- Email: [email protected]
Videolaryngoscopy as a new standard of care
136
| Correspondence
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Cavus E, Thee C, Moeller T, Kieckhaefer J, Doerges V, Wagner K. A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia. BMC Anesthesiol 2011; 11: 6 3. Turkstra TP, Jones PM, Ower KM, Gros ML. The Flex-It stylet is less effective than a malleable stylet for orotracheal intubation using the GlideScope. Anesth Analg 2009; 109: 856–9 4. Platts-Mills TF, Campagne D, Chinnock B, Snowden B, Glickman LT, Hendey GW. A comparison of GlideScope video laryngoscopy versus direct laryngoscopy intubation in the emergency department. Acad Emerg Med 2009; 16: 866–71 5. Cavus E, Callies A, Doerges V, et al. The C-Mac videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study. Emerg Med J 2011; 28: 650–3 6. Kim HJ, Kim JT, Kim HS, Kim CS, Kim SD. A comparison of glidescope videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children. Ped Anes 2011; 21: 417–21
Declaration of interest None declared. doi:10.1093/bja/aev192
Videolaryngoscopy as a new standard of care B. D. Lafferty*, D. R. Ball and D. Williams Glasgow, UK *E-mail: [email protected]
Editor—Zaouter and colleagues1 call us to adopt videolaryngoscopy as a new standard of care. They ask, ‘What is limiting us?’, replying that ‘It is only a cost issue.’ We believe that there are other reasons hindering a greater uptake of videolaryngoscopy, those rooted in our habits, our behavioural responses to learning. Skills in airway management are acquired during a long apprenticeship and consolidated by continual deliberate practice.2 Macintosh laryngoscopy is a time-honoured skill, a key part of a skill sequence leading to tracheal intubation, which the authors give prime status: ‘no other anaesthetic gesture is this important’.1 With practice, not only does laryngoscopy become habitual, but it is consolidated into the broader habit of the stepwise intubation sequence, becoming a form of ‘involuntary automaticity’.3 Tracheal intubation then becomes a collection of habits based on fast decisions termed ‘System 1’ thinking,4 also called heuristics. Crosskerry5 describes these as ‘rules of thumb, intuitions, abbreviations, simple judgements and short cuts. They are particularly prominent in the dynamic decision-making that characterizes the work of anaesthesiologists . . . .’ These habits have emotional content6 and may not change easily. In our hospital, we have placed a videolaryngoscope (Mcgrath MAC; Aircraft Medical, Edinburgh, UK) in every airway cart since
May 2014. A tally of use can be done by counting the number of blade sheaths used: 200 over 10 months (until end of February 2015). Yet over the same period, 5720 Macintosh disposable blades have been used. Thus, based on our findings, we disagree with the authors′ assertion that ‘If a videolaryngoscope is available in every operating theatre . . . there is no doubt that anaesthesiologists will use it’.1 In our hospital, old habits do not change easily. With videolaryngoscopy, gaining a view is the easy part; particular skills are needed to manipulate the tracheal tube with optimal use of a stylet and avoiding potential trauma in the pharyngeal ‘blind spot’.7 For the GlideScope (Verathon Medical, Bothell, WA, USA) device, ‘expertise is reached after 76 attempts’.8 Most difficult airway encounters are unpredicted; the Danish Airway Registry documented that 93% of difficult tracheal intubations were unpredicted.9 Unskilled use of a videolaryngoscope for a difficult airway should be a thing of the past. We need to be ready, able, and willing to learn to use these devices. This requires motivation; we need ‘implementation intentions’.10 Videolaryngoscopy has much to offer, and we agree with the authors that it should become a standard of care. We suggest that use of the videolaryngoscope should be routine. This does three things: the user gains proficiency in use, not only for easy but also for difficult intubations; that proficiency
Downloaded from http://bja.oxfordjournals.org/ at University of Edinburgh on June 22, 2015
laryngoscopists, have not been extensively studied, but preliminary evidence points to a higher degree of difficulty and longer time to intubate with videolaryngoscopy.6 Lastly, equipment malfunction may on occasions necessitate reverting back to conventional laryngoscopy. Limited training and experience with the backup technique in that instance seems worrisome. We can assume that the availability of standard laryngoscopes is likely as uniform as the availability oftracheal tubes across all major health care facilities in the world. With the advent of newer videolaryngoscopes, each with their own nuances, learning curves, and proprietary equipment, exceptional challenges and difficulties would be placed on any anaesthesia providers entering a work environment which employs devices they are unfamiliar with. Securing an airway remains the most essential skill in anaesthesia, particularly in difficult scenarios. We must avoid creating a culture wherein future generations may find themselves struggling should their videolaryngoscopes fail. To quote King Lear, ‘striving to better, oft we mar what’s well’. We support the use of new technology since it cannot be ignored. However, we believe that it can be accepted wholeheartedly only after we have assurance of expertise with the tried and tested techniques.
Correspondence
is an emotional skill and a rational one; and routine use sends a cultural message across the user′s institution that videolaryngoscopy is the way forward.
Acknowledgements We thank Peter Toni for providing information on our hospital’s equipment use.
Declaration of interest D.R.B. has received equipment for evaluation, teaching, and charity work from Aircraft Medical, Cook Medical, Intavent Direct, Olympus Medical, P-3 Medical, Storz Medical, and Trucorp. D.R.B. is co-author of the Airway Alert system cited by the authors.
1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Erisson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79: S70–81
3. Toft B, Massie-Taylor H. Involuntary automaticity: a worksystem induced risk to safe health care. Health Serv Man Res 2005; 18: 211–6 4. Kahneman D. Thinking Fast and Slow. London: Allen Lane, 2011 5. Croskerry P. The theory and practice of clinical decisionmaking. Can J Anesth 2005; 52: R1–8 6. Damasio A. Descarte’s Error. New York: Avon, 1994 7. van Zunert A, Pieter B, van Zunert T, Gatt S. Avoiding palatopharyngeal trauma during videolaryngoscopy: do not forget the ‘blind spot’. Acta Anaesthesiol Scand 2012; 56: 532–4 8. Cortellazzi 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: 290–5 9. Norskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. 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: 272–81 10. Gollwitzer PM. Implementation intentions: strong effects of simple plans. Am Psychol 1999; 54: 493–503
doi:10.1093/bja/aev193
Videolaryngoscope as a standard intubation device F. S. Xue*, G. P. Liu and C. Sun Beijing, People’s Republic of China *E-mail: [email protected]; [email protected]
Editor—The editorial article by Zaouter and colleagues1 recommending videolaryngoscopy as a new standard of care was of great interest. Videolaryngoscopes are indeed promising intubation devices because they provide an improved laryngeal view. However, we do not agree with the authors that videolarygnoscopes should replace direct laryngoscopes and be used for all intubations in current practice. The quantitative review and meta-analysis regarding the performance of video- and direct laryngoscopes indicate that in patients with a normal airway, the success rate of intubation with videolarygnoscopes is approximately the same as with direct laryngoscopes, but the intubation time is significantly prolonged with videolaryngoscopes;2–6 that is, tracheal intubation in patients with a normal airway can be achieved quickly and in a cost-efficient manner with direct laryngoscopes. In fact, the most convincing literature to date supports the use of videolaryngoscopes only in unanticipated, difficult, or failed intubations with direct laryngoscopy.2 3 6 The available evidence also shows that videolaryngoscopes are associated with better intubation success and faster intubation time only for inexperienced operators, but they provide no benefit in either of these outcomes with experienced operators.3 6 Thus, we argue that videolaryngoscopes are not the best care for all patients and the direct laryngoscope is not an outdated intubation device, especially for providers able to complete substantial training in controlled circumstances, such as
experienced anaesthetists, who are often called as airway experts. Furthermore, there are several different types of videolaryngoscopes available, each with a different blade shape, user interface and geometry, and tube insertion strategy.2 3 So far, there is inconclusive evidence to indicate which videolaryngoscope design could be more advantageous in various clinical situations. Thus, the open questions remain. Which videolaryngoscope is the most cost-effective device for routine or difficult intubation? Which one is the optimum to become a new standard of care? Given that device-specific proficiency is critical for successful use of any intubation device, if videolaryngoscopes are used as routine intubation devices, do anesthesiologists need to learn and achieve clinical competence for all devices? Perhaps, there might be a need to revise the current airway training programmes because they do not include videolaryngoscopic intubation training in the minimal skill set acquired by a trainee during an airway rotation.7 In addition, most of current difficult airway algorithms are developed as rescue guides in the event of difficult or failed direct laryngoscopy, and these algorithms rely on videolaryngoscopes as rescue tools for difficult or failed direct laryngoscopy.8–10 Although use of videolaryngoscopes is rapidly growing in clinical practice, there is still no evidence-based airway algorithm where tracheal intubation relies mainly on videolaryngoscopy. If videolaryngoscopes are used as the routine first-line intubation devices, one pertinent question is, what should one do in the
Downloaded from http://bja.oxfordjournals.org/ at University of Edinburgh on June 22, 2015
References
| 137
| Correspondence
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Cavus E, Thee C, Moeller T, Kieckhaefer J, Doerges V, Wagner K. A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia. BMC Anesthesiol 2011; 11: 6 3. Turkstra TP, Jones PM, Ower KM, Gros ML. The Flex-It stylet is less effective than a malleable stylet for orotracheal intubation using the GlideScope. Anesth Analg 2009; 109: 856–9 4. Platts-Mills TF, Campagne D, Chinnock B, Snowden B, Glickman LT, Hendey GW. A comparison of GlideScope video laryngoscopy versus direct laryngoscopy intubation in the emergency department. Acad Emerg Med 2009; 16: 866–71 5. Cavus E, Callies A, Doerges V, et al. The C-Mac videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study. Emerg Med J 2011; 28: 650–3 6. Kim HJ, Kim JT, Kim HS, Kim CS, Kim SD. A comparison of glidescope videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children. Ped Anes 2011; 21: 417–21
Declaration of interest None declared. doi:10.1093/bja/aev192
Videolaryngoscopy as a new standard of care B. D. Lafferty*, D. R. Ball and D. Williams Glasgow, UK *E-mail: [email protected]
Editor—Zaouter and colleagues1 call us to adopt videolaryngoscopy as a new standard of care. They ask, ‘What is limiting us?’, replying that ‘It is only a cost issue.’ We believe that there are other reasons hindering a greater uptake of videolaryngoscopy, those rooted in our habits, our behavioural responses to learning. Skills in airway management are acquired during a long apprenticeship and consolidated by continual deliberate practice.2 Macintosh laryngoscopy is a time-honoured skill, a key part of a skill sequence leading to tracheal intubation, which the authors give prime status: ‘no other anaesthetic gesture is this important’.1 With practice, not only does laryngoscopy become habitual, but it is consolidated into the broader habit of the stepwise intubation sequence, becoming a form of ‘involuntary automaticity’.3 Tracheal intubation then becomes a collection of habits based on fast decisions termed ‘System 1’ thinking,4 also called heuristics. Crosskerry5 describes these as ‘rules of thumb, intuitions, abbreviations, simple judgements and short cuts. They are particularly prominent in the dynamic decision-making that characterizes the work of anaesthesiologists . . . .’ These habits have emotional content6 and may not change easily. In our hospital, we have placed a videolaryngoscope (Mcgrath MAC; Aircraft Medical, Edinburgh, UK) in every airway cart since
May 2014. A tally of use can be done by counting the number of blade sheaths used: 200 over 10 months (until end of February 2015). Yet over the same period, 5720 Macintosh disposable blades have been used. Thus, based on our findings, we disagree with the authors′ assertion that ‘If a videolaryngoscope is available in every operating theatre . . . there is no doubt that anaesthesiologists will use it’.1 In our hospital, old habits do not change easily. With videolaryngoscopy, gaining a view is the easy part; particular skills are needed to manipulate the tracheal tube with optimal use of a stylet and avoiding potential trauma in the pharyngeal ‘blind spot’.7 For the GlideScope (Verathon Medical, Bothell, WA, USA) device, ‘expertise is reached after 76 attempts’.8 Most difficult airway encounters are unpredicted; the Danish Airway Registry documented that 93% of difficult tracheal intubations were unpredicted.9 Unskilled use of a videolaryngoscope for a difficult airway should be a thing of the past. We need to be ready, able, and willing to learn to use these devices. This requires motivation; we need ‘implementation intentions’.10 Videolaryngoscopy has much to offer, and we agree with the authors that it should become a standard of care. We suggest that use of the videolaryngoscope should be routine. This does three things: the user gains proficiency in use, not only for easy but also for difficult intubations; that proficiency
Downloaded from http://bja.oxfordjournals.org/ at University of Edinburgh on June 22, 2015
laryngoscopists, have not been extensively studied, but preliminary evidence points to a higher degree of difficulty and longer time to intubate with videolaryngoscopy.6 Lastly, equipment malfunction may on occasions necessitate reverting back to conventional laryngoscopy. Limited training and experience with the backup technique in that instance seems worrisome. We can assume that the availability of standard laryngoscopes is likely as uniform as the availability oftracheal tubes across all major health care facilities in the world. With the advent of newer videolaryngoscopes, each with their own nuances, learning curves, and proprietary equipment, exceptional challenges and difficulties would be placed on any anaesthesia providers entering a work environment which employs devices they are unfamiliar with. Securing an airway remains the most essential skill in anaesthesia, particularly in difficult scenarios. We must avoid creating a culture wherein future generations may find themselves struggling should their videolaryngoscopes fail. To quote King Lear, ‘striving to better, oft we mar what’s well’. We support the use of new technology since it cannot be ignored. However, we believe that it can be accepted wholeheartedly only after we have assurance of expertise with the tried and tested techniques.
Correspondence
is an emotional skill and a rational one; and routine use sends a cultural message across the user′s institution that videolaryngoscopy is the way forward.
Acknowledgements We thank Peter Toni for providing information on our hospital’s equipment use.
Declaration of interest D.R.B. has received equipment for evaluation, teaching, and charity work from Aircraft Medical, Cook Medical, Intavent Direct, Olympus Medical, P-3 Medical, Storz Medical, and Trucorp. D.R.B. is co-author of the Airway Alert system cited by the authors.
1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Erisson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79: S70–81
3. Toft B, Massie-Taylor H. Involuntary automaticity: a worksystem induced risk to safe health care. Health Serv Man Res 2005; 18: 211–6 4. Kahneman D. Thinking Fast and Slow. London: Allen Lane, 2011 5. Croskerry P. The theory and practice of clinical decisionmaking. Can J Anesth 2005; 52: R1–8 6. Damasio A. Descarte’s Error. New York: Avon, 1994 7. van Zunert A, Pieter B, van Zunert T, Gatt S. Avoiding palatopharyngeal trauma during videolaryngoscopy: do not forget the ‘blind spot’. Acta Anaesthesiol Scand 2012; 56: 532–4 8. Cortellazzi 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: 290–5 9. Norskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. 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: 272–81 10. Gollwitzer PM. Implementation intentions: strong effects of simple plans. Am Psychol 1999; 54: 493–503
doi:10.1093/bja/aev193
Videolaryngoscope as a standard intubation device F. S. Xue*, G. P. Liu and C. Sun Beijing, People’s Republic of China *E-mail: [email protected]; [email protected]
Editor—The editorial article by Zaouter and colleagues1 recommending videolaryngoscopy as a new standard of care was of great interest. Videolaryngoscopes are indeed promising intubation devices because they provide an improved laryngeal view. However, we do not agree with the authors that videolarygnoscopes should replace direct laryngoscopes and be used for all intubations in current practice. The quantitative review and meta-analysis regarding the performance of video- and direct laryngoscopes indicate that in patients with a normal airway, the success rate of intubation with videolarygnoscopes is approximately the same as with direct laryngoscopes, but the intubation time is significantly prolonged with videolaryngoscopes;2–6 that is, tracheal intubation in patients with a normal airway can be achieved quickly and in a cost-efficient manner with direct laryngoscopes. In fact, the most convincing literature to date supports the use of videolaryngoscopes only in unanticipated, difficult, or failed intubations with direct laryngoscopy.2 3 6 The available evidence also shows that videolaryngoscopes are associated with better intubation success and faster intubation time only for inexperienced operators, but they provide no benefit in either of these outcomes with experienced operators.3 6 Thus, we argue that videolaryngoscopes are not the best care for all patients and the direct laryngoscope is not an outdated intubation device, especially for providers able to complete substantial training in controlled circumstances, such as
experienced anaesthetists, who are often called as airway experts. Furthermore, there are several different types of videolaryngoscopes available, each with a different blade shape, user interface and geometry, and tube insertion strategy.2 3 So far, there is inconclusive evidence to indicate which videolaryngoscope design could be more advantageous in various clinical situations. Thus, the open questions remain. Which videolaryngoscope is the most cost-effective device for routine or difficult intubation? Which one is the optimum to become a new standard of care? Given that device-specific proficiency is critical for successful use of any intubation device, if videolaryngoscopes are used as routine intubation devices, do anesthesiologists need to learn and achieve clinical competence for all devices? Perhaps, there might be a need to revise the current airway training programmes because they do not include videolaryngoscopic intubation training in the minimal skill set acquired by a trainee during an airway rotation.7 In addition, most of current difficult airway algorithms are developed as rescue guides in the event of difficult or failed direct laryngoscopy, and these algorithms rely on videolaryngoscopes as rescue tools for difficult or failed direct laryngoscopy.8–10 Although use of videolaryngoscopes is rapidly growing in clinical practice, there is still no evidence-based airway algorithm where tracheal intubation relies mainly on videolaryngoscopy. If videolaryngoscopes are used as the routine first-line intubation devices, one pertinent question is, what should one do in the
Downloaded from http://bja.oxfordjournals.org/ at University of Edinburgh on June 22, 2015
References
| 137