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Erschienen in: Annals of Intensive Care 1/2019

Open Access 01.12.2019 | Letter to the Editor

Comparing video and direct laryngoscopy for tracheal intubation in the general ward

verfasst von: Liu-Jia-Zi Shao, Fu-Shan Xue, Rui-Juan Guo, He Yang

Erschienen in: Annals of Intensive Care | Ausgabe 1/2019

Hinweise
This comment refers to the article available at https://​doi.​org/​10.​1186/​s13613-018-0428-0.
Abkürzungen
VL
video laryngoscopy
DL
direct laryngoscopy
Editor,
In a retrospective study by Baek et al. [1] comparing video laryngoscopy (VL) and direct laryngoscopy (DL) for intubation in the general ward, they showed that the use of VL was associated with a higher first-attempt success rate, but did not reduce intubation-related complications. The strengths of this study are a large sample and the use of consistent patients needing urgent intubation in the general ward by medical emergency team. Furthermore, the authors had applied right statistical methods including multivariable logistic regression analysis, propensity-score matching and subgroup analysis to determine associations of studied devices and intubation outcomes. Other than the limitations described in discussion, however, there are several issues in this study that need further discussion and clarification.
First, authors did not provide the positions of patient’s head during laryngoscopy and intubation. Because the use of DL to obtain the laryngeal visualization requires alignment of the oral, pharyngeal and laryngeal axes, a sniffing position is often recommended for intubation with DL. In contrast, the use of VL to visualize the larynx does not require alignment of three airway axes. Thus, intubation with VL has no specific requirement of patients’ head position [2]. We believe that ignorance of this factor would have biased the intubation outcomes in the favor of VL.
Second, to predict difficult airways, several factors including blood/vomitus/secretion in the airway, cervical immobilization, neck trauma/mass or vocal cord palsy, 3-3-2 rule, short neck, obesity, limited mouth opening, small mouth and large tongue, were assessed before intubation. It is usually considered that no single factor can accurately predict difficult airway as each factor individually has a rather low positive predictive value. If a patient has more predictors of difficult airway at the same time, however, the likelihood of difficult airway will increase [3]. For this reason, the National Emergency Airway Management Course has developed a LEMON score for identification of difficult airways in the emergency setting [4].
Third, main reasons for intubation in this study were respiratory failure and airway protection, but median intubation time with DL and VL was long up to 4 min. Other than first-attempt success rate, intubation time also is a concern for critical patients requiring urgent intubation, especially patients at risks of hypoxia and aspiration [5]. We are argued that this study would have provided more useful information about the choice of two intubation devices in the general ward, if a reasonable cutoff time had been included in the definition of first-attempt success rate.
Finally, experience and competency with VL and DL are critical for successful intubation. Because frequency and number of using two devices before study were not provided, the definitions that divided experienced and inexperienced intubators in this study could not accurately indicate the competency levels of intubators with VL and DL. Thus, it is difficult to determine whether a higher first-attempt success rate with VL is really attributable to a better performance. We are concerned that the results of this study may only map different learning curves of DL and VL for intubators, and do not measure the real efficiency of studied devices for urgent intubation in the general ward.

Authors’ contributions

LJZS, FSX, RJG and HY carefully read the manuscript by Baek et al. and analyzed their methods and data. LJZS suggested comment points and drafted this manuscript. FSX, RJG and HY revised the comment points and this manuscript. All authors read and approved the final manuscript.

Acknowledgements

All authors have no financial support and potential conflicts of interest for this work.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Not applicable.
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Not applicable.

Funding

None.

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
Literatur
1.
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2.
Zurück zum Zitat Rothfield KP, Russo SG. Videolaryngoscopy: should it replace direct laryngoscopy? a pro-con debate. J Clin Anesth. 2012;24:593–7.CrossRef Rothfield KP, Russo SG. Videolaryngoscopy: should it replace direct laryngoscopy? a pro-con debate. J Clin Anesth. 2012;24:593–7.CrossRef
3.
Zurück zum Zitat Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth. 2016;117(Suppl 1):i60–8.CrossRef Natt BS, Malo J, Hypes CD, Sakles JC, Mosier JM. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth. 2016;117(Suppl 1):i60–8.CrossRef
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Zurück zum Zitat Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology. 2013;118:251–70.CrossRef Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology. 2013;118:251–70.CrossRef
5.
Zurück zum Zitat Soyuncu S, Eken C, Cete Y, Bektas F, Akcimen M. Determination of difficult intubation in the ED. Am J Emerg Med. 2009;27:905–10.CrossRef Soyuncu S, Eken C, Cete Y, Bektas F, Akcimen M. Determination of difficult intubation in the ED. Am J Emerg Med. 2009;27:905–10.CrossRef
Metadaten
Titel
Comparing video and direct laryngoscopy for tracheal intubation in the general ward
verfasst von
Liu-Jia-Zi Shao
Fu-Shan Xue
Rui-Juan Guo
He Yang
Publikationsdatum
01.12.2019
Verlag
Springer International Publishing
Erschienen in
Annals of Intensive Care / Ausgabe 1/2019
Elektronische ISSN: 2110-5820
DOI
https://doi.org/10.1186/s13613-018-0476-5

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