The Use of a Video Laryngoscope by Emergency Medicine Residents Is Associated With a Reduction in Esophageal Intubations in the Emergency Department

Abstract

Objectives: The purpose of this investigation was to compare the incidence of esophageal intubations (EIs) when emergency medicine (EM) residents used a direct laryngoscope (DL) versus a video laryngoscope (VL) for intubation attempts in the emergency department (ED). Methods:Prospectively collected continuous quality improvement data on tracheal intubations performed by EM residents in an academic ED over a 6-year period were retrospectively analyzed. Following each intubation, EM residents completed a data form with patient, intubation, and operator characteristics. Data collected included the method of intubation, drugs used, device(s) used, number of attempts, outcome of each attempt, occurrence of EIs, and occurrence of adverse events (hypoxemia, aspiration, dysrhythmia, hypotension, and cardiac arrest). The incidence of EI was compared between intubation attempts with a DL and with a VL (GlideScope â or C-MAC â ). Propensity score matching and conditional logistic regression were used to analyze the association between the intubation device (DL vs. VL) and EI.Results: Over the 6-year period, 2,677 patients underwent 3,425 intubation attempts by EM residents with a DL or a VL. A DL was used in 1,530 attempts (44.7%) and a VL was used in 1,895 attempts (55.3%). There were 96 recognized EIs (2.8%). The incidence of EI when using a DL was 78 of 1,530 attempts (5.1%; 95% confidence interval [CI] = 4.1% to 6.3%) and when using a VL was 18 of 1,895 attempts (1.0%; 95% CI = 0.6% to 1.5%). Based on the propensity score matched analysis, the odds ratio for the occurrence of an EI for DL versus VL was 6.9 (95% CI = 3.3 to 14.4). Patients who had inadvertent EIs had a higher incidence of adverse events (49.5%; 95% CI = 38.9% to 60.0%) than patients in which EI did not occur (19.8%; 95% CI = 18.3% to 21.4%). Conclusions:The use of a VL by EM residents during an intubation attempt in the ED was associated with significantly fewer EIs compared to when a DL was used. Patients who had inadvertent EIs had significantly more adverse events than those who did not have EIs. EM residency training programs should consider using VLs for ED intubations to maximize patient safety when EM residents are performing intubation.ACADEMIC EMERGENCY MEDICINE 2015;22:700-707 © 2015 by the Society for Academic Emergency Medicine A irway management is a vital area of expertise for the emergency physician. Emergency medicine (EM) residents must learn the important skill of laryngoscopy and tracheal intubation during their training. It is the responsibility of EM faculty to teach residents how to intubate critically ill and injured patients in the emergency department (ED), while at the same time providing safe patient care. Achieving this

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

“…Video laryngoscopy use during emergency airway management is increasing over time, while DL use is decreasing, particularly when a difficult airway is anticipated . Multiple ED observational studies support this evolution in clinical practice having shown that VL improves glottic exposure and first‐attempt success and reduces the incidence of peri‐intubation adverse events . A single‐center registry from an academic ED reported that CMAC‐facilitated intubations resulted in significantly higher first‐attempt success compared with DL but did not specifically compared VL to A‐DL .…”

“…Direct laryngoscopy (DL) has been the historical standard for emergency airway management; however, video laryngoscopy (VL) has been shown to improve glottic view and first‐attempt success compared to DL in emergency department (ED) patients and its use in preference to DL has steadily increased . Maximizing first‐attempt success improves patient safety, reduces peri‐intubation adverse events, and the available evidence supports the use of VL as the first‐line device for emergency airway management . Glottic view is superior with VL because it effectively places the operator's eye at the leading edge of the blade, allowing the clinician to see around the base of the tongue and overcoming the challenge of creating a direct line of sight.…”

“…[1][2][3][4] Maximizing firstattempt success improves patient safety, reduces peri-intubation adverse events, and the available evidence supports the use of VL as the first-line device for emergency airway management. [5][6][7] Glottic view is superior with VL because it effectively places the operator's eye at the leading edge of the blade, allowing the clinician to see around the base of the tongue and overcoming the challenge of creating a direct line of sight. However, VL systems are more expensive than their DL counterparts and those with hyperangulated blades (i.e., GlideScope, King Vision, and CMAC d-blade) require additional training and practice as the mechanics of intubation differ significantly from standard geometry blades (CMAC, GlideScope teaching blade, McGrath Mac).…”

Current evidence for the use of C-MAC videolaryngoscope in adult airway management: a review of the literature

“…For emergency airways, most observational and retrospective studies indicate that C-MAC device performs better than direct laryngoscope, especially for patients with a Cormack–Lehane grade 3 or 4 41–48,50,51. After a failed first intubation attempt in the emergency department, C-MAC device is more successful at second attempt than the direct laryngoscope 51.…”

“…Several observational and retrospective studies from emergency department, prehospital and ICU patients showed that a V-MAC or C-MAC device, compared with a direct laryngoscope, was associated with a significantly better visualization of the larynx and a higher proportion of successful intubations, especially for patients with predicted difficult intubations 43–47. Furthermore, the use of C-MAC videolaryngoscope during emergency intubation was associated with significantly fewer esophageal intubations compared with direct laryngoscopy 43,48,49…”