Compare and contrast direct laryngoscopy with video laryngoscopy for intubation in the ICU.
(10 marks)
Syllabus topic/section:
2.1.5 Respiratory Intensive Care: Airway management
Discussion:
This question focused on a comparison of two techniques for airway access (laryngoscopy) but was interpreted as a discussion of laryngoscope devices by many. Candidates who performed less well spent time describing the types of blades, screens, batteries and power supply without any reference as to how this affects the clinical view, the operators' ability to perform an intubation, the indication for intubation, first pass success rate and the rate of complications for example. Notable factual errors were also common among the responses. For example, there was a bias towards interpreting the difficulty of the direct technique as beneficial, a claim hard to substantiate.
Candidates who performed well were able to discuss the indications, technique differences, complications, logistical differences and similarities between the 2 techniques. Candidates could consider the why, when and how of intubation as a potential structure and utilise a table to effectively compare and contrast the 2 different techniques. Candidates who were aware of published data displayed mastery of the subject and were rewarded accordingly, even if specific trial names were not mentioned. Answers which mentioned the rate of Oesophageal intubations, glottis visualisation, differing adjuncts in teaching and supervision were superior.
The rubric is provided to aid the candidate's future study.
|
a) VL vs DL (10 marks) |
Not clear on key differences or/and omission of key safety points 0 - 4.5 marks |
Clear understanding of differences in use for VL vs DL, especially for key points (e.g. technique, improvement in safety outcomes with VL, complication rates). 5 - 6.5 marks |
At standard PLUS: Advanced perspective on role of VL vs DL. May include some mention of relevant studies. 7 - 10 marks |
Whether this rubric will actually "aid the candidate's future study" seems unlikely, considering the Spartan austerity of the rubric text. We are informed that the candidates needed to demonstrate a "clear understanding of differences" for the techniques they were asked to compare and contrast, and that a superior answer offered "an advanced perspective". Neither item is informative with respect to the desirable content or how its presentation was expected to be structured. However, though the rubric is mute as to what the "key points" were supposed to be, the examiner's comments reveal some elements that could be cobbled together into a guide for future struggles with videolaryngoscopy questions:
Thus:
| spect | Videolaryngoscopy | Direct laryngoscopy |
| Logistics and technology |
An extra device in a busy room. Requires a powerpoint or battery. Multitudes of devices - hard to standardise training for them all. |
Small and unimposing. Requires no power source. Devices are uniform in shape and performance. |
| Technique | "Look down, look up, look down, look up"- the technique calls for changing attention between the airway and the screen | Relies on the alignment of axis to achieve line of sight of the glottis |
| Indication |
Improve first pass success rates in routine intubation Rescue failed direct attempts with DL First line for anticipated difficult airway |
High volume use environment with experienced operators (eg. operating theatres) - batch-sterilising metal DL blades may be more economical than using single-use blades for VL, saving equipment costs |
| View | Improved view over DL - 96% were Grade 1, vs. 6%, in Foulds et al (2016) | For many patients and for experienced operators, view may be noninferior to DL |
| First pass success rate |
DEVICE trial: 85.1% success rate No difference in MACMAN trial |
DEVICE trial: 70.8% success rate No difference in MACMAN trial |
| Complications |
Laryngeal injury reduced Oesophageal intubation reduced Dental injury same Palatine injury may be increased Increased distance from the airway results in less infectious risk for the operator |
Rates of intubation related complications prior to VL were already low with DL Increased exposure of the operator to exhaled patient pathogens, eg. COVID |
| Teaching |
Easier to demonstrate anatomy and technique to onlookers |
Manufacturers all produce very similar devices. Easy to standardise teaching. |
| Supervision |
Shared mental model of the team Supervision of junior trainees is made easier |
Relies on clear communication between the operator and supervisor |
| Evidence | ||
* To continue to call this section "Discussion", now that the college calls their discussion of the answers "Discussion", would risk an escalation in the overall silliness of which this site is already so guilty.
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https://www.thebottomline.org.uk/summaries/icm/foulds/
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AnaesthesiaUK have a nice page about McCoy blades.
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