A deliberately restricted laryngeal view with the GlideScope® video laryngoscope is associated with faster and easier tracheal intubation when compared with a full glottic view: a randomized clinical trial.

INTRODUCTION: During video laryngoscopy (VL) with angulated or hyper-curved blades, it is sometimes difficult to complete tracheal intubation despite a full view of the larynx. When using indirect VL, it has been suggested that it may be preferable to obtain a deliberately restricted view of the larynx to facilitate passage of the endotracheal tube. We used the GlideScope® GVL video laryngoscope (GVL) to test whether deliberately obtaining a restricted view would result in faster and easier tracheal intubation than with a full view of the larynx. METHODS: We recruited 163 elective surgical patients and randomly allocated the participants to one of two groups: Group F, where a full view of the larynx was obtained and held during GVL-facilitated tracheal intubation, and Group R, with a restricted view of the larynx (< 50% of glottic opening visible). Study investigators experienced in indirect VL performed the intubations. The intubations were recorded and the video recordings were subsequently assessed for total time to intubation, ease of intubation using a visual analogue scale (VAS; where 0 = easy and 100 = difficult), first-attempt success rate, and oxygen saturation after intubation. Complications were also assessed. RESULTS: The median [interquartile range (IQR)] time to intubation was faster in Group R than in Group F (27 [22-36] sec vs 36 [27-48] sec, respectively; median difference, 9 sec; 95% confidence interval [CI], 5 to 13; P < 0.001). The median [IQR] VAS rating for ease of intubation was also better in Group R than in Group F (14 [6-42) mm vs 50 mm [17-65], respectively; median difference, 20 mm; 95% CI, 10 to 31; P < 0.001). There was no difference between groups regarding the first-attempt success rate, oxygen saturation immediately after intubation, or complications. CONCLUSIONS: Using the GVL with a deliberately restricted view of the larynx resulted in faster and easier tracheal intubation than with a full view and with no additional complications. Our study suggests that obtaining a full or Cormack-Lehane grade 1 view may not be desirable when using the GVL. This trial was registered at ClinicalTrials.gov: NCT02144207.

Acute airway management in the emergency department by non-anesthesiologists.

PURPOSE: The responsibility of acute airway management often falls into the hands of non-anesthesiologists. Emergency physicians now routinely use neuromuscular blockade to facilitate intubation. The literature in support of this practice has almost exclusively been published in emergency medicine (EM) journals. This body of literature is presented and issues of educational support are discussed. SOURCE: A narrative review of the literature on the practice of airway management by non-anesthesiologists. PRINCIPAL FINDINGS: A significant proportion of acute airway management occurring outside the operating room is being performed by non-anesthesiologists. Rapid sequence intubation (RSI) is recognized as a core procedure within the domain of EM. RSI is being performed routinely by emergency physicians practicing in larger centres. Anesthesiologist support for the practice of RSI by non-anesthesiologists has been weak. Formal educational support outside of postgraduate training in the form of dedicated programs for advanced airway management are now being offered. The majority of the literature on the use of RSI by non-anesthesiologists represents retrospective case series, observational studies and registry data published in EM journals. The reported success rates for RSI performed by non-anesthesiologists is high. Complication rates are significant, however reporting consistency has been poor. CONCLUSIONS: The role of non-anesthesiologists in acute airway management is significant. Despite shortcomings in methodology, current evidence and practice supports the use of RSI by trained emergency physicians. Constructive collaborative efforts between anesthesiology and EM need to occur to ensure that educational needs are met and that competent airway management is provided.

Laryngoscopic intubation: learning and performance.

BACKGROUND: Many healthcare professionals are trained in direct laryngoscopic tracheal intubation (LEI), which is a potentially lifesaving procedure. This study attempts to determine the number of successful LEI exposures required during training to assure competent performance, with special emphasis on defining competence itself. METHODS: Analyses were based on a longitudinal study of novices under training conditions in the operating room. The progress of 438 LEIs performed by the 20 nonanesthesia trainees was monitored by observation and videotape analysis. Eighteen additional LEIs were performed by experienced anesthesiologists to define the standard. A generalized linear, mixed-modelling approach was used to identify key aspects of effective training and performance. The number of tracheal intubations that the trainees were required to perform before acquiring expertise in LEI was estimated. RESULTS: Subjects performed between 18 and 35 laryngoscopic intubations. However, statistical modeling indicates that a 90% probability of a "good intubation" required 47 attempts. Proper insertion and lifting of the laryngoscope were crucial to "good" or "competent" performance of LEI. Traditional features, such as proper head and neck positions, were found to be less important under the study conditions. CONCLUSIONS: This study determined that traditional LEI teaching for nonanesthesia personnel using manikin alone is inadequate. A reevaluation of current standards in LEI teaching for nonanesthesia is required.