Seeing is believing: getting the best out of videolaryngoscopy
2016; Elsevier BV; Volume: 117; Linguagem: Inglês
10.1093/bja/aew052
ISSN1471-6771
Autores Tópico(s)Voice and Speech Disorders
ResumoAlmost half of all incidents reported to the 4th National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society (DAS) described airway complications that followed primary problems with intubation, including failed tracheal intubation, delayed tracheal intubation, and ‘can’t intubate can’t oxygenate’ (CICO) situations.1Cook TM Woodall N Frerk C Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1170) Google Scholar In addition, considerably more than half of the incidents reported to NAP4 involved problems with intubation as the airway incident progressed.1Cook TM Woodall N Frerk C Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1170) Google Scholar The recently published DAS 2015 guidelines emphasize the importance of the first attempt at laryngoscopy, with the aim of Plan A being to ‘maximize the likelihood of successful intubation at first attempt, or failing that, to limit the number and duration of attempts at laryngoscopy, to prevent airway trauma and progression to a CICO situation.’2Frerk C Mitchell VS McNarry AF et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1138) Google Scholar It is recognized that a suboptimal attempt at laryngoscopy is a ‘wasted attempt’ and that, if intubation fails, the chance of success declines with each subsequent attempt at laryngoscopy.2Frerk C Mitchell VS McNarry AF et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1138) Google Scholar, 3Connelly NR Ghandour K Robbins L Dunn S Gibson C Management of unexpected difficult airway at a teaching institution over a 7-year period.J Clin Anesth. 2006; 18: 198-204Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 4Sakles JC Chiu S Mosier J Walker C Stolz U The importance of first pass success when performing orotracheal intubation in the emergency department.Acad Emerg Med. 2013; 20: 71-78Crossref PubMed Scopus (313) Google Scholar The importance of first-pass success is arguably even greater in the critically ill patient, when multiple attempts at intubation lead to high rates of severe hypoxia and other life-threatening (or life-ending) complications.5Nolan JP Kelly FE Airway challenges in critical care.Anaesthesia. 2011; 66: 81-92Crossref PubMed Scopus (76) Google Scholar Videolaryngoscopy is undoubtedly one of the major advances in practical anaesthesia in recent years. At present, the main challenges are to determine to what extent it should penetrate routine clinical practice and to determine which devices are best. The progression from standard Macintosh laryngoscopes to videolaryngoscopes has been likened to the advance from standard mobile cell phones to smart phones.6Zaouter C Calderon J Hemmerling TM Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 114: 181-183Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar Several editorialists have called for videolaryngoscopy to be a first-line technique for airway management.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 8Pott LM Murray WB Review of video laryngoscopy and rigid fiberoptic laryngoscopy.Curr Opin Anaesthesiol. 2008; 21: 750-758Crossref PubMed Scopus (70) Google Scholar, 9Aseri S Ahmad H Vallance H Video laryngoscopy improves endotracheal intubation training for novices.Br J Anaesth. 2015; 115: 133Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 10Marshall SD Pandit JJ Radical evolution: the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation.Anaesthesia. 2016; 71: 131-137Crossref PubMed Scopus (46) Google Scholar Importantly, the role of videolaryngoscopy in difficult intubation has recently been recognized in the DAS 2015 guidelines, which recommend that all anaesthetists are trained in videolaryngoscopy and that all anaesthetists have immediate access to a videolaryngoscope at all times.2Frerk C Mitchell VS McNarry AF et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1138) Google Scholar Videolaryngoscopy has been recommended for intubating obese patients,3Connelly NR Ghandour K Robbins L Dunn S Gibson C Management of unexpected difficult airway at a teaching institution over a 7-year period.J Clin Anesth. 2006; 18: 198-204Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 11Putz L Dangelser G Constant B et al.Prospective trial comparing Airtraq and Glidescope techniques for intubation of obese patients.Ann Fr Anesth Reanim. 2012; 31: 421-426Crossref PubMed Scopus (11) Google Scholar, 12Maassen R Lee R van Zundert A Cooper R The videolaryngoscope is less traumatic than the classic laryngoscope for a difficult airway in an obese patient.J Anesth. 2009; 23: 445-448Crossref PubMed Scopus (41) Google Scholar a group known to have a higher risk of complications associated with airway management.12Maassen R Lee R van Zundert A Cooper R The videolaryngoscope is less traumatic than the classic laryngoscope for a difficult airway in an obese patient.J Anesth. 2009; 23: 445-448Crossref PubMed Scopus (41) Google Scholar Beyond anaesthesia, predictions have been made that videolaryngoscopy will dominate the field of emergency airway management in the future.4Sakles JC Chiu S Mosier J Walker C Stolz U The importance of first pass success when performing orotracheal intubation in the emergency department.Acad Emerg Med. 2013; 20: 71-78Crossref PubMed Scopus (313) Google Scholar, 7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 13Sakles JC Rodgers R Keim SM Optical and video laryngoscopes for emergency airway management.Intern Emerg Med. 2008; 3: 139-143Crossref PubMed Scopus (41) Google Scholar It seems that cost is the main consideration holding back the tide.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 9Aseri S Ahmad H Vallance H Video laryngoscopy improves endotracheal intubation training for novices.Br J Anaesth. 2015; 115: 133Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar There are many reasons for such enthusiasm. Firstly, there are numerous technical benefits. Videolaryngoscopy gives the user a better view of the larynx than with a standard Macintosh laryngoscope (direct laryngoscopy).2Frerk C Mitchell VS McNarry AF et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1138) Google Scholar, 6Zaouter C Calderon J Hemmerling TM Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 114: 181-183Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 8Pott LM Murray WB Review of video laryngoscopy and rigid fiberoptic laryngoscopy.Curr Opin Anaesthesiol. 2008; 21: 750-758Crossref PubMed Scopus (70) Google Scholar, 12Maassen R Lee R van Zundert A Cooper R The videolaryngoscope is less traumatic than the classic laryngoscope for a difficult airway in an obese patient.J Anesth. 2009; 23: 445-448Crossref PubMed Scopus (41) Google Scholar This improved laryngeal view is the result of two factors: for videolaryngoscopes with Macintosh-shaped blades, a camera on the distal end of the blade gives an increased field of view compared with direct laryngoscopy, whereas for videolaryngoscopes with extra-curved blades, this increased field of view is augmented by the capacity to ‘see around the corner’ and gain a view of structures that are beyond the reach of Macintosh-style blades.6Zaouter C Calderon J Hemmerling TM Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 114: 181-183Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar This improved view of the larynx is seen even with only minimal head and neck manipulation.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 12Maassen R Lee R van Zundert A Cooper R The videolaryngoscope is less traumatic than the classic laryngoscope for a difficult airway in an obese patient.J Anesth. 2009; 23: 445-448Crossref PubMed Scopus (41) Google Scholar Appropriately chosen videolaryngoscopes are therefore beneficial for the management of both anticipated and unanticipated difficult laryngoscopy.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 14Enomoto Y Asai T Arai T et al.Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study.Br J Anaesth. 2008; 100: 544-548Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar, 15Lafferty BD Ball DR Williams D Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 115: 136-137Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The force required when intubating with a videolaryngoscope is less than that required for direct laryngoscopy, resulting in less risk of trauma to soft tissues and teeth,14Enomoto Y Asai T Arai T et al.Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study.Br J Anaesth. 2008; 100: 544-548Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar, 16Norskov AK Rosenstock CV Wetterslev J et al.Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database.Anaesthesia. 2015; 70: 272-281Crossref PubMed Scopus (201) Google Scholar, 17Pieters B Maassen R Van Eig E Maathuis B Van Den Dobbelsteen J Van Zundert A Indirect videolaryngoscopy using Macintosh blades in patients with non-anticipated difficult airways results in significantly lower forces exerted on teeth relative to classic direct laryngoscopy: a randomized crossover trial.Minerva Anesthesiol. 2015; 81: 846-854PubMed Google Scholar, 18Lee RA Zan Zundert AA Maassen RL Forces applied to the maxillary incisors during video-assisted intubation.Anesth Analg. 2009; 108: 187-191Crossref PubMed Scopus (64) Google Scholar, 19Russell T Khan S Elman J et al.Measurement of forces applied during Macintosh direct laryngoscopy compared with GlideScope® videolaryngoscopy.Anaesthesia. 2012; 67: 626-631Crossref PubMed Scopus (86) Google Scholar and a reduced incidence of sore throat.18Lee RA Zan Zundert AA Maassen RL Forces applied to the maxillary incisors during video-assisted intubation.Anesth Analg. 2009; 108: 187-191Crossref PubMed Scopus (64) Google Scholar, 19Russell T Khan S Elman J et al.Measurement of forces applied during Macintosh direct laryngoscopy compared with GlideScope® videolaryngoscopy.Anaesthesia. 2012; 67: 626-631Crossref PubMed Scopus (86) Google Scholar Several videolaryngoscopes have a higher rate of successful intubation when used as a rescue device when direct laryngoscopy fails.2Frerk C Mitchell VS McNarry AF et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1138) Google Scholar, 20Kelly FE Cook TM Boniface N et al.Videolaryngoscopes confer benefits in human factors in addition to technical skills.Br J Anaesth. 2015; 115: 132-133Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 21Aziz MF Healy D Kheterpal S et al.Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions.Anesthesiology. 2011; 114: 34-41Crossref PubMed Scopus (302) Google Scholar, 22Asai T Liu EH Matsumoto S et al.Use of the Pentax-AWS in 293 patients with difficult airways.Anesthesiology. 2009; 110: 898-904Crossref PubMed Scopus (187) Google Scholar As most difficult intubations are not anticipated,14Enomoto Y Asai T Arai T et al.Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study.Br J Anaesth. 2008; 100: 544-548Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar, 15Lafferty BD Ball DR Williams D Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 115: 136-137Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar first-line use of videolaryngoscopy not only reduces the risk of difficulty, but, when this occurs, eliminates the need for the intubator to swap to another device when time and oxygenation are critical. The number of attempts at laryngoscopy can be kept to a minimum, and it is highly likely that unanticipated difficult intubation would be less frequent if videolaryngoscopes were used as a first-line technique.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar Secondly, there are significant training advantages associated with using videolaryngoscopes, though perhaps restricted to videolaryngoscopes that have a remote screen rather than one attached to the laryngoscope handle. When the trainer can observe the larynx on a screen while the trainee performs laryngoscopy, the trainer can help the trainee to optimize the blade position and advise the trainee on where to place the tracheal tube by pointing out necessary landmarks on the screen.9Aseri S Ahmad H Vallance H Video laryngoscopy improves endotracheal intubation training for novices.Br J Anaesth. 2015; 115: 133Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar As the view of the larynx can be seen by trainee and trainer, and the technique can be optimized in real time, it is more likely that a trainee will be able to complete an intubation themselves without the trainer taking over.23Kelly FE Cook TM Randomised controlled trials of videolaryngoscopy vs. direct laryngoscopy on intensive care are needed.Intensive Care Med. 2014; 40: 765Crossref PubMed Scopus (8) Google Scholar This is especially useful for rapid sequence inductions and in patients at risk of hypoxia.9Aseri S Ahmad H Vallance H Video laryngoscopy improves endotracheal intubation training for novices.Br J Anaesth. 2015; 115: 133Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Whether the trainee is ‘allowed’ to see the screen or simply to use the videolaryngoscope for direct laryngoscopy (with reference to the screen only if difficulties are encountered) can be decided according to training aims. Five studies have now demonstrated that training novice intubators in direct laryngoscopy is more effective when the trainee uses a videolaryngoscope rather than a standard Macintosh laryngoscope.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 9Aseri S Ahmad H Vallance H Video laryngoscopy improves endotracheal intubation training for novices.Br J Anaesth. 2015; 115: 133Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 24Low D Healy D Rasburn N The use of the BERCI DCI Video Laryngoscope for teaching novices direct laryngoscopy and tracheal intubation.Anaesthesia. 2008; 63: 195-201Crossref PubMed Scopus (89) Google Scholar, 25Herbstreit F Fassbender P Haberl H Kehren C Peters J Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students.Anesth Analg. 2011; 113: 586-590Crossref PubMed Scopus (56) Google Scholar, 26Kaplan MB Ward DS Berci G A new videolaryngoscope—an aid to intubation and teaching.J Clin Anesth. 2002; 14: 620-626Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 27Howard-Quijano KJ Huang YM Matevosian R et al.Video-assisted instruction improves the success rate for tracheal intubation by novices.Br J Anaesth. 2008; 101: 568-572Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar Thirdly, there are non-technical or human factors advantages associated with videolaryngoscopy, again seen best with devices that have a separate screen. The whole team can see the view of the larynx, improving teamwork and communication. The anaesthetic assistant can see when the intubator is struggling much earlier and can anticipate the ‘next step’, ensuring that the necessary equipment is immediately to hand.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 9Aseri S Ahmad H Vallance H Video laryngoscopy improves endotracheal intubation training for novices.Br J Anaesth. 2015; 115: 133Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 23Kelly FE Cook TM Randomised controlled trials of videolaryngoscopy vs. direct laryngoscopy on intensive care are needed.Intensive Care Med. 2014; 40: 765Crossref PubMed Scopus (8) Google Scholar, 26Kaplan MB Ward DS Berci G A new videolaryngoscope—an aid to intubation and teaching.J Clin Anesth. 2002; 14: 620-626Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 27Howard-Quijano KJ Huang YM Matevosian R et al.Video-assisted instruction improves the success rate for tracheal intubation by novices.Br J Anaesth. 2008; 101: 568-572Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar When applying cricoid force, the anaesthetic assistant can assess whether this is improving the view of the larynx or, conversely, displacing or even compressing the larynx and making the view worse, and can immediately adjust the direction and degree of cricoid force as necessary.23Kelly FE Cook TM Randomised controlled trials of videolaryngoscopy vs. direct laryngoscopy on intensive care are needed.Intensive Care Med. 2014; 40: 765Crossref PubMed Scopus (8) Google Scholar, 26Kaplan MB Ward DS Berci G A new videolaryngoscope—an aid to intubation and teaching.J Clin Anesth. 2002; 14: 620-626Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Videolaryngoscopes can help trainee anaesthetic assistants to learn how to perform cricoid pressure, with their supervisor directly supervising them and helping them to adjust it as needed. The fact that the whole team can see the tracheal tube pass through the vocal cords, rather than only the intubator, provides clinical governance advantages. One author has described this as ‘multi-person visualisation’.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar In our experience, it simply changes difficult airway management from ‘I’ to ‘we’. Fourthly, the ability to record the intubation as a ‘digital airway record’ has advantages. It may be useful for training (to review with a trainee at leisure) or as part of the medicolegal records.6Zaouter C Calderon J Hemmerling TM Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 114: 181-183Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, 28Behringer EC Kristensen MS Evidence for benefit vs novelty in new intubation equipment.Anaesthesia. 2011; 66: 57-64Crossref PubMed Scopus (87) Google Scholar New medical diagnoses, such as vocal cord malignancies, have also been made with use of videolaryngoscopy during training.29Lomasney C Thornton M Unexpected benefit of videolaryngoscopy.Br J Anaesth. 2014; 113: 1059-1060Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Finally, emerging evidence hints at benefits for the anaesthetist in addition to the patient. Grundgeiger and colleagues30Grundgeiger T Roewer N Grundgeiger J et al.Body posture during simulated tracheal intubation: GlideScope videolaryngoscopy vs Macintosh direct laryngoscopy for novices and experts.Anaesthesia. 2015; 70: 1375-1381Crossref PubMed Scopus (22) Google Scholar demonstrated an improvement in the intubator's ‘total body position’ when using videolaryngoscopy compared with direct laryngoscopy. As described, these advantages are likely to be even more important when intubating critically ill patients, such as in the intensive care unit, where airway management is especially high risk.5Nolan JP Kelly FE Airway challenges in critical care.Anaesthesia. 2011; 66: 81-92Crossref PubMed Scopus (76) Google Scholar, 31Larsson A Dhonneur G Videolaryngoscopy: towards a new standard method for tracheal intubation in the ICU?.Intensive Care Med. 2013; 39: 2220-2222Crossref PubMed Scopus (18) Google Scholar, 32De Jong A Clavieras N Conseil M et al.Implementation of a combo videolaryngoscope for intubation in critically ill patients: a before–after comparative study.Intensive Care Med. 2013; 39: 2144-2152Crossref PubMed Scopus (62) Google Scholar In the NAP4 report, complications of airway management were up to 60 times more likely to occur in the intensive care unit than in the operating room, and when they happened they were more likely to result in death or brain injury (61%) than incidents occurring in the operating room (14%).33Cook TM Woodall N Harper J Benger J Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency department.Br J Anaesth. 2011; 106: 632-642Abstract Full Text Full Text PDF PubMed Scopus (615) Google Scholar There are now a large number of videolaryngoscopes available, with the number constantly increasing and many existing devices being modified. Although this can create a confusing picture, the devices can be broadly classified into the following three groups: (i) devices with a Macintosh-like blade, such as AP Advance (Venner Medical International, St Helier, Jersey, UK), C-MAC (Karl Storz Endoscopy, Slough, Berkshire, UK), GlideScope MAC (Verathon Medical, Bothwell, WA, USA), and McGrath Mac (Aircraft Medical, Edinburgh, UK); (ii) devices with an extra-curved blade, such as AP Advance with difficult airway blade (Venner Medical), C-MAC D blade (Karl Storz Endoscopy), GlideScope (Verathon Medical), King Vision with standard blade (Ambu, St Ives, Cambridgeshire, UK), and McGrath Mac with curved blade (Aircraft Medical); or (iii) devices with a channelled blade (conduited VL), such as Airtraq (Teleflex, Morrisville, NC, USA), Pentax AWS (Ambu), and King Vision (Ambu). It is highly likely that not all videolaryngoscopes are equal, and it is therefore important to understand which videolaryngoscopes perform better than others.34Asai T Videolaryngoscopes: do they truly have roles in difficult airways?.Anesthesiology. 2012; 116: 515-517Crossref PubMed Scopus (76) Google Scholar However, the current evidence base has focused on comparing videolaryngoscopy with direct laryngoscopy, and there is little high-quality evidence regarding the relative performance of different videolaryngoscopes at present. Mihai and colleagues35Mihai R Blair E Kay H Cook TM A quantitative review and meta-analysis of performance of non-standard laryngoscopes and rigid fibreoptic intubation aids.Anaesthesia. 2008; 63: 745-760Crossref PubMed Scopus (144) Google Scholar published a meta-analysis in 2008, but were unable to draw clear or useful conclusions regarding which performed best, reporting that most studies were of poor quality and that the vast majority of studies did not include truly difficult patients. A Cochrane meta-analysis on the topic is in progress.36Lewis SR Nicholson A Cook TM Smith A Videolaryngoscopy versus direct laryngoscopy for adult surgical patients requiring tracheal intubation for general anaesthesia.Cochrane Database Syst Rev. 2014; (Issue 5. Art. No.: CD011136, Available from) (accessed 10 March 2016)doi:10.1002/14651858.CD011136http://www.cochrane.org/CD011136/ANAESTH_videolaryngoscopy-versus-direct-laryngoscopy-for-adult-surgical-patients-requiring-tracheal-intubation-for-general-anaesthesiaGoogle Scholar Manikin studies and numerous small patient studies shed little light on the topic, and there are no large randomized controlled trials to date. Co-ordinated efforts to collect comparative clinical data would help to guide implementation. Despite the many advantages described here, there are potential pitfalls that may be encountered when using videolaryngoscopy, most of which are readily avoided with care and knowledge. We propose the following ‘rules of videolaryngoscopy’ to help maximize the benefit the intubator can gain from using these devices. The technique for videolaryngoscopy (particularly with extra-curved and conduited blades) differs from that for direct laryngoscopy, and manufacturers’ recommended techniques for many videolaryngoscopes differ from each other. This has important implications. Experienced anaesthetists, skilled at intubation using a Macintosh laryngoscope, cannot expect to be able to use a videolaryngoscope effectively without training and practice. Although some reports describe very short learning curves,7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar, 27Howard-Quijano KJ Huang YM Matevosian R et al.Video-assisted instruction improves the success rate for tracheal intubation by novices.Br J Anaesth. 2008; 101: 568-572Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar Lafferty and colleagues15Lafferty BD Ball DR Williams D Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 115: 136-137Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar reported that 76 intubations with a GlideScope were needed to achieve competence.37Cortellazzi P Caldiroli D Byrne A Sommariva A Orena EF Tramacere I Defining and developing expertise in tracheal intubation using a GlideScope® for anaesthetists with expertise in Macintosh laryngoscopy: an in-vivo longitudinal study.Anaesthesia. 2015; 70: 290-295Crossref PubMed Scopus (83) Google Scholar The 2015 DAS guidelines emphasize the need for all anaesthetists to be trained in the use of videolaryngoscopes. Given that trainee anaesthetists rotate to different hospitals, they will also need to be trained fully in the videolaryngoscope(s) available at each hospital.2Frerk C Mitchell VS McNarry AF et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1138) Google Scholar This is likely to require an increase in formal training in these techniques. Of note, videolaryngoscopes with a Macintosh-type blade can be used for both direct laryngoscopy and videolaryngoscopy and do use a similar technique, giving them an important advantage for training. The videolaryngoscope blade is inserted into the oral cavity using the standard direct laryngoscopy technique, and the glottis can then be seen either under direct vision or on a video screen. There are numerous different designs of videolaryngoscopes, and several require different techniques for use.35Mihai R Blair E Kay H Cook TM A quantitative review and meta-analysis of performance of non-standard laryngoscopes and rigid fibreoptic intubation aids.Anaesthesia. 2008; 63: 745-760Crossref PubMed Scopus (144) Google Scholar For example, the C-MAC is designed to be used as a standard Macintosh laryngoscope, while the GlideScope is inserted along the centre of the tongue without the need for tongue displacement.7Paolini JB Donati F Drolet P Review article: video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?.Can J Anesth. 2013; 60: 184-191Crossref PubMed Scopus (105) Google Scholar Insertion depth and direction of applied forces for the Airtraq and many extra-curved videolaryngoscope
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