Videolaryngoscopy: Should this be the
Standard of Care for Emergency
Intubations: What is the Evidence
Joseph E Pellegrini, PhD, CRNA
Conventional Laryngoscopy
 Conventional laryngoscopy depends on achieving a “line of
sight” from operator to glottic inlet with a recommendation
to place patient in a traditional sniffing position.
 Sniffing position results in optimum alignment of the three axes
 Oral ---Pharyngeal---laryngeal to achieve a “line of site”
 1-4% of all cases this is very difficult to achieve or impossible
 Often you cannot predict these difficult or impossible cases
o Many of these intubations are effectively “blind” requiring increased
neck extension, external laryngeal manipulation or the use of a gum
elastic bougie
Conventional Larygoscopy
 Conventional laryngoscopy requires flexing of the
lower cervical spine and extending the atlantooccipital joint
 Line of Site
Line of Site – Traditional Laryngoscopy
Easy to lose Line of Site
Often morbidity secondary to poor alignment or technique
Videolaryngoscopy
 Videolaryngoscopy consistently improves the view of the
larynx even in conditions where direct laryngoscopy may
lead to poor view (i.e. cervical spine cases)
 Videolaryngoscopy allows the camera to act an “eye” of the
operator and is situated in the pharynx of the patient
 Enables projection of glottis on monitor without the need to anteriorly
displace the lower jaw and reduce the cervical spine motion
 Allows the operator to “see around the corner”
 Less sympathetic response
 Less leverage required
 More easily tolerated in an “awake” patient
Videolaryngoscopy Line of Sight
 PROS - Rothfield
 Approximately 25 million patients are intubated/year for
surgical procedures
 Overall safety of anesthesia markedly improved with advent of
SaO2 and ETCO2 monitoring
 Morbidity with ETT placement alone ranges from 4-22%
 Reported decreased morbidity/adverse events with video versus
traditional laryngoscopy
 Multiple studies have shown that using video to assist intubation is
effective and reduces morbidity

Allows you to “look around the corner” without
hyperextending neck etc.
 CONS - Russo
 Some studies dispute all positive videolaryngoscopy findings
when intubation is performed by experienced anesthesia
providers
 Only effective when used by novices or outside OR’s
Anesthesia providers should only use as “backup” to CL?
 Report decreased effectiveness when video used in face of blood,
emesis etc.
 Can be obscured by sunlight etc.
 Various publications show that “direct view” does not ensure
placement
 Too angular versus too deep

Intubation outside the OR
 Intubation outside of OR associated with increased morbidity
and mortality
 Data suggest that in-hospital “first pass” intubation success
rates varies from 50-98%
 Most studies evaluated efficacy with anesthesia providers
 Achieved higher success rates
 Many “codes” are done without anesthesia presence
 Limited data
 Studies indicate increased adverse events in hospital with direct
tie-in to survival rates
 Increased morbidity outside anesthesia specialties
Video-laryngoscopy
 Conventional Laryngoscopy fraught with problems


Poor illumination
Limited view angle (10-15 ◦)
 Insufficient view is Number 1 reason for failure both in and out of the OR

Especially apparent in NON- ANESTHESIA PROVIDERS
 Intubations outside operating room often performed by NON
ANESTHESIA PROVIDERS in many institutions
 OB Anesthesia carried CODE BEEPER
 Sometimes could not respond immediately to code and reliance on
emergency room and ICU physicians to facilitate intubation
 Respiratory therapists presence consistent at all codes
 Often anesthesia paged emergently to intubate after multiple
attempts
 Study Proposed
 Glidescope introduced
 Training provided
 Comparative study formulated
 Study efficacy, time to intubate, differences between providers, complications
etc.
Complication rate: N=105 intubations
3 traumatic bloody airways
1 esophageal intubation
No dental trauma
 Lessons Learned
 Glidescope difficulties
 Failure to intubate initially

Inability to place tube despite clear visualization
o Stylet – need to use GS specific stylet
• Flexible stylet
o Scope too deep
• Pull back ¼” =
success
Inadequate relaxation
o Use of succinylcholine versus midazolam versus nothing
 Over-eager residents
o Placing GS using conventional approach

 Training parameters established
 Success rates approached 100% in final stages of study
 Glidescopes purchased throughout hospital and findings presented at corporate level
 Found to be easier to use than C-MAC and other devices by NON ANESTHESIA
PERSONNEL
Intubation in the Field
 Paramedics have been able to intubate in the field since 2003
 Endotracheal intubations are essential components of
paramedic training
 Higher survivability in areas where intubation is performed
in the field
 Some problems arise once transported to hospital secondary
to:
 Malpositioned tubes
 Multiple attempts
 Experience of paramedic teams
 Rural versus metro
Pre-hospital Intubation
 Overall intubation success
rate 85.3%
 Average paramedic
experience 59.5 months
 Average number of
attempts per paramedic
1.3 (1-2.75)
 Mean intubation success
rate per paramedic was
80.6 ± 22.3
Maryland Data – Pre-hospital
Intubations
 Intubations success rate in Baltimore City ranged
from 78-98% successful
 Variability among EMT providers
 Dependent on trauma versus cardiac arrest
 Higher success rates noted in cardiac arrest cases
 EMTs well versed in use of airway adjuncts and
alternative airways
 Varied results in other counties
Maryland Data – Pre-hospital
Intubations
 Arundel County
 Intubation success approximately 80%
 Carroll County
 Intubation success rates unknown
 Prince Georges County
 Intubation success rates unknown but suspected to be 70%
 Howard County
 Intubation success rates 64% with a first pass success rate
of only 59%
 Cardiac arrest

Multiple co-morbidities documented
 Ability to study alternative techniques based on
 CMO for Howard County
 Interest by Howard County FD, EMT Divisions
Maryland Data – Pre-hospital
Intubations
 Study Design
 Implementation of county-wide education for all EMTs
 Placement of Ranger Glidescopes on all EMT
 Data collection tool formulated to collect variables of interest
 Intubation attempts, Time to intubation, Number of EMTs , Rationale for
intubation, Success rates
 Prospective study approved by
 State of Maryland IRB
 Howard County IRB
 Saint Agnes Hospital IRB
 Governor O’Malley’s office
Maryland Data – Pre-hospital
Intubations
 Other variables measured
 Age
 Gender
 Mallampati
 Laryngeal view
 Number of patients at scene
 Initial saturation/Vital Signs
 Final ETCO2
Glidescope Ranger
Maryland Data – Pre-hospital
Intubations
 344 cardiac arrest incidents evaluated
 152 intubations evaluated using Videolaryngoscopy
 192 intubation evaluated using Conventional laryngoscopy
 3 patients could not be intubated
 Could not ventilate nor intubate
 5 patients used alternative techniques
 2 King LTD Airway
 3 Bag-valve mask
Intubation Success (Percentages)
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
First Attempt
Second attempt
Third Attempt
Videolaryngoscopy Success Rates
Overall Success
Seaman K., Rothfield K, Pellegrini J. Video Laryngoscopy
Improves Intubation Success in Cardiac Arrest and Enables
Excellent CPR Quality
Percentages of Overall Success Rates
100
90
80
70
60
50
Series1
40
30
20
10
0
Videolaryngoscopy
Conventional Laryngoscopy
Maryland Data – Pre-hospital
Intubations
 Interruption in CPR
 Mean duration between VL and CL
 45.1 seconds (CI 37.1-53.0 seconds)
 Associated almost exclusively with CL
 CPR Fraction was 87.5% in VL group in patients where CPR analytics
available
o CPR was uninterrupted in VL cases which equates to increased survivability
 Primary reason for intubation
 58% cardiac arrest or airway protection
 Airway protection secondary to drug overdose
 35% trauma
 Automobile accident
 GSW
 Other
Maryland Data – Pre-hospital
Intubations
 Other variables measured
 Age
 54.2 ± 23.6 years
 Gender
 65% male
 35% female
 Laryngeal view
 85% Grade 1-2 view on first attempt
 10% Grade 4 views
 8 Patients required rescue methods with GS
Maryland Data – Pre-hospital
Intubations
 Initial saturation/Vital Signs
 70% no recorded Oxygen saturation initial (on arrival to
scene)
 Final Saturation levels (on arrival to ED)
 49% had no recorded saturation levels
 51% had recorded saturation levels ranging from 85% to
100%
 Final ETCO2
 Median ETCO2 levels 25 mmHg
 60% of population had ETCO2 < 30 mmHg
Maryland Data – Pre-hospital
Intubations
 Tube properly placed on arrival to ED
 97% ratio of tube properly placed on arrival to ED
 37% increase
 Other Complications
 Inappropriate tube size attempts
 6 ETT required placement using smaller tube
 Fogging of lens
 Inability to adequately displace tongue
 Cords clearly visible but unable to place tube
 Aspiration
 52% reported aspiration present on initial laryngoscopy
o 22% blood
o 23% gastric contents
o 7 % foreign material
Maryland Data – Pre-hospital
Intubations
 Plans for Future Studies
 Other Counties
 Refined educational tools
 New standards for troubleshooting
 National implications
 Expansion
 All first responders
 Survival Data
 Did not measure survival ratios
 New code mantra
 ETCO2
 Intubation attempts
 No disruption of CPR reported when GS was used
Study
Subjects
Design
Results (time to intubation)
Comments
Anderson, Rovsing, & Olsen, 2011
100 morbidly obese pts with BMI >35
(50 in glidescope group and 50 in DL
group)
RCT, providers had experience with at
least 20 glidescope intubations
DL: 32 sec
VL: 48 sec
Glidescope intubation lasted slightly
longer, but was of no clinical significance
because there were no significant drops
in SpO2 in either group. DL intubations
were rated as more difficult than VL
intubations, and DL intubations required
significantly more lifting force. No
difference in postoperative sore throat.
Ndoko et al, 2008
106 morbidly obese patients with BMI
>35 (53 pts in each group)
RCT, intubations performed by providers
skilled in both techniques
DL: 56 sec
VL: 24 sec
Better maintenance of SpO2 levels with
VL compared to DL. Greater increase in
MAP, heart rate, and bispectral index
number was seen with the DL group.
More intubations were rated as difficult in
the DL group, and there was a higher
incidence of postoperative sore throat in
this group as well.
Ranieri, Filho, Batista, & do Nascimento,
2012
132 morbidly obese pts with BMI >35
(DL: 64pts, Airtraq VL: 68 pts)
RCT, all intubations performed by
anesthesiologists highly experienced in
both VL and DL
DL: 37 sec
VL: 14 sec
Improved vocal cord view and faster time
to intubation with the VL as compared to
Dl.
Dhonneur et al 2009
318 morbidly obese pts with BMI >35
(106 in each group of LMA CTrach,
Airtraq Laryngoscope (VL), and
Macintosh laryngoscope)
RCT, intubations performed by senior
anesthesiologists experienced in the use
of VL
DL: 69 sec
VL: 29 sec
This study also compared the use of a
videoscopic intubating LMA, but for our
purposes we extrapolated data just from
the other 2 groups. VL resulted in less
shunting and better arterial O2
saturations as compared to DL. VL
allowed for the fastest definitive airway,
as compared to both other modalities.
Arterial oxygenation was of better quality
during use of VL compared to DL.
Marrell, Blanc, Frascarolo, & Magnusson,
2007
80 morbidly obese pts (BMI >35)
RCT, all intubations performed by same
DL: 93 sec
senior anesthesiologist. Laryngoscopy
VL: 59 sec
was performed with the same
videolaryngoscope (MAC 3 blade Airtraq)
but in the control group the screen was
hidden.
Found better view with VL vs DL and
faster time to intubate, but no significant
difference in lowest SpO2 during
intubation
Videolaryngoscopy
 Bottom Line
 Pros
 Easier to master than conventional laryngoscope
 Novice mastery
o Can be used by wide variety of professionials & paraprofessionals
 More easily tolerated than CL in awake patients
 Less sympathetic discharge
 “Intubation by committee”
 More useful in patients with limited mobility or possess a difficult airway
 Promotes faster time to intubation & less adverse events in morbidly obese
patients
 Cons
 Technology driven with all inherent problems
 Enough said
 Decreases skill in novices
 Cannot be used in all settings
Pellegrini@son.umaryland.edu