Has Video Laryngoscopy Improved First Pass and Overall Intubation Success in the University of Florida Health Emergency Department?

Abstract

Background: Airway management is an integral skill for emergency physicians and is a significant part of the residency training. With the introduction of video laryngoscopy the EM community has quickly embraced what was initially a difficult airway adjunct and is now moving towards becoming a standard of care, particularly for difficult airways. The ultimate place of video laryngoscopy in EM airway management is at this time undecided. Video laryngoscopy has been shown to improve first pass success and time to intubation for novice operators but not for experienced operators. Research has also shown that repeated intubation attempts predict worse outcomes, namely hypoxic insults, cardiac arrest, aspiration, need for surgical airway, and increased mortality overall. Since video laryngoscopy was re-introduced in the UF Health Emergency Department January 2013 and its role in airway management is unfolding, an evaluation in our ED is timely and important. Objectives: Identify the rate of first pass success for endotracheal intubation at UF Health ED January 2012-January 2013 when no VL was available in the ED. Identify the rate of first pass success for endotracheal intubation at UF Health ED January 2013-January 2014 after the launch of CMAC in the ED. Categorize first pass success rates by post graduate year. Of note, at our center, interns are required to use direct visualization only and are not allowed to use the video screen of the CMAC, for training purposes. Methods: Retrospective chart review of all ED intubations of adults (age 18+), comparing first pass and overall intubation success between January 2012-January 2013, when no video laryngoscopy was available in the ED, to January 2013-January 2014, after CMAC was launched for use in the ED. T-tests will be used to compare the percent success as well as the number of attempts in the before and after study period. Regression analysis will be used to predict first-pass success of intubation. Results: Interns made 12% of first attempts, PGY2s 45%, PGY3s 35%, attendings 7%, and PAs 0.5%. The first attempt was successful in 82% of intubations. First-attempt success was similar for direct (81%) and video laryngoscopies (85%) (p=0.5). This finding held for each stratum of experience, from PGY1 through attending. Conclusion: Use of video laryngoscopy was not associated with improved first-attempt success at our hospital. This may be because our interns are required to use direct laryngoscopy, since the least experienced operators might benefit most from the newer technology. We also acknowledge the high likelihood of Type II statistical error, in light of our numerical findings and clear prior evidence of the superiority of video laryngoscopy.