Will Video Laryngoscopy become the norm?

[u/Radiant_Alchemist]

I love VL. They make standard laryngoscopes look brutal. They're less traumatizing, they give a better view, they have a better first-pass success. Sure you need to learn direct laryngoscopy but let's say in 5 years from now will they be used as routine in OR and ER intubations? Or will they be saved for hard cases?

I've been told that the equipment tends to suck and that we won't have VL as available as in the current department that I'm working so I should stick to Macintosh and McCoy.

[u/AlanDrakula]

Its been normal for a minute

[u/OysterShocker → u/[deleted]]

They are the standard now for most intubations in North America. Most ER and anesthesia residents, for example, will be better at VL than DL.

[u/Eohde → u/OysterShocker]

Even within our EMS system, it’s the standard for all of us paramedics. Any of our older paramedics that are too stubborn to do VL and continue to do manual without a decent reason can expect to sit in front of our medical director.

Being able to record and directly confirm placement, let alone the speed it lets intubation happen has no excuse for it not to be standard even for us. The new McGrath video scopes are extremely affordable and allow for manual intubation if for whatever reason the video is being a problem.

[u/Aviacks → u/Eohde]

I had a new medic on flight refuse to learn VL. Til we got a GCS 3 500# train wreck that the ED failed to intubate several times. I’m like “you got one shot and when you can’t see shit I’m tubing him with the glidescope”, airway was FILLED with dried snot and vomit.

He took one look and went “what the fuck? Okay your turn.” lol. I had to literally PUSH the snot off the vocal cords because it was hardened from mouth breathing 40 times a minute for two hours while snowed on ketamine and haldol, couldn’t suction it even a little.

We spent several hours going over VL technique after that lol. I admire the ones that keep up DL skills and he was quite good at it, I saw him get some obese no neck trainwrecks no problem several times, but one day you find the scenario it isn’t enough even with good positioning and technique.

[u/IntensiveCareCub → u/OysterShocker]

Anesthesia resident here: this is very program dependent. 90% of my intubations are DL. I only use VL for anticipated difficult airways and out of OR intubations (simply because that’s what’s more readily available).

[u/Penlight_Nunchucks → u/IntensiveCareCub]

In the ER every airway is an anticipated difficult airway, I would conjure NOT using VL at this point would open your litigation if there was a bad outcome.

[u/PerrinAyybara → u/IntensiveCareCub]

Typical anesthesia isn't comparable to the ED or Prehospital world. All of our airways are expected to be difficult and/or crash airways by the nature of the reasons we intubate.

[u/IntensiveCareCub → u/PerrinAyybara]

Difficult airways and physiologically challenging intubations are very different things. You can have patients with easy airways who are physiologically challenging, and vice versa. Just because someone requires optimization prior to intubation, that doesn't make them "difficult." Anesthesia does all the STAT airways for the hospital here and we do DL sometimes, just depends on what's available for equipment. It's perfectly safe in properly trained hands.

There are very few intubations where you can't spend even a few minutes optimizing the patient (impending airway closure, uncontrollable UGI/airway hemorrhage, to name a few)... improving their BP, pre-oxygenating, better positioning, etc. go a long way in making your intubation safer. It's good to have VL available nearby if needed and while data does show that VL has higher first past success, this difference diminishes with more experienced intubators.

I think the last point is the bigger caveat here. The experience in the emergency medicine world is significantly less than that of anesthesia both in intubating and managing the hemodynamics (especially in EMS where maybe paramedics rarely intubate, and I say this as someone who was a paramedic prior to medical school). That's not to say ED docs / paramedics aren't good at intubating - like anything else though it's a skill, and the more you do the better you get.

Point being, I don't think the rationale for ED/EMS using VL is because the airways are more difficult, but rather that the higher first past success rate is more applicable in less experienced personnel.

[u/SolitudeWeeks → u/[deleted]]

It's been years since I've seen an intubation done without VL. The only reason our direct blades aren't collecting dust is because we QC them.

[u/newaccount1253467 → u/SolitudeWeeks]

I like to take them into the room with me for every intubation just as a safety net. I can't remember the last time I actually used one.