Learning Curves for Direct Laryngoscopy and GlideScope® Video Laryngoscopy in an Emergency Medicine Residency

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Abstract

Introduction

Our objective is to evaluate the resident learning curves for direct laryngoscopy (DL) and GlideScope® video laryngoscopy (GVL) over the course of an emergency medicine (EM) residency training program.

Methods

This was an analysis of intubations performed in the emergency department (ED) by EM residents over a seven-year period from July 1, 2007 to June 30, 2014 at an academic ED with 70,000 annual visits. After EM residents perform an intubation in the ED they complete a continuous quality improvement (CQI) form. Data collected includes patient demographics, operator post- graduate year (PGY), difficult airway characteristics (DACs), method of intubation, device used for intubation and outcome of each attempt. We included in this analysis only adult intubations performed by EM residents using a DL or a standard reusable GVL. The primary outcome was first pass success, defined as a successful intubation with a single laryngoscope insertion. First pass success was evaluated for each PGY of training for DL and GVL. Logistic mixed-effects models were constructed for each device to determine the effect of PGY level on first pass success, after adjusting for important confounders.

Results

Over the seven-year period, the DL was used as the initial device on 1,035 patients and the GVL was used as the initial device on 578 patients by EM residents. When using the DL the first past success of PGY-1 residents was 69.9% (160/229; 95% CI 63.5%–75.7%), of PGY-2 residents was 71.7% (274/382; 95% CI 66.9%–76.2%), and of PGY-3 residents was 72.9% (309/424; 95% CI 68.4%–77.1%). When using the GVL the first pass success of PGY-1 residents was 74.4% (87/117; 95% CI 65.5%–82.0%), of PGY-2 residents was 83.6% (194/232; 95% CI 76.7%–87.7%), and of PGY-3 residents was 90.0% (206/229; 95% CI 85.3%–93.5%). In the mixed-effects model for DL, first pass success for PGY-2 and PGY-3 residents did not improve compared to PGY-1 residents (PGY-2 aOR 1.3, 95% CI 0.9–1.9; p-value 0.236) (PGY-3 aOR 1.5, 95% CI 1.0–2.2, p-value 0.067). However, in the model for GVL, first pass success for PGY-2 and PGY-3 residents improved compared to PGY-1 residents (PGY-2 aOR 2.1, 95% CI 1.1–3.8, p-value 0.021) (PGY-3 aOR 4.1, 95% CI 2.1–8.0, p<0.001).

Conclusion

Over the course of residency training there was no significant improvement in EM resident first pass success with the DL, but substantial improvement with the GVL.

Related collections

Most cited references 8

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Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients.

Stuart A McCluskey, Kyle Bishop, Allan A Pacey … (2005)

To evaluate a new videolaryngoscope and assess its ability to provide laryngeal exposure and facilitate intubation. Five centres, involving 133 operators and a total of 728 consecutive patients, participated in the evaluation of a new video-laryngoscope [GlideScope (GS)]. Many operators had limited or no previous GS experience. We collected information about patient demographics and airway characteristics, Cormack-Lehane (C/L) views and the ease of intubation using the GS. Failure was defined as abandonment of the technique. Data from six patients were incomplete and were excluded. Excellent (C/L 1) or good (C/L 2) laryngeal exposure was obtained in 92% and 7% of patients respectively. In all 133 patients in whom both GS and direct laryngoscopy (DL) were performed, GS resulted in a comparable or superior view. Among the 35 patients with C/L grade 3 or 4 views by DL, the view improved to a C/L 1 view in 24 and a C/L 2 view in three patients. Intubation with the GS was successful in 96.3% of patients. The majority of the failures occurred despite a good or excellent glottic view. GS laryngoscopy consistently yielded a comparable or superior glottic view compared with DL despite the limited or lack of prior experience with the device. Successful intubation was generally achieved even when DL was predicted to be moderately or considerably difficult. GS was abandoned in 3.7% of patients. This may reflect the lack of a formal protocol defining failure, limited prior experience or difficulty manipulating the endotracheal tube while viewing a monitor.

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Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis

Donald Griesdale, David Liu, James McKinney … (2011)

Introduction The Glidescope® video-laryngoscopy appears to provide better glottic visualization than direct laryngoscopy. However, it remains unclear if it translates into increased success with intubation. Methods We systematically searched electronic databases, conference abstracts, and article references. We included trials in humans comparing Glidescope® video-laryngoscopy to direct laryngoscopy regarding the glottic view, successful first-attempt intubation, and time to intubation. We generated pooled risk ratios or weighted mean differences across studies. Meta-regression was used to explore heterogeneity based on operator expertise and intubation difficulty. Results We included 17 trials with a total of 1,998 patients. The pooled relative risk (RR) of grade 1 laryngoscopy (vs ≥ grade 2) for the Glidescope® was 2.0 [95% confidence interval (CI) 1.5 to 2.5]. Significant heterogeneity was partially explained by intubation difficulty using meta-regression analysis (P = 0.003). The pooled RR for nondifficult intubations of grade 1 laryngoscopy (vs ≥ grade 2) was 1.5 (95% CI 1.2 to 1.9), and for difficult intubations it was 3.5 (95% CI 2.3 to 5.5). There was no difference between the Glidescope® and the direct laryngoscope regarding successful first-attempt intubation or time to intubation, although there was significant heterogeneity in both of these outcomes. In the two studies examining nonexperts, successful first-attempt intubation (RR 1.8, 95% CI 1.4 to 2.4) and time to intubation (weighted mean difference −43 sec, 95% CI −72 to −14 sec) were improved using the Glidescope®. These benefits were not seen with experts. Conclusion Compared to direct laryngoscopy, Glidescope® video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airways.

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Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.

Harald Groeben, Parichehr Nouruzi-Sedeh, Cynthia Schumann (2008)

Tracheal intubation is the preferred technique to secure the airway and apply mechanical ventilation. However, when performed by untrained medical personnel, tracheal intubation via direct laryngoscopy has a high rate of failure. The GlideScope (Verathon Medical Europe, Ijsselstein, Netherlands) technique improves the success rate for difficult tracheal intubation performed by experienced physicians; whether this technique improves the success rate for normal intubations when performed by inexperienced personnel as well is unknown. Therefore, the authors compared the success rate of direct laryngoscopy versus the GlideScope technique performed by personnel inexperienced in tracheal intubations. Twenty volunteers, who had had only manikin training for tracheal intubation, attempted 5 intubations with either technique in patients scheduled for general anesthesia within a time limit of 120 s. Two hundred patients were divided into 2 groups for intubation via direct laryngoscopy (n = 100) or the GlideScope technique (n = 100). Between groups, there was neither a clinically relevant difference in the anthropometric data nor in the medication used for anesthesia. The overall success rate was 93% for the GlideScope technique versus 51% for direct laryngoscopy (P < 0.01). Time for intubation was 89 +/- 35 s for direct laryngoscopy versus 63 +/- 30 s for GlideScope technique (P < 0.01). Tracheal intubation is the preferred technique to secure the airways in patients with a high risk of aspiration and is important in emergency medicine. Direct laryngoscopy with the Macintosh blade has a success rate of only 51% in our subjects. Using the GlideScope technique, a success rate of more than 90% within 120 s can be achieved after the first attempt, even in personnel untrained in intubation.

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Author and article information

Journal

Journal ID (nlm-ta): West J Emerg Med

Journal ID (iso-abbrev): West J Emerg Med

Journal ID (publisher-id): WestJEM

Title: Western Journal of Emergency Medicine

Publisher: Department of Emergency Medicine, University of California, Irvine School of Medicine

ISSN (Print): 1936-900X

ISSN (Electronic): 1936-9018

Publication date (Print): November 2014

Publication date (Electronic): 29 October 2014

Volume: 15

Issue: 7

Pages: 930-937

Affiliations

[* ]University of Arizona, Department of Emergency Medicine, Tucson, Arizona

[† ]University of Arizona College of Pharmacy, Department of Pharmacy Practice and Science, Tucson, Arizona

[‡ ]University of Arizona College of Medicine, Tucson, Arizona

Author notes

Address for Correspondence: John C. Sakles, MD. University of Arizona, Department of Emergency Medicine, 1501 N. Campbell Avenue, PO Box 245057, Tucson, AZ 85724. Email: sakles@ 123456aemrc.arizona.edu .

Article

Publisher ID: wjem-15-930

DOI: 10.5811/westjem.2014.9.23691

PMC ID: 4251257

PubMed ID: 25493156

SO-VID: 1113e472-5d51-4ab5-8e38-a9dd252cf568

License:

This is an Open Access article distributed under the terms of the Creative Commons Non-Commercial Attribution License, which permits its use in any digital medium, provided the original work is properly cited and not altered. For details, please refer to http://creativecommons.org/licenses/by-nc-nd/3.0/. Authors grant Western Journal of Emergency Medicine a nonexclusive license to publish the manuscript.