New Intubation Method - looking for feedback from the field

[VentMonkey]

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.

Nail on the head, tank. Excellent post! Also, in your experience (you too, @Remi) how receptive are anesthesia folks to some of these newer gimmicks or devices on the whole?

Do most of you guys typically stick to what you're taught, focusing on the basics of positioning, as you've pointed out, or are they fairly receptive to these sorts of devices?

 

[Ishay Benuri MD]

Thank you E tank. I agree with VentMonkey that it's an excellent post; but I disagree with the notion that we should close our eyes in the face of reality. Learning curve, till a practitioner reaches proficiency, will always be for any medical task even with excellent training. I do believe that nothing beats endotracheal tube for emergency scenarios (and I won’t bring studies although I have) and that if an alternative methods is chosen this is only due to the fact that the learning curve for endotracheal intubation is too slow and kills people. I believe that if Macintosh (certainly not comparing myself to him) would have decided to dedicate his career training young anesthesiologist how to use properly a straight blade, instead of introducing his curved blade, many lives would have been lost. I think that the advantage of my device is that the use of the loop is optional. If the practitioner is well trained the loop will be discarded but if he needs the small shove – the loop will be there…

 

[BassoonEMT]

Another thing to keep in mind, the one thing that (most) higher-ups value more than patient lives is money. Unless there is a mandate, or a major lack of skill/success within the company that they can prove beyond a doubt would be resolved with your product, they will not spend the extra money. Even if it's only a few cents.

 

[Ishay Benuri MD]

Another thing to keep in mind, the one thing that (most) higher-ups value more than patient lives is money. Unless there is a mandate, or a major lack of skill/success within the company that they can prove beyond a doubt would be resolved with your product, they will not spend the extra money. Even if it's only a few cents.

I agree with you, BassiinEMT that the device must be cost effective The cost of producing SGA balloon is more expensive than a plastic lever and plastic tubing so I believe it will be more cost efficient.

 

[BassoonEMT]

This device is certainly NOT a replacement for an SGA. You NEED a back-up airway device. Especially in the instance of RSI.
This is not a guaranteed airway device. As superior as ETI, sometimes you can't do it. There's no such thing as "eliminating the need" for another airway device.

Does the cost of your plastic lever and plastic tubing include the engineering and adaption necessary for current manufacturers to either modify existing blades or make new ones? Machines would have to be redesigned.

 

[Ishay Benuri MD]

This device is certainly NOT a replacement for an SGA

When an anesthesiologist decides to use SGA - he usually thinks about the extubation and not of how difficult it will be to insert. - and in this case my device certainly doesn't replace SGA.

When an EMT inserts SGA - it is only because he wants to secure the airway as quickly as possible - in this sense my device DOES replace SGA.

 

[BassoonEMT]

I can not speak for what is done in hospital. My limited knowledge from clinicals was "they decide based on sedation and aftercare requirements."

When an Paramedic inserts an SGA, it is because they are unable to intubate. Some protocols call for using it right away, with no tube attempt. But for the most part, it is because, for whatever reason, intubation was not successful. If you emergently need to secure an airway, the reason you need to do so quickly would probably also contraindicate use of an SGA. Airway burns/swelling, aspiration, etc.

Necessity for speed is not a reason for poor patient care.

If you need to RSI, and for whatever reason your tube is not successful, you insert a supraglottic. Blind insertion, grab the jaw and shove it in. Airway relatively secured. Your device requires direct laryngoscopy. It does NOT replace an SGA.

Saying "you can do it quickly too" doesn't mean it replaces an SGA.

 

[BassoonEMT]

You need a backup airway device. Your additions to a laryngoscope is not an airway device. A tube is a tube.

 

[Ishay Benuri MD]

You need a backup airway device. Your additions to a laryngoscope is not an airway device. A tube is a tube.

I agree, BassoonEMT, and therefore I am refining my previous post - I believe that the loop mechanism I propose will be helpful enough for most difficult airway that the need for SGA will drop dramatically, but SGA will remain an important backup device.

 

[BassoonEMT]

THAT i can agree with. And you may be right. My initial point remains though, while it may be cheaper than the SGA, that will still exist. It MAY be used less and therefore save money, but that's not a guarantee that will convince many companies.

 

[Ishay Benuri MD]

Does the cost of your plastic lever and plastic tubing include the engineering and adaption necessary for current manufacturers to either modify existing blades or make new ones? Machines would have to be redesigned

Regarding the engineering - I am adding a link to my previous invention

To manufacture these devices from scratch to a device that can be inserted into humans - the cost was about $120K

Regarding adaptation in the blades - I'll answer in the following post.

 

[Ishay Benuri MD]

Regarding the adaptation to existing products…

One of the options considered - and this is also a reply to Grimes post at the head of the thread - to use a mounting mechanism requiring only to create slots on a blade (enabling a company to have a monoply on the product) alternatively a model capable of mounting on the tip of any blade could be used, or a complete unit - blade and loop could be sold. I can't imagine that the added unit should cost more than 1 dollar to manufacture. The blade cost should not change at all.

 

[StCEMT]

When an Paramedic inserts an SGA, it is because they are unable to intubate. Some protocols call for using it right away, with no tube attempt. But for the most part, it is because, for whatever reason, intubation was not successful.

Necessity for speed is not a reason for poor patient care.

Not necessarily. My buddy had a guy crash on him a few minutes from the hospital Sunday. Driving down busy city streets are not where I'd even consider intubating with a 4 minute ETA. SGA and be done. Speed isn't always poor patient care.

That being said, I'd be curious to try this. I think E Tank's response is more accurate for what I found to help get the best results for me personally, but that doesn't mean this doesn't offer something.

 

[BassoonEMT]

Not necessarily. My buddy had a guy crash on him a few minutes from the hospital Sunday. Driving down busy city streets are not where I'd even consider intubating with a 4 minute ETA. SGA and be done. Speed isn't always poor patient care.

That being said, I'd be curious to try this. I think E Tank's response is more accurate for what I found to help get the best results for me personally, but that doesn't mean this doesn't offer something.

Yes, my comment was obviously geared toward on-scene.

And the point I was making remains, this product would not replace the SGA in that scenario either.

I never said it was bad. But i can't see it as replacement to any existing device, even standard laryngoscopes, in the near future.

 

[phideux]

What happens if you squeeze the handle a bit too much??? Tube lassoed to the blade??? Will the loop release if this happens????

 

[Ishay Benuri MD]

The loop can open and close by control of the triger. One of the safety mechanisim is release of the loop when tension is increased beyond certain level.

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[Ishay Benuri MD]

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[Ishay Benuri MD]

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[Ishay Benuri MD]

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[Ishay Benuri MD]

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