Video laryngoscopy should be “standard of care”

Hopefully you will have been following the video laryngoscopy standard of care debate on EMRAP. If you haven’t, airway guru Ron Walls stated a few months ago that video laryngoscopy was the standard of care. He got slammed and had to back up a bit.

My much less expert opinion is with Ron. While video laryngoscopy is not standard of care yet, it should be. If you have a video laryngoscope, eg a Glidescope or C-Mac, in your department but chose to use an old-fashioned laryngoscope and there is a failed intubation and a poor outcome how are you going to defend yourself and how are you going to live with yourself?

And if you haven’t got a video laryngoscope in your department, why not? If I could get one into our back water ED 2 years ago, you can get one.

Personally I’m a C-Mac fan for ease of use and the ability to use it as a direct laryngoscope if there is too much blood and secretions down the hole to get a good video view.

Use a video laryngoscopy for every intubation so that everyone is familiar with it – rather than trying to get the hang of it when confronted with a difficult intubation. The whole team can see what is going on down the hole, I can see whether or not my colleague got the tube down the right hole.

That’s my 2c worth.

And a reminder to check that you are getting a good picture through the scope before you use it. Sometimes the techs don’t quite get all the goobies off the video lens – give it a wipe with an alcohol swab and you are back in action.

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  1. Well Chris, as you know I have a slightly diffeent take on this. Although I agree that it is a nice toy to have I totally disagree that it should be “the standard of care”. There should NOT BE a “standard of care” in these cases. Current evidence suggests no real difference between the traditional and video laryngoscopes and both had documented cases of failure with one followed by a success with the other. What this suggests id that, most of the time it does not matter what you use, but sometimes you need to try one and then convert to the other. Your argument about defending yourself is not ethical- we are not supposed to do things to be able to “live with ourselves” but to make the pt better. If you take the VA scopes as the “standard of care” and fail with it, all you achieved is that you can defend yourself, the pt is just as dead though and may be more likely do be so because you did not consider using an old fashioned scope since you used the “best there is”.
    The cost difference is not insubstantial and the ongoing cost is also much bigger since they are more likely to break down. Since we are on the subject what are you going to do if the scope does break and you have never used a standard one?
    The bottom line is- if you can afford one, go for it, but it rarely makes a difference and make sure you can still use the old fashioned one if you are failing with the expensive toy.

  2. Ah, can always rely on you to have a contrary opinion, and it’s great to have some lively debate :-)

    I’ll let you and Ron Walls argue about the evidence as you are both much better at it than me. From what I heard from Ron’s talk the two types of scopes are only equivalent in very experienced intubators hands – and that is not most ED docs.

    What do we do if the scope breaks? Well, with the C-Mac at least, it’s pretty much the same action as an old fashioned laryngoscope so we can just use the the old one, which we keep as back up and test before each intubation.

    Thanks for your input.

    :-)

  3. Hi guys. you are both right.
    the standard of care is a provider who can execute a failed airway drill without hesitation and not get caught up in glottic fascination syndrome.

    I think we should still teach DL. I also think VL will eventually become best practice standard for orotracheal intubation and will become personally affordable to all. so then it will be user choice.

    but seeing the cords, getting the perfect view is not the whole shooting match , is it?

    check out this very recent case
    http://thebluntdissection.com/2012/10/26/a-difficult-airway/

    The caution outnof that case is that the quest for the perfect view,made even more seductive with VL, can lead us down a deadly path..that maybe v hard to return from.

    so in fact the standard of emergency airway care is a provider who knows when to stop and move onto the next part of their failed airway drill. its got nothing to do with VL or DL.