Airway / Toxicology (June 2017)
AIR: Toxicology
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
8 comments
VL > DL… period
Now, not that I’m biased or anything, let dig into Larcarrou et al.
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FIrst of all, the study was in France. I’m not sure of the exact differences in their training compared to ours in the US. However, if you look at Table 3: Most of the intubation attempts were done by internal medicine residents. And a third of the “experts” were medical intensivists. At least in the US, those would not be considered ones most experienced with airway management. So I’m not sure how well this studies applies to our ED setting and EM trained physicians.
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Second, “All physicians working at the participating ICUs received
hands-on training in the use of the video laryngoscope and
conventional (direct) laryngoscope.” The study doesn’t specify how much training exactly. But one can imagine that usually people have had more experience with DL than VL.
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Third, the glottic view was WAY BETTER with VL than DL. We know this is the case from prior studies, but doesn’t always translate to first pass success. Common sense tells me, “when there’s a view, there’s a way”. If you can’t see, you haven’t even gotten through the first and most important hurdle to intubation. I’d rather be able to see and not pass, then not see and not be able to pass the ETT.
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Remember, VL takes a different set of stereotactic hand-eye coordination skills to pass the tube. It’s akin to video games. And how much games are they playing in France? Not enough apparently!
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And I don’t put much stock in the “higher rates of severe life-threatening complications” consider it’s 2 vs. 6. Numbers are too few to say anything.
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Discuss!
Turner et al.
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I’ve always advocated using upright positioning for obese patients. It’s nice to see feasibility in a wide variety of patients in this study.
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Keep in mind this is a feasibility study. That means it’s doable in the ED, but we don’t know for sure if upright positional causes better first pass success. As the study states, there might be unaccounted for reasons residents chose to intubate in certain positions. For instance, perhaps patients intubated in supine position had more CV compromise.
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Lastly, the group of patients intubated in the most upright position also were the ones most likely to have undergone VL as opposed to DL, HMMMMMM CURIOUS. Perhaps that had something to do with the better first pass success? See my comments on the previous article.
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Turner et al.
Strengths: This was a prospective observational study which looked at the success of first pass intubations using upright positioning at differing angles from supine. This was the first study looking at success using upright positioning for patients in an ED setting. Attempts were made to control bias with patient characteristics.
Weakness: The institution where the study was carried out had no method for tracking the number of intubations performed. The paper states that residents assumed half of the intubations were missed in this study. Additionally, and the paper does mention this as a limitation, there is no information about how residents made their decisions with regards supine versus upright.
Outcomes: Not a randomized controlled study but findings suggest that first pass success rates greater in patients who were sat upright versus those that were positioned supine.
Outcomes change your practice: As Alex mentioned in his comments, it is almost always useful to elevate obese patients. I imagine elevating the HOB for many other patients would also ease achieving a satisfactory view. It makes sense that this could potentially reduce aspiration as well.
#VLvsDL
– Strengths? Multicenter RCT. Power sufficient. Like that they tried to standardize the intubation protocol. Thought the MACOCHA score was an interesting tool to use.
– Limitations? Only one type of video laryngoscopy was used. Non-experts did most of the intubations – not sure what all the “training” entailed. Study not blinded.
– Outcomes? Among ICU pts, there was no difference in VL vs DL. VL a/w higher rates of life-threatening complications.
– Change practice? Not really. For starters, this study was in an ICU population where I won’t be intubating. Although I haven’t had too much practice with it, I kind of want to get my hands on the C-MAC. According to the article, you’re more likely to see the glottis but have an issue with the ETT insertion (unclear why) – sounds more like provider error (again, what was the training?).
#intubationposition
Strengths? I like how we’re reviewing literature that’s challenging dogma (eg, intubation position, contrast induced AKI, etc.). The fact that the study is done with residents makes it more generalizable to our program.
Limitations? Prospective observational study (not an RCT). The residents could pick their own position which introduces bias. Relatively small study completed at 2 institutions. Apparently there was an issue with the data collection as not all eligible intubations were captured.
Outcomes? The more upright the patient, the higher likelihood of first pass success among these emergency medicine residents.
Change practice? It’s never really crossed my mind. We always hear about it when it comes to obese patients – however, I have yet to see it. I think for sure I’ll give upright intubation a shot at simulation to get a feel for it and if there’s an opportunity to intubate someone who would seem reasonably “easy”, I could see myself having a conversation with the attending to attempt an upright intubation after explaining the reported benefits (ie, improved pre-oxygenation, better glottis view, etc.)
Upright intubation
1. It’s attempting to shed light on an interesting question and the study population is extremely relevant… Other than that, I don’t think there are any.
2. This study has many limitations. First, it was hardly a blind study (not that it could be), but it also only used residents from one program. Also, the residents got to pick the angle of the bed they used, which could certainly cofound results as they might have chosen supine for anticipated difficult airway (as they would be more comfortable with this position). Also, over half of the intubations were done in the upright position, which is not an equal distribution at all. And I’m curious to know the gender/height distribution of the residents. Did they give the women stools? Are their beds lower? And they don’t give a picture of a real human in their upright position – just a manikin. It has been suggested in other studies that if you don’t position the patient appropriately, an upright position can do more harm than good.
3. There are advantages to preforming intubation in an upright position.
4. Not really – it may make it more likely for me to try an upright intubation just to see how it goes, but I’m skeptical.
VL vs DL
1. Well designed RCT involving 7 different ICUs
2. The study compared C-MAC to DL with Mac blade – Glidescope type blades w/ acute angles were not studied. It is also a different population than ED patients – certainly more applicable than an OR population, but potentially less patients where VL would be useful (ie trauma).
3. VL compared to DL in ICU patients did not improve first pass intubation rates and was associated with higher rates of severe life threatening complications.
4. This study might make me less likely to use the C-MAC. It certainly won’t change whether or not I use the Glidescope on patients where I anticipate a difficult airway.