From seven years in the ED then 25 years in anesthesia, I have used every technique available to access airways.
The Shikani fiber optic is probably the best tool for oral f/o.
It is taught wrong.
Stand to the side of the patient.
Access and traction tongue.
Place loaded scope into the mouth.
Immediately look and follow the base of tongue to epiglottis.
Assistant w jaw lift.
Intubate.
As fast or faster than DL.
Given the physics of the scope, it is difficult at best to stand at the head of the patient and defeats the early look and smooth progression to the cords.
Fast load
Portability
Ease of use
No broken teeth
Are pluses
Nasal still requires traditional f/o.
All the drawbacks of f/o still apply mostly relating to obstruction of view.
Blood, mucous, gastric contents all still major obstacles that may favor DL.
Great article. I work at a Level 1 trauma center and we have multiple VL’s for the OR. The anesthesia providers still tend to use traditional DL for most airways unless it’s a difficult airway exam. Things like equipment turnover, missing blades or stylets, etc., tend to make accessing a blade harder than it should be. Equipment also tends to break more times than one would think. I’ve been in anesthesia for 15 years and I’ve seen the trajectory with VL increasing; especially in ICU. Personally most of my intubations are done with a traditional laryngoscope and I am comfortable using all airway platforms- direct, video, and FOB ( which is slowly being replaced by VL)
The same patients intubated in the OR and later in the ICU, all by anesthesia personnel, had a worse view with DL in the ICU. For patient and environmental reasons this makes sense to me.
I have the luxury of having a stream of OR patients to keep myself sufficient with direct laryngoscopy but for patients in the ICU I want a hyperangulated blade and get the tube in the trachea with as little drama as possible.
I work at a teaching hospital in Canada, ICU with a background and practice in anesthesia. We have CMACs in every OR and several in the ICU. I trained with DL (I’m old.)
As a teacher it is much easier and less stressful to teach on video, including if I’m teaching DL using the CMAC blades (with the video only visible to me).
One comment I can offer, based on my own observation, is that positioning is much more important with DL than with VL, and one of the challenges current trainees have when the VL view is poor due to positioning is having an approach to ideal positioning. I suspect that one of the explanations for VL having higher first pass success in trainees particularly is because adequate visualization is more tolerant of poor positioning than with DL. When I was learning with DL I quickly learned that good positioning was a key factor in success. It still is, just less so with VL.
From seven years in the ED then 25 years in anesthesia, I have used every technique available to access airways.
The Shikani fiber optic is probably the best tool for oral f/o.
It is taught wrong.
Stand to the side of the patient.
Access and traction tongue.
Place loaded scope into the mouth.
Immediately look and follow the base of tongue to epiglottis.
Assistant w jaw lift.
Intubate.
As fast or faster than DL.
Given the physics of the scope, it is difficult at best to stand at the head of the patient and defeats the early look and smooth progression to the cords.
Fast load
Portability
Ease of use
No broken teeth
Are pluses
Nasal still requires traditional f/o.
All the drawbacks of f/o still apply mostly relating to obstruction of view.
Blood, mucous, gastric contents all still major obstacles that may favor DL.
Great article. I work at a Level 1 trauma center and we have multiple VL’s for the OR. The anesthesia providers still tend to use traditional DL for most airways unless it’s a difficult airway exam. Things like equipment turnover, missing blades or stylets, etc., tend to make accessing a blade harder than it should be. Equipment also tends to break more times than one would think. I’ve been in anesthesia for 15 years and I’ve seen the trajectory with VL increasing; especially in ICU. Personally most of my intubations are done with a traditional laryngoscope and I am comfortable using all airway platforms- direct, video, and FOB ( which is slowly being replaced by VL)
As anesthesia critical care attending:
I almost exclusively DL in the OR for patients with a low predicted difficulty given its simplicity for my typical workflow.
I almost exclusively VL in the ICU for everyone.
This decision was somewhat informed by this study I read in training:
https://journals.lww.com/anesthesiology/fulltext/2018/08000/comparison_of_tracheal_intubation_conditions_in.23.aspx
The same patients intubated in the OR and later in the ICU, all by anesthesia personnel, had a worse view with DL in the ICU. For patient and environmental reasons this makes sense to me.
I have the luxury of having a stream of OR patients to keep myself sufficient with direct laryngoscopy but for patients in the ICU I want a hyperangulated blade and get the tube in the trachea with as little drama as possible.
I work at a teaching hospital in Canada, ICU with a background and practice in anesthesia. We have CMACs in every OR and several in the ICU. I trained with DL (I’m old.)
As a teacher it is much easier and less stressful to teach on video, including if I’m teaching DL using the CMAC blades (with the video only visible to me).
One comment I can offer, based on my own observation, is that positioning is much more important with DL than with VL, and one of the challenges current trainees have when the VL view is poor due to positioning is having an approach to ideal positioning. I suspect that one of the explanations for VL having higher first pass success in trainees particularly is because adequate visualization is more tolerant of poor positioning than with DL. When I was learning with DL I quickly learned that good positioning was a key factor in success. It still is, just less so with VL.