The video laryngoscope as primary intubation instrument
The British Journal of Anaesthesia has published an article on their website written by a highly experienced Dutch Anesthesiologist, Dr. Nigel Jack. Dr. Jack used the Medan Video Laryngoscope on every patient that needed to be intubated under his care for a period of five months, which was as he describes an eye opening experience.
He used the Medan Video Laryngoscope in every possible situation he encountered: from patients with a Malampati 1, to a patient with a very difficult intubation in his medical history. An intubation that had succeeded but at the cost of a few teeth. His experiences during this five month period have led to the publication you can continue to read below or on the website of the British Journal of Anaesthesia
Five months clinical experience with a video laryngoscope as primary intubation instrument.
The Macintosh laryngoscope is about 80 years old. I have been using it for about half that time. I was given the opportunity of trying a handheld video-laryngoscope in the setting of a large peripheral hospital in the Netherlands. I used the instrument as first choice for all intubations for five months.
The video laryngoscope is not new, but is still largely reserved for difficult intubations. This was understandable when the price of these instruments was high, but in the meantime instruments are coming to the market at a price comparable with traditional laryngoscopes.
Some colleagues use direct laryngoscopy as first choice because they are afraid that they will otherwise lose routine. This is like only performing peripheral blocks using ultrasound, after attempts with the nerve stimulator fail, so as not to lose routine.
Two illustrative examples
A general anaesthetic for a ENT operation: On the previous occasion it was a very difficult intubation. Direct laryngoscopy failed, after which a disposable video-scope was tried without success and with a broken front tooth. Eventually a blind nasal intubation succeeded. On the second occasion, intubation with the video-scope was easy. The problems, low level panic and broken tooth of the first occasion would not have happened if the anaesthetist had used a video laryngoscope with which he was skilled, and as first choice.
The second case was again an ENT operation in an adult man. I had done the induction, and the intubation with the video-scope, and not met any difficulties. After I had left the theatre, the ENT surgeon turned the head of the patient, extubating him in the process. The anaesthetic assistent called a passing colleague, and by the time I arrived on the scene, the intubation had failed, and the colleague was struggling with a disposable video-scope. With some difficulty he re-intubated the patient. I had been spared a difficult intubation by using the video-scope as my first choice; not even recognising that it was a difficult intubation. Although my colleague was competent and experienced, he only used the video-scope when faced with a difficult intubation, whereas I had the advantage of having used it for months on a daily basis. You don't want to be on the learning curve in a difficult situation.
Video-laryngoscopy gives a better view of the cords, requires less force, spares the upper teeth and the cervical spine. With practice it is just as quick as using a traditional instrument.
During the period I was using the laryngoscope, several other difficult intubations were encountered on the department, some expected, some not. It was interesting that the standard reaction of my colleagues was not to ask for the difficult intubation cart, but to ask me to bring my laryngoscope. Intubation was carried out successfully in each case.
A lot of time and money is spent on trying to reduce complications, many of which efforts are of dubious value. Statistics show that airway and intubation problems are by far the most frequent cause of anaesthetic complications. Using the video-scope as first choice for intubation will lead to a drastic reduction in difficult intubations, and less morbidity, even though it may never render direct and fibre laryngoscopy completely obsolete. (There are hybrid video-scopes that also allow direct laryngoscopy). My five month's experience was more convincing than all the studies I have read. My opinion is that direct and fibre laryngoscopy should be learned, but video-laryngoscopy should become the new gold standard for intubation.
Source: British Journal of Anaesthesia