Has Video Laryngoscopy Improved First Pass and Overall Intubation Success in the University of Florida Health Emergency Department?
Published Date: February 26, 2016
Has Video Laryngoscopy Improved First Pass and Overall Intubation Success in the University of Florida Health Emergency Department?
Bobby Desai*, Jordan Rogers, Hannah Eason-Bates and Emily Weeks
Department of Emergency Medicine, University of Florida, PO Box 100186, Gainesville, FL 32610, USA
*Corresponding author: Bobby Desai, Department of Emergency Medicine, University of Florida, PO Box 100186, Gainesville, FL 32610, USA, E-mail: firstname.lastname@example.org
Desai B, Rogers J, Eason-Bates H, Weeks E (2016) Has Video Laryngoscopy Improved First Pass and Overall Intubation Success in the University of Florida Health Emergency Department?. J Eme Med Int Care 2(1): 108. Doi: http://dx.doi.org/10.19104/jemi.2016.108
Objectives: The goal of this study was to determine the rate of first pass success with the use of direct laryngoscopy compared with video laryngoscopy as it varies with experience of the operator.
Methods: A retrospective chart review of all emergency department (ED) intubations of adults (age 18+), comparing first pass and overall intubation success between January 2012-January 2013, when no video laryngoscopy was available to January 2013-January 2014, after video laryngoscopy was launched for use in the ED. T-tests were used to compare the percent success as well as the number of attempts in the before and after study period. Regression analysis was used to predict first-pass success of intubation.
Results: First year residents made 12% of first attempts, second year residents made 45% of first attempts, third year residents made 35% of first attempts, attending physicians made 7% of first attempts, and physician assistants 0.5% of attempts. The first attempt was successful in 82% of intubations. First-attempt success was similar for direct (81%) and video laryngoscopies (85%) (p = 0.5). This finding held for each level operator of experience, from first year resident through attending level experience.
Conclusions: Use of video laryngoscopy was not associated with improved first pass success at this institution. This may be because first year residents are required to use direct laryngoscopy, since the least experienced operators might benefit most from the newer technology. There is also a possibility of a Type II statistical error, many variables involved in first pass success.
Keywords: Laryngoscopy; Resident; Intubation
Airway management is an integral skill for emergency medicine physicians and is a significant part of residency training . Direct laryngoscopy (DL) has been the mainstay of clinical practice for airway management. With the introduction of video laryngoscopy (VL), the emergency medicine (EM) community has embraced what was initially a difficult airway adjunct and is now moving towards becoming a standard of care, particularly for difficult airways [2-4]. The ultimate place of video laryngoscopy in EM airway management is at this time undecided. Airway management is a high risk procedure in EM populations; the risks associated with intubation in coding, hypotensive, or traumatized patients are significant and appropriately using the many adjuncts available can prevent an airway catastrophe [5-7]. Learning to properly use first line management techniques as well as adjunctive devices is an important part of everyday practice and residency training . As an initial skill every EM resident learns is how to utilize DL for endotracheal intubation; however in the training period it can be difficult to communicate verbally what is being observed visually in the high stress environment of crash intubations. VL can serve as a method to allow increasing independence, as it offers the ability to practice DL for the operator and provides continuous indirect video for observers of the procedure, so feedback can occur in real time to the operator. VL has been shown to improve first pass success and time to intubation for novice operators but not for experienced operators . Research has shown that repeated intubation attempts predict worse outcomes, namely hypoxic insults, cardiac arrest, aspiration, need for surgical airway, and increased mortality overall [10-12]. VL was re-introduced in this institution’s emergency department in January 2013 and since its role in airway management was relatively new, an evaluation of the use of VL in this ED was considered to be timely and important, given the fact that many attending providers were becoming accustomed to using this modality for all airways, including those deemed to not be critical in nature.
Design and Selection Criteria
Retrospective chart review of all ED intubations of adults (age 18+), comparing first pass and overall intubation success between January 2012-January 2013, when no video laryngoscopy was available in the ED, to January 2013-January 2014, after video laryngoscopy was launched for use in the ED. T-tests were used to compare the percent success as well as the number of attempts in the before and after study period. Regression analysis was used to predict the first-pass success of intubation.
This study was carried out in a high volume, high acuity, and Level 1 trauma center with an annual census of 120,000 patients per year.
Investigators performed a retrospective chart review of all ED intubations from January 2012-January 2014 and compared first pass and overall intubation success between January 2012-January 2013, when no VL was available in the ED, to January 2013-January 2014, after video laryngoscopy was launched for use in the ED. Patient Selection: All ED patients undergoing endotracheal intubation in the UF (University of Florida) Health Emergency Department between January 2012-January 2014. Inclusion criteria: All patients ages 18 and older requiring airway management. Exclusion criteria: Pediatric patients (less than 18 years of age), charts that do not include complete data e.g. lacking documentation regarding number of intubation attempts. The VL used in this institution is the C-MAC manufactured by the KARL STORZ Company.
Data analysis was performed to compare the success rates of intubation before the introduction of video laryngoscopy and after the introduction of video laryngoscopy in the ED. The T-test was used to compare the percent success as well as the number of attempts in the before and after study period. Analysis also included demographic information. Regression analysis was used to predict first-pass success of intubation.
Results were shown in tables 1 to 4.
Table 1: Demographics
Table 2: Number of attempts per resident year
Table 3: Overall first pass success rate
Table 4: Overall results
We set out to prove that VL was superior to DL for all learners at all stages of their training. VL has been shown to provide better exposure to anatomy than traditional laryngoscopy and has been shown to significantly improve rates of successful endotracheal intubation, especially in difficult airways. The use of VL provides a magnified and colored view of the anatomy and additionally provides a camera view which is more proximally situated to the glottic orifice than the eye of the physician . It additionally provides the ability of supervising physicians to observe technique of blade insertion in terms of seeing the airway anatomy, as well as technique and success of endotracheal tube insertion. VL additionally has the advantage over conventional laryngoscopy, that it is easy to use even for inexperienced providers . However, there are certain disadvantages to VL for inexperienced users. These users may forego the utilization of proper fundamentals of airway management due to their increased confidence with VL. They may forego proper positioning including ramping for the obese patient and use of awake intubation techniques, which are imperative in the high risk difficult airway . Thus, in this institution, early managers of the airway taught basic techniques, including proper use of direct laryngoscopy which accounted for the low numbers of VL attempts.
Data analysis indicates that first-pass intubation success rates were overall not affected by instituting VL into practice at this facility. Likely contributors to this finding include training established with providers in direct laryngoscopy as opposed to video laryngoscopy, and ease of intubation with known practices. Overall, first year residents intubated least out of residents, and had least exposure to video laryngoscopy. However, success rates of first-pass attempts overall were not improved with the use of VL in the first year of training. This may be attributed to the fact that first year residents are not generally allowed to use the VL screen when intubating, and are required to perform direct laryngoscopy using the VL. In addition, second year residents intubated the most in the department and had the highest first-pass success rate out of residents. This could be attributed to the most overall exposure time to VL use. Lastly the first-pass success in third year residents for intubations were more successful in use of the VL than first year residents, but less successful than second year residents. A significant number of procedures during the third year of training are handed off to first and second year residents, and perhaps this attributed to a smaller population size overall and therefore decreased successes. Overall, theorized improvements in first-pass intubation successes were not observed since introduction of VL into the ED setting.
This study was undertaken at only one institution where first year residents routinely were tasked with utilizing direct laryngoscopy instead of video laryngoscopy, which potentially could have altered the results. In addition, pediatric patients were not included in the study. Lastly, due to issues with lack of documentation within charts, some data was unable to be analyzed, including number of attempts and documentation of a potentially difficult airway. Additionally, due to charting issues, it was difficult to determine if VL was used as a primary modality for teaching purposes versus rescue modality.
Based on our data, we found that VL when compared to DL failed to provide a better first pass rate of endotracheal intubation by trainees at different levels. Further study and delineation between first pass success rates among different patient populations, including pediatric patients should be conducted to further evaluate the use of VL in the ED. Specific to this institution, criteria need to be developed to determine when more inexperienced physicians should utilize VL as a primary modality in airways deemed not to be critical in nature.
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Copyright: © 2016 Desai B, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.