The 61th Ontario Medical Association Anesthesia Meeting Videolaryngoscopy should NOT be the Standard of Care for Routine Laryngoscopy Matteo Parotto, MD PhD Assistant Professor Department of Anesthesia University of Toronto Staff Anesthesiologist and Intensivist Department of Anesthesia and Pain Management Toronto General Hospital

Disclosure

University of Padua Founded in 1222 Schola medica 1250 Galileo Galilei Pietro d’Abano Giovanni Battista Morgagni Elena Cornaro Piscopia insert map (in a previous slide)

Andrea Vesalio De humani corporis fabrica 1543 Med Hist 1971; 15; 336-51

Dr. Philip Jones

Use Videolaryngoscopy for Success rates? Use Videolaryngoscopy for Routine Laryngoscopy! Impaired direct laryngoscopy / fiberoptic intubation skills? Complications?

Success rates

improved view when compared with direct laryngoscopy, but that does not necessarily translate to better intubation success

Brown CA 3rd, et al. Ann Emerg Med 2010;56:83-8. Brown et al compared direct laryngoscopy and videolaryngoscopy (C-Mac Videolaryngoscope) in 198 emergency department patients 22% of the glottic views graded as CL 3 or 4 during direct laryngoscopy remained the same during videolaryngoscopy Brown CA 3rd, et al. Ann Emerg Med 2010;56:83-8.

They found a failure rate of 7.5% Cavus et al evaluated the C-Mac during prehospital emergency intubation performed by physicians They found a failure rate of 7.5% For both these studies, the reasons for failed videolaryngoscopy were technical problems (eg, low battery, monitor malfunctions) or obstructed view due to blood and secretions Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597. Cavus E, et al. Emerg Med J 2011;28:650-3.

In a retrospective study of 822 emergent intubations, Sakles et al In a retrospective study of 822 emergent intubations, Sakles et al. reported equivalent overall success rates with use of the Glidescope VideoLaryngoscope vs Direct Laryngoscopy (84% vs 86%, respectively) Ural et al. compared endotracheal intubation before and after Glidescope implementation in an ICU, and did not observe a difference in the success or complication rates of emergent airway management Sakles JC, et al. J Emerg Med 2012; 42: 400-5. Ural K, et al. Crit Care Resusc 2011; 13: 89-96.

Our study demonstrates that visualization of the vocal cords was improved by using the C-MAC videolaryngoscope compared with direct laryngoscopy Better visualization did not improve first-attempt success rate

Paolini JB, et al. Can J Anesth 2013; 60: 184-91 NOT ALL airway situations and complications can be dealt with using video-laryngoscopy Paolini JB, et al. Can J Anesth 2013; 60: 184-91

Aziz MF, et al. Anesthesiology 2011; 114: 34-41. The strongest predictor of videolaryngoscopy failure is altered neck anatomy, presence of a surgical scar, radiation changes, or a mass Aziz MF, et al. Anesthesiology 2011; 114: 34-41.

Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597. It is reported that direct laryngoscopy was the main rescue technique in some cases of failed videolaryngoscopy Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597.

Aziz MF, et al. Anesthesiology 2011; 114: 34-41. Providers should maintain their competency with alternate methods of tracheal intubation, especially for patients with neck pathology Aziz MF, et al. Anesthesiology 2011; 114: 34-41.

Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597. Oropharyngeal blood or secretions rarely obstruct the laryngeal view during direct laryngoscopy unless massive bleeding occurs However, a single drop of blood or smear of secretion on the lens or video chip completely obliterates the view with the videolaryngoscope Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597.

Paolini JB, et al. Can J Anesth 2013; 60: 184-91 Competency? Paolini JB, et al. Can J Anesth 2013; 60: 184-91

Complications

Complications of videolaryngoscopy Intraoral injuries such as palatopharyngeal, anterior tonsillar pillar or soft palate perforations, are reported Not with direct laryngoscopy!

Complications of videolaryngoscopy The common factor associated with such injuries is the blind advancement of the endotracheal tube When upward force is applied to the videolaryngoscope to achieve better laryngeal visualization, the tonsillar pillars and related structures may be stretched taut and become susceptible to perforation Cooper RM. Can J Anaesth 2007;54:54-7.

At our institution, we have a statistically higher rate of injury using videolaryngoscopy compared to direct laryngoscopy The right tonsillar pillars and soft palate are the most frequently injured, with through-and-through perforation of the soft tissues being the most common type of injury

The most common repair of injuries required simple closures, and long-term harm was very rare

Impaired direct laryngoscopy / fiberoptic intubation skills?

Aziz MF, et al. Anesthesiology 2011; 114: 34-41. Even the most enthusiastic providers of video-laryngoscopy should maintain their competency with alternate methods of tracheal intubation, as intubation with videolaryngoscopes is not always successful Aziz MF, et al. Anesthesiology 2011; 114: 34-41.

Maharaj CH, et al. Anesthesia 2007; 62: 272-8. The substantial decline in direct laryngoscopy skills over time emphasize the need for continued reinforcement of this complex skill Maharaj CH, et al. Anesthesia 2007; 62: 272-8.

Other drawbacks

Paolini JB, et al. Can J Anesth 2013; 60: 184-91 If physicians involved in airway management are trained to use videolaryngoscopes as first-line tools, then these devices should be available at all times in every environment where they could be needed (ED, ICU, hospital wards, pre-hospital) This implies regular checking and maintenance of several costly devices Paolini JB, et al. Can J Anesth 2013; 60: 184-91

Canadian Airway Focus Group. Can J Anesth 2013; 60: 1089-1118 Documenting the difficult airways patient letter at discharge transfer of information while in hospital bed/room DIFFICULT AIRWAY sign specific tool within the Electronic Patient Record? local/national databases? insert image of difficult airway sign? Canadian Airway Focus Group. Can J Anesth 2013; 60: 1089-1118

Paolini JB, et al. Can J Anesth 2013; 60: 184-91 If intubation is easier, a potential danger could be a casual attitude toward airway management Video-laryngoscopes have the potential to provide a false sense of security, leading the anesthesiologist to omit basic safety rules Paolini JB, et al. Can J Anesth 2013; 60: 184-91

Conclusions

Paolini JB, et al. Can J Anesth 2013; 60: 184-91 Video-laryngoscopes have the potential to increase patient safety by facilitating learning, teaching, and success of tracheal intubation Video-laryngoscopy has the potential to become a first-line option for intubation in the near future This shift implies: The development of new algorithms to define the proper role of each type of video-laryngoscope and to identify appropriate alternatives in case of failure Adequate skill acquisition by operators Paolini JB, et al. Can J Anesth 2013; 60: 184-91

Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597. For now at least, direct laryngoscopy remains a relevant skill for those able to complete substantial training in controlled circumstances Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597.

Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597. With further refinements in technology, however, this may no longer be the case. Is it time for direct laryngoscopy to “rest in peace”? Probably not just yet– but it should start getting its affairs in order and drafting a will. Rothfield KP, et al. Journal of Clinical Anesthesia 2012;24:593–597.

Dr. Philip Jones

Thank you for your attention Thank you for your attention. *questions?* Thank you for your attention