New Intubation Method - looking for feedback from the field

[DesertMedic66]

I'd imagine the lever would be in a pretty awkward position while intubating. For me I would not be able to squeeze the lever due to my thumb/palm being on the main handle.

 

[Ishay Benuri MD]

My question is how is this device operationally different than a (specialty) laryngoscope blade with a flex-tip to help lift anterior anatomy and help provide a cleaner path to the cords?

My device is not intended to change the position of the anatomy rather it is a device that uses the anatomy (thus is much more safe and effective). One of the drawback of the flex-tip (as far as I understood from a paramedic that used it) was that besides only minimally changing the view, the need to remove the thumb to press the trigger during maximal force was very difficult. In my device you don't need to use substantial force to change the anatomy, you only need to place the laryngoscope in the right position and constricting the loop does all the work. I believe (I might be wrong..) that if the novice EMT will concentrate and trained to just find the vallecula and less to try and see the cords (which my device enables), it will improve the learning curve substantially .

 

[Ishay Benuri MD]

I'd imagine the lever would be in a pretty awkward position while intubating. For me I would not be able to squeeze the lever due to my thumb/palm being on the main handle.

You are so right, Desert Medic66! If I had to both induce force on the handle and press the handle together, it would be very awkward for me also. But if you only need to use minimal strength on the handle, pressing the trigger becomes very comfortable. I should mention that I also patented a special trigger handle that is requires minimal pressing to achieve desired loop constriction, so even medics with small hands could use it.

 

[Ishay Benuri MD]

I can see people monkeying around trying to put the bougie through the loop when that time could be spent monkeying around trying to put the tube through the cords.

Thank you hometownmedic5 for bringing this up. This is an image of the prototype (used an endoscopic snare as a loop - will be made of plastic tubing in future models). As you can see - even if you try hard you couldn't enter a bougie or tube not through the loop. Also as I mentioned before you don't have to use this feature at all. If you are able to insert the tube through the cords, you don't need to do any additional steps besides pressing a button that disconnects one side of the loop and withdraw the laryngoscope.

 

[Ishay Benuri MD]

By the way, I held the position you see in the above image (CL3) for volunteers who never held a laryngoscope in their life. They all succeded 1st attempt intubation (with out seeing any vocal cords).

 

[medicsb]

Not quite sold on the device, but the idea of something helping to guide the bougie or ETT anteriorly is not a bad idea. Part of learning to manage a difficult airway is know where to aim the tube when you can see the epiglottis but not the cords, which means aiming the tube or bougie anteriorly. I had a difficult airway the other day for which the CMAC didn't help (I used the disposable blade version, which I now think is far inferior to the non disposable version). After goosing the tube, I changed to DL and a bougie and aimed anterior with success. Usually I have success with just aiming the ETT anterior, but I have on occasion have had that not work due to what I suspect is too acute of an angle for me to pass the tube, and this sort of device intends to help navigate that angle.

Unless well-experienced with intubation, I would generally advise against aiming anterior, but something like this might make me more comfortable with novices doing such.

 

[VFlutter]

I like the concept however I do not necessarily see a benefit over using a bougie and the "trigger" method. I do not tend to have trouble manipulating the bougie anteriorly.

 

[E tank]

The first image is a stylet that, when advanced, anteriorly directs the tube to the degree that the operator needs. The second has a pull ring that shortens the inside curve of the tube and thus directs the tip of the tube anteriorly to the degree that the operator needs.

 

[Ishay Benuri MD]

Thank you E tank, this is an issue that I really need this forum to help me with - I am posting again the image of my prototype demonstrating Cormack 3 position - I would be grateful for your feedback and feedback from others - what would you prefer in this situation (emergency scenario)? A tube with maneuvering capabilities or the loop mechanism I proposed. Also what do you believe would be more efficient for a novice EMT (also in emergency scenarios)?

 

[NomadicMedic]

Eliminate all the issues with an SGA.

 

[Ishay Benuri MD]

Eliminate all the issues with an SGA.

Thank you NomadicMedic. I recieved this reply from about 10% of the paramedics I contacted. They especially mentioned the King LT-D. I couldn't figure out why didn't the rest of the paramedics offer this solution as the ultimate device. Does it have any drawbacks?

 

[NomadicMedic]

Thank you NomadicMedic. I recieved this reply from about 10% of the paramedics I contacted. They especially mentioned the King LT-D. I couldn't figure out why didn't the rest of the paramedics offer this solution as the ultimate device. Does it have any drawbacks?

In the case of an MCI, if you were attempting an airway at all, I'd vote SGA. Especially if it presents as a difficult airway on the first look. The King is an easy to place blind insertion device and would serve to mange that airway until the patient was evacuated to the hospital.

While I applaud your inventiveness, this seems like another tool created to solve a problem that doesn't really exist. If a medic can't intubate on the first pass unassisted, they shoukd be trained to move to a bougie or VL or (my preference) elect to place an SGA.

 

[Ishay Benuri MD]

While I applaud your inventiveness, this seems like another tool created to solve a problem that doesn't really exist

Thanks again NomadicMedic, I appreciate the complement. I have to understand a crucial point you brought up "a problem that doesn't really exist". What do you mean by that?

 

[Ishay Benuri MD]

 

[Ishay Benuri MD]

 

[Ishay Benuri MD]

Eliminate all the issues with an SGA.

SGA certainly has its problems and hasn't replaced endotracheal intubation in the OR (and that's in ideal setting for SGA - fasting patient, not requiring chest compression) - bellow a survey published 2010 (more than 2 decades after LMA has been introduced).

 

[Ishay Benuri MD]

If a medic can't intubate on the first pass unassisted, they shoukd be trained to move to a bougie or VL or (my preference) elect to place an SGA.

 

[Ishay Benuri MD]

this seems like another tool created to solve a problem that doesn't really exist

Isn't there something weird in the following data: CL grade I view 83%, 1st pass success only 73.3% (20% of the cases it took more than 2 minutes).

 

[StCEMT]

I'll throw in my $0.02 as the newbie that you are directing this product to. I understand your idea and like the concept and that you are trying to find solutions, but without trying it myself I'm not sure I'd necessarily call it my solution. My problem is lack of exposure and experience and I already have tools to help make my first attempt more successful. What I don't have is first a higher level of first hand experience to problem solve the variety of airway problems I can run into and in my opinion that would be much more valuable. That's more of a department thing though, I realize that isn't something you can change.

My other thing is that I am not very big on intubating in many patients. Your article about first pass success with cardiac arrest is a prime example here. Most other members here already know, but my last arrest the I went with an SGA. The other medic on scene wanted to intubate, but that isn't how we or the fire departments are supposed to be doing it anymore and for good reason. We don't need to right away. 10 minutes later that guy was awake and moving, intubating would have just been more of a hassle. Throw in patients who are hypoxic, hypotensive, etc. and those are a few other reasons I wouldn't be intubating someone. If I need a quick advanced airway, it takes me all of 5 seconds to put in an igel. I can't intubate that fast.

If I had to choose equipment set up for a true difficult airway, my preference would be VL with a Kiwi grip set up. I've used VL and it was easier to find what I was looking for (not being bent over or sprawled out on the floor probably helps) and I find a bougie to be easier to manipulate in the right direction. I like your idea, but I'm not sure I'd get the same degree of flexibility in overall manipulation that I would with a VL+bougie, at least trying to picture how it would work mentally.

 

[E tank]

Here's the thing...the primary and most frequent reason for anyone being unsuccessful in laryngoscopy and intubation is patient positioning. Meticulous detail must be paid to optimizing and lining up the 3 columns, 2 curves or 3 axes or whatever way a person visualizes the glottis.

I teach larygoscopy and intubation and I have well into the 5 figure range of performing them. I miss occasionally and it is because I get complacent and sloppy with what I consider an "easy" airway. Excellent positioning (shoulder roll, excellent head support, slight anterior positioning of the head, etc.) will improve the view in the vast majority of patients. Physicians whose job it is to intubate are taught this to a degree that paramedic/EMT programs just don't do. That's why they're better at it, and no novel device will make up the difference for that training. Physicians are better at intubating with VL than paramedics too for the same reason.

Someone in another thread wondered, correctly, that for the expectations put on paramedics to intubate people, the amount of time training and continuing to train is disproportionate given other areas of expectation that they are trained in. Way more time is spent in cardiopulmonary critical care for example. Obviously, programs will vary.

There have been novel devices for laryngoscopy and intubation coming along for years and they all have one fatal flaw in common and that is they are made with the assumption that DL and intubation lack just enough complexity that a gimmick will fix all of the difficulty associated with it.

The answer: train people well, and keep them trained. In my opinion, if someone doesn't perform at least one routine intubation per week when they are newly trained and once per month when a veteran, there can be no meaningful expectation for greater than a 50% success rate in a life and death emergency. I'm sure someone will chime in with some study numbers, but that is my ancectodal experience.