0:00

Welcome

0:00

back to RebelCast. I'm your host Salim Rezaei

0:03

and this is episode 121. And

0:05

today we're going to be talking about the battle

0:07

of the blades.

0:09

Video laryngoscopy versus direct laryngoscopy,

0:12

specifically in relation to the device

0:14

trial.

0:15

Now, many of us know there's been this ongoing

0:18

debate whether we should be using video laryngoscopy

0:21

or direct laryngoscopy as our first choice

0:23

for successful first pass intubation.

0:26

There's a huge, huge, huge debate

0:28

in the airway community, and you

0:30

have to go no further than social media to see the

0:32

back and forth on this. But today

0:35

we're going to talk about a recent trial that

0:37

got published, the device trial,

0:40

and

0:41

which one is actually better for first pass

0:43

success. But before I get

0:45

too far into that, let

0:47

me introduce not one, but

0:49

two people that are going to help me with this paper who

0:52

did pretty much the entire write

0:54

up of this paper. Marco Propercy

0:57

and Will Smith.

0:58

Guys, Marco, why don't you start? Tell

1:00

us a little bit about yourself, where you work, what

1:02

you do, and then Will, why don't you follow

1:04

up and let us know as well.

1:06

Hey folks, it's Marco Propercy here. I

1:08

am vice chair of emergency

1:10

medicine and assistant program director at

1:13

New Vance Hospital in Poughkeepsie.

1:15

And I'm also associate editor of Rebel

1:17

EM. Hey guys, my name's Will. I

1:19

just graduated as a resident. Dr.

1:22

Propercy was actually one of my

1:24

attendings up in New York. And

1:27

now I'm back where it all started

1:29

in Northern California where I used to work as a tech and

1:32

kind of got the itch to go to medical school.

1:35

Thank

1:35

you guys for taking the time to do this. I know

1:37

we were working on our crazy schedules and finally

1:39

found a time that works for all of us. Will,

1:42

why don't you start us off? What's the paper

1:44

that we're going to be covering today? So this paper was

1:46

written by

1:48

Precker, Driver, Trent et al.

1:51

It's video versus direct laryngoscopy

1:53

for tracheal intubation of critically ill patients.

1:56

It looks like it was published in New England Journal

1:59

of Medicine.

1:59

June 16th, 2023.

2:03

And Marco, what's the clinical question these authors

2:05

were trying to answer?

2:06

Selena, the authors were trying to determine in critically

2:09

ill patients, does the use of video

2:11

laryngoscopy compared to direct

2:13

laryngoscopy improve first-pass

2:16

success rate of intubation?

2:18

And Will, can you just briefly tell us a little

2:20

bit about what these authors did? Yeah,

2:23

so this is a pragmatic multi-center, unblinded,

2:25

randomized parallel group trial

2:27

that combined both video and direct

2:30

laryngoscopy for tracheal intubation

2:32

in critical patients. There were a total

2:34

of 11 medical centers throughout the US, just

2:37

over 1,400 patients from 17 different sites, including

2:41

about 10 ICU locations, as

2:44

well as seven emergency departments. And

2:47

the trial was

2:48

registered on clinicaltrials.gov. Perfect,

2:51

and so they included basically adults

2:54

that were aged greater than or equal to 18 years

2:56

of age and were undergoing orotracheal intubation

2:59

and located in a participating unit. Exclusion

3:02

criteria, I'll list in the show notes. And

3:05

Marco, let's talk about the primary

3:07

outcome. What was the primary outcome of this paper?

3:11

The primary outcome was successful

3:13

intubation on the first attempt. The

3:16

authors defined the primary outcome as

3:18

the correct

3:18

placement of endotracheal

3:20

tube with a single insertion of

3:23

the laryngoscope blade and

3:25

endotracheal tube or a bougie.

3:28

I'm glad they defined that because it seems like

3:30

different trials define first-past

3:32

success in different ways. And we'll talk a little bit

3:34

more about that when we get into the discussion. Now,

3:37

Marco, what were some of the key secondary

3:39

outcomes that we're gonna cover today? So

3:41

secondary outcomes included severe complications

3:44

of tracheal intubation. And this is important

3:46

because this is a composite

3:48

and they defined it as one or more of the following,

3:51

which had to occur within two

3:54

minutes after successful intubation. And

3:56

they included severe hypoxemia,

3:59

which was... pulse oximeter reading less

4:01

than 80%, severe hypotension

4:03

with a systolic blood pressure less than 65, cardiac

4:07

arrest not resulting in death within one

4:09

hour, or cardiac arrest resulting

4:12

in death within one hour. And we'll

4:14

list all the exploratory outcomes in the

4:16

show notes. There was a ton of them and too

4:18

much to bore the listener with, but they'll

4:21

all be listed there. Now, we'll

4:23

let's start with the population when we get into

4:25

the results here. So can you tell us a little

4:27

bit about this population we're about to

4:29

evaluate this paper on? Yeah,

4:31

so there was a total of 1420

4:34

patients that were enrolled around

4:37

the same amount were included in the primary analysis,

4:39

about 700

4:40

and five were randomly

4:42

drew the video laryngoscopy, whereas

4:45

the cohort of the direct intubations

4:47

was about 710. The most common

4:49

indications for intubation were altered

4:52

mental status, and that was around 45%. And then the rest,

4:54

the next most common

4:57

would be respiratory failure, which was around 30%. Around 70%

4:59

were intubated in the emergency

5:02

department, which kind of, we'll talk about

5:04

this more obviously, but it does make it a little more applicable

5:07

to emergency medicine. And then typically the

5:09

people doing the intubations

5:10

were either residents. Now it didn't

5:12

specify whether this was a first day first

5:14

year resident, or, you know, some of

5:16

the four year programs out there, but it was mostly

5:18

either EM residents, or it was critical care

5:20

fellows. And I think they, and

5:22

that makes up about 90% of the people, the

5:26

operators here, and then the operators typically

5:28

had around 50 intubations

5:31

worth of experience. And that ranged from anywhere

5:34

from 25 to around 90. What

5:37

was kind of the range there previous intubation.

5:39

So now this is, you know, talking around those, the

5:42

ones that we kind of set at around 50, almost 70%

5:46

of those had been done video, video learngoscopy.

5:48

So a lot of the background from the learners

5:50

coming in or the operators was

5:53

primarily video, but that didn't necessarily

5:56

change the one to one, whether they

5:58

were going direct or video. Yeah.

5:59

So pretty much these were easy intubations

6:02

for the most part done by trainees

6:05

is is basically what I'm gathering from what you

6:08

spelled out Now Marco,

6:10

let's talk about this primary outcome first

6:12

pass success. Was there a difference

6:15

between the two groups? Yeah So actually

6:17

the investigators found for first pass

6:19

success There was a statistically

6:21

significant difference among the two groups

6:24

and actually in the video laryngoscopy

6:26

group They found that that first pass success

6:28

rate was 85% and

6:31

it was just 70% in the direct

6:33

laryngoscopy group No, that's huge. That's

6:35

a absolute risk difference of 14% and

6:38

what about any of the key secondary outcomes?

6:40

Was there a difference between the two groups? Yeah

6:43

151 patients in the video laryngoscopy group Which

6:45

is about 21% and 20% of

6:48

the patients in the direct laryngoscopy group

6:51

met the secondary outcome It was a very small

6:53

absolute risk difference that did not reach statistical

6:55

significance and to remind listeners severe

6:58

complications during intubation Was that

7:00

secondary outcome now when we talk

7:02

about the exploratory outcomes, I'm just gonna

7:04

list a few of them here But successful

7:06

intubation on first attempt without severe complications

7:10

There was a trend toward

7:10

video laryngoscopy being better than

7:12

direct laryngoscopy 68.7% versus 59% Failure

7:17

to intubate the trachea due to inadequate

7:20

view was 3.7% in video laryngoscopy

7:23

and 17.3% in direct

7:25

laryngoscopy and if we look at the median

7:27

time to intubation video laryngoscopy

7:30

was 38 seconds Direct laryngoscopy

7:32

was 46 seconds

7:34

So let's get into some of these strengths and limitations

7:36

guys. So Marco, let's start

7:38

with you So obviously this study addresses

7:40

a clinically relevant and heavily

7:42

debated question where the

7:44

patient groups balanced at baseline

7:47

Yeah, if you look at table one and

7:49

almost all these trials, these are all the demographic

7:51

information And what we find is that the randomization

7:54

process was actually sound and it appears

7:56

that based on the demographics that the patients

7:58

have the same prognosis

7:59

in each group. So I thought the balancing

8:02

was pretty sound. Awesome. And then I really liked

8:04

the inclusion criteria being broad. It

8:06

allowed for a diverse patient population to

8:09

be included. And that's basically what we do in

8:11

the emergency department, right? We see everyone

8:13

and everything all the time. So I like

8:15

that they didn't wean this down to like a niche

8:18

population. They just took all comers.

8:20

The other thing that really kind of leads

8:23

us to

8:24

believing in that primary outcome is they did

8:26

multiple sensitivity analyses and

8:29

they accounted for factors such as trial

8:31

site, protocol violations, missing

8:33

data, and additional analyses. And

8:36

they found that there was no difference in any of those

8:39

groups, regardless of what you did, VL

8:41

or DL. So that really kind of adds

8:44

a lot of validity to that primary outcome.

8:46

Now, Will, when we get to the limitations,

8:49

one of the issues that I've seen come up on social

8:51

media and that we brought up as we were reviewing this

8:54

paper was that most facilities

8:56

were teaching hospitals. So can

8:58

you elaborate on that a little bit more? Yeah,

9:00

so like we had said that most of these, almost 90%

9:03

were either residents or they were fellows. So

9:05

still very much a younger crowd,

9:08

like the average intubations was

9:10

only like 50% or sorry, 50 total

9:13

intubations. So not a ton of experience.

9:16

Most of these people had had experience

9:18

on video laryngoscopy. So kind

9:20

of already going into this, regardless

9:23

of which direction they were supposed to be going with

9:25

direct or video, most of their experience

9:27

was already in that video setting. Yeah,

9:30

they already don't have a lot of experience doing intubations

9:32

and most of the experience that they did have was with

9:35

video laryngoscopy, which is gonna bias

9:37

the trial toward favoring video laryngoscopy.

9:40

Now, the other issue I had with this paper,

9:43

Will, was what about like

9:45

the modes of

9:46

oxygenation? What types of meds do

9:49

they use for induction and paralytics?

9:51

Do we have any good information on

9:53

that?

9:54

No, I mean, they did say that, I

9:56

think that there was an area that talked about

9:58

pre-oxygenation.

9:59

Um, but I didn't remember seeing anything

10:02

that specifically says what, uh,

10:04

induction medications they used. Um,

10:07

or had there been any attempts like other times

10:09

I had, they had already gotten stuff by the time they got to

10:11

the hospital or anything like that. So some of

10:13

that can still, uh, be a bit of a question

10:15

mark and make it a little more difficult on your first

10:18

pass. Okay. Marco, the trial

10:20

got stopped a little prematurely. What

10:22

does that do with the outcomes that we're, we're talking

10:24

about? Yeah. I mean, I can't really see this

10:26

specifically with, with pharmaceutical studies,

10:29

which this was not,

10:29

but, uh, it's, it's a giant, a

10:32

red flag for me. We always have to be cautious

10:34

about trials stopped early for benefit. Most

10:37

often what we see is that there would be regression

10:39

to the mean and many of these data and

10:42

these findings would actually potentially

10:44

be washed away if the trial had been able

10:47

to be concluded to, to completion.

10:49

One of the good things here is that they actually had a

10:52

priority stop criteria. So they had predetermined

10:54

stop criteria, which they decided upon

10:56

before the trial, uh, began, um, and

10:59

which they met on interim analysis. So this

11:01

is not, not quite the same, uh, level that

11:03

you see in these pharma companies. Got it. And

11:05

then what about the type of blade in terms

11:08

of geometry that was being used in this study?

11:10

Cause we haven't mentioned that yet. And I think that

11:12

that's a really important point to bring up. Yeah.

11:15

I remember, I mean, I'm, I'm going back about more than 15

11:17

years. I started residency in 2008

11:19

and I mean, we really didn't even

11:21

have video at my residency shop, but we

11:23

had all this talk on Mac and Miller. And,

11:26

and by the time I graduated is when we first started

11:28

with glide scopes and then there was standard

11:30

geometry and hyperangulated, but they

11:33

actually didn't mention and they didn't require any

11:35

specific blade geometry. So they, they left

11:37

that up to the user to determine what

11:40

type of blade geometry they, they want, which is

11:42

actually pragmatic. But what we found is

11:44

most of these blades were standard geometry. So it's going

11:46

to limit the generalizability to other

11:48

different types of blades.

11:49

Now, well, you had already mentioned that

11:52

the majority of intubations, 90% of them were performed

11:54

by emergency medicine residents and critical care

11:56

fellows. Now, what do you think

11:58

this does? for people that

12:01

have more experience. Do you think that

12:03

this study applies to people who like,

12:06

for example, when I started residency,

12:08

I trained in DL. The first three years

12:11

I did residency, I did a combined EM, IM

12:13

residency. The last two years is kind of when

12:15

video learning goscopy got introduced. And

12:18

then I started learning on video learning goscopy.

12:20

So I kind of learned backwards, but obviously

12:22

by the time these studies are coming out, I

12:24

now have experience with both DL and VL.

12:27

Yeah, I think that that's a good point. I think

12:29

that

12:29

a lot of the modern

12:32

training is most

12:34

with video. And also

12:37

it's like you say, it's the time you train. I know

12:39

I just recently got out of training, but

12:41

I think I'm even gonna have a different experience than

12:44

my future, the residents

12:47

going through my program now because I went through COVID.

12:49

So I probably by the end of my first

12:51

year, I probably had close to 75 intubation. So

12:54

I was very, very comfortable

12:56

with that. But, and I think it mentioned this in the article,

12:59

that I was also kind of not

13:01

expected to do video, but it was

13:04

promoted that I do video because it actually keeps

13:06

you further away from the airway and your

13:08

face isn't always in there, right? With direct,

13:10

you have to be able to be quite a bit closer

13:13

to the patient than you do with video.

13:15

And even with that said, at my shop, our

13:18

video was typically the hyperangulated

13:20

blade, which this study kind

13:22

of doesn't really suggest. It says the

13:25

natural geometry blade. And

13:27

then when I think we had a CMAK and when it was

13:29

actually working, we would actually like flip the

13:31

screen

13:32

so our attending could see it. And then

13:34

we were intubating direct, which

13:36

was kind of an interesting thing. So even

13:39

though I'm pretty versed in video,

13:42

I learned on hyperangulation and not

13:44

the geometry, which it sounds like this

13:47

was certainly in favor of. All right, let's get

13:49

into the discussion. So Marco, one of your

13:51

big points that you brought up as we were

13:53

peer reviewing this was their primary outcome

13:55

of first pass success. So let's

13:58

talk a little bit about that.

13:59

What do you think about that as a primary outcome?

14:02

And what do you think are some

14:04

of the issues with that outcome? Yeah, I

14:07

think we really don't have a choice when we're talking about

14:09

these types of device trials because you

14:12

have to be able to pick something that's going to allow

14:14

you to compare it to the other previous trials.

14:17

So first-pass success is that because it's basically

14:20

what they look at in every similar type

14:22

of trial. So it allows you,

14:24

it gives you a comparison. Typically

14:27

first-pass success is a disease-oriented

14:29

outcome. We

14:32

do know that the worse you perform in first-pass

14:34

success,

14:35

the more potential harm you could be exposing to the patient.

14:37

So to a degree, it's a surrogate for

14:39

a patient-oriented outcome, but it's technically a

14:42

disease-oriented outcome. And for people who have

14:44

problems with this, and I'm not saying you have a problem with

14:46

it, Marco, but it seems like most

14:48

of the issues we have with intubation

14:51

happen when the patient starts getting hypoxic

14:54

as we're trying to get the endotracheal

14:56

tube in the trachea. So what I'm saying is you have

14:58

to pull the laryngoscope out and then you have to reoxygenate

15:01

the patient. That seems like a good

15:03

timestamp or disease-oriented

15:06

timestamp for when we see a lot

15:08

of these issues. And so I actually don't have

15:10

a problem with this, even though it's kind of disease-oriented

15:12

and a surrogate. But another

15:14

problem I had that we brought up in the limitations

15:17

is we don't have a lot of important information

15:20

despite that being the primary outcome

15:22

of first-pass success. And I

15:24

wanted you to talk a little bit about

15:27

what was some of the important

15:29

information that we just didn't have that you absolutely

15:31

have to have if you're talking about an intubation

15:34

trial. Yeah, I completely agree with the point. I

15:36

think what you're alluding to is this two-minute

15:39

timeframe on the secondary

15:41

outcomes is somewhat problematic

15:43

to me. Two minutes is a really

15:46

short amount of time to see some of these things. In

15:48

my mind, when I see that, it's like, well, what is going

15:50

on with this patient that they are becoming so hypoxic

15:53

within this two-minute timeframe where they're dropping their

15:56

pressure?

15:57

And we really don't know, one, what medications

15:59

were given.

15:59

to these patients. So were they induced

16:02

and paralyzed with succinylcholine or rock

16:04

uronium or were they given a tomodate or they

16:06

given ketamine and that's a whole different debate we're

16:08

not going to get into now, but all these medicines

16:10

have different pharmacokinetic profiles and are going

16:13

to be more prone to hypotension

16:15

and different characteristics than others.

16:17

So I think what medicine they received

16:19

is pivotal to determining whether

16:21

or not those medicines could have contributed to this

16:24

hypotension or hypoxemia. The

16:27

other thing I think

16:28

they didn't really mention is what

16:30

mode of pre oxygenation. I think that's again

16:33

more of a surrogate. If somebody is getting

16:36

a 10 liter nonrebreather or you

16:38

know a few liters on nasal cannula, that's not quite

16:40

the same thing as getting BiPAP. So that

16:42

tells me that if somebody is so sick that they're requiring

16:44

BiPAP prior to intubation, then perhaps

16:47

they're at a higher risk for getting

16:49

hypoxic during that procedure. And

16:52

that's more likely to whatever disease is

16:54

causing their requirement

16:56

for intubation and not necessarily the

16:58

type of device or medicine given per

17:00

se. So Will, you brought up

17:02

the operator issue that we talked about. And

17:04

so again, we've stated this like

17:06

the third time I'm stating it majority of the

17:08

intubations were done by either residents or fellows.

17:10

We got that. And most of them had 50 prior

17:13

intubations,

17:14

but what I want

17:16

you to kind of dive into is they also looked

17:19

at residents and fellows based on

17:21

number of intubations that they had like

17:24

less than 25 between 25 and 50 and then up

17:27

to 100.

17:28

Was there a trend there that they noticed

17:31

in this study that's worth kind of bringing

17:33

up? Yeah. So essentially we have kind of three different

17:35

categories. It's less than 25% had been

17:39

performed via video laryngoscopy 25 to 75% and

17:41

then above 75%. So of the people who

17:45

did video laryngoscopy over

17:49

half, so about 56% hit that 25 to 75% that that's

17:51

where they

17:54

were experienced. Whereas it's

17:56

kind of the same for those that got pegged with the direct

17:58

laryngoscopy. 60% of

18:02

their intubations had been from

18:04

experience with video. So

18:06

really, if the average is

18:09

around 50, they've only intubated someone 25 times

18:11

with direct, and

18:14

now they're trying to do it on hopefully

18:16

a first pass potential. And

18:19

I think that that can be kind of problematic, and again,

18:21

skew the numbers one direction. But

18:24

regardless, it does show that the population of operators

18:27

are significantly more versed in

18:30

video with, like I think

18:32

it's probably close to 95% have had over 25%

18:37

of their intubations

18:37

be video laryngoscopy.

18:40

Yeah, and one of the things that came up was the

18:42

view that they were able to get, right? This Cormac-Lahane

18:45

grade. And did they notice

18:47

a difference when they're talking about these

18:50

residents and fellows intubating, whether they used VL

18:52

versus DL? Yeah, so actually

18:55

there was a pretty significant, so grade

18:57

one view was achieved 76% of the time using VL compared

19:01

to less than half, so like 45% direct. So

19:05

again, that skews things significantly

19:07

in the direction of

19:09

video. And then I wanna talk a little bit about

19:12

preparation here if that's okay with you guys.

19:14

So to ensure successful intubation,

19:17

we have to really plan, right? And

19:20

I think this is something that we don't always do when

19:22

we assume an airway is gonna be easy, but

19:25

I think it's important to have a plan A, a

19:27

plan B and a plan C. And

19:29

I think you need to be facile in

19:32

both plan B and plan C. Obviously

19:34

your best attempt is gonna be your first attempt,

19:37

but if you never practice plan B and

19:39

you never practice plan C and plan

19:41

A fails, how do you expect plan

19:44

B

19:44

or C to bail you out? And

19:46

so that's my issue when we get into this debate

19:48

of VL versus DL. I think

19:51

the answer is already pretty straightforward

19:53

and we'll get into that when we talk about conclusions, but

19:56

I think it's important to have other airway

19:58

techniques that you feel facile. And

20:01

one of the questions that came up in one of my

20:03

social media platforms is, well, if we're

20:05

supposed to do VL on everything, then

20:08

how are we supposed to get good at doing

20:10

DL?

20:11

And Will, I think you alluded

20:14

to this during COVID, but there are

20:16

Laryngoscope blades out there like C-Mac

20:18

and McGrath that allow you

20:20

to do both VL and DL

20:22

in one. And

20:23

you can literally turn the screen around where

20:26

somebody can still watch what you're doing,

20:28

but you can actually work with DL. And

20:30

so for me, what this answers is not

20:33

the standard versus hyperangulated geometry

20:35

debate, which I have my own

20:37

thoughts on, but it's there are better

20:40

Laryngoscope blades out there that allow us to do both so

20:42

that we can practice B and

20:44

C in terms

20:45

of our plans. Do you guys, either one of you have

20:47

thoughts on that? Yeah, I would. I would agree

20:50

with you 100%. I think

20:52

that just like you, Salim,

20:54

I'm actually EMI. I'm also, I think we probably trained

20:56

around the same time. So we really

20:58

didn't have the opportunity to train with video because

21:00

it just wasn't accessible or

21:03

readily available.

21:04

But I find that compared

21:07

to my own training,

21:08

that you

21:09

just have so much more latitude when

21:11

you're in a training facility and you can see exactly

21:14

what the resident is doing. You really

21:16

give them the opportunity because you know,

21:18

OK, they're right there. Plus, you can give

21:20

them direct instruction. These are the bottom

21:22

of the cords. Pull back. You're a little bit too

21:24

anterior or something. So really,

21:27

without being able to see them

21:29

on to see the cords and see the anatomy for the patient

21:31

on the monitor, it's difficult to give

21:33

that feedback instruction. And what you're more

21:36

doing or what I recall is just somebody standing over

21:38

your ear, over your shoulder. Do you see

21:39

the cords? Do you see the cords? Do you see the cords? Do you see the

21:41

cords? It's like this is a difficult procedure,

21:44

high stress, potentially life and death. The

21:46

last thing you want is somebody kind of micromanaging

21:49

you in helicopter

21:51

parenting, per se, while

21:53

you're trying to do this. So seeing that video

21:56

screen in front of you, it really allows

21:58

the attending physician to do that. to have comfortability

22:01

knowing that you're in the right position.

22:04

And again, they can give you that feedback and instruction

22:06

if you're doing something wrong. And if they need to

22:08

jump in, because you're just so far, you know,

22:11

in left field, and you're not in the right direction at all,

22:13

then then they know and they can they can do that when

22:15

they feel it's necessary. So I'm, I'm

22:18

heavily in favor in

22:20

a video laryngoscopy with the either

22:22

standard geometry blade, that's, again,

22:25

C Mac, that could be McGrath, or that could be that glidescope

22:28

with the

22:29

standard geometry blade. Yeah, I certainly

22:31

agree. I think video is

22:33

the way to go. But I think just as importantly, if not

22:35

more importantly, is to have those

22:37

A, B and C options and have them every

22:40

single time. Even if this is, you know,

22:42

you're going to do an intubation where maybe

22:44

the patient's in like rapid CHF,

22:47

and you know that they're probably that's what we're

22:49

going to go down, but we're going to go ahead

22:51

and try BiPAP and something first having that A, B

22:53

and C every time regardless of the into the

22:56

how easy or difficult the intubation is, I

22:58

think is what's really important because for

23:01

as frustrating as it may be being micromanaged

23:03

trying to shove a tube down someone's throat. If

23:06

it's 3am, and you're the only doc in

23:08

house, and there is no one

23:11

to take over for you, and there is no one to help out

23:13

with pointers, you need to naturally be

23:15

able to go from A and say this isn't working.

23:17

Now I need to go to B now I need to go to C. And

23:20

so having, you know, video

23:22

being your first shot, I think that that's a great thing, but

23:24

then not being afraid to take

23:27

a step back and then maybe move to the bougie, which

23:29

also, you know, they did quite a few times in

23:32

this study, and it seems like it

23:34

helped quite a bit. But to be

23:36

able to have that regimen, I need to go from one

23:38

to two to three to the next thing

23:41

because trying a every single

23:43

time is only going to, you know, damage it more if it's not

23:45

working. And so then it's time to

23:47

move on to B and C. And Selim, I just want to highlight

23:50

again that I think

23:52

really the important thing is one of

23:54

the important things to know is that vast

23:57

majority of the time, I think video is going to be fine,

23:59

right? There's there's really a huge difference

24:01

because you're going to see the airways going

24:03

to go okay. You're not going to have any secretions

24:05

or vomit or blood in there. Um, but

24:08

like you alluded to, you need to plan

24:10

for a B and C. So you really

24:12

don't know, uh, 100% certainty

24:15

that this person is going to have a bloody airway

24:18

or you're going to paralyze them. They're going to have a belly

24:20

full of blood or a belly full of vomit and they're immediately

24:22

going to start vomiting. And those are not

24:24

the times where you want to use video or where video is going

24:26

to be helpful. A bloody camera is not going to make

24:28

it easier for you to get, uh, first pass success.

24:32

And you have to prepare for these situations

24:34

so that when

24:36

you're in them, you know what to do when you're

24:38

not, uh, you're not afraid and you know how to

24:40

handle it. Um, and they don't happen often,

24:42

but I can think of a handful of times in my

24:44

career, the, the most difficult intubations are

24:46

the ones of these upper GI bleeds that get

24:48

intubated and all of a sudden they just start vomiting

24:51

a belly full of blood and the camera's just

24:53

not going to be able to help you in those situations. Yeah. 100%.

24:56

So here's what the authors concluded guys

24:58

among critically ill adults undergoing

25:00

tracheal intubation in an emergency department

25:03

or ICU, the use of a video laryngoscope

25:06

resulted

25:06

in a higher incidence of successful intubation

25:08

on the first attempt than the use of a direct

25:10

laryngoscope. Close quotes. So

25:13

will, what is our conclusion? And then Marco,

25:16

I'm going to have you give us the clinical bottom

25:18

line. Yeah. So, uh, I think when it comes to

25:20

video versus direct laryngoscopy, um,

25:22

there's definitely a higher association

25:25

of first pass success with video compared

25:27

to direct. These operators were a

25:29

little, uh, less experienced, because

25:32

these were, you know, basically trainees or fellows

25:35

that were more experienced

25:36

with, uh, video laryngoscopy. Um,

25:38

but I think nonetheless, the video

25:41

laryngoscopy offers advantages,

25:43

uh, so you can visualize anatomy, which

25:46

is going to help with your first pass success. Um,

25:48

and then it's also going to help those people, uh,

25:51

you know, the other operators in the room that might be

25:53

able to offer some encouragement, see the same

25:55

thing that, uh, that the intubator

25:57

is seeing. And Marco, the clinical bottom line.

25:59

Yes, the bottom line.

26:01

We recommend video laryngoscopy with

26:03

a standard geometry blade. And that's whatever device

26:06

you want to use, the McGrath, the CMAQ.

26:08

These allow, these devices allow for a

26:11

seamless transition to direct laryngoscopy

26:13

if you have an unexpected complication, like

26:15

a bloody airway. Additionally, using

26:17

VL allows and provides

26:20

the resident physician a lot of latitude

26:22

because we know the attending is gonna be able to

26:24

see what they're seeing and they can give

26:26

them that direct feedback to make sure that the patient

26:29

is safe. And they're providing the proper

26:31

supervision

26:31

to that resident trainee or fellow.

26:34

And there you have it, Rebeliam listeners. Leave us your

26:36

thoughts, comments, and questions. Thanks for tuning

26:38

in.

26:39

And until next time.