Videolaryngoscopy with Glidescope Reduces Cervical Spine Movement in Patients with Unsecured Cervical Spine

The Journal of Emergency Medicine, Vol. 44, No. 4, pp. 750–756, 2013 Copyright Ó 2013 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2012.07.080

Original Contributions

VIDEOLARYNGOSCOPY WITH GLIDESCOPE REDUCES CERVICAL SPINE MOVEMENT IN PATIENTS WITH UNSECURED CERVICAL SPINE Clemens Kill, MD,*† Joachim Risse, MD,* Pascal Wallot, MD,*† Philipp Seidl,* Thorsten Steinfeldt, MD,*† and Hinnerk Wulf, MD*† *Department of Anesthesiology and Critical Care and †Department of Emergency Medicine, Philipps-University, Marburg, Germany Reprint Address: Clemens Kill, MD, Department of Emergency Medicine, Philipps-University, Marburg D-35033, Germany

, Abstract—Background: Unconscious patients with severe trauma often require urgent endotracheal intubation. In trauma victims with possible cervical spine injury, any movement of the head and neck should be avoided. Study Objectives: We investigated the effect of GlideScope videolaryngoscopy on cervical spine movement compared with conventional laryngoscopy in anesthetized patients with unsecured cervical spines. Methods: Sixty patients scheduled for elective surgery with general anesthesia and without anticipated airway problems were enrolled in the study after ethics committee approval and written informed consent. Intubation was performed with videolaryngoscopy (GlideScopeÒ, Verathon Inc., Bothell, WA) or conventional laryngoscopy (MacIntosh). Using video motion analysis with a lateral view, the maximum extension angle a was measured with reference to anatomical points (baseline and line drawn from processus mastoideus to os frontale [glabella]). Values were analyzed using Mann Whitney U-tests. Results: The deviation of a was a median 11.8 in the videolaryngoscope group and 14.3 in the conventional group (p = 0.045), with a maximum of 19.2 (videolaryngoscopy) vs. 29.3 (conventional). Intubation by physicians with some experience in videolaryngoscopy was associated with a reduced angle deviation (a = 10.3 ) compared to inexperienced physicians (12.8 , p = 0.019). Intubation time was a median 24 s (min/max 12/75 s) in the MacIntosh group and 53 s (min/max 28/210 s) in the GlideScope group. In 3

patients randomized to the conventional group in whom conventional intubation failed, intubation could be successfully performed using videolaryngoscopy. Conclusion: GlideScope videolaryngoscopy reduces movements of the cervical spine in patients with unsecured cervical spines and therefore might reduce the risk of secondary damage during emergency intubation of patients with cervical spine trauma. Ó 2013 Elsevier Inc. , Keywords—intubation; cervical spine injury; cervical spine movement; videolaryngoscopy; GlideScope

INTRODUCTION Securing the airway of unconscious patients with severe trauma is a standard procedure in pre-hospital medicine on the scene as well as in the Emergency Department (ED). An unknown but significant number of trauma victims with severe traumatic brain injury also suffer cervical spine (C-spine) trauma. These patients often require urgent airway management in the emergency situation to secure the airway and maintain appropriate ventilation (1). The recommended gold standard for securing the airway in patients with known trauma of the C-spine is fiberoptic intubation, but this procedure requires a great deal of operator experience and might be difficult to use in an out-of-hospital emergency setting (2,3). For emergency intubation of trauma victims with possible

Disclaimer: The authors declare that there are no conflicts of interests that could inappropriately influence (bias) this work. Dr. Kill received a travel grant from Verathon Europe.

RECEIVED: 8 August 2011; FINAL SUBMISSION RECEIVED: 12 February 2012; ACCEPTED: 1 July 2012 750

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C-spine injury, it has been recommended for many years to immobilize the head and neck by manual in-line stabilization (MILS) to prevent secondary damage, but this maneuver has not been proven to be very effective for immobilization of the C-spine (4,5). Moreover, data exist showing that success rates in conventional intubation decrease if MILS is performed, thus, MILS might be dangerous in patients requiring urgent intubation and ventilation (6). We investigated the effect of videolaryngoscopy on C-spine movement during intubation and compared it to conventional laryngoscopy in anesthetized patients with unsecured C-spines. MATERIALS AND METHODS After approval by the local institutional ethics committee and patient written informed consent, 60 adult patients scheduled for elective surgery requiring general anesthesia with endotracheal intubation and with American Society of Anesthesiologists physical status I–III were enrolled. Patients with gastroesophageal reflux disease, with an abnormal physical status of the upper airway (e.g., after C-spine trauma), C-spine previously operated on, oropharyngeal or hypopharyngeal tumors, macroglossia, mandibular retrusion, or other known airway difficulties were excluded. Patients were pre-medicated with 2 mg oral clorazepate before surgery. Markers were fixed on the head and neck of patients to mark the os frontale (glabella) and the mastoid. The head was positioned on a standard ring pillow (height 45 mm), and a digital video camera (Sony DCR-TRV30E; Sony, Tokyo, Japan) was positioned with a lateral, horizontal view of the patient’s head and neck at a height of 110 cm and a distance of 65 cm to the right processus mastoideus. The focal length of the lens was 1.9 mm. The tape recording was started and anesthesia was induced with 1–2 mg/kg fentanyl and 1–2 mg/kg 1% propofol, followed by a propofol infusion starting with 10 mg/kg/h. Muscle relaxation was induced with 0.3 mg/kg rocuronium bromide followed by at least 3 min of bag-mask ventilation. Immediately after induction of anesthesia, the patients were randomly assigned to either conventional laryngoscopy (MacIntosh) or videolaryngoscopy (GlideScopeÒ; Verathon Inc., Bothell, WA) by sealed envelope randomization. Intubation was performed using a MacIntosh blade (size 3 or 4) in the MacIntosh group or the GlideScope GVLÒ (size 4) multiple-use blade in the videolaryngoscopy group. In both groups, an endotracheal (ET) tube with stylet inner diameter (ID) 7.5 mm was used in female patients and an ID 8.0 mm was used in male patients; in the GlideScope group, the GlideRite Guide was inserted into ET tubes of the same size.

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The time from the beginning of laryngoscopy to successful placement of the ET tube was recorded. All anesthesiologists were instructed to avoid moving the C-spine to minimize C-spine movements during laryngoscopy, but the head and neck were not immobilized. The anesthesiologists’ general professional experience as well as hands-on experience with the GlideScope was documented. External laryngeal pressure was allowed to improve the glottic view. The video motion records were analyzed using a grid overlay recording; the screenshots before the start of intubation and at the maximum extension were used for measuring the differences between angles by the marked anatomical points previously described. The type of laryngoscope that had been used was obscured by picture editing to cover this area when the angles were measured (Figure 1). The angles were evaluated by independent investigators blinded to the technique, who averaged the results for further analysis. Sample size calculation assuming Da of 4 (95% confidence interval) required 60 patients to be enrolled. Because there was such a small study cohort, for purposes of statistical analysis we compared the two groups using the statistical method ‘‘intention to harm.’’ The values were expressed as median with interquartile range (IQR) for non-parametric data; they were analyzed using the Mann Whitney U-test, with p < 0.05 being statistically significant (SPSS for Windows v. 15.0; IBM, Armonk, NY). Data are presented as cumulative relative frequency graphs and box-and-whisker diagrams. RESULTS After written informed consent was obtained, 60 patients were enrolled who had no significant differences in biometric data (Table 1). All enrolled patients were able to be included in further evaluation. The angle deviations of a were a median of 11.8 (IQR 5.2 ) in the videolaryngoscopy group and 14.3 (IQR 8.3 ) in the conventional group (p = 0.045); the maximum angle deviations were 19.2 (videolaryngoscopy) vs. 29.3 (conventional) (Figure 2). A post hoc analysis showed that intubation by physicians with some experience in videolaryngoscopy (more than five applications) was associated with less angle deviation (a = 10.3 , IQR 6.3 ) than inexperienced physicians (12.8 , IQR 3.5 , p = 0.019) (Figure 3). Thirty-three laryngoscopists participated in the study; the GlideScope experience of all participating anesthesiologists was a mean of 9.9 ( 6 8.6) intubations. The GlideScope had been available for a period of 6 months before this investigation. In 3 patients randomized to the conventional group, the conventional intubation performed by an anesthesiologist with more than 2 years professional experience

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Figure 1. Measurement of cervical spine movements during endotracheal intubation (angle deviation using described and marked anatomical landmarks, No. 28 GlideScope above, No. 51 MacIntosh below).

failed during several attempts but was then successfully completed using videolaryngoscopy. These 3 patients were pre-operatively classified as Mallampati 3, 2, and 2, respectively, with mean body mass indices of 28, 26, and 29 kg/m2, respectively. In all three cases the angle deviations were larger with direct laryngoscopy than with videolaryngoscopy. Direct comparison of the 3 patients who had failed intubation showed the following angle deviations: no. 25 Mac 17.9 / 8.6 GS, no. 37 Mac 10.6 / 4.9 GS, no. 48 Mac 16.4 / 9.1 GS. Time to successful completion of intubation was a median 24 s, with an IQR of 16 s (min/max 12/75 s) in the MacIntosh group and 53 s with IQR 26 s (min/max 28/ 210 s) in the GlideScope group. The subgroup of physicians with at least some experience in GlideScope procedures (more than five applications) successfully

completed intubation significantly faster using the GlideScope (47 s/IQR 22 s vs. 61 s/IQR 26 s, p = 0.014) than inexperienced physicians. DISCUSSION We compared tracheal intubation with videolaryngoscopy (GlideScope) with the conventional (MacIntosh) blade and found significantly less C-spine movement in the videolaryngoscopy group. Physicians with some experience in the use of the GlideScope performed videolaryngoscopy faster and with less extension than inexperienced physicians. Our results demonstrate that there is a small reduction of reclination angle of a median in the GlideScope group (median 11.8 vs. 14.3 in the conventional group), but a greater difference in maximum angles (19.2 vs. 29.3 , respectively). Unfortunately, we do not know the range of movement that would be acceptable in injured

Table 1. Biometric Data of Patients Enrolled in the Study Parameter

Macintosh

GlideScopeÒ

Independent Two-Sample t-Test (p-Value)

Group (n) Gender (male/female) Age (years) mean 6 SD/(range) Weight (kg) mean 6 SD Height (cm) mean 6 SD Body mass index (kg m 2) mean 6 SD Mallampati score (%): I II >II

30 19/11 63 6 12/(36–87) 84 6 12 172 6 8 28.3 6 5.8

30 13/17 61 6 15/(31–87) 82 6 17 169 6 9 28.8 6 3.5

0.125 0.587 0.516 0.099 0.743

9 (30.0) 17 (56.67) 4 (13.33)

5 (16.67) 19 (63.33) 6 (20.0)

0.225

Videolaryngoscopy and Cervical Spine Movement

Figure 2. Cervical spine movement during endotracheal intubation with conventional laryngoscopy versus videolaryngoscopy. The degree of cervical spine movement (deviations in ) was measured by video analysis using pre-marked anatomical landmarks.

C-spines without causing secondary damage, but it is generally recommended to minimize mobilization in suspected or potential spine trauma patients. This study was planned without MILS, because in real emergency situations MILS is not routinely used in all unconscious patients without obvious trauma. Videolaryngoscopic intubation took a significantly longer time compared to conventional intubation in our study (especially for the physicians with no previous experience of using this method). We assume this was due to the relatively low levels of experience of laryngoscopists with the routine use of the GlideScope compared to the thousands of conventional intubations performed. This might be a disad-

Figure 3. Cervical spine movement during endotracheal intubation with conventional laryngoscopy vs. videolaryngoscopy of the entire conventional group, the entire videolaryngoscopy group, and the videolaryngoscopy group depending on hands-on experience (low level of experience: maximum five procedures performed previously). GS = GlideScope; Mac = MacIntosh.

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vantage in emergencies because a prolonged intubation time is considered to be a risk factor for the aspiration of gastric contents. On the other hand, there were 3 patients in the present study who could not be intubated by conventional means on the first attempt, but were then successfully intubated via videolaryngoscopy with GlideScope. Videolaryngoscopy and the GlideScope in particular are well-investigated devices in the management of difficult airways, providing a better view of the glottis compared with the MacIntosh blade (7–9). The advantages of videolaryngoscopy have been previously demonstrated in patients with reduced neck mobility who are undergoing elective surgery (10–13). Medical staff with limited experience in conventional intubation might have improved success rates using videolaryngoscopy as a first-line device in emergency airway management (14–17). In emergency treatment on the scene or during transportation with limited access to the patient’s head, videolaryngoscopy might also be advantageous because a direct view of the glottis is not necessary for intubation (18). In a recent published study, Sakles et al. found a higher first-attempt success rate when intubation in the ED was performed with GlideScope (19). In patients with known C-spine injury and elective anesthesia, fiberoptic intubation is regarded as the gold standard and is associated with fewer C-spine movements, even when compared to videolaryngoscopy (3). Turkstra et al. investigated C-spine movement using fluoroscopy to compare the MacIntosh blade to the GlideScope with a lighted stylet in MILS. They found reduced movements with use of the GlideScope and the lighted stylet (20). Malik et al. compared the MacIntosh blade, the GlideScope, Truview EVO2 (Truphatek International Ltd, Netanya, Israel), and the AWS laryngoscope (Pentax, Tokyo, Japan), which were used by at least one of the three anesthetists experienced in the use of each laryngoscope in patients with MILS of the C-spine (21). They recorded the intubation difficulty score, the Cormack and Lehane glottic view, the need for optimization maneuvers, and the time to intubation, but not movements of the C-spine itself. They confirmed that the GlideScope improved the Cormack and Lehane grade and reduced the number of optimization maneuvers compared with the MacIntosh blade. The GlideScope was the only device that was successful in achieving tracheal intubation in all of the patients studied (21). Robitaille et al. investigated C-spine movements by fluoroscopy in 20 patients under MILS and found no difference in C-spine extension between the MacIntosh blade and the GlideScope, but limitations to this study were mentioned (22). When anatomical variations or limitations in fluoroscopic visualization prevented use of the

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standard reference points, alternative reference points were determined case by case by the radiologist (22). The group of Bathory et al. evaluated the GlideScope for tracheal intubation in patients with C-spine immobilization with a semi-rigid collar, first recording the Cormack and Lehane grade using the MacIntosh blade and then performing intubation with the GlideScope. They reported an improved view of the glottis with the GlideScope, and the mean time to intubation with the GlideScope was 50 s, which is almost identical to the results of the present study (23). Limitations The method of video motion analysis of the C-spine has been validated by video fluoroscopy in several previous investigations (24,25). Nevertheless, a limitation of our study might be that the use of such a video motion recording device does not show the details of the exact segmental location of C-spine movement, although investigators working with fluoroscopy stated that the movements of an uninjured C-spine cannot exactly match the segmental movement of an unstable, injured C-spine. A second limitation could be the large number of anesthesiologists performing intubations in our study, as well as their limited experience in using the GlideScope, because the investigation was performed shortly after introduction of the GlideScope in clinical use. This might be more representative of the reality of emergency treatment in the field, but it might also have caused a greater variation between individuals and might reduce the positive effects of the GlideScope found in our study. Nevertheless, we were able to show a reduced extension when using the GlideScope. As a further limitation to our study, we did not use MILS as recommended for suspected C-spine injury. This was to avoid movements being caused by a second manual intervention. The small difference between the angles in the groups might have been smaller still if MILS had been used. Furthermore, MILS is a generally recommended and widely used procedure, but its effectiveness for immobilization of the C-spine is not evidence based (4,5). MILS might even be disadvantageous, as was recently documented by the group of Thiboutot et al. (6). In a randomized controlled trial, they showed that the rate of failed tracheal intubation at 30 s was 50% (47/94) in the MILS group, compared to 5.7% (6/105) in the control group (p < 0.0001), and that laryngoscopic grades 3 and 4 were more frequently observed in the MILS group (6). These findings could be interpreted as an argument for the use of procedures like GlideScope videolaryngoscopy, which are independent from establishing a direct view to the glottis. Zamora et al. demonstrated that, in a cadaver investigation comparing different techniques

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of laryngoscopy with and without C-spine collar, in contrast to the MacIntosh blade, intubation with the GlideScope is not compromised by immobilization of the C-spine (26). In another recent published study, Hirabayashi et al. also investigated the distortion of C-spine in a radiographic view without immobilization and found reduced distortion with GlideScope compared to conventional intubation (27). Finally, a further limitation of our study is the large number of difficult intubations in the conventional group (3 of 30, or 10%). This differs from the usual findings in the current literature on difficult intubations. For example, in another study with a similar number in the conventional Macintosh group, there was only one failure in 28 patients (28). Our investigation might have been influenced by the requirement of intubation without MILS, related to the instruction for physicians to intubate with a minimum of C-spine motion. Our data suggest that the results of videolaryngoscopy with GlideScope might be improved if physicians experienced in airway management are given some additional training in videolaryngoscopy to learn the differences in this procedure compared to direct laryngoscopy. CONCLUSION This study shows that the use of GlideScope videolaryngoscopy is associated with reduced movements of the C-spine, and therefore this might be an option for primary urgent airway management in patients with C-spine trauma. Additional investigations in the prehospital setting are recommended to evaluate the effectiveness of GlideScope videolaryngoscopy in the emergency treatment of patients with C-spine trauma on scene. REFERENCES 1. Wong E, Ng YY. The difficult airway in the emergency department. Int J Emerg Med 2008;1:107–11. 2. Brimacombe J, Keller C, Kunzel KH, Gaber O, Boehler M, Puhringer F. Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers. Anesth Analg 2000;91:1274–8. 3. Wong DM, Prabhu A, Chakraborty S, Tan G, Massicotte EM, Cooper R. Cervical spine motion during flexible bronchoscopy compared with the Lo-Pro GlideScope. Br J Anaesth 2009;102: 424–30. 4. Turner CR, Block J, Shanks A, Morris M, Lodhia KR, Gujar SK. Motion of a cadaver model of cervical injury during endotracheal intubation with a Bullard laryngoscope or a Macintosh blade with and without in-line stabilization. J Trauma 2009;67:61–6. 5. Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med 2007;50:236–45. 6. Thiboutot F, Nicole PC, Trepanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth 2009; 56:412–8.

Videolaryngoscopy and Cervical Spine Movement 7. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anaesth 2005;52:191–8. 8. Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, Waeber JL. Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways*. Anaesthesia 2008;63:1358–64. 9. Serocki G, Bein B, Scholz J, Dorges V. Management of the predicted difficult airway: a comparison of conventional blade laryngoscopy with video-assisted blade laryngoscopy and the GlideScope. Eur J Anaesthesiol 2010;27:24–30. 10. Agro F, Barzoi G, Montecchia F. Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization. Br J Anaesth 2003;90:705–6. 11. Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y. 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; 100:544–8. 12. Gunaydin B, Gungor I, Yigit N, Celebi H. The Glidescope for tracheal intubation in patients with ankylosing spondylitis. Br J Anaesth 2007;98:408–9. 13. Lai HY, Chen IH, Chen A, Hwang FY, Lee Y. The use of the GlideScope for tracheal intubation in patients with ankylosing spondylitis. Br J Anaesth 2006;97:419–22. 14. Kim HJ, Chung SP, Park IC, Cho J, Lee HS, Park YS. Comparison of the GlideScope video laryngoscope and Macintosh laryngoscope in simulated tracheal intubation scenarios. Emerg Med J 2008;25: 279–82. 15. Nasim S, Maharaj CH, Malik MA, O’Donnell J, Higgins BD, Laffey JG. Comparison of the Glidescope and Pentax AWS laryngoscopes to the Macintosh laryngoscope for use by advanced paramedics in easy and simulated difficult intubation. BMC Emerg Med 2009;9:9. 16. Nouruzi-Sedeh P, Schumann M, Groeben H. Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel. Anesthesiology 2009;110:32–7. 17. Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, Waeber JL. Learning curves of the Glidescope, the McGrath and the Airtraq laryngoscopes: a manikin study. Eur J Anaesthesiol 2009;26:554–8.

755 18. Nakstad AR, Sandberg M. The GlideScope Ranger video laryngoscope can be useful in airway management of entrapped patients. Acta Anaesthesiol Scand 2009;53:1257–61. 19. Sakles JC, Mosier JM, Chiu S, Keim SM. Tracheal intubation in the emergency department: a comparison of GlideScopeÒ video laryngoscopy to direct laryngoscopy in 822 intubations. J Emerg Med 2012;42:400–5. 20. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005;101: 910–5. 21. Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison of Macintosh, Truview EVO2, Glidescope, and Airwayscope laryngoscope use in patients with cervical spine immobilization. Br J Anaesth 2008;101:723–30. 22. Robitaille A, Williams SR, Tremblay MH, Guilbert F, Theriault M, Drolet P. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg 2008;106: 935–41. 23. Bathory I, Frascarolo P, Kern C, Schoettker P. Evaluation of the GlideScope for tracheal intubation in patients with cervical spine immobilisation by a semi-rigid collar. Anaesthesia 2009;64: 1337–41. 24. Descarreaux M, Blouin JS, Teasdale N. A non-invasive technique for measurement of cervical vertebral angle: report of a preliminary study. Eur Spine J 2003;12:314–9. 25. Wu SK, Lan HH, Kuo LC, Tsai SW, Chen CL, Su FC. The feasibility of a video-based motion analysis system in measuring the segmental movements between upper and lower cervical spine. Gait Posture 2007;26:161–6. 26. Zamora JE, Nolan RL, Sharan S, Day AG. Evaluation of the Bullard, GlideScope, Viewmax, and Macintosh laryngoscopes using a cadaver model to simulate the difficult airway. J Clin Anesth 2011;23:27–34. 27. Hirabayashi Y, Fujita A, Seo N, Sugimoto H. Distortion of anterior airway anatomy during laryngoscopy with the GlideScope videolaryngoscope. J Anesth 2010;24:366–72. 28. Chalkeidis O, Kotsovolis G, Kalakonas A, et al. A comparison between the Airtraq and Macintosh laryngoscopes for routine airway management by experienced anesthesiologists: a randomized clinical trial. Acta Anaesthesiol Taiwan 2010;48:15–20.

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ARTICLE SUMMARY 1. Why is this topic important? Immobilization of the cervical spine during airway management is generally recommended in unconscious patients with severe injury. The effects of direct laryngoscopy vs. videolaryngoscopy with GlideScopeÒ on cervical spine movement during intubation is still unclear. 2. What does this study attempt to show? This study demonstrates possible differences in the reclination of the head and neck caused by intubation with MacIntosh vs. GlideScope laryngoscopy. This investigation was performed in patients scheduled for elective surgery without expected difficult airway. 3. What are the key findings? Videolaryngoscopy with GlideScope leads to reduced reclination angles of the cervical spine during intubation. Three of 60 patients in whom conventional intubation failed could then be successfully intubated with GlideScope. 4. How is patient care impacted? The routine use of GlideScope videolaryngoscopy in emergency patients with unknown status of the cervical spine may be helpful to avoid unnecessary movement of the cervical spine.