New Intubation Method - looking for feedback from the field

Ishay Benuri MD

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Hi all. My name is Ishay Benuri. I am a pediatric gastroenterologist who volunteers in as an EMT at United Hatzalah service in Israel.

After I failed to intubate a trauma patient in the field, I developed a device that is mainly intended as a bridged till a novice paramedic reaches high level of proficiency in endotracheal intubation.

The device is also intended for video assisted laryngoscopy (since even with proper visualization of the vocal cords, guiding the tube in is not always simple). I'll be grateful for any feedback regarding the technology.
 

OnceAnEMT

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Welcome. Interesting approach. I'm not at that level yet, but I do have some questions.

Are you constructing these as a modification to a stock laryngoscopes, or are they a whole new device?

What material is the loop made of?
 
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Ishay Benuri MD

Ishay Benuri MD

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Good question, Grimes. Both approaches are possible. The company that will agree to manufacture the device will have to decide what it prefers (mainly financial decision). The loop will be made of plastic tubing that can be detached on one side of the blade by a press of a button after the insertion has been accomplished, The practitioner doesn't have to use the loop, he can introduce the device when difficult intubation is anticipated and use the added feature only if he needs too..
 

Akulahawk

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Interesting concept. From what I saw of the video, it appears that this device basically just something to pull on the intubation device (bougie or ETT) and aim it more squarely at the glottis and therefore introduce it into the trachea. Is this device designed to work with a bougie so that you can then slide an ETT over bougie like would normally be done with a bougie-assisted intubation or is it also designed to be used with standard endotracheal tubes so a bougie doesn't necessarily have to be used?

In a sense, this seems to be to be a device that takes the place of digital intubation. Fortunately I've never had to use that technique and if I do, I hope to never get bit...
 

EpiEMS

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Stepping a titch further back, I'm curious why advanced airway management was being performed at what I presume was an MCI?
 

E tank

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Couple of thoughts...If the glottis is so difficult to target in these situations, how is this loop going to be any easier? Even if the operator does hit the loop, the tube/bougie has to be at the precise level of the glottis in order to be drawn anteriorly without being impeded or obstructed by the tissue between the UES and the glottis. That will be very difficult to do in emergency intubations.

By the looks of the procedure in the video, in order to be consistently successful using the technique, you'd need to be an expert laryngoscopist . This introduces another order of complexity rather than taking one away.

My opinion.
 
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Ishay Benuri MD

Ishay Benuri MD

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Thank you Akulahauk for bring this up. The device is intended for both bougie and ETT, but at the initial prototype phase it was simpler to target the bougie as the tube of choice.
I believe that digital intubation is here to stay and that in the near future blind intubation will be unacceptable (though it could be easily accomplished with this device). Still 1st pass failure rate in VL is 8-30% and the better we see with VL doesn't mean we clear the path to the tube -the opposite is true we try less to do so. Thus, I believe that his tube maneuvering device will be more and more essential as video assisted intubation becomes more common .

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Handsome Robb

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Stepping a titch further back, I'm curious why advanced airway management was being performed at what I presume was an MCI?
Where'd you get MCI from his post? Just because it's a trauma patient in Israel?


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Ishay Benuri MD

Ishay Benuri MD

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That's also an important point E tank. I must point out that my main goal was not to complicated an already complicated situation; that's why I insisted that the device won't change anything from what the EMT is used to. He/she slides in the device without needing to take into account the loop and does the procedure as he used to. If the blade is not at all at the right place (let's say at the teeth level in the esophagus) the device won't be helpful. But if he is close to the glottis the loop doesn't only approximates the tube but also creates a "step" that the intubator can use to curve the tip anteriorly.

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Ishay Benuri MD

Ishay Benuri MD

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It was MCI. But I couldn't know that because most of the casualties were about a 100 meter away. I had a one severely injured casualty in my vicinity.

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MonkeyArrow

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Where'd you get MCI from his post?
If you watched the video, the subtitle said, "He tries to intubate the most severely injured casualty while stabilizing his neck." Based on this statement, an appropriate inference could be made that there are multiple patients and that triage had been conducted, both of which lead to a logical conclusion of an MCI.
 

Handsome Robb

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If you watched the video, the subtitle said, "He tries to intubate the most severely injured casualty while stabilizing his neck." Based on this statement, an appropriate inference could be made that there are multiple patients and that triage had been conducted, both of which lead to a logical conclusion of an MCI.
Ah fair enough. I didn't watch it.


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MonkeyArrow

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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?
 

hometownmedic5

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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.

Basically, instead of dumbing down ETI with gadgets, I'm more in favor of smartening up with longer and recurring airway management training for paramedics; along with minimum competency evaluations often enough to maintain proficiency. I have to take a 12ld competency test every year, even though i read them and treat accordingly daily; but nobody has seriously evaluated my intubation skills since my registry practical(if you're even willing to consider that a worthwhile evaluation(which I'm not)).

As usual, I'm going to take the position of higher education as the answer, not toys or lower expectations. None of the above is to say that the device in questions isn't innovative and intriguing. It's a good bit of brain work there Dr, i just dont personally feel as if it is the correct solution to the problem you have identified.
 

E tank

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If the blade is not at all at the right place (let's say at the teeth level in the esophagus) the device won't be helpful. But if he is close to the glottis the loop doesn't only approximates the tube but also creates a "step" that the intubator can use to curve the tip anteriorly.

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Well, that's just it, Dr. Benuri, the leading edge of the blade (that is, the tip) needs to be engaging the epiglottis in one way or the other (in the valecula or lifting it) in order to have the loop in position to be able to align the bougie with the glottic axis. It seems to me, you'd be putting the bougie/tube right thru the glottis to snare the loop, in which case you'd be where you'd want to be without engaging the loop.
 

E tank

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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?
Those blades manipulate the anatomy, while his manipulates the tube. There is a reason why those blades didn't catch on.
 

Carlos Danger

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I think it's an interesting concept, considering that difficulty in entering the glottis with the ETT seems to be a somewhat common problem, even when a good view is obtained.

I don't know how useful it would be in actual practice. I think a lot would come down to the design of the actual device, and how easy it is to use.
 

FLMedic311

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I feel like @E tank said it best in that this device is self limiting in that only someone that is well trained and experienced in proper positioning, anatomy, and epiglottoscopy.
 
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Ishay Benuri MD

Ishay Benuri MD

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First of all, I would like to express my sincere appreciation to this forum (the 1st forum I presented my device to)! All the issues raised above are very important to address and it helps me understand what I need to clarify in my future presentations. I'll try to address all the points you guys raised. I'll do it in several posts (between meetings and patients…).
 

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