Hyperangulated video laryngoscopy in the emergency department: An analysis of errors and factors leading to prolonged apnea time.

BACKGROUND

Video laryngoscopy (VL) is a widely utilized method for endotracheal intubation that both increases first pass success and reduces esophageal intubations. Use of VL in a teaching environment allows for real-time feedback for new learners and creates an opportunity for education and quality improvement. There is limited research on the difficulties that VL users face during intubation attempts. This study aims to explore the errors practitioners make while using hyperangulated video laryngoscopes and investigate how the errors affect intubation time.

METHODS

We conducted a retrospective observational study of 101 intubations performed using hyperangulated VL at a single academic hospital. All intubations were performed by Emergency Medicine residents with supervision from attending physicians. Videos were reviewed by two persons and discrepancies were resolved by a third party. The variables included were grade of view, intubation times, and multiple noted errors of intubation consistent with those previously studied.

RESULTS

First pass success occurred in 84.9 % of intubations; of those, the median time (IQR) to obtain a view of the vocal cords was 7 (5-11) seconds and the median time for tube delivery was 26 (20.75-43) seconds. 67.0 % of successful intubations reviewed contained at least one error. 43.8 % of intubations had errors in blade placement. The second most frequent error was difficulty with tube delivery occurring in 39.6 % of intubations. Inappropriate use of suction was another studied error; unnecessary suctioning accounted for 35.7 % of all cases where suction was used, and suction was not performed when indicated in 9.0 % of cases.

CONCLUSIONS

Correct blade placement and anterior delivery of the endotracheal tube are the most challenging steps of the intubation process for our residents. Future educational sessions for novice intubators can focus on techniques such as proper patient positioning, endotracheal tube and stylet molding, and hand positioning for delivering the endotracheal tube (ETT) to help mitigate these errors.