Vidéolaryngoscopie: Un standard ? Pas si sûr et pas partout !
Videolaryngoscope as a standard intubation device
Un éditorial récent, présentant la vidéolaryngoscopie comme le standard pour toute intubation (1), dans le BJA a déclenché plusieurs réactions. Nous rapportons là l'une d'elle qui apporte un gros bémol à cette position (ce n'est pas la seule). La vidéolaryngoscopie ( ou plutôt les vidéolaryngoscopes car le choix est grand) doivent certainement trouver leur(s) place(s): . Non pas permettre une intubation facile mais améliorer la sécurité des patients/blessés pris en charge. L'objectif de l'intubation n'est pas de voir le plan glottique mais d'insérer une sonde dans une trachée, ce qui n'est pas la même chose. Dans notre contexte de traumatologie faciale il est fort probable que la vidéolaryngoscopie soit inopérante. Que faire alors ? Ne pas pouvoir s'appuyer sur des pratiques ayant fait leurs preuves ne parait pas actuellement raisonnable même si la maîtrise de ces dernières demande un investissement personnel. On en revient à une chose essentielle qui est l'entraînement à des pratiques qui certes sont peu fréquentes mais qui feront la différence et qui font que l'on peut parler de médicalisation de l'avant.
The editorial article by Zaouter and colleagues (1) recommending videolaryngoscopy as a new standard of care was of great interest. Videolaryngoscopes are indeed promising intubation devices because they provide an improved laryngeal view.
However, we do not agree with the authors that videolarygnoscopes should replace direct laryngoscopes and be used for all intubations in current practice. The quantitative review and meta-analysis regarding the performance of video- and direct laryngoscopes indicate that in patients with a normal airway, the success rate of intubation with videolarygnoscopes is approximately the same as with direct laryngoscopes, but the intubation time is significantly prolonged with videolaryngoscopes; that is, tracheal intubation in patients with a normal airway can be achieved quickly and in a cost-efficient manner with direct laryngoscopes.
In fact, the most convincing literature to date supports the use of videolaryngoscopes only in unanticipated, difficult, or failed intubations with direct laryngoscopy. The available evidence also shows that videolaryngoscopes are associated with better intubation success and faster intubation time only for inexperienced operators, but they provide no benefit in either of these outcomes with experienced operators. Thus, we argue that videolaryngoscopes are not the best care for all patients and the direct laryngoscope is not an outdated intubation device, especially for providers able to complete substantial training in controlled circumstances, such as experienced anaesthetists, who are often called as airway experts. Furthermore, there are several different types of videolaryngoscopes available, each with a different blade shape, user interface and geometry, and tube insertion strategy. So far, there is inconclusive evidence to indicate which videolaryngoscope design could be more advantageous in various clinical situations. Thus, the open questions remain. Which videolaryngoscope is the most cost-effective device for routine or difficult intubation? Which one is the optimum to become a new standard of care? Given that device-specific proficiency is critical for successful use of any intubation device, if videolaryngoscopes are used as routine intubation devices, do anesthesiologists need to learn and achieve clinical competence for all devices? Perhaps, there might be a need to revise the current airway training programmes because they do not include videolaryngoscopic intubation training in the minimal skill set acquired by a trainee during an airway rotation.7 In addition, most of current difficult airway algorithms are developed as rescue guides in the event of difficult or failed direct laryngoscopy, and these algorithms rely on videolaryngoscopes as rescue tools for difficult or failed direct laryngoscopy.
Although use of videolaryngoscopes is rapidly growing in clinical practice, there is still no evidence-based airway algorithm where tracheal intubation relies mainly on videolaryngoscopy. If videolaryngoscopes are used as the routine first-line intubation devices, one pertinent question is, what should one do in the event of a difficult or failed videolaryngoscopy? It must be emphasized that despite the very good visualization of the glottis, videolaryngoscopy does not give a 100% success rate. In a two-centre study, the GlideScope videolaryngoscope failed once every 33 patients with a difficult airway and once every 16 patients with failed direct laryngoscopy. Thus, if videolaryngoscopes are part of a new airway management protocol in which they are routinely used as first-line intubation devices, there would be a need to reconsider airway management algorithms and adopt a strategy to manage failures.
Finally, Zaouter and colleagues (1) advise integration of videos obtained during videolaryngoscopic intubation into an anaesthesia information management system. To the best of our knowledge, most videolaryngoscopes used in current practice have no such function to transmit moment-by-moment videos into an anaesthesia information management system, and some of them even have no functional design for recording and saving intubation pictures. Perhaps, the manufacturers of videolaryngoscopes should be encouraged to provide such electronic additions to their products in order to integrate imaging of the patient's tracheal intubation into anaesthesia electronic charting. We believe that with further developments and refinements in technology, this may no longer be an issue.