EMS Today: A Showcase for Intubation Devices
By Dan White
Photo by Dan White
A demonstration of the new Levitan FPS Scope.
The big new trend at EMS Today this year was the rapid growth of new optical and video intubation devices. It’s particularly incongruous that in a month when the big feature article in JEMS is about “The Vanishing ET Tube”, our industry introduces several new tools that make intubation easier and possibly safer.
Larger versions of these devices have been in most anesthesiologists’ arsenal for years. They allow the clinician to view the intubation procedure on a remote screen. Often these devices can provide a much broader field of view in high definition color and manufacturers continue to make them smaller and more rugged, with some models engineered specifically for EMS use.
I saw several brand-new intubation devices at EMS Today. Some I had never even heard of previously. Every single one was of very high-quality construction. Many hold the promise to make quickly securing a definitive advanced airway easier, safer, and faster.
The first two intubation devices that caught my attention came from Clarus Medical. One features a compact screen on the handle. It blends the benefits of an optical stylet with video technology. It can display or export the video signal with a convenient USB port.
Another device at EMS Today worth mentioning was the new Levitan FPS Scope. This device is a malleable fiber optical stylet with a small view port and oxygen insufflation port. This provides assistance to those learning how to use the device by exploiting that little-credited teacher’s helper, body memory.
Body memory is what allows you to ride a bicycle even if you have not done so for decades -- your body remembers how, but it needs plenty of repetition to acquire the memory.
Developing that body memory is what becomes mission-critical with each new trick in your bag. How many tricks will you try to learn to do well and what other skill could that effort degrade. These are the issues that can complicate and reduce the net value of acquiring new skills. That’s what I like about the Levitan Scope: it’s the same old laryngoscopy technique I’ve always used before, just with an added twist at the end.
You hold the Levitan in your right hand with your ET tube loaded on it, and a laryngoscope in your left hand just like you are used to. Once you see the tip approach the glottis, you transition from looking in the mouth to looking through the eye port to pass the tube under direct visualization. You can follow the tube all the way in and watch as it passes through the chords. If for any reason the view becomes obscured, as what might occur with blood or vomitus in the airway, you still have a great fallback position.
Next you turn on the special LED at the stylets tip and use it just like a light wand for trans-illuminated tracheal intubation. Frankly I could see just using it as a stylet on easy tubes. After all, as you approach the glottis, if you can see it easily enough, you’ll probably stick it in. Personally, I’d like to play with the idea of turning on the trans-illuminating LED light as I begin to insert the tube - for routine external visual confirmation of placement as I pass the glottis.
I see the potential for this one device, the Levitan, to provide an escalating level of response to each individual airway challenge. It’s also one of the most compact and economical of the new intubation devices I saw at the show.
Photo by Dan White
The Clarus Video System in use.
A sexy new video laryngoscope on display was the C-MAC Video Laryngoscope from Karl Storz. This versatile system operates in a similar manner to the Ranger Glidescope. It has a laryngoscope component and a separate view screen system. The quality was simply stunning, with the robust laryngoscope component exhibiting the finish and feel of an expensive handgun. This stuff is so nice I was a little nervous to ask how much it cost, and as it turned out, if you have to ask, you probably can’t afford it. But for best in class, these systems have to be on your short list.
The public did not get a chance to see the new Coopdech C-Scope, but EMS1.com received a private showing. This video laryngoscope has a traditional look, with a screen that while not as vividly clear as the Pentax, was noticeably larger and located right on the handle. The handle itself provides a more traditional laryngoscope feel, and uses replaceable blades that will come in a variety of sizes and style.
The next new advancement in intubation looked like a regular laryngoscope with two lights. But it is far more than it initially appears. The IntuBrite has a second Ultraviolet light, which causes the vocal chords to stand out like you have never seen them before. The blades themselves are completely disposable. The handle is also very innovative -- it has a much more ergonomic design which enhances operator control. The curved shape helps you direct the lifting force to its greatest advantage.
The last new airway toy at EMS Today was not a laryngoscope at all; it’s a new bougie from SunMed. This new malleable “introducer” is a big improvement on what is a great second-line airway technique.
The original introducer or bougie is also often called a gum elastic bougie. For those who don’t know what a Bougie is, here’s the definition: “A thin cylinder of rubber, plastic, metal or another material that a physician inserts into or though a body passageway, such as the esophagus, to diagnose or treat a condition. A bougie may be used to widen a passageway, guide another instrument into a passageway, or dislodge an object.”
“Introducer” is probably a more accurate description of the bougie, since you put it in first when confronted with a difficult intubation and then send the ET tube down over the long stylet. (An even better technique is to pre-load the introducer in the ET tube, holding them together in your right hand. That way you are not fumbling when trying to hold the introducer in place, while feeding the tube down over the top.)
Photo by Dan White
A SunMed Malleable Introducer, AKA a bougie.
The new SunMed Malleable Introducer is the first one of its kind built to use exactly that way. The tube stays firmly secured by the movable tube stop allowing you to leave a few inches of bougie protruding out the end of your ET tube and then form it to your preferred shape. Once you get the end of the introducer up under the epiglottis, you slide your tube into the trachea using the introducer as a guide wire. This simple device is so inexpensive (10$) that everybody should have one in his or her kit.
Also worth noting at EMS Today was representation of the different leading rescue airways. The King Airway recently gained a large following in EMS and the following continues to grow. The King Airway is a fast and simple way to secure an airway for resuscitation when intubation is difficult or unavailable.
Another great new supraglottic airway on display was the LMA Supreme. The new LMA Supreme™ is much more suitable for EMS than any other laryngeal mask airway. The carefully tested design results in a quick learning curve for easy insertion. Subtle refinements in the mask make correct placement easy. With its integrated drain tube and verifiable placement; the LMA Supreme™ inspires real confidence managing pre-hospital airway emergencies.
Both the King and LMA Supreme are supraglottic rescue airways -- neither deeply penetrates the esophagus like an EOA, Combitube, or Easytube. The upper part of the Supreme's internal mask provides the function of the upper balloon on the King. The flexible tip of the Supreme rests on top of the esophageal sphincter while the King's small balloon fits just inside or against the sphincter. Both are single lumen airways and neither can invade the trachea. Both have a gastric port for rapid decompression of the abdomen. Consequently, I see them as much the same type of device.
They also share one critical advantage over their predecessors: they are small enough to fit in most intubation kits. A backup airway back in the truck is no airway at all.
I've been very reluctant to embrace rescue airways. It was hammered into my head as a youth that Intubation is the gold standard. Therefore if I was having trouble it was because my tools were not good enough, or even more likely because I wasn't. That hard line old-school attitude kept me from seeing the truth: these things work.
There is a mounting body of evidence supporting the broader adoption of fast, supraglottic airways. They do not appear to allow gastric regurgitation during CPR very often, as I had once feared. In some situations they have real advantages. We need to focus on what gets the job done adequately in the most hands. It's time for these new supraglottic airways to become an integrated part of EMS airway management.
We can always strive to do a better job of managing the emergency airway. New technologies such as those we saw at EMS Today may prove to have a vital role. Some of these new devices are expensive but compared to the cost of a new LED light bar, the price justifies itself considering the potential benefit. We can -- and should -- be masters of a full range of critical life-saving skills that reflect the best standards of care and advancements in technology.
As a matter of fact, that’s what we have always done.