post

Video laryngoscopes: what is your point of view?

OK, today insead of me prattleing on a about a topic I am going to ask you all a question.

I have been looking at a few video laryngoscopes for my place and have lots of questions – what works well, what looks good but doesn’t work, what is easiest in practice???

So I want to know from you – the readers / experts in your field – which video laryngoscope system works best in your theatre or ED?

I will start the ball rolling with a link to an article that compared a few devices – CMAC, Airtraq, Glidescope or MacIntosh.

I never know how to interpret these articles done in specialist practice under very different circumstances to real world practice.  So I want your opinion, can we reach a concensus.

There is a prize for anybody who beats Dr Minh to the punch for comments –  I just know Mihn has thought about this a lot!

Casey

Comments

  1. Jonathan Ramachenderan says:

    Hey Casey

    Great to have met you the other week.

    The CMAC is what we use here in Joondalup. I like it for 2 distinct reasons.

    1) Teaching – Great tool for demonstrating airway anatomy to students, great way to understand the process of laryngoscopy and grading airways,

    2) Difficult Intubation – Together with either a 3 or 4′ blade, +/- bougie and appropriate positioning, the CMAC has been extremely useful in our department for our difficult intubations (Known grade 3-4, predicted and unpredicted difficult airways).

    Last week we had a young lady for a hemithyroidectomy with a small jaw, malampati 4 and a TMD < 6cm. We obtained a grade 4 view with a MAC 4 blade but with the CMAC + 4' blade we obtained a grade 2B view of the cords and managed to pass the ETT.

    THanks mate.

  2. I am partial to the glidescope, to the extent that I use it as my primary airway device because I feel it is so superior to traditional blades.
    It is shaped quite differently than a traditional MAC blade, and it’s use is subtly different. The blade is a curve, or an arc and the best way to place it is by rotating it along that arc just like you rotate a suture needle along it’s arc. This means that you can intubate someone with incomplete mouth opening due to trauma or trismus quite easily, as long as their mouth can admit the profile of the glidescope blade. It’s also great for doing an airway with the patient in the seated position for those vomiting overdosed folks….
    I think that most departments bring video laryngoscope into the department as a reduce device. The skills of these devices are not the same as a traditional laryngoscope, and I think it is worthwhile to use whatever device you get as a primary device for 6 months (or maybe less if you do a high volume of emergency intubations) to become proficient with that particular device. In my department the people who took the time to really get a feel for the nuances of video laryngoscopy all now use it as a first pass airway manoeuvre.
    Aaron

  3. CMAC for teaching institutions. You can turn the screen away from the resident and they get a standard macintosh intubation and you get to see what they are doing wrong.

    Glidescope for non-teaching. Disposable blades take such a huge headache away.

    If Storz develops disposable blades then I would stay with them for both. I hear glidescope is developing macintosh shaped blades in which case I may flip-flop.

  4. I like to C-MAC – it’s good for teaching and I believe accelerates the learning curve for novice incubators

    That said, it’s an expensive piece of kit and not ideally suited to the rough-and-tumble of prehospital work.

    Like you Casey, I’m trying to narrow down options for my rural practice. So far I’ve narrowed it down to three – the AirTraq, the KingVision and the AmbuAscope.

    Quite like the AirTraq – easy to startup, gives an improvement of at least 1 on the CL grade (IV to III) and is cheap as chips with a shelf life of ~ 36 months. I’ve got a couple in my prehospital bag and will probably use on a list every few months just for practice. However, not sure if I will stick with it longterm, as I think the KingVision may supercede this.

    KingVision has only arrived today – basically a screen like the C-MAC directly coupled to a disposable laryngoscope. It’s a bit more pricey at around $2K for the screen and five blades, but I think has superior optics and the added advantage of the screen allowing ALL in the resus room to see passage of the ETT through the cords. A box of them has just arrived today from the rep and I’m going to play with ‘in ager’ over the next month and report back. But first impressions are good as is informal feedback from colleagues in the retrieval service.

    Thirdly, I’m looking at purchasing the AmbuAscope – the green in me rebels at the idea of disposable kit, but the reality is that our small country hospital won’t be able to afford a decent fibre optic tower…and fibre optic can be not just expensive but fiddly for nursing staff to set up at 3am in the heat of the moment. The Ascope is relatively cheap ($2800 for five scopes and a reusable monitor), small enough to use both in theatre, resus bay and at the roadside, and can purchase intubating LMAs for $7.50 each. Startup is real quick and even a relative novice like me can direct the scope adroitly via oral or nasal routes, as well as through the iLMA to achieve a slick intubation in under 45 seconds. I can see a real use for this adjunct in the punters for whom I’d consider an awake fibre optic (recent GSW to face and traumatic tracheostomy from ‘glassing’ in a pub), or secondary retrieval where have time to sort out definitive airway.

    So, bottom line – C-MAC and others are great but pricey. For a small country hospital on a budget, then if spend under $5K can get both AmbuAscope and a brace of KingVisions, or AmbuAscope and a handful of AirTraqs if really pushed for cash.

    Oh, and a Frova bougie if you haven’t already got one.

    Lastly, I wonder if there are economies of scale to be had here. In my region (South Australia) there is no agreed difficult airway equipment between the numerous country hospitals – indeed the suggestion has been that individual hospitals purchase the gear they need. To my mind this is crazy, and might make more sense to have an agreed uniformity between rural hospitals and allow cycling of equipment between them and other serves such as metro and retrieval before expiry date. Also obvious ramifications for training…nothing worse than being called down to ED for a difficult airway only to find that their equipment is unfamiliar – concordance between rural hospitals, retrieval and possibly major hospitals would obviate this.

    Tim Leeuwenburg
    Kangaroo Island, SA

  5. Minh Le Cong says:

    Hi guys, just found this discussion trail now! Having posted my review of the King vision VL only last night to EMCrit blog! What a coincidence!
    And we had a recent retrieval case of an impossible airway with acute angioedema!
    Personally for rural docs, there is now no question about VL choice. It’s the King Vision VL. Go check out my review. In a group practice of 7doctors, you could buy one each for less than the price of a CMAC or glidescope!
    I generally agree with Tim’s thinking on this, but have some doubt still about the utility of the Ambuscope for emergency and remote medicine. awake FOB and awake intubations sound great and are de rigeur in anesthesia but I wonder if they promote the sense that any airway can be managed orally? The Jankowski case in Perth had the issue of the FOB being considered to try to reintubate when the airway had clearly failed. In other words, I think in emergency airway management having too many choices is not as good an idea as it might seem.

    Apart from pricing, the other issue with VLs that have separate displays to the actual airway device li.e a cord is used to attach display to laryngoscope, is that ergonomically this is not as intuitive as having the device a single working unit with display and blade together.

    The VL no one has mentioned here that also gets a mention from me is the AV laryngoscope distributed by LMA Pacmed here. Before the King Vision came, I was saving up money to get one of these. it still costs around $7000 and the disposable blades are $45 each I think but it works just like a normal LED laryngoscope with usual Mac blade shape but has a detachable video display and guided channel blade for difficult airways. So it has the benefit of the CMaC in working like a normal laryngoscope but is fully self contained and so more portable.

    The Airtraq is not a video laryngoscope as you know but is almost as good as devices costing 100x more! in fact the King Vision VL is almost like the AirTraq but with the bonus of a true video capability . The Airtraq view is through an eyepiece which I don’t like and it is not as panoramic a view as most VL devices can deliver.

    one caution regarding using VL for all your intubations though. You should not lose your DL skills. Probably best to mix it up and be selective for first pass. You can always have VL as a backup in case of unexpected difficulty.It’s remarkable if you read the literature about VL in prehospital services in Europe and find that the backup technique most prehospital anesthetists used when VL failed was in fact DL!!!

    The game changing role I see VL, is with lower pricing and mass availability, the occasional intubator can more easily gain and maintain intubation competency. This has been a difficult area to determine best practice of skills maintenance for intubation. but VL techniques allow the occasional incubator much better success rates of optimal laryngeal visualization and little training to gain reasonable intubation success rates.

  6. toby thomas says:

    I’ve bought the AP Direct by Pacmed (not sure if MInh is referring to a different model or whether he’s doing retireval and just hit some turbulance and it’s a typo) It wroks (and thats what you get for being a smartarse about typos) well but the image is not as good as you get with the C-mac. It’s main problem , however, is the connection between the screen and the handle – if you bump it, the screen can turn off in the middle of your intubation attempt.

    I’ve not tried the King VIsion but its available locally for $900 for the handle and about 30$ each for the blades. I was told that the blades only cone in size 3 at the moment but they are planing to make other sizes soon.

  7. Tim Leeuwenburg says:

    Agree with you Minh about the dangers of monkeying about with fibreoptic scopes….that said, having trialled the KingVision today, my choice is made – KingVision VL as an adjunct to difficult airways after DL….and if all else fails, surgical airway scalpel-bougie-ETT.

    I will however get the Ascope too as it’s nice to do an AFOI now-and-then in the anticipated difficult airway in theatre.

    Great forum BTW.

  8. Minh Le Cong says:

    Thanks Toby …yes my mistake ..AP video laryngoscope…Xmas come early ,mate ? I agree it does seem weird having a detacheable display held on with magnets !
    The difficult airway blade seemed pretty awesome when I tried it out though ..is that your impression too?

    • toby thomas says:

      Not sure about Christmas coming early but when my wife finds out it will definitely be a divorce come early. I forgot to mention the difficult airway blade. It gets an excellent view of the cords and an easy intubation using a bougie. It’s a bit harder with a tube and stylet due to the steep angle of the blade (if that makes sense)

  9. Rajesh Malik says:

    Hi Guys, thought I’d pitch my two cents worth. I’ll be specific as I have used almost all of them.
    Starting with the Glidescope. Of all the videoscopes it has the best image. However its blades are the downside. They simulate a D-blade of the Macintosh, hence the requirement to use their own Stylet which is actually a learning curve, the introduction angle etc..Also the issue with disposable blades which does not make it prospective in our cash starved institutions.
    Next is the C-Mac whose blades actually simulate the Macintosh. So it is not a shift from daily practice. As Scott mentioned you can turn it away for teaching as you can intubate in usual circumstances. However I have found people struggling with it and have had to use the bougie as Toby mentioned which is fine. My message for C-Mac users is to actually decide pre insertion and use the bougie upfront rather than coming back and then trying again. The C-Mac is also armed with a D-blade for anterior larynxes but I don’t see a place for it in an ED with Anaesthetic backup.The turnover time of C-Mac blades is approx. 2 hrs so you are handicapped for that period.
    Minh & Toby talked about King vision & AP which are more or less similar to the Mcgrath scope with a video screen on top. These ones are not bad but are more popular for individual buyers rather than teaching institutions.
    The Airtraq is a completely different ball game. Its use is limited to certain instances & cases eg. difficult airways. It cannot be used with small mouth openings. It is great as it can convert a Grade 4 into a Grade 1, our experience has been such. Also it helps where C-spine movement is restricted. But there is no video screen as you have to look through an optical view which actually discourages its use even with the most experienced operators.Using the Airtraq is again a learning curve as most experienced operators have often failed, hence the least popular of all. My experience is once you’ve learnt its usage it is a great tool.
    Close to the Airtraq is the Pentax scope which is similar to the Airtraq in structure but fitted with a video screen with a target symbol on the monitor and you can align the glottic opening on the target symbol. Its advantage to the Airtarq is that it has suction port as well.
    Finally given a choice in a major ED my take would be for C-Mac with the Pentax for difficult airway .
    For a regional center or individual use King vision would be the best around.
    One must remember that using the C-Mac would not completely deskill us as opposed to all other video scopes around.

  10. Good post Rajesh, and especially useful to run the comparisons.

    Often forgotten is the price differential. It’s all well and good for gurus on various airway courses or anaesthetic special-interest-groups to favour the high end kit…but as Rajesh highlights, the C-MAC probably has it for the teaching hospital…the KingVision for the individual or small rural hospital.

    Am I alone in topicalising the airway and considering AFOI for the anticipated difficult airway? Hence the Ascope for planned difficult airway, reserving DL and then KingVision for RSI.

    • Minh Le Cong says:

      Its a good question Tim
      May I try to answer it with a thought experiment, loosely based on a recent event I audited

      You are away on holiday when the GP registrar back at work on your small rural island hospital calls you up for advice. He has 6 months anaesthetic training where he did lots of DL, LMA and RSI work but never did an awake FOB assisted intubation.

      He has a young man with acute angioedema deteriorating despite emergency treatment. The patient is hypoxic but still alert ( desaturates to 80% off oxygen 15L/min). His CO2 is 74 , pH 7.1. He has a Mallampati 5 ( real description from audit)

      The retrieval team is grounded due to bad weather but responding by road which will take around 3-4 hrs.

      The registrar asks you if he should :
      1. Start biPAP and wait for the cavalry
      2. Try an awake intubation using the AmbuScope you showed him on his first day of orientation, with backup LMA and full surgical airway setup
      3. RSI using the KingVision you showed him, with backup LMA and full surgical airway setup

      ???

  11. Casey Parker says:

    Hi Tim
    Good question. If you want to see a great awake FO intubation demo – go to Emcrit and search for the “Infamous Awake Intubation” post. Scott gets his Residents to tube each other – lots of pearls and laughs!
    Casey

    • Tim Leeuwenburg says:

      Mmmm. Got a feeling this one went bad! Not keen in using this kit de novo when shit hits the fan…whch is why advocate using the kit you will use for bailout on routine lists. A novice pissing about with AFOI for first time on this patient is inviting trouble.

      Impressed with the MP V score – photographed a Mallampati 0 last month (could see cords when opened mouth and phonated, sitting up – impressive).

      So, how did your (hypothetical) case pan out?

      • Minh Le Cong says:

        OKay
        Tim, what would you have advised that registrar?
        I will post the case to Casey as a separate blog..its worth a think as it posed a lot of issues for retrieval, remote GP care and human factors.

        My point is that your airway gear should be tailored to suit the lowest common denominator. It is arguable to get gear that requires an experienced user, unless said experienced user is going to be on call and available 24/7. Now that is fine in a major hospital ED , ICU or OT. but in remote and rural hospitals its not going to happen long term. When your locum relieving GP or GP registrar is dealing with that nightmare airway the gear should be as simple as pushing two bits together and turning it on…or ideally just turning it on.

        Awake intubation is quite a skill with a good measure of luck thrown in

  12. Tim Leeuwenburg says:

    I hear you Minh, and agree that kit should be kept as simple as possible – plan for the locum doctor, agency staff and retrieval service weathered in. Assuming that we need to crack on with RSI (rapid sequence intubation, not necessarily a really stupid idea!) in hands of the occasional intubator, then do everything to maximise chances – position, intubation checklist, role allocation, DAS algorithms.

    I agree the KingVision has a role here. I reserve the right to keep my ascope for use in selected patients in OT, but I wouldn’t be using it in these circumstances, and reiterate that it has no role in the hands of someone who has ‘seen one’ but not used. AFOI has a role in airway management, but I dont think this is it.

    Anyway, I’ve bitten at the bait and posted in the case scenario conccordant with this thread.

    Great blog BTW and great to get inout from a variety of sources. Minh and Casey, you guys are da bomb!

  13. Just got back from the rural GP-anaesthetists organised by the NSW rural doctors network – a great event, combining a day of lectures aimed at the rural workforce, along with a day in the Royal North Shore sim lab doing workshops and sim-sessions on a variety of ‘brown trouser and bicycle-clips’ anaesthetic scenarios

    Anyhow, video laryngoscopes were discussed by several and a few good pioints raised which I hadn’t really articulated before

    In essence

    – C-MAC and other devices at high-end are great, but too expensive for small rural hospitals which seem to have to make own purchasing decisions on equipment and beg for cash

    – any device should be simple, easily assembled and relatively cheap

    – AirTraq is the cheapest – but the need to peer through the viewing port means that you rapidly lose situational awareness in a sick patient = BAD

    – KingVision (or Pentax) with attached video screen in the handle allow you to visualise the cords AS WELL as maintain surveillance on patient/monitors/team which is a huge advantage. The KingVision device is easily activated (push handle onto blade) and an assistant can be rapidly instructed. Cost for the KingVision is only about $1200 for screen and a box of 10 blades i.e.: affordable = GOOD

    – the technique with these VLs is slightly different, with many initially advancing too far. I’ve found that loading my ET tube into the channelled blade then putting bougie through the ETT so that tip extends about 1cm with some coude bend BEFORE intubation helps – so that when I see cords can advance bougie and railroad ETT in one swift movement

    What was interesting (for me) was how some of the metro anaesthetic speakers recommended that rural docs MUST have suggumadex, desflurane, BIS, remifentanil, FFP & platelets, advanced anaesthetic workstations & fibreoptic scopes in their health units….and seemed aghast that the rural hospital didn’t.

    Reality is that even within NSW their seems discordance in what equipment people have and what ‘minimum standard’ is acceptable.

    • Minh Le Cong says:

      The controversy over rocuronium /sugammadex vs suxamethonium

      have we had that debate yet on Broome Docs?

      its a hot topic amongst retrieval services.
      Like VLs , expense has been the main barrier in preventing widespread adoption. Expense of the emergency reversal dose of sugammadex = $400 a pop. But you get a lot for your money…full TOF reversal within 90 seconds from full paralysis with rocuronium. at 1.2 mg/kg dosing for RSI.

      but like the current range of VLs coming out ( like the King Vision), the price is dropping and as soon as sugammadex drops in price or another rival comes to compete with it

      A lot of opinion is that the end of suxamethonium will be heralded.

      Now what does this mean for rural docs and hospitals.

      watch this space! I’d keep my sux for now but start becoming more familiar with rocuronium for RSI. Its basically fast acting vecuronium when dosed at 1.2mg/kg for RSI. Intubating conditions as good as 1.5mg/kg sux but 15 seconds slower. Sure it lasts 45 min at that dose but whether you have sugammadex reversal or not, some folk argue if its a true emergency airway then leaving them paralysed for all your rescue techniques makes a lot of sense.

      Pretty hard to do a surgical airway when the patient starts to move..

      Which brings us back to your initial airway decision..not to be taken lightly of course. If they need a secure airway then they need it..none of this waking them up and deciding what to do next!

  14. Exactly!

    Had this very discussion yesterday with a metro anaesthetist when discussing RSI in trauma at a GP-anaesthetists meeting.

    First up, the metro anaesthetist didn’t want to entertain the idea of ketamine for RSI because of the ‘risk of raised ICP’. Truly, I thought we’d put that to bed long ago.

    Next up,the rural docs as a group discussed sux vs roc for RSI. I’m coming around to roc at 1.2mg/kg…but the old chestnut of ‘must use sux because if cannot intubate you can always wake the patient up’ was the mantra from the metro docs.

    Really? If I’ve got a clapped out trauma patient who needs airway securing, then I think this is fuzzy logic. Waking up is not always an option…better to push on with DL, VL, iLMA, proseal etc…all the way to surgical airway if that’s what is needed. In which case, roc is perfect.

    Of course, if they can be awoken safely and transported with unsecured airway, then by all means we should do so! Whilst I like the idea of suggamadex, I do wonder if having it around lends itself to a feeling of false security.

    What do I mean? Well there’s evidence that the time taken to draw it up exceeds the time to critical desat (in fact, probably does for sux to wear off too if we are being honest). I’ve heard figures of 6.7mins to draw it up PLUS the time to go from full paralysis to TOF of 90 secs i.e. : over 8 mins from ‘get the suggamadex’ to it working

    I’ll stick with sux for now, thanks. If I do use roc for RSI with ‘bail out’ suggamadex, then I’ll be following Cliff Reid’s sage advice:

    – Brief the team that rocuronium is to be used and that should an unanticipated difficult airway situation be encountered, then sugammadex will be used to reverse the effects of the rocuronium.

    – Allocate the task of drawing up the sugammadex to a specific team member who has no additional role in the rapid sequence induction.

    – Before induction, a calculation is made of the dose of sugammadex (16 mg/kg) that would be required and the volume of drug that should be drawn up.

    – The instruction is given that should the anaesthetist not confirm intubation within 2 min, then the sugammadex is to be drawn up and handed to the anaesthetist for administration.

  15. Does it matter that much. If you use the shovel or the spade you still get a hole.

    Be careful with mankin studies as they can favour one device over another depending on the mankin. eg the pentax needs the epiglottis elevated like a miller so that is not a problem in a manikin but could be in a floppy human epiglottis. They often use inexperience personal to increase the effect difference.

    Videolaryngoscope choice – it does not really matter as long as you get appropriate training and practice. I have used all the devices mentioned. Each has there own problems and failure mechanism. Even similar devices have mild technique variation eg pentax and king vision.

    Essentially the choice depends on a few factors

    1. Shape
    Hyperangulated eg macgrath, glidescope
    Bullard shape eg airtraq, pentax, king vision
    Macintosh shape eg C mac, also available in macgrath and glidescope

    2. Channeled or non channeled

    3. Portability

    4. Cost

    5. Teaching device for direct laryngoscopy

    6. Ability to record the intubation (training and one day maybe medico legal for paramedics)

  16. Well, after all that…are you any closer in choosing a device, Casey? Is money no object?

    Like I said, KingVision VL and AmbuAscope get my vote as tick most of the boxes mentioned by Mike (above)…but most importantly are affordable

    Having similar kit in hospitals as well as retrieval service would allow equipment recycling as near ends of shelf-life, particularly if not needed

    You also need a CEO/DON who is happy to let you use the kit on elective lists as training for the nightmare airway (and we’ve just had a ‘robust’ debate elsewhere in ‘the airplanes & airways’ thread on this!)

  17. I haven’t heard of aidtronix video laryngoscope, all I hear is KingVision.
    Has anyone had experience with buying one?
    This is the video laryngoscope I am considering.
    https://www.aidtronixusa.com/pages/video-laryngoscope-v1

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