It would be a fair assessment to say that video laryngoscopy has a different feel and approach to intubation than direct laryngoscopy. Most of the resistance and missed opportunities by healthcare and EMS providers when it comes to video laryngoscopy revolve around – and can typically be corrected by – adequate initial education and continued training.
Setting providers up for success takes practice, and practice is required for both successful direct and video laryngoscopy use. Practice should occur not just in sterile classroom situations, but in austere and atypical situations as well. First, ensure providers understand why and when to use video laryngoscopy.
Airway landmark identification
Take, for instance, an anaphylactic patient. Intramuscular epinephrine, nebulized albuterol, intravenous methylprednisolone, and other medication options haven’t led to any patient improvement, so now they’re deteriorating. As the patient’s wheezing worsens and stridor exacerbates, your level of concern for your patient’s airway control increases. So, you decide to intubate your patient.
Here’s a perfect example of where endotracheal intubation should be preferred over using a supraglottic airway (as there’s a risk of the airway physically closing off). Direct laryngoscopy can be successful, but excessive airway swelling may alter your landmark identification and result in a decreased Mallampati score.
You may reach for your bougie to try to blindly insert it into the trachea, but what if you reach resistance?
Video laryngoscopy plays a key role in this particular case. Even if airway swelling results in an altered view of the vocal cords, prior education and practice at recognizing the visible airway anatomy can help to guide you in the right direction. Having a better view that you (and your partner) can see will help to guide your stylet-loaded ET tube or bougie, toward the trachea.
With proper practice, a better view should result in increased intubation success.
Suctioning in conjunction with intubation
Here’s another example. It’s not always the meatball in the oropharynx that causes an airway obstruction. After all, the narrowest part of the adult airway is at the vocal cords. More often than not, it’s emesis, secretions or even blood that obstructs your view of the patient’s airway anatomy.
Excessive fluid can certainly complicate any intubation procedure and often requires an additional component: suction.
While mechanical or automatic/vacuum suction may help to clear the path, you still need to rely on what you can actually see in order to secure your airway. If you constantly have to suction secretions from the airway, then your efforts toward securing that airway seem to be put aside.
Secretions present as complications. Clear or frothy secretions present as one set of complications, while opaque or thick emesis or blood present as an entirely different set.
Having a video view of the airway can ease your suction stress because you’re now able to utilize two sets of hands to visualize the same airway structures. One provider can focus on intubation, while the other can maneuver the suction catheter, as both get the full view of the oropharynx. Video laryngoscopy allows for suctioning to be utilized in conjunction with intubation; not in competition with it.
Establishing a comfort zone, finding landmarks
Taking a step back, laryngoscopy requires a fairly in-depth knowledge of the upper airway anatomy. The more that providers see “normal” airway structures through the eyes of video laryngoscopy, the more they’re able to recognize – and mitigate – situations where their patient presents as anything but normal.
Utilizing high-fidelity mannequins, watching intubation videos and recordings of video laryngoscopy, and simply practicing often are great opportunities to learn how to master this skill.
Start out with sterile conditions:
- A well-lit room.
- Proper patient positioning.
- No time restraints.
- With experienced users available to guide the learning process.
This will help to build not only recognition and experience, but also confidence and comfort.
Once basic skills mastery (and understanding) can be obtained, then providers can advance on to atypical and challenging conditions.
Remember:
- Practice before patient use.
- Practice in sterile conditions before austere conditions.
- Practice often (even at the beginning of each shift).
Master the use of both direct and video laryngoscopy and understand their strengths … then choose your tool wisely.