Correspondence
Table 1 Asleep vs awake FOI
| 135
Table 2 Indications for FOI. TMJ- temporomandibular joint January–June 2011
Number of asleep FOIs performed Number of awake FOIs performed
January–June 2014
258
158
53
56
Previous difficult intubation Poor mouth opening Poor TMJ movement Poor neck movement Trauma Abscess Tumour Congenital issues Unstable cervical spine DLT/ bronchoscopy
7.4
4.2
12.9 4.5 15.8 2.0 0.2 6.7 0.5 11.4 38.6
12.9 3.8 14.3 1.7 1.4 9.8 0 11.8 40.1
continue to be so, by embracing VL while continuing to develop the knowledge, skills and experience in FOI needed.
Declaration of interest None declared.
Funding
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Royal College of Anaesthetists. Annex C- Intermediate Level Training 2010. Available from: http://www.rcoa.ac.uk/ system/files/TRG-CCT-ANNEXC_0.pdf (accessed 13 March 2015) doi:10.1093/bja/aev191
Videolaryngoscopy - for all intubations? R. Bulatovic* and R. Taneja Ontario, Canada *E-mail: [email protected]
Editor—We read with interest Dr Zaouter’s editorial on the evolving role of videolaryngoscopy in anaesthestic care.1 Overall we do agree with the authors that videolaryngoscopes will and should be available freely in the foreseeable future. As anaesthetists working in a teaching hospital, we already note that residents often choose these as their first-choice for laryngoscopy in anticipated difficult intubations. However, with increasing availability of new technology such as this, we must acknowledge that trainees will progressively lose their skills with conventional laryngoscopy. This may have safety implications for patients needing anaesthesia in remote locations where videolaryngoscopy may not be the norm. Hence, our younger colleagues, having to provide anaesthetic services
in such settings, may find themselves underprepared or unable to secure an airway. Furthermore, do not believe that videolaryngoscopes should be used for all intubations indiscriminately. Even though their use is associated with improved glottic visualization,2 the process of placing a tracheal tube takes longer and is more difficult with videolaryngoscopy.3 4 Thus, one might choose to perform a conventional laryngoscopy for a patient who needs rapid sequence induction (for an anticipated easy airway that has a high risk for aspiration). Additionally, reports exist of intubations which failed using videolaryngoscopy but were subsequently successful with direct laryngoscopy by the same operator.5 Pediatric intubations, which are challenging even for experienced
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
given that VL is indicated particularly where bag-mask ventilation is deemed possible, but intubation difficult. Table 2 shows that the greatest reduction in FOIs occurred in patients who were previously difficult to intubate and those with poor neck and jaw movement- patients in whom VL is indicated. The number of FOIs performed on patients with poor mouth opening remained unchanged- patients in whom awake FOI is indicated. This analysis supports our theory that the introduction of videolaryngoscopes accounted for the reduction in FOIs. Between 2011 and 2014 a new thoracic theatre was opened in our hospital. This is indicated by the slightly increased proportion of DLT checks. Apart from this theatre, lists and case mix remained largely unchanged. In conclusion, the introduction of videolaryngoscopes to our hospital has resulted in a 38.8% reduction in the number of asleep FOIs performed. VL is clearly an important part of the anaesthetist’s armamentarium when faced with a difficult airway. However, FOI provides a route to endotracheal intubation when VL is impossible. Thus it remains a core clinical learning outcome required of anaesthetic trainees by the Royal College of Anaesthetists.2 We have shown that when VL becomes available, training opportunities with FOI markedly decrease. It is therefore incumbent upon us to recognize this and ensure that training and experience with FOI does not suffer. As the authors rightly state ‘we have always been pioneers in patients’ safety’. Let us
2011 Proportion 2014 Proportion of cases (%) of cases (%)
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 Carleton University 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.
Table 1 Asleep vs awake FOI
| 135
Table 2 Indications for FOI. TMJ- temporomandibular joint January–June 2011
Number of asleep FOIs performed Number of awake FOIs performed
January–June 2014
258
158
53
56
Previous difficult intubation Poor mouth opening Poor TMJ movement Poor neck movement Trauma Abscess Tumour Congenital issues Unstable cervical spine DLT/ bronchoscopy
7.4
4.2
12.9 4.5 15.8 2.0 0.2 6.7 0.5 11.4 38.6
12.9 3.8 14.3 1.7 1.4 9.8 0 11.8 40.1
continue to be so, by embracing VL while continuing to develop the knowledge, skills and experience in FOI needed.
Declaration of interest None declared.
Funding
References 1. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3 2. Royal College of Anaesthetists. Annex C- Intermediate Level Training 2010. Available from: http://www.rcoa.ac.uk/ system/files/TRG-CCT-ANNEXC_0.pdf (accessed 13 March 2015) doi:10.1093/bja/aev191
Videolaryngoscopy - for all intubations? R. Bulatovic* and R. Taneja Ontario, Canada *E-mail: [email protected]
Editor—We read with interest Dr Zaouter’s editorial on the evolving role of videolaryngoscopy in anaesthestic care.1 Overall we do agree with the authors that videolaryngoscopes will and should be available freely in the foreseeable future. As anaesthetists working in a teaching hospital, we already note that residents often choose these as their first-choice for laryngoscopy in anticipated difficult intubations. However, with increasing availability of new technology such as this, we must acknowledge that trainees will progressively lose their skills with conventional laryngoscopy. This may have safety implications for patients needing anaesthesia in remote locations where videolaryngoscopy may not be the norm. Hence, our younger colleagues, having to provide anaesthetic services
in such settings, may find themselves underprepared or unable to secure an airway. Furthermore, do not believe that videolaryngoscopes should be used for all intubations indiscriminately. Even though their use is associated with improved glottic visualization,2 the process of placing a tracheal tube takes longer and is more difficult with videolaryngoscopy.3 4 Thus, one might choose to perform a conventional laryngoscopy for a patient who needs rapid sequence induction (for an anticipated easy airway that has a high risk for aspiration). Additionally, reports exist of intubations which failed using videolaryngoscopy but were subsequently successful with direct laryngoscopy by the same operator.5 Pediatric intubations, which are challenging even for experienced
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on June 22, 2015
given that VL is indicated particularly where bag-mask ventilation is deemed possible, but intubation difficult. Table 2 shows that the greatest reduction in FOIs occurred in patients who were previously difficult to intubate and those with poor neck and jaw movement- patients in whom VL is indicated. The number of FOIs performed on patients with poor mouth opening remained unchanged- patients in whom awake FOI is indicated. This analysis supports our theory that the introduction of videolaryngoscopes accounted for the reduction in FOIs. Between 2011 and 2014 a new thoracic theatre was opened in our hospital. This is indicated by the slightly increased proportion of DLT checks. Apart from this theatre, lists and case mix remained largely unchanged. In conclusion, the introduction of videolaryngoscopes to our hospital has resulted in a 38.8% reduction in the number of asleep FOIs performed. VL is clearly an important part of the anaesthetist’s armamentarium when faced with a difficult airway. However, FOI provides a route to endotracheal intubation when VL is impossible. Thus it remains a core clinical learning outcome required of anaesthetic trainees by the Royal College of Anaesthetists.2 We have shown that when VL becomes available, training opportunities with FOI markedly decrease. It is therefore incumbent upon us to recognize this and ensure that training and experience with FOI does not suffer. As the authors rightly state ‘we have always been pioneers in patients’ safety’. Let us
2011 Proportion 2014 Proportion of cases (%) of cases (%)
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 Carleton University 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.
