Is It Better to Have Seen and Failed or Never to Have Seen At All?

UPDATE:  The manuscript of the MACMAN study was simultaneously published in JAMA and presented at SCCM (Lascarrou JB, et al. JAMA. Published Online Jan 24, 2017).  While the peer reviewed primary results are unchanged, demonstrating that videolaryngoscopy improves the glottic view but does not improve the ability to pass the endotracheal tube compared to direct laryngoscopy, one of the secondary results deserves some mention.  It wasn’t presented in the brief late-breaker presentation at ESICM, so I hadn’t discussed it previously.  Lascarrou and colleagues also found a higher rate of severe life-threatening complications with videolaryngoscopy, namely severe hypoxemia, hypotension, and cardiac arrest.  While I am not entirely sure what to make of this finding, I do think it should cause us some pause.  If this is true (and it may just be a type 1 error that secondary analyses are prone to), then not only should we not use VL as the primary intubating device for all our intubations in the ICU, but we should think carefully about which ones we do use it for (and be selective in whom we use it in).  And, while these most recent studies have been informative on the risks and benefits of both VL and DL, there remain unanswered questions.  These studies do not include patients who the clinician believes they have to use VL for intubation, nor do they look exclusively at high risk populations such as morbid obesity or high Mallampati or MACHOCA scores.  I suspect additional studies will be forthcoming in the future and that this field will continue to evolve.  However, in the meantime, both of these most recent well-designed and conducted randomized controlled trials, make it apparent that we should not be using VL as the default intubation device in all our critically ill patients.

 

October 4, 2016;  08:55

In the last couple of decades, some of the biggest advances in medicine have involved technology.  The videolaryngoscopy represents one of these technological advances for assisting with endotracheal intubation.  FDA approval of devices simply requires demonstration that the device does what it claims to do, but does not require demonstration of improved outcomes or any clinical benefit. While there are a number of different videolaryngoscopes, they are all designed with a camera on the end of a laryngoscope connected to some form of a screen that displays the image the camera projects.  Numerous studies have demonstrated that videolaryngoscopes improve the view of the glottis and vocal cords (Cormack Lehane Glottic View Grade) over direct laryngoscopy during endotracheal intubation.  Some of these studies suggest that time to intubation may also be shorter using videolaryngoscope.  These data (probably combined with some allure of new technology) resulted in many opining that the videolaryngoscopy should be the standard of care for intubation in critically ill patients, and should be used in all intubations in the ICU, especially by inexperienced operators.  However, the studies providing the data supporting these recommendations were conducted in the operating room on patients undergoing intubation for surgical procedures.  And most of them studied experienced anesthesiologists as the operators.

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