Video Laryngoscopy Reduces the Rate of Esophageal Intubations Performed by Emergency Medicine Trainees

• Airway management is a vital skill in emergency medicine (EM)

– Need to balance EM trainee education with patient safety

• Esophageal intubation (EI) has been associated with numerous complications

– Hypoxemia, regurgitation, aspiration, bradycardia, dysrhythmia, mainstem bronchus intubation, and cardiac arrest

• Direct laryngoscopy (DL) has been the primary intubation technique in the emergency department (ED)

– Intubator is the only person seeing the laryngeal structures

– Limits ability of the supervising physician to teach and assist the trainee

• Video laryngoscopes (VL) allow the supervising physician to provide real-time feedback during the procedure

– GlideScope (GVL) and CMAC are common devices

• Hypothesis: use of VL would decrease occurrence of inadvertent EI

Parisa P. Javedani, Uwe Stolz, Eric A. Chase, Jessica Garst-Orozco, and John C. Sakles

Methods:• Retrospective analysis of prospectively collected

continuous quality improvement data (CQI) for all tracheal intubations by EM trainees in a level I trauma academic ED over a 6 year period– Data form completed by the EM resident – Analysis included patients in whom intubation was

attempted using either a DL or VL (GVL or CMAC)

• Primary outcome: occurrence of EI

• Secondary outcome: occurrence of adverse events (AE)

• Propensity score matching with conditional logistic regression to reduce bias (since device was purposefully chosen by the physician performing the intubation)– DL vs. VL for each intubation attempt with

attempts resulting in EI matched randomly to 4 cases without an EI

• Multivariate logistic regression used to calculate adjusted odds of an EI for VL vs. DL

Background:

Limitations:• Single-center study in an academic level I trauma

center• EM trainees use VL more frequently than DL

– Results not generalizable to setting with limited VL experience

• Number of intubation per individual operator, experience with difficult airways, and experience with each device were varied among each operator

• Observational, non-randomized data• 10% of forms filled out on delayed basis, subject to

recall bias• May be additional confounder or risk factors for

EI contributing to the observed differences that were not accounted for

Conclusions:

• Use of VL by EM trainees was associated with a nearly seven-fold reduction in Eis when compared to the use of DL

– Magnified view allows for easier identification of the anatomy

– Attending physician can visualize on the screen what the operator is seeing, which allows the supervising physician to provide real-time feedback

• Patients who underwent EI had significantly higher occurrence of AE

– Aspiration, dysrhythmia, hypotension, and hypoxemia

• 3,425 total intubation attempts in 2,677 patients by EM trainees

– VL in 1,895 (55.3%, 95% CI: 53.6 to 57.0) • GVL used in 1,064 (56.2%) of attempts• CMAC used in 831 (43.9%) of attempts

– DL in 1,530 (44.7%, 43.0 to 46.4)

• 96 (2.8%, 95% CI 2.3 to 3.4) EIs:– VL in 18/1,895 attempts (1.0%, 95% CI: 0.6 to 1.5)– DL in 78/1,530 attempts (5.1%, 95% CI: 4.1 to 6.3)

• VL decreased the odds of an EI by 6.85 (95% CI 3.26 to 14.41) compared to DL in the propensity score matched analysis

– VL decreased odds of EI by 7.80 (95% CI: 3.96 to 12.37) in the logistic regression using the propensity score and accounting for confounders

– VL decreased odds of EI by 8.22 (95% CI: 4.2 to 16.08) when only accounting for confounders

Results:

 EI

n=93

No EI

n=2,584 

AE n % 95% CI n % 95% CI p-value

Aspiration 8 8.6 3.8 to 16.3 36 1.4 0.9 to 1.9 <0.001

Cardiac Arrest

0 0 0 to 3.9 12 0.5 0.2 to 0.8 1.0

Dysrhythmia 3 3.2 0.7 to 9.1 14 0.5 0.3 to 0.9 0.019

Hypotension 2 2.2 0.3 to 7.6 17 0.7 0.4 to 1.1 0.14

Hypoxemia 33 35.5 25.8 to 46.1 433 16.8 15.3 to 18.3 <0.001

Total 46 49.5 38.9 to 60.0 512 19.8 18.3 to 21.4 <0.001

Typical DL View

Typical VL View

GVL CMAC