Video Laryngoscopy - Research Paper Example

Video Laryngoscopy Video Laryngoscopy Intubation is needed when general anaesthesia is given. During anaesthesia itbecomes impossible for the patient to breath adequately as the sedatives given in anaesthesia paralyzes the diaphragm. The intubation procedure must be accomplished in a rapid and precise method; in order for the patient’s condition to improve or stabilize.  Generally, there are two methods to perform intubation and they are oral and nasal intubation. However, oral intubation is commonly practised by the professionals. Oral intubation can be performed by either direct laryngoscopy or video laryngoscopy. Primarily the video laryngoscope was used by the anesthesiologists when faced with difficulty during intubation. The high success rate of video laryngoscopy while dealing with difficult and complicated air ways have led professionals to acknowledge it as a beneficial tool in pre-hospital setting.(Hurford, 2010).   The three main components of a successful intubation Intubation is successfully done with the help of skilled technicians, the use of accurate tool and of course a good technique. Skilled clinicians Clinicians should be highly trained in order to perform intubation as it might follow complications. A report states that 31% of tracheal intubation resulted in failure in the Greater Miami area (Pouliot). The failure is because the paramedics less frequently operate cases that require tracheal intubation. It has also been observed that all paramedics are not efficiently trained to carry out intubation. Moreover, a number of paramedics are usually assigned tasks such as on the fire apparatus or the ambulance. Hence the paramedics remain less acquainted with the procedure of intubation. Some paramedics have just placed one or two tubes in a year. This criterion has put forth a challenge for the medical directors and the service training staff as they have to refresh the paramedics frequently on this critical skill. Lack of sufficient practice has resulted in misplaced endotracheal tubes by the paramedics. A lot of problem is faced during intubation in a moving ambulance and in the tight confines and configurations presented by the helicopters. All the above mentioned reasons stresses the use of video laryngoscopy for intubation.(Heightman, 2011). The estimated training period for the paramedics is around 1000 hours or more. Yet it is less than the training and educational period of the anestheologists who spent years in medical education after which they are legible for a doctorate degree. Although the program length of the CRNA is 24 to 36 months but one year experience is required in an acute setting such as an emergency room and complete additional training in a large hospital setup to acquire the degree of a CRNA. In USA the CRNA are expected to devote 1800 clinical hours and administer 800 anesthetics at one out of many clinical programs available throughout USA. Hence comparatively the paramedics are insufficiently trained to conduct tracheal intubation. The training process of video laryngoscopy is not complicated. In fact the techniques of video laryngoscopy can be easily mastered by the paramedics in comparison to the techniques applied in direct lyrangoscopy. Hence it facilitates paramedics who are working in less than optimal circumstances. Method used Among the two methods of intubation endotracheal intubation is the most acknowledged method whereas nasotracheal intubation is conditionally performed. In a survey the success rate of first-pass intubation and time to intubation showed no differences with video laryngoscope or direct laryngoscope when endotracheal intubation was being conducted by the experts. However differences were appreciable when performed by the non experts. Hence this shows that paramedics who are less skilled in performing endotraceal intubation will be at an advantage by using video laryngoscopy. In endotracheal intubation the video laryngoscope serves to provide better visualization of the glottis than the direct lyrangoscopy (DE, 2012). In another survey seventy patients that required nasotracheal intubation were randomly operated with either direct or Glide scope video laryngoscopy. The time period and easiness in intubation were judged. The operation was assessed by a blind observer and the operators were blind until the start of intubation. A Visual Analog Scale assessed the ease of intubation. The number of attempts and failures along with other things were recorded. The results showed that the median with Glide scope Video laryngoscopy was faster in comparison with video laryngoscopy. The data on the Visual Analog Scale depicted that intubation was easier with video laryngoscopy than direct laryngoscopy. Incidents such as the postoperative moderate and sore throat were greatly minimized with the application of Video laryngoscopy. The Magil forceps were not used in Video laryngoscopy but were used in Direct Laryngoscopy (PM, 2008). Complicated airway vs. Uncomplicated airway Trauma patient The airway plays an important role in intubation. A complicated airway can make intubation difficult to perform. Severe facial trauma is an example of a complicated airway. Severe facial trauma causes fractures of the maxillofacial bones, bleeding, and deformity of the airway. It is difficult to visualize the airway. As a consequence the practitioners are unable to ensure an unobstructed air way for the patients to breathe through. Neck injuries are another difficulty that practitioners face. The practitioners face difficulties to envisage the anatomy of the airway. This is because in neck injuries cervical spine immobilization must be done to avoid further damage. Dr. Lindsay agrees (2009), that intubation is more difficult when the cervical spine is immobilized. In addition, the complication of or pharyngeal edema is another challenge that practitioners face. Trauma to the larynx and trachea may cause swelling and displacement of structures, such as the epiglottis, arytenoids cartilages and vocal cords, thereby increasing the risk of cervical airway obstruction. 2. Medical emergency patients Intubation for medical emergency patient is neither simple nor straight forward. Intubation in cardiac arrests usually requires more than one attempt. It also requires competence which is not gained easily and hence needs a lot of practice. Intubation is followed by positive pressure ventilation which lowers preload and cardiac output. It also adversely affects chest compressions and may result in interrupting chest compressions which again have gross outcomes (Vlessides, 2010). Other medical emergencies such as Oropharyngeal edema also complicate intubation. Medical instruments used to intubate There are two types of lyrangoscope, standard and the video lyrangoscope. Standard laryngoscopy predated video laryngoscopy but the latter has more advantages. It provides visual access to larynx and glottis. Standard laryngoscopy is commonly used in comparison to video laryngoscopy. The advantage of video laryngoscopy is that the doctors are confident that they have correctly placed the tube. A screen allows others present during the operation to ask questions. Video laryngoscopy also facilitates teaching many health professionals and Ems personnel. This is achieved by the use of Internet display either through live transmission or by the display of captured images. In video laryngoscopy there is a clear exposure to glottis. Better visualization during intubation ensures safety, efficiency and lowers rate of incidence of a disease. (Lindsay, 2009) The doctor also doesn’t need to move the neck of the patient with the use of this method. The other advantage of video laryngoscopy is that the time to intubation is lesser than direct laryngoscopy. The intubation is achieved in seconds. An estimated result depicts that the average time taken to intubate in video laryngoscopy is 21 seconds (range8-43 seconds) and 42 seconds in direct laryngoscopy (range 28-90 seconds). Models for direct layryngoscope There are three models for direct laryngoscope. There are two basic styles of the laryngoscope blade: the straight and the curved type. The Macintosh is highly used among the curved blade whereas the Miller is most popular among the straight blades. It is flat from the beginning and has a curved tail. The flat portion is designed to reduce trauma whereas curved tail helps in lifting the epiglottis. These features provide greater exposure to larynx especially in cases where intubation is difficult to perform. Another method uses fibre optics in direct laryngoscopy. This method is easily accessible. An optic fibre, less than 4mm is inserted into the nostril and is guided through the neck, until it just lies above the larynx. It is easily accessible and easy to use. Optic fibre endoscopy plays an important role in the evaluation of neurological disorder. Models for video lyrangoscopy: These include the following: a. Glide scope ranger b. Truview PCD-R c. McGrath Series 5 d. McGrath Mac e. C-Mac f. Storz DCI The video laryngoscopes can be classified in two ways. One way is how the screen is connected to the handle. The video laryngoscope can be further classified into ones in which the endotracheal tube is preloaded on the device compared to those which require the endotracheal tube to be freely inserted into the oral cavity. Storz DCI, C-Mac and Glidescope ranger has a large separate view screen (Rothfield et al 2011). Glide scope Ranger is a portable, battery powered device designed for pre-hospital settings. It consists of a plastic handle along with a curved blade. The camera is embedded into the under surface of the blade and connected to a separate video monitor. The device is easy to use even in patients with complicated airways. Truview PCD-r provides the most successful options for intubation. The user is provided with a list of working alternatives. It also provides maximum versatility. The Storz DCI integrates a fibre optic bundle in the standard Macnotish blade. A camera is placed in the laryngoscope handle that produces the image. It has been successfully used in difficult airways, bariatic and pediatric surgical patients. McGrath series 5 is powered by a single AA size battery and is attached to a coloured LCD screen. It is easy to use as its application is similar to direct laryngoscopy. This device has shown high success rate of intubation and is capable of easily securing the air way. It will be an effective source for paramedics while carrying out intubation in patients with normal airway. Case studies comparing video laryngoscopy to direct laryngoscopy First-pass intubation success same in direct versus video laryngoscopy The success rate in the first –pass intubation using standard laryngoscopy is higher as compared to video laryngoscopy. The survey shows that standard laryngoscopy had 90.3% success rate where as video laryngoscopy performed with Glide scope had a success rate of 88.8% and Storz endoscope had 84.1% success rate. However, the overall success rate for first-pass intubation was around 89%. Although standard laryngoscopy showed a higher success rate but doctors use video laryngoscope as a rescue attempt whenever the first-pass intubation with standard laryngoscopy fails. It was observed that there wasn’t a need to return to spontaneous ventilation or seek another technique as all attempts with video laryngoscopy were successful. Patients that had predicted difficulties with intubation like decreased mouth opening, decreased cervical range of motion and had shown difficulties in intubation earlier are successfully intubated with video laryngoscopy. Almost 44% of the practitioner prefers video laryngoscopy because of training purposes. This is not clear though it is seen as a lack of experience of handling the video laryngoscope (Vlessides, 2012). Tracheal intubation in the emergency dept. A comparison of the glidescope video laryngoscopy to direct laryngoscopy Dr. Sakles, Dr. Moiser, dr. Chiu and Dr. Keim. The first attempt success rate was higher with Glide scope video Laryngoscopy (GVL) as compared to Direct laryngoscopy (DL). In most cases Glide scope was used as a rescue device when attempts with direct laryngoscopy failed. In the cases dealing with direct laryngoscopy it was mainly used as the initial device. GVL shows high first-pass success in all airways and also in airways where there was a difficulty predicted. However, GVL shows a lower success rate than Direct Laryngoscopy when more than one attempts are required. The success rate was high when senior residents carried the task as compared to the junior residents with both the devices. This predicts the significance of experience in process of intubation (Rothfield et al 2011). The failure with direct laryngoscopy was encountered due to an unclear view of the airway. However, failure of Glide scope video laryngoscopy was reported due to an inability to direct endotracheal tube into the air way. The result shows that Glide scope video laryngoscopy provides a better view of the Cormeck-Lehame and lesser time period for intubation compares to Direct Laryngoscopy in patients with cervical immobility. However, the advantage of VGL dwindles if it required to be used more than once. A study conducted in 2000 of 305 pediatric patients depicted the need for improved methods. The failures met in intubation were obvious considering the variable intubation skills of the EMS personnel and adverse conditions such as limited lightning, weather conditions, trauma etc. As direct endoscopy in such cases is filled with problems and difficulties, the EMS medical directors are looking forward to new and improved methods for intubation. Video laryngoscopy befits their requirement. Professional opinions on the promising future of video laryngoscopy Dr. Lars p. Bjoernsen, md & dr. Bruce lindsay, md Video laryngoscopy in the pre-hospital setting The paramedics and the emergency care provider should be prepared to deal with patients suffering from grossly damaged airways. Video laryngoscopy (VDL) has shown great success rate in emergency intubation. VDL have lower weight and high resolution. They are also available in compact a size which makes video laryngoscopy useful for the paramedics. It is useful for patients when there is a limited access to their head like during extrication or air medical settings. Video laryngoscope is beneficial in dealing with difficult airways such as in patients with survival pain pathology. Video Laryngoscopy was highly recommended by anesthesiologists that practised intubation on daily basis. Such personalities include Richard Cooper, BSc, MSc, MD, FRCPC; John Doyle, MD, PhD adn Ron Wall, MD. They raised questions concerning the viability of direct laryngscopy in comparison to video laryngoscopy. Richard Cooper has appreciated this technology by characterizing it as strong and less likely to damage. Dr. Kenneth p. Rothfield The results of a trial study of video laryngoscopy in an ems system Emergency intubation by emergency care provider may be subjected to intubation failure, repeated attempts and high rate of complications.The application of glide scope video laryngoscopy by the EMS resulted in an increased intubation success rate up to 61%, in Howard County, Maryland. According to the survey glide scope rangers were place in twelve emergency vehicle service (EMS) vehicles (Rothfield et al 2011). The paramedics were given the required training. Forty two cases of cardiac arrest were encountered and treated. Glide scope video laryngoscope was used for the first pass intubation. Conventional laryngoscopy was identified as a rescue air way device. The survey resulted in 95% overall success in intubation. The first pass success rate with Glide scope was 60%. With minimum training the emergency medical provider performed intubation at a higher success rate (Hurford, 2010). Conclusion Looking forward to the difficulties associated with intubation, the new improved methods such as video laryngoscopy are recommended. The Video laryngoscopy as compared to direct laryngoscopy has a higher first-pass success rate. It is successfully performed in a few numbers of attempts as compared to direct laryngoscopy and also has a shorter time frame. Although direct laryngoscopy is widely used but doctors and practitioners recommend video laryngoscopy as it requires less training, in particular by the paramedics. The Screen provides others in the room to examine intubation and raise questions. Not only its application but its size is also favorable for use in intubation. The most important factor is the visualization. The glottis and the larynx are far clearer in video laryngoscopy than in direct laryngoscopy. Hence the doctors are sure about placement of the endotracheal tube. Consequently the challenges and difficulties experienced during the process of intubation have guided experts to consider video laryngoscopy as an advantageous tool to be utilized in the field. References Hurford, W.E. (2010). ‘The Video Revolution: A New View of Laryngoscopy’, Respiratory Care, Volume 55, Number 8, August 2010, pp. 1036-1045 Lindsay, B. (2009) Video Laryngoscopy in the pre-hospital setting, vol. 24(3) p267 Rothfield, K., Seaman, K., Duell, M., Pellegrini, J. (2011). ‘Video laryngoscopy Improves EMS Intubation Success in Cardiac Arrest Patients’, Circulation. 124: A33 Santeago, A. (2012). CRNA Career Profile - Careers for CRNAs (Certified Registered Nurse Anesthetist). Retrieved online from http://healthcareers.about.com/od/nursingcareers/p/CRNAprofile.htm Vlessides, M. (2010). First-Pass Intubation Success Same in Direct Versus Video Laryngoscopy, Anaesthesiology News, 38:3. Retrieved online from http://www.anesthesiologynews.com/ViewArticle.aspx?d=Technology&d_id=8&i=March+2012&i_id=820&a_id=20337 A.J heightman, 2011, Video Laryngoscopy place in ambulance Read More