Smile for the Camera DRAFT V0.03.pptx
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Introductory/onboarding training for Video Laryngeoscopy, specifically for the MacGrath VL. NOTE: This is meant to be part of a larger educational endeavor including online, hands on, and team based training.
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Smile for the Camera DRAFT V0.03.pptx
- 2. First Things First: Remember the Goal, Remember the Plan VL is just part of the strategy
- 3. Objectives • Discuss the use of Video Laryngoscopy in the out of hospital setting • Review the ACCESS SWO for Advanced Airway Management • Describe the skill of Video Laryngoscopy using the Stryker McGrath Mac video Laryngoscope using size 1-4 Mac Blades and the McGrath “X Blade” • Describe strategies and best practices for the use of video laryngoscopy in the ACCESS system • Review confirmation of placement of the endotracheal tube • Review post intubation management
- 4. Tasks • By the end of this training: • Discuss and practice Direct Laryngoscopy (DL) AND Video Laryngoscopy (VL) • Complete skills practice for VL using: • Adult • Pediatric • Infant • Complete Checkoffs for: • DL/VL • MAI • SGA
- 5. Video Laryngoscopes • 1970s – Fiberoptic Scopes (bronchoscopes, etc) used to place ETT • 1990s – Fiberoptic Laryngoscopes • 1998 – First VL prototype • Early 2000s – Commercial VL (Glidescope) became common in ORs and ICUs • 2013 – American Society of Anesthesiologists recommended VL for first attempts and standard equipment in OR's • 2017 – Difficult Airway Society (DAS) recommends VL for First Attempt and for difficult airway management • 2022 – AHA VL in cardiac arrest: VL had better FPS
- 6. ACP approach to VL • Groundwork pre-covid in 2018. • Covid slowed everything • Mid COVID AHA paper supporting VL and ETT over SGA • 2020 review of Airway Success rates and possible solutions • ACCESS Advanced Airway Course • Improved airway onboarding in academy • Pursuit of VL via grants and matching funding • 2023 VL – 20+ units and disposables - • EMSAVE Grant FY 23 (round 1) – 5 VL • EMSAVE Grant FY 23 (round 2) – 5 VL • ACP FY 23-24 budget – 10 VL
- 7. The Case for VL Evidence Review
- 9. “To Long: Didn’t Read” • Video Laryngoscopes: • Improved view of Glottic Opening in most cases • The more difficult the airway, the greater the impact of VL • Improved First Pass Success • Improved (decreased) total number of intubation attempts
- 10. What VL does not do…
- 11. To VL or to DL: Is that even a question?
- 12. The McGrath MAC VL
- 13. Why the McGrath? • Durable • Small, light weight • History of successful use in EMS with overall positive reports in EMS and HEMS • “Standard Geometry” Similar approach to direct laryngoscopy. • NOTE: THERE ARE SOME KEY DIFFERENCES DISCUSSED LATER • Size Range 1-4 Mac = Infant to adults • “X Blade” = Hybrid hyperangulated blade for difficult adult intubations
- 15. Types of Blades • MAC VL Blades size 1-4 • Disposable • Use with Bougie, Stylet or similar • X Blade – Approx size MAC 3 • Disposable • ONLY use with a rigid Stylet
- 16. Blade Choice: What Size? “I’m a Mac #4 blade for traditional laryngoscope. The McGrath (MAC) #4 usually goes way too deep. The # 3 is perfect.” -Craig Wheeler , Flight Paramedic “I’ve found the 4 blade is often too big for even large adults. ” -Amanda Lawrence, Flight Nurse
- 17. Blade Choice: MAC or X Blade? “X-blade for predicted difficult or as second line, in my practice. Nothing wrong with choosing it first, but I appreciate the DL&VL aspect of standard geometry blades as DL is my most experienced technique ” Chad Pomerleau,Flight Paramedic “Also… personal preference is to default to the x- blade. X-blade can be used on normal or difficult intubations. A MAC3 or 4 can’t be used on difficult intubations.” -Kevin Travis, Training Officer
- 18. Deployment • 1 McGrath VL on ALS transport units • Deployment in ALS non-transport units TBD • ETT Kit • Size 3 and 4 McGrath Blade in ETT Kit • X blade in ETT kit • Ped Kit • Size 1 and 2 • Back Up (wall) • Sizes 1-4 (1 each) • X Blade (1 each) • Daily Check • Battery Life – 250 minutes • Swap at < 20 minutes • Low batts will be given to Training for use in class
- 19. McGrath MAC Daily Check • Daily Check • Battery Life – 250 minutes • Swap at < 20 minutes • DO NOT THROW AWAY. • Swap with BCs • Low batts will be given to Training for use in classes
- 20. Cleaning the McGrath • 70% Isopropyl Alcohol (Blue top Wipes) • Quaternary Ammonia + Isopropyl Alcohol (purple Top Wipes) • Remove battery before cleaning. • Battery can be cleaned separately. Do not replace until dry. • Do not dip into IPA. Use wipes. • Use only IPA on camera stick • Do NOT use bleach (Orange Top) , or grey top wipes.
- 21. VL Tips and Tricks
- 22. Progressive Laryngoscopy is essential. • Do not “Shove it in and hope for the best” • “Progressive Laryngoscopy” is essential. Even more so with VL • Epiglottoscopy Laryngoscopy Intubation • Improves success rate • Decreases patient injury
- 23. “Progressive Laryngoscopy” Methodically progressing down the tongue to the epiglottis is a simple roadmap to the larynx. Vocalize as you go. 1. Tongue. 2. Still all tongue. Stay the course. 3. The epiglottis appears. 4. Move into the vallecula and lift.
- 24. Do not hyper-focus on the Camera • VL is an important tool in managing the airway but one should be aware of possible complications that can be avoided. • Injuries have been documented by providers focusing on the camera and being careless with passing the tube through the oral/hypopharynx • Significant potential for perforation of the oropharynx when the tip of the ETT containing the rigid stylet is not carefully visualized all the way back into the oropharynx before turning attention away from the posterior oropharynx to the VL monitor. • Use a “Mouth-Screen-Mouth” approach
- 25. GlideScope video laryngoscopic view of ETT perforating the palatoglossal arch and soft palate. ETT, endotracheal tube. Huffman et al. Video Laryngoscopic Oropharyngeal Injury. J Oral Maxillofac Surg 2016.
- 26. GlideScope video laryngoscopic view of ETT perforating the palatoglossal arch and soft palate. ETT, endotracheal tube. Huffman et al. Video Laryngoscopic Oropharyngeal Injury. J Oral Maxillofac Surg 2016.
- 28. The importance of SALAD (suction) with VL
- 29. “SALAD and VL”: • “When training your people have them make a habit of always using SALAD technique with Ducanto suction even if the airway appears to be clean. - Stephen Wilcox, Flight Paramedic
- 30. “Laryngoscopic Paradox”: • The camera can mislead your perspective and cause esophageal intubation. • Often the best “view” (grade 1) may result in lower success rates. • A grade 1 view may be “too deep”. • The “second best” view (grade 2) may result in better success.
- 33. “Laryngoscopic Paradox”: • “With VL you can have “too good” of a view that can obstruct your ETT placement.” - Michael Revland, Flight Paramedic Mayo Clinic
- 34. “Laryngoscopic Paradox”: • “for some reason with the view from a single point with the McGrath it seems remarkably easy to go deep” - Chad Pomerleau, Flight Paramedic
- 35. “Laryngoscopic Paradox”: • “Stress proper technique and placement in the vallecula since it is a Mac style blade. Most failures we have had in the field are from placing the tip underneath the epiglottis and it being too deep. • They get a great view of cords but the curve of the blade can push the ET Tube towards the esophagus when not placed right.” - Chris Foerster, Training Officer, Tx • “It seems like no matter how many times you train on this, most people still make this mistake repeatedly in real life with actual missed tubes before it finally sticks. Seen the same from both medics and ED docs. Greig Samuelson, Training Officer, S.C.
- 36. “Laryngoscopic Paradox”: • “Go in with suction ahead of your blade (SALAD technique) [avoids goop on your lens], gain a grade one view then back up to a grade two view and go bougie first every time regardless of predicted difficulty“ - Derek Michael, Flight Paramedic
- 37. “Laryngoscopic Paradox”: • “You back up to a grade 2 view bc the lens placement in a grade one view will lead u to believe you are going straight in, but in reality you’ll fight to keep it out of the esophagus nearly every time. With a grade 2 view you will be lined up perfectly.” - Derek Michael, Flight Paramedic
- 38. “Laryngoscopic Paradox”: • “Been using the McGrath for almost 5 years now. Love it. My advise to anyone new. If you have a poor view or having trouble passing a bougie or Tube, back up. It’s almost always because the blade is too deep.” - C.J. Saunders, Flight Paramedic
- 41. Unrecognized (or recognized too late) Esophageal Intubation occurs in up to 8% of prehospital intubations…why? • MISTING IN TUBE 69%* • Lung Sounds 14%* • 5 point Lung Sounds 18%* • (Adds Epigastic sounds to assessment) • EDD 9%* Hansel, J., Law, J. A., Chrimes, N., Higgs, A., & Cook, T. M. (2023). Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis. Anaesthesia, 78(8), 1020– 1030. https://doi.org/10.1111/anae.16059
- 42. Anchoring Bias: One false positive leads to more false positives NAEMSP Florida Chapter. (2023, August 30). Jan Hansel MD: Strategies to Confirm ETT placement (8/29/23). https://www.youtube.com/watch?v=mDaq12pR4jM
- 43. “Glottic Impersonation” : VL Does NOT reduce unrecognized esophageal intubations. • VL can cause “false positive” too. • VL does not reduce bias • VL screens may mislead providers • The McGrath is vulnerable to this.
- 45. Quick Reminder what is needed for ETT confirmation
- 46. “Sustained” ETCO2 • “Sustained” ETCO2 is defined as a minimum of 7 consecutive breaths. The ETCO2 is consistent or increasing amplitude of the capnogram over 7 breaths. • The level of CO2 rises and falls appropriately with exhalation and inhalation. • The peak amplitude/change of CO2 is a minimum of 7.5 mm Hg above the baseline. • The capnogram is clinically appropriate.
- 48. Appendix 3.1 (Released NOV 2023) • Assume esophageal intubation until proven otherwise by ETCO2 • EZ cap is only a bridge to wave form capnography • Sustained ETCO2 is the gold standard. Regardless of the use of VL, or the perceived “passing of the tube” visualized on the camera, sustained ETCO2 remains the gold standard for confirmation. “No trace, No tube”.
- 49. One final time…. Remember the Goal, Remember the Plan VL is just one part of the strategy
- 50. Wrapping Up • Skill demonstration • Skills check offs
Editor's Notes
- Background of VL Fiber-optic scopes 1970’s Fiber-Optics laryngoscopes early 1990s First video prototype 1998 Weiss M. Video-enteroscopy: A new aid to routine and difficult tracheal intubation. British Journal of Anaesthesia. 1998;80:525-527. DOI: 10.1093/bja/80.4.525 1st commercial VL: The Glidescope 2001 2013 - the American Society of Anesthesiologists (ASA) suggested the use of video laryngoscopy as the first choice in airway management in its algorithm of airway management Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for the management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251-270. DOI: 10.1097/ALN.0b013e31827773b2 2015 - The Difficult Airway Society (DAS), in the 2015 algorithm, recognized the use of video laryngoscopy as part of airway management and suggested to all anesthesiologists the adoption of the video laryngoscopy skill Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for the management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. 2015;115:827-848. DOI: 10.1093/bja/aev371 2017 - DAS presented video laryngoscopy as an equivalent technique to direct laryngoscopy in the first attempts of intubation in the airway management algorithm in intensive care units (ICUs) Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, et al. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018;120:323-352. DOI: 10.1016/j.bja.2017.10.021
- The McGRATH™ MAC VL uses “standard geometry” curved blades closely approximating Macintosh laryngeoscope blades used in DL. These blades come in sizes 1-4 closely approximating their DL counterparts. Blade selection is based on providers clinical judgement. Clinical reports indicate that providers should “lead” the blade with a suction catheter and use a bougie when possible as a best practice. The McGrath X Blade is a hyperangulated blade approximately the size of a MAC 3 blade. It contains a more “acute curvature” (hyperangulation) and slimmer blade than other McGRATH™ MAC VL blades. It is easily distinguished by it’s yellow label affixed to the blade.
- 70/30 IPA (Isopropyl Alcohol) is a low toxicity solvent made of a mix of 70% pure isopropyl alcohol and 30% water. This is generally the mixture used in first aid products such as rubbing alcohol. Monitor: Ensure the 70% IPA wipe gets into the various grooves around the screen. 2. Monitor Hinge: Rotate the monitor to the upright position. Feed the 70% IPA wipe into the space between the monitor and handle to ensure. effective penetration. Rotate the monitor to its opposite position and repeat. 3. Battery Bay: Ensure all surfaces of the Battery Bay (with battery removed) are thoroughly treated with the 70% IPA wipe. Ensure that the join between the battery module and the handle is thoroughly treated with the 70% IPA wipe. 4. Handle: Ensure all surfaces of the handle are thoroughly treated with the 70% IPA wipe. 5. Clip and Heel Area: Take particular care in ensuring that the small metal clip feature is clean, in particular the internal corner between the clip and the surrounding plastic body. 6. Camera Stick: Ensure all surfaces of the camera stick are thoroughly treated with the 70% IPA wipe. 7. Camera Lens: Clean the camera lens with the 70% IPA wipe, ensure that the interface between the metal Camera Stick and camera lens is clean.
- Conceptually, direct laryngoscopy can be thought of as progressive visualization of intra-oral and pharyngeal soft tissue structures as the laryngoscope blade is advanced and landmarks are exposed. The laryngoscope blade functions as both a retractor and an illuminator during this process. There are three “stages” to this process: Epiglottoscopy Laryngoscopy Intubation
- This works with both Mac and Miller. Cramming in the miller and withdrawing is a poor method and often causes trauma to the airway. Advancing while watching allows you to observe the airway, guide the tool and make better clinical observations and decisions. Additionally, identifying landmarks reduces the incidence of glottic impersonation.
- Be mindful not to hyperfocus on the camera, and avoid injuries to the soft tissue structures of the airway by careless passage of the ETT. The most common injuries occur to the Tonsillar Pillars and soft pallet, but can occur to any structure. Soft tissue injuries commonly occur when the intubating provider concentrates on the video monitor and blindly inserts the GlideScope® into the oropharynx
- . GlideScope video laryngoscopic view of ETT perforating the palatoglossal arch and soft palate. ETT, endotracheal tube. Huffman et al. Video Laryngoscopic Oropharyngeal Injury. J Oral Maxillofac Surg 2016.
- Intraoral view of palatoglossal arch laceration with Dingman retractor in place. Huffman et al. Video Laryngoscopic Oropharyngeal Injury. J Oral Maxillofac Surg 2016
- Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis J. Hansel, J. A. Law, N. Chrimes, A. Higgs, T. M. Cook First published: 16 June 2023 https://doi.org/10.1111/anae.16059 Citations: 2 30 studies in a meta-analysis. Most studies were at low risk of bias in most domains, and included a mix of human, animal and cadaver studies. As the studies were designed to distinguish between tubes placed in the trachea or oesophagus, this analysis determines the utility of the tests to confirm tracheal intubation and at the same time to exclude oesophageal intubation.
- What are we saying here: That if you get a false positive on your first assessment, you are “anchored” to that assumption and more likely to disregard sunsequent assessments that contradict the original conclusion, even ETCO2. One false positive will lead to 91-95% disregarding of a valid capnograph. Two false positives will lead to 99% disregarding of a valid capnograph. We must be aware of our own anchoring biases, and that not all assessments are “equal”.
- All of these were believed to have visually pass through the cords.
- Colormetric ETCO2: Colorimetric ETCO2 (i.e. EZCAP) is inherently inferior to waveform capnography and is intended only as a bridge or backup if waveform ETCO2 is delayed. Waveform ETCO2: As esophageal intubation is not necessarily always associated with a completely flat or absent ETCO2, the standard of a “sustained” ETCO2 immediately after placement of the advanced airway and through out patient care until transfer of care is required.
- VL does not preclude accidental and unrecognized esophageal intubation. In some cases, mis-identifying landmarks and limited camera view lead to esophageal intubation. In other cases an over-reliance on VL and anchoring bias convinced providers into discounting clear signs of esophageal intubation. Providers should always be cognizant that no procedure nor technology is foolproof.