That Time of Year Again (VL vs DL)

[Ronin786]

https://www.nejm.org/doi/full/10.1056/NEJMoa2301601?query=featured_home

Seems like a study to this extent comes out every couple years. Anybody doing anything different? Anecdotally I've noticed most residents and/or CRNAs nowadays use VL as their first option.

Abstract​

BACKGROUND​

Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.

METHODS​

In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

RESULTS​

The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, −3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.

CONCLUSIONS​

Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195. opens in new tab.)

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[patriot6]

Not surprising.

But, you still have to be able to DL in a pinch.

 

[drmwvr]

Not as many VL's laying around a busy OR as conventional laryngoscopes, they get lost or thrown away (or important parts do) and sometimes get damaged/broken. Just on a pragmatic level, unless the hospital can buy and maintain a ton of them, routine use by lots of people for every patient isn't really practical.

 

[dabears505]

The only reason to use dl is if you place double lumen tubes regularly. They are harder to place with the glidescope. Our place does not have cmac which might make that easier.

 

[Urzuz]

Any anesthesiologist worth their salt knows how to use a regular old school laryngoscope. Not every site that needs anesthesia coverage will have a video laryngoscope in every room. Additionally, what are you going to do in an active tonsillar bleed or an actively puking patient when the camera lens gets obscured?

It makes me cringe when I see young anesthesiologists use VL on every single patient. I liken it to young general surgeons doing nothing but robot cases through training and not having the ability to do a regular laparoscopic or God forbid an open case — these are necessary skills if you want to be a well rounded physician.

I’ll never put my ego ahead of patient care and will jump to VL if I feel like I may traumatize the airway or there’s cause for concern…but 99% of the time I’ll at least attempt to DL patients first to keep my skills up.

 

[pgg]

This study should mean nothing at all to us.

The problem with all of these studies (well ... one problem) is their chosen endpoint is clinically irrelevant 99% of the time.

primary outcome was successful intubation on the first attempt

So what? What's the consequence of a failed first attempt, in the real world, for virtually every patient we see? Absolutely nothing. You try again with the same or different tool, and you get it. It's not like a dreaded failed attempt results in broken teeth or an avulsed uvula. Unless, apparently, you're one of the unlucky 21% (21%!!!) of patients in either group of this study who had a severe complication.


How often is the 1st attempt really critical for us? Patients at high risk for aspiration, yes. Suspected difficult airways, maybe. Concerns about desaturation and resulting instability if the airway isn't secured quickly, sure. But those patients don't sneak up on you, and you make a safe plan, which may or may not involve VL.

Also, with due respect to our ER and non-anesthesia ICU colleagues, they are on average about as good with an airway as a November CA1. Their 1st-attempt success or failure rate should mean nothing to us.

Again, in both the VL and DL groups, 21% of their patients (21%!!!) had what they called a severe complication!

What this study shows is that ER and ICU residents are bad at airway management in general, and slightly less bad if they start with VL, but they hurt the same number of people regardless of which tool they use.

Can anyone imagine a world in which

severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death

was happening 21% of the time we touched an airway? (OK, I suppose most of us will give some phenylephrine peri-induction but in our world that's not a complication - I interpret their use of the term vasopressor to be in an ACLS context.)

 

[aneftp]

Not as many VL's laying around a busy OR as conventional laryngoscopes, they get lost or thrown away (or important parts do) and sometimes get damaged/broken. Just on a pragmatic level, unless the hospital can buy and maintain a ton of them, routine use by lots of people for every patient isn't really practical.

Not a good enough excuse in this day and age.

A McGrath costs around $1250 in bulk. That’s chump change with hospitals spending. Less than 15k for 90% of hospitals. Yes McGrath’s can get stolen or lost (more likely stolen) lock it up in Pyxis

 

[pgg]

Not a good enough excuse in this day and age.

A McGrath costs around $1250 in bulk. That’s chump change with hospitals spending. Less than 15k for 90% of hospitals. Yes McGrath’s can get stolen or lost (more likely stolen) lock it up in Pyxis

Locking an emergency airway tool up in a Pyxis is the most hospital-administrator-esque thing I've heard so far today.

VL devices should be ubiquitous and readily available. It should be like epinephrine, or dantrolene, or a defibrillator. That doesn't mean they should be used for every case. Even if some undertrained undersupervised trainees are making those things necessary 21% of the time.

 

[patriot6]

A mac3 and a bougie has almost no limits

 

[Urzuz]

A mac3 and a bougie has almost no limits

That’s a funny way of spelling Miller 2

 

[thinkorswim]

Any properly trained anesthesiologist should be proficient with both in any situation.

But for me, it just comes down to cost. We have a McGrath in every OR and it’s cheaper to use than the disposable DLs.

 

[godfather091]

My mcgrath at my job got stolen after leaving in an OR a single time.

 

[dannyboy1]

Let’s be honest. VL is vastly superior to DL in both first pass success and ease of use. I will not provide anesthesia without knowing that there is VL readily available in the building. In our main shop we have glidescope or McGrath available in every room. As anesthesiologists it makes us uncomfortable because “other” providers are able to learn to quickly and easily secure the airway. It is what it is.

 

[DrOwnage]

My current gig has a mcgrath on top of every cart in every OR or site plus glidescopes. We just VL every time. I'm spoiled, not sure how I will go back to normal at some point.

 

[dannyboy1]

The only reason to use dl is if you place double lumen tubes regularly. They are harder to place with the glidescope. Our place does not have cmac which might make that easier.

McGrath works even better

 

[okayplayer]

The decision of which device to use (DL/VL) should be fully at the discretion of the anesthesiologist doing the procedure and questioned by nobody. Both options should be readily available at all anesthetizing locations.

Final answer.

 

[pgg]

As anesthesiologists it makes us uncomfortable because “other” providers are able to learn to quickly and easily secure the airway.

79% of the time without major complications, apparently!

 

[bourg]

These studies come out from time to time, it's pretty obvious that VL increases first pass, specially in the ER and ICU. Videolaryngoscopy, however, is far from being a reality in most third world countries. At my institution in Brazil, there are 3 (generic, not McGrath, not Glidescope) VLs for the entire hospital.
Also, when I read that VL is cheaper than DL because of disposable laryngoscopes... It's a complete different reality I can't even imagine.

 

[vector2]

I think most of the time even in experienced hands McGraths cause less stimulation than DL, so I've started using it pretty routinely for hearts, carotids, and other cases where a heavy handed induction isn't ideal.

 

[nimbus]

Not as many VL's laying around a busy OR as conventional laryngoscopes, they get lost or thrown away (or important parts do) and sometimes get damaged/broken. Just on a pragmatic level, unless the hospital can buy and maintain a ton of them, routine use by lots of people for every patient isn't really practical.

We have VL in every room now. It’s always my 1st choice.

 

[nimbus]

Mcgraths have a tendency to crawl into a bag and show up on Craigslist or eBay. The big stand mounted glidescopes don’t.

 

[aneftp]

Mcgraths have a tendency to crawl into a bag and show up on Craigslist or eBay. The big stand mounted glidescopes don’t.

Yup. My place had around 10 walk out recently.

 

[nimbus]

Yup. My place had around 10 walk out recently.

Years ago we got 3 glidescopes and 3 Mcgraths. All the Mcgraths disappeared in a few short months but the glidescopes stayed put until we got newer versions.

 

[deleted1156848]

I think most of the time even in experienced hands McGraths cause less stimulation than DL, so I've started using it pretty routinely for hearts, carotids, and other cases where a heavy handed induction isn't ideal

How about glidescope? I can’t stand when residents or CRNAs stare at a screen and twist and turn the tube in place then get stuck at the aretynoids and do some bizarre corkscrew tracheostomy attempt in an otherwise easy airway where barely any manipulation would have been required with DL.

 

[zizzer]

Perhaps it's unfair of me, but anytime I hear somebody insisting on VL for most or all intubations, I suspect they're not very good at DL.

 

[nimbus]

Perhaps it's unfair of me, but anytime I hear somebody insisting on VL for most or all intubations, I suspect they're not very good at DL.

Probably true.

I trained and practiced for over 10 yrs before VL became widely available. I’ve been using almost exclusively VL for over 5 years. My DL skills have definitely declined while my VL skills have improved. There are nuances to it that I’ve learned with time and practice. VL is my current weapon of choice because I’m better with it. Overall I’m smoother with VL than I ever was with DL. So easy even a caveman could do it!

 

[medicine2wallstreet]

The decision of which device to use (DL/VL) should be fully at the discretion of the anesthesiologist doing the procedure and questioned by nobody. Both options should be readily available at all anesthetizing locations.

Final answer

Man you sound like alot of fun.

 

[nimbus]

How about glidescope? I can’t stand when residents or CRNAs stare at a screen and twist and turn the tube in place then get stuck at the aretynoids and do some bizarre corkscrew tracheostomy attempt in an otherwise easy airway where barely any manipulation would have been required with DL.

It’s not the glidescope. It’s their technique. They’re not doing it right. Help them get better.

 

[Iso4ane]

Honestly, what I want to see is time to intubation and grade of view in a group of CA1s at one year that used mostly VL and a 2nd group that spent their first six months using DL only.

 

[deleted1156848]

It’s not the glidescope. It’s their technique. They’re not doing it right. Help them get better.

don’t even know why I come here

 

[zizzer]

The inconvenience of finding one of the Glidescopes, wheeling the large thing to the room and finding a space for it, maybe needing to plug it in, connect the appropriate cables, turn it on, open, lube and insert a stylette, is also a factor for routine use compared to simply opening an ETT and a blade.

McGraths aren't as cumbersome, but they aren't available any hospital I work at and even at my residency they weren't in all ORs and required the anesthesia technicians to bring them. Assuming you're using a hyperangulated one, you still need to go through the pain of styletting the ETT.

 

[Simba1711]

I think we all agree that keeping up with dl skills is important. One thing to note tho is the disposable blade piece for the McGrath is probably safer to the environment than wasting the entire handle, blade, and battery for the disposable laryngoscopes we use for the dl. With all the waste we produce it’s such a small drop in the bucket. Wish we could be more environmentally friendly.

 

[BlueRug]

Let’s be honest. VL is vastly superior to DL in both first pass success and ease of use. I will not provide anesthesia without knowing that there is VL readily available in the building. In our main shop we have glidescope or McGrath available in every room. As anesthesiologists it makes us uncomfortable because “other” providers are able to learn to quickly and easily secure the airway. It is what it is.

Let's be honest. Defaulting to VL for all intubations and refusing to provide anesthesia without a VL in the building is weaksauce.

Do you refuse to place IV's without ultrasound in the building as well?

 

[agammaglobulin]

Something yet to be mentioned - VL allows for a decent reduction in induction drug dosage. I completed residency w almost all DL, now have McGrath in every room for past 5 years. Induction dose of propofol w VL is considerably less than DL. Much less pressure required for the average patient to get a view. I see a lot less tachycardia during intubation and less hypotension after the tube is in.

Why wouldn’t you use the best equipment you have to secure an airway for each patient? Doesn’t make sense not to. Having VL in every OR and NOT using it would be dumb.

 

[GassYous]

The inconvenience of finding one of the Glidescopes, wheeling the large thing to the room and finding a space for it, maybe needing to plug it in, connect the appropriate cables, turn it on, open, lube and insert a stylette, is also a factor for routine use compared to simply opening an ETT and a blade.

McGraths aren't as cumbersome, but they aren't available any hospital I work at and even at my residency they weren't in all ORs and required the anesthesia technicians to bring them. Assuming you're using a hyperangulated one, you still need to go through the pain of styletting the ETT.

I rarely use a stylet with the mcgrath. Maybe like once in every 100

 

[PpfSuxTube]

So bunch of novices are better using glidescope than dl, but in general are ****e at both... wow

 

[PpfSuxTube]

Until there's a head to head of staff anesiologist success rate, or even like ca3s are any of these study any relevance to us?

My toddler gets most of his rice dinner in his ear. Should I eat rice thru my ear then?

 

[nimbus]

don’t even know why I come here

You described bad technique. Everybody should work as hard to refine their VL technique as they do on their DL technique. If you witness a resident or CRNA struggling with direct laryngoscopy, you wouldn’t throw up your hands and say, “I can’t stand this.” You’d give them tips to make it easier and smoother. The same is true for video laryngoscopy.

 

[anaesthetic]

You described bad technique. Everybody should work as hard to refine their VL technique as they do on their DL technique. If you witness a resident or CRNA struggling with direct laryngoscopy, you wouldn’t throw up your hands and say, “I can’t stand this.” You’d give them tips to make it easier and smoother. The same is true for video laryngoscopy.

Can’t count the number of times a resident or experienced CRNA would get a grade IIb view with the Glidescope only for me to take over, re-engage, and adjust to get a grade I view.

It is definitely a refinable skill. I do both DL and VL on a consistent basis depending on the patient and case, no preference at all really.

 

[nimbus]

Let's be honest. Defaulting to VL for all intubations and refusing to provide anesthesia without a VL in the building is weaksauce.

Do you refuse to place IV's without ultrasound in the building as well?

We bring VLs when we go on remote mission trips. It’s that important. Every anesthetizing location in the USA should have one readily available. I’d argue for ultrasound too.

I trained and practiced in the bad old days before VL and ultrasound were widely available. Patients were getting hurt because we didn’t have those tools.

 

[GravelRider]

When is McGrath going to improve their picture quality? Every McGrath I’ve used looks like I’m looking at my parent’s tv from the 80s in miniature. I prefer glidescope to McGrath for many reasons, but picture quality sits pretty high on that list. I also prefer the rigid stylet that comes with glidescope for maneuvering the tube into the airway for intubations that are more difficult.

I mostly prefer DL to VL because I think intubation (not getting a view) is actually significantly easier with DL. If I can get an equivalent view with DL and VL then placing the tube is easier with DL.

Mac 4 is clearly the superior choice for direct laryngoscopy.

 

[Ezekiel2517]

I feel like, for well-trained physicians, this comes down to personal preference. I have VL available to me at all times and will use it if I feel l need to, but my default is always DL. Tbh I just get more personal satisfaction placing an ETT under direct laryngoscopy lol. VL feels a bit like cheating for me. Probably also why I don't like to use the U/S to place an art line despite having U/S available to me at all times and even having a portable U/S literally a few feet away from me in my bag lol. And why my first line of choice is always a left subclavian instead of an U/S guided IJ (though the fact that I had to place hundreds of subclavians in fellowship likely has something to do with this). I dunno, something about not using VL/ultrasound just makes it more fun for me and the procedural aspect of the specialty is one of the reasons I went into it.

A quick anecdote tho. In my former group we had a colleague get called to the SICU for an emergent intubation. He/she assumed there would be a Glide/Mcgrath available there but for some reason one was not. He/she refused to attempt intubation with the DL supplies provided, until a tech could retrieve a Mcgrath from the OR. This is despite the patient clearly needing to be tubed in that moment. The trauma surgeon ended up intubating using DL on first attempt. Not exactly a good look for the anesthesia dept lol. So just make sure to keep your skills, and your confidence in them, up

 

[kb1900]

Can’t count the number of times a resident or experienced CRNA would get a grade IIb view with the Glidescope only for me to take over, re-engage, and adjust to get a grade I view.

It is definitely a refinable skill. I do both DL and VL on a consistent basis depending on the patient and case, no preference at all really.

you can be so much lazier with VL to get a good view. no need for positioning lining up axes etc. but that’s how you **** up your ability to pass the tube. it looks so bad when you got a grade one view and fiddle with the tube for 20 seconds corkscrewing and what not


having said that, McGrath is my weapon of choice for floor/ED/icu tubes. I bring a bronchosocpe to any difficult airway call

 

[Iso4ane]

Something yet to be mentioned - VL allows for a decent reduction in induction drug dosage. I completed residency w almost all DL, now have McGrath in every room for past 5 years. Induction dose of propofol w VL is considerably less than DL. Much less pressure required for the average patient to get a view. I see a lot less tachycardia during intubation and less hypotension after the tube is in.

That assumes you use good technique, which you likely picked up from learning DL. VL greatly lowers the skill ceiling required to obtain a view, so people can used poor technique to still get a view in a majority of patients.

 

[woopedazz]

I don't trust any airway papers coming out of the US. Too many are "provider studies" with an endpoint of "avoided killing them this time."

... And somehow both groups are well populated.

I don't wanna read a study where >50% of the data is filled by EMT and the remainder by ED/ICU

 

[BLADEMDA]

A mac3 and a bougie has almost no limits

I think VL should be the norm because if I was the patient that's what I would prefer for myself or family members. It isn't just about "first pass success'" but rather being gentle, limiting trauma and staying off the teeth. I much prefer my CRNAS use a VL for these reasons and I breathe a sigh of relief when I see them with the VL. As for the "bougie" a VL plus bougie or disposable fiberoptic has an even higher success rate IMHO. I was trained on the MAC blade with bougie then switched to the Miller blade with bougie in the mid 1990s.

AS a senior anesthesiologist who keeps up with the times, the VL is to the MAC blade what U/S is to the nerve stimulator. Both has their roles but their is no doubt which has the superior technology.

Finally, one must maintain skills with the standard larygoscope because BLOOD in the airway sometimes requires us to go "old school" and do direct laryngoscopy. The question is how many intubations are needed to maintain old school skills.

 

[BLADEMDA]

Probably true.

I trained and practiced for over 10 yrs before VL became widely available. I’ve been using almost exclusively VL for over 5 years. My DL skills have definitely declined while my VL skills have improved. There are nuances to it that I’ve learned with time and practice. VL is my current weapon of choice because I’m better with it. Overall I’m smoother with VL than I ever was with DL. So easy even a caveman could do it!

I agree with you and when you leave your ego out of the equation and focus on the patient, it is quite clear the VL is superior in terms of safety, smoothness and first pass success. I won't go so far as to say that one should never do a DL, but that's where your judgment comes into play. While I prefer VL, I wouldn't say that my skill with VL is superior to DL. Maybe over the next decade I can post that I no longer do DL routinely and have switched to VL.

I still do arterial lines "old school" about 1/3 of the time. Some of my colleagues can't do an arterial line without ultrasound. That's how they were trained and I respect the fact they need the technology to place the line. I do prefer U/S as my first pass success is much higher. Perhaps, VL for the new graduate is replacing the DL and as long as that anesthesiologist is capable of DL, maybe this isn't a bad thing.

 

[pgg]

one must maintain skills with the standard larygoscope

Well that's the problem, right? If VL is the #1 goto because it's "better" for patients as you claim, then ...

Experienced anesthesiologists can't "maintain" skills that are never used.

Inexperienced anesthesiologists can't acquire skills that are never used.

The question is how many intubations are needed to maintain old school skills.

More than zero. And zero is how many you should be doing, if you really actually believe that VL is the superior method for patients.

Or are you going to start including on your consent something like "I'm going to use a method I believe to be inferior to secure your airway, because I haven't done it for a while, and I want to knock the rust off, is that OK with you?"


Or maybe we could just admit that there's absolutely nothing wrong with DL for the vast, vast majority of patients we intubate.

And maybe we can acknowledge that VL isn't always easier than DL for securing some airways.

If you want to insist that your CRNAs use VL, that's a different issue. Their DL skill maintenance isn't your problem, and you're always standing right there ready to take over and get the airway if there's a problem. Maybe with DL.

I still do arterial lines "old school" about 1/3 of the time.

I think that's wrong and ridiculous. I learned without ultrasound, and I use it now 100% of the time. I never, ever do an arterial line without it. I don't like to throw shade with the term dinosaur very often, but people who don't use ultrasound for arterial lines are dinosaurs.

I do prefer U/S as my first pass success is much higher.

Well, yeah, duh. Of course it is.

Another benefit of ultrasound for arterial lines is that after looking with the ultrasound, you might not even attempt that location at all. It is not unusual at all for me to look at some crusty old vasculopath's radial artery with ultrasound, see how small, calcified, tortuous, or thrombosed that thing is, and go look at the other side, or go straight to a brachial. You "old school" a-line starters would stab away for a couple of attempts before changing plans.

I agree with you and when you leave your ego out of the equation and focus on the patient, it is quite clear the VL is superior in terms of safety, smoothness and first pass success.

I think you should listen to yourself here, and leave your ego out of the equation and focus on the patient. It is quite clear ultrasound guided a-lines are superior to "old school" a-lines in terms of safety, smoothness and first pass success.


Also -

it is quite clear the VL is superior in terms of safety

That is not clear at all. The whole point of this thread is how dumb this article is for its "better first pass success" endpoint, and it doesn't even claim superior safety. In fact, it found equivalent safety (~21% serious complications in both groups).

 

[Ronin786]

To PGG's point, I think the context of the study needs to be taken into account. In the ED/ICU with a trainee and a dying patient, first pass might actually matter. For the vast majority of us on this board, practicing in the OR, first pass success is not necessary.

Heck there's a reason the trainees come to the OR to learn how to intubate, because we know when the SRNA and the rotating ER resident all miss their "first-pass" it means absolutely nothing and we take over and get it right.

The equivalent complications during intubation just goes to show how securing the airway isn't really a problem nowadays and this study and its kind are just ways to spend money and promote the authors.

 

[CoolDoc1729]

https://www.nejm.org/doi/full/10.1056/NEJMoa2301601?query=featured_home

Seems like a study to this extent comes out every couple years. Anybody doing anything different? Anecdotally I've noticed most residents and/or CRNAs nowadays use VL as their first option.

Visiting from EM. 21% major complications is wild, I can’t remember the last time I had any of these come up, knock on wood.

Typically intubating either for respiratory failure not improving with BIPAP, status epilepticus, severely altered mental status, or airway-proximate bleeding (hemoptysis, upper GI bleed, trauma). I use VL first for the non bleeders and DL +\- bougie first for the bleeders. I am single covered at night, no ENT coverage and there is a crna but they are also responsible for ~300 bed hospital with ob so I’d have no confidence they would be available if I needed help. For urgent but not crash airways like worsening angioedema I do call them esp since we do not have a fiber optic scope. I think mid year CA 1 is probably a fair comparison. I only do about 5-6 intubations per month, I wouldn’t expect to be as good as anyone from the anesthesia team. When I trained we did not have VL until 3rd year.