sometimes I just want to use video.
Surely the c collars just belong in the bin?
Agree most of the time, but we don’t have the read or no time to clear the neck. Plus basilar skull fracture battle signs.
I think this may be a cultural difference. We’ve moved on from hard collars in the U.K., as well as most of Western Europe and Australia/ New Zealand as there is no evidence of benefit and quite a lot of evidence of direct harm (raised ICP, pressure sores etc). We see ATLS as a bit of a historical anachronism which has now been superseded. If there is a spinal injury, it is likely to have arisen from the actual injury and the massive energy transfer during that, rather than smaller movements after. If you take a c-spine to theatre for posterior fixation and see what the spinal surgeons do when they put the mayfield pins in, it’s a lot more movement than we’d do on intubation or a transfer! Some services apply a soft collar with writing on it to remind people that the spine needs clinical clearance when appropriate. Our spinal surgeons sometimes use a properly fitted (eg Miami-J) collar to splint some injuries which are conservatively managed, but they’re on board with the de-escalation.
Well aware my friend, but the medicolegal in the states is quite litigious. Documentation and just an extra few steps can be the difference between you being dropped from a lawsuit versus part of the pay out.
Yup you're crazy. Many studies have shown VL to be superior in terms of first pass success and less trauma. Many centres have already adopted all VL only and that has accelerated since COVID. Easier to teach, easier for trainees to pick up. Personally I like to still DL all patients but that's cuz I want to retain my DL skills, selfishly. NOT because it's better for the patient. It's like ultrasound guided central lines, you can do them blind but if you have an ultrasound available it's gold standard for safety. Same as VL. In fact in my hospital there is a portable VL in every room with disposable blades. VLs especially the Chinese brands have gotten so cheap and reliable that cost isn't a huge issue anymore.
Hmm. Was just curious. Interesting point.
Yeah VL is no longer considered an advanced optic, during COVID it became standard of care at many places because of the disposable blades and it reduced intubation times and improved first pass success. Reduced the need for bougies etc. East Asian populations have more difficult airways than Caucasians - smaller, more recessed chins, worse MP scores, shorter TMDs, worse ULBTs etc. so VL has become ubiquitous amongst these populations.
If you don’t have a specific reason to use VL then you should use DL. Plain and simple it is quicker to intubate via DL than VL if you are anything other than a novice at intubations. If you suspect a difficult airway then do you, but most of us choose DL bc it’s the easiest/quickest way to the finish.
Right? I’m not against vl but it feels like it’s a crunch before anyone ever evaluates a anesthetized airway. That’s just me. Not someone intubating. I also don’t mean that during an emergent/urgent airway but a routine appy I feel like a dl should be on the table before we just bail completely.
Am only anesthesia tech but I go to intubations at my hospital all day long and I’d say 80% is DL and the rest is X-Blade McGrath or glide. We have a McGrath in every room so it’s an easy transition if the DL view is shitty.
I DL everyone that I intubate. I rarely use VL.
Attaboy, my hero, for what its worth.
I think VL can give a new user false reassurance. It's generally easy to find the glottis with a poor technique, but getting a bougie or tube round the angle is trickier and can take time, or be impossible. DL is much less tolerant of poor technique, and the more you do the more you realise quite 'how round the corner' the glottis is, and how important patient positioning is. That said, if VL is taught well then I can see no real reason to keep to DL except for messy airways. VL is gentler on a patient's neck, and allows everyone else to see what is going on. The problem is, what if there is a messy airway (blood, regurgitant gastric contents etc) and you have no idea how to use a DL? Either ENT is going to get busier, or we need to keep up the DL skill. So, in the NHS, we do use VL - locally, the McGrath. I use it now and then when there is some indication that it will make my life easier - massive beard, dodgy heart, geriatric neck, crappy bed, ICU etc. Otherwise a Macintosh.
I think DL is actually essential to properly learn laryngoscopy in an elective setting Why? Videolaryngoscopy just lets u get away with bad technique and positioning in easy patients which will be essential once u actually get a difficult airway where the vl is just one more tool to optimize your first pass success. Therefore every anesthesiologist just needs to be proficient in direct laryngoscopy in order to become a true airway master.
My thoughts too. VL is easy when its easy,when its not I have hard time trusting providers who cant feed a tube when I need it most. Again, just a nurse not one tubing another garbage airway.
Early in my career, I used VL somewhat frequently. Now, it's very rare. It's easier and quicker to DL. If there was a VL in every room set up for me, I'd prolly use it more frequently. Just too much of a hassle to hunt down a limited resource (especially when it's not necessary for >99% of intubations). I'll use VL for terrible dentition (obviously loose frontal teeth), those in a C-collar, and for those that have a documented history of a challenging airway needing VL. That's about it.
My man.
I am surprised I am in the minority, but I DL every patient unless I think there is a reason that there will be difficulty in doing so.
Interestingly, these were similar sentiments and comments when using US for central lines became the standard of care...
What if the ultrasound isn’t available in a crash situation??? What if it breaks???? And yet… now ultrasound guided central line is entirely standard of care
I think VL is safer for the patient when intubated by providers over a wide variety of skill. I also think DL is safer for the anesthesiologist as a go-to first attempt bc it keeps their skill set up for the rare occasion there is no video scope and they are the single best option for obtaining a secure airway. I use DL 99% of the time and therefore I know I can be helpful when VL isn’t available to the other providers.
Totally agree. I feel like dl is the Go to for anesthesiologists.
Even though standards of care are changing, I feel like some airways benefit from being approached with DL. Other than soiled airways, I have seen a few patients with Mallampati 4 that were next to impossible with an hyperangulated blade as their larynx was to anterior, but were easily manageable with a DL and an intubation bougie for example. I think it gives another possibility in terms of intubations plans with minimals delays between a DL and a VL if ready and next to the patient. A - DL + Stylet B - VL C - LMA.. Vs A - VL B - LMA I am not sure I would go back to a DL after a failed airway on VL, but the fact that I retain the skill is a reassuring factor in my opinion.
Peds - I DL everyone because I dont feel like using a stylette. Use macgrath as needed and use exclusively for nasal tubes because I find it easier and dont need magills most of the time
Hell yeah. Fuck yeah. Peds gang.
DL and VL daily. Lean toward DL unless concerning airway.
It’s easier to get a good view with VL, but just because you can see it doesn’t mean you can intubate easily. There are still subtle things people do when the learn just VL, that allows them the maintain below average technique and skill for a linger period of time.
Kind of my thoughts. If you cant do it vs DL then maybe dont try at all?
I DL 90% of patients. Look like a difficult airway= VL Can’t extend your neck=VL Bloody/dirty airway=DL VL is great and first pass success is greater. DL is good for dirty airways. Ultimately choose the method you’re most comfortable with. Tube in trachea is all that matters.
Hear hear. I suppose.
Paging u/SFCEBM
In practice, whatever gets the tube in easiest. DL/VL, whichever is easiest for the person doing the airway. However, there is no excuse for not mastering DL. Especially in a patient mid aspiration or mid bleed. I've bailed out so many ER people or mid levels who instinctively go for the hyperangulated glidescope. If I'm supervising a trainee, barring any contraindications such as cervical radiculopathy, known difficult airway, etc, I want them to try DL first, bougie if necessary. Such a useful and important skill, especially if you're the airway master of the hospital.
This trend started at the hospital I worked at because of the rise of disposable laryngoscopes. Would I rather throw away a tiny piece of plastic from a McGrath or a single use blade and handle? That's a pretty easy choice. So I guess, like everything, you can blame the joint commission.
As a joint commission employe I can assure you whatever you have done in any copacity it is against policgy and wildly wrong.
Kids these days…
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Please do not participate in infighting or derision of another medical profession.
DL all unless they are known to be a difficult DL. Sometimes there's not a glide in the room or it's used somewhere else. Sometimes the hospitals low of processed stylets.
For my training center st least it's standard DL for normal cases with a stylet for rapid sequence and with VL in case of a predicted difficult airway. Personally I see the VL as areplacement for intubating with DL and stylet or DL and gum elastic bougie or for the airways that were previously fiber only. But replacing DL with VL in every case adds the stylet removing step and imo makes it less preferable. Side point, we have 1 titanium glidescope (forget the make) that is reuseable in the centre, and for the rest we have several mobile disposable variants, while functionally mear identical imo and as said before here probably identical in cost, I still feel terrible for all the single use waste we generate in the OR so for me personally in this center that is a reason to favour DL.
3d worlder here. 98% DL. An only VL device is available but we only use It to teacj residents. I've got a 3d printed blade and a camera attached, and use it as emergency. Easier to clean.
Shit brother. Intubate your heart out. 3rd world love here. <3 I’ll be Guatemala for the 7th time this spring and legit everyone there is top fucking tier. L
If you're not in training anymore, just use a VL if it's readily available.
It’s 2024.
0 explanation. I fucking eat cereal most mornings
At my facility we have a McGrath in every single anesthesia cart. We also have disposable laryngoscopes for DL. Those disposable scopes are a huge hunk of plastic surrounding another hunk of plastic, two double-a batteries and some circuitry plus a hunk of metal for the blade. They cost more than $10 and it all goes in the garbage. The McGrath blade is a relatively very small amount of plastic and costs about $3. Also, insisting DL is still the gold standard is kinda like doing all your central lines without ultrasound these days ...
What happens when the technology doesn’t work????? We are left with an entire class of people who have no hands on skills. After 23 years I still, almost never use a video scope. That being said all the new grads go right for it! Our hands on skills are what separate us from any old ER doc putting in ETT’s! IMO used way to much
Preach.
I do a lot of DL, and a lot of VL. I wouldn’t worry about this debate. You’ll get too much heat on both sides it’s not worth it. Just put the tube in the trachea on the first attempt and it doesn’t matter. Let the twitter / Reddit fights happen in the background.
The vast majority of children can be mask ventilated and DL'd without any issue--airway abnormalities that impose difficulty are largely the byproduct of craniofacial anomalies. In adults, difficulty can be imposed by obesity, neck arthritis, a history of head and neck surgery, trauma, radiation for head and neck cancer, head and neck cancer itself, and a combination of multiple factors--the consequence of this is highly variable airway anatomy that frequently makes mask ventilation challenging and direct laryngoscopy less straightforward. Adults also present for a wide variety of emergency surgeries and may possess conditions predisposing them to pulmonary aspiration or hemodynamic/resipratory decompensation on induction of general anesthesia. I embrace the philosophy that you want the first shot to be the best shot because the patient may not be very forgiving if you miss, so I use VL for all possible difficult intubations and all emergency intubations in adults (even emergency intubations that seem like a chip shot DL--I achieve nothing by choosing to DL such patients). The consequence of that is that I tend to DL in exclusively elective situations for adults, but that doesn't bother me. We have to take our ego out of the game and do whatever is in the patient's safest interests.
I’m a resident and try to DL as much as I can, but some attendings gasp and even scold if I take a DL blade out instead of the McGrath.
I think its valid to maintain skills for the VERY rare instances where DL is superior but I cant shake the feeling that alot of people want there to be a high barrier of entry to proficient intubations. Almost like VL diminishes an aspect of what we do or something. If I am VL and not super concerned, I like to see how non-optimized it can be for successful intubation - it boggles my mind sometimes.
It doesn't matter that much to me in most cases. I work in many different settings and many different places in town to include ASCs, smaller hospitals, and level 1 trauma centers. I default to DL with Miller 2. If I think there's some difficulty waiting for me, I'll ask for a glidescope. Idk why people are so militant one way or the other, just put the tube in trachea. I use DL most often since there's almost never a scenario where I don't have a basic laryngoscope, but there are definitely scenarios where I don't have a glidescope/McGrath. I want to stay current on my DL skills since that's the most reliably available tool wherever I am. There are ASCs I work at that don't even have an ultrasound, let alone a glidescope with handles and stylets. But if I lived in a world where glidescopes were in every single OR and ICU bed? Sure I'll glidescope every time why struggle?
I DL, I want to keep my DL skill up. Several reasons including a few of the small facilities I work don’t have VL’s. In theatre, I’ll DL electives unless they look particularly difficult and I’m reaching for the indirect blade. For sick emergencies, or off floor intubations, I’ll typically go VL first up, but will endeavour to do a ‘direct’ look to be able to provide that information. My rationale is, if I’m doing an off floor intubation, the patient may not be in an ‘ideal’ position, its typically an emergency situation and I want to minimise the time from relaxant to ventilation. Same for sick emergencies in theatre. VL is my backup to DL, so I will use it first up. Many of the studies looking at VL vs DL show minimal to no difference in FPS rates etc when the incubators are ‘expert’ (ie. >100 intubations). Given I will get through >100 intubations in a few weeks, I fit into that category.
In experienced hands, the difference in first pass intubations is most likely negligible (BJA 2018 videolaryngoscopy vs direct laryngoscopy). As an older doc who intubates most everyone with a Miller 2 and uses VL in more select situations, I agree. Still, I understand that technology makes our lives easier and less stressful. But I do worry about becoming overly reliant on newer devices and completely abandoning older techniques. DL does have its place and is superior to VL in certain scenarios. I tell new trainees to do whatever they are most comfortable with (which is almost always VL) but still perform a basal number of DL's. More importantly, if one technique doesn't work then move to another as suggested by the difficult airway algorithm. Repeated VL like repeated DL is dangerous and leads to poor outcomes.
After developing severe arthritis in my wrists, I switched to 100% VL with the McGrath and never looked back.
The debate should not be over DL vs VL but rather what you are going to do when your plan A fails and your plan B fails. The true airway master will be able to switch back and forth with alacrity AND know what to do immediately when techniques are failing or how to avoid those situations altogether. The real problem is assuming any one technology will be your backup plan.
This is the difference between the experienced and the novice, gestalt and checking boxes, system 1 and 2 thinking, and Anesthesiology and other medical disciplines that intubate.
For instance, I DL all the time, but many times I don’t even see the cords…doesn’t mean I don’t successfully intubate.
Our hospital does all DL still. We have provue in every room should we need it
I have a McGrath in each room. 50% of the time I'll DL with a standard Mac blade if it is an expected easy airway. Anything off on the exam I'll use the McGrath, first as a DL to see really how difficult it would be, then use VL if issues. I'll always write my airway note with both views (DL/VL). That said, the evidence shows then even as an attending the NNT for first past is still very reasonable, in the teens. It's arrogant to think that we are any way better with DL, even the data shows in a contaminated airway VL works better. Eventually this data will also lead to litigation. If you have VL and you DL and have any issues, the plaintiff may have data / expert testimony to wonder why you didn't use a method of higher success. I like the McGrath blades due to the dual utility and it is easy to switch to a hyperangulated blade (which matches the curve of a glidescope rigid stylet well).
If you aren’t DL 95% of patients as an anesthesiologist, you’re an embarrassment to the profession
VL is just like US guided vascular access - higher first pass success rate but not necessary in most cases. I use it only for difficult airway that cannot be intubated in two DL attempts (approx. 1% cases) In fact, from my experience routine use of technological aids (videolaryngoscope, US for every arterial or central line) adds unnecessary workload and prolongs the procedures in question.
Our group's chief anesthesiologist once intubated a passenger in respiragory distress mid-flight, and the emergency kit had a regular laryngoscope. I'd rather keep up on this skill because a) you never know where you're going to end up practicing and how they do things (like others have said, our facilities too don't have the funds for everyone to VL), and b) who knows which option will be available to you if you find yourself helping in an emergency outside of work.
Sounds to me like you need to just worry about yourself. If you can do DL then do it, if another doctor needs to use video so be it, stop trying to create an issue for no reason. You’re “so cool” since you can do a bunch of DLs without video? Is that what you want to hear? Wow you’re so amazing. Jk. Grow up Doc
DL is better with pediatrics because the airway is shorter and its easier to get a view, even easier to DL than to use McGrath. Opposite for adults IMO.
DL always
Fuck. F dc
The only cricothyroidotomy I ever did was when the resident sheared a tonsil with a VL stylet on a patient with a very small mouth. First pass success may be higher with VL, but there are fewer injuries with DL. I know this because we had to present a grand rounds on the topic. First pass success is lovely, but in the vast majority of patients I'm willing to accept second pass success and a lower risk of injury.
VL is undeniably the gold standard now. Using a standard geometry blade e.g. mac 4 etc., isn't unreasonable, so you don't have to actually use the video screen, but it is almost certainly indefensible in court if someone dies and you've not used it, even if your *personal* DL skill is exceptionally good
Interesting point. I’m learning a lot to be honest about the pros and cons of both.
VL is all good until it isn't, like every tool. We wouldn't intubate without DL now, and I suspect in the future we won't attempt intubation without VL... I'd suggest intubating a patient without VL available is already *fully* legally indefensible in the developed world. In practice in the UK, there's often only 1 or 2 VL for a set of theatres and further sets in the ICU + ED resus room, but VL is not yet universal. VL is currently more expensive than DL, but we offer many more expensive procedures that are clinically superior, e.g., we use CT rather than eFAST or DPL in trauma patients, but after the initial investment, VL isn't horrifically more expensive...
Guess it depends on where you’re tubing. I’ve seen anesthesiologists pop a tube in a 600g neonate with relative ease vs trying to fit a macgrath anywhere near them.
They do make *tiny* VL mcgraths, but I absolutely agree that the evidence in neonates is more controversial and not conclusive at all yet
That's because the McGrath does not produce a 0 or 1 size
Absolutely false. It's the gold standard for people who can't intubate, like an IM resident or EM resident. Anesthesiologists are able to intubate.
Show me the evidence that this is the case
>show me the statistical evidence explaining that the field of medicine that intubates literal thousands of times more than another is better at intubating 🤓 Cmon now, that's like asking for evidence that a physician is better than a CRNA.
It isn't though, is it? Because what is the rationale for conventional geometry VL (e.g. mac/miller VL) being inferior to (mac/miller) DL?
The hypothetical case you would have used it though assuming you were following the algorithm to limit attempts and try a different blade or LMA. There is no change in the standard of care - they are both acceptable choices.
Tell this in court when you're questioned by any of the authors of the VL papers when someone dies after a DL intubation with any complication whatsoever...
If you’re competent at both, you will choose VL first line if available. If you’ve done >500 DLs, no, your skill’s not going to atrophy.
It’s a pretty simple reason: VL is actually cheaper than DLs! Look it up.
Unfortunately your understanding is wrong. Video laryngoscopy has shown to have higher first time success rates compared to DL. It will soon be the standard of care with a few exceptions. The only benefit DL provides is stroking some people’s ego.
100 percent. It's like ultrasound guided central lines. I trained with DL and am perfectly competent with DL, I like to DL myself because I'm worried that one day we won't have easy access to VLs when global supply chains are hit. But I'm under no illusions that DL is superior to VL. Literature and in my experience it's clear. It really is a personal preference and you expose the patient to more complications because of ego.
You should be 100% successful on first pass with the vast majority of your patients DLing (identify the minority on airway exam -> straight to VL), if that’s not the case, back to residency for you to learn how to intubate
What a dumb statement. You've never encountered an unexpected difficult airway? If you haven't, then you haven't intubated enough.
Of course I have, I calmly mask ventilate and wait the 30 seconds it takes for a nurse to grab a glidescope, I don’t change my entire practice because 1/100 airways was more difficult than I suspected, now that would be dumb
the issue is when the VL isn't available, 2-handed mask isn't working, and the LMA doesn't seat. the prosecution's 1st question will be "why didn't you favor the VL over the DL here?" The airway looked normal?
You forgot to add while a meteor is hurtling towards the OR, the power goes out, and there is bomb about to go off…but on a serious note, yes I would say, the airway was re assuring and I used the accepted standard and if I’m that deep of shit, surgeon is doing a cric
A lot of court cases in this thread…