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This month we continue our look at trends spotted at the ACEP Scientific Assembly held last October. This month we’ll look at a trend that has been slowly gaining momentum over the past several years: fiber-optic airway management. Fiber-optics are slowly moving from the realm of anesthesiology and the OR to being the new standard of care in emergency medicine. The fiber-optic evolution continued at ACEP with a couple of new products as well as improvements on many others.
Note: Some vendor sites may require the creation of a user account in order to access their catalog.

altAirTraq by King Systems
The Gist: The AirTraq has been around for a few years now as a poor-man’s fiber-optic substitute. It is a great option for EMS systems as well as smaller volume EDs as it is completely disposable and relatively affordable. The AirTraq uses a prism as a substitute for fiber-optics. King Systems improves on this device by adding a video-system to clip onto the scope allowing multiple people to observe - as well as record - the intubation.
ETA: Currently Available www.kingsystems.com

altBRS-5000 Flexible Bronchoscope by Vision Sciences
The Gist: The BRS-5000 is a take on standard flexible bronchoscopes with a slight twist. The scope itself is encased within a plastic sheath that also contains the suction port. This allows for continued use of the bronch without the need to send it out for sterile processing. This may sound like a minor issue but if you are in a department with one bronch and no overnight processing it can literally be the difference between life or death for a patient.  Another benefit of not having to rely on sterile processing is that you do not have to worry about them “misplacing” your bronch.  After losing a $12,000 bronch to sterile processing a few years ago (I’m pretty sure I saw it on Ebay later that week) I always get a queasy feeling when I see my bronch walk off in a stranger’s hands.  Optics on the BRS-5000 are adequate and the system comes with its own LCD screen. Vision Sciences also offers an NP scope.
ETA: Currently Available www.visionsciences.com

altVideo RIFL by AI Medical Devices
The Gist: The Air RIFL has been around for a few years now.  For those not familiar with it, it is a rigid fiber-optic intubating scope similar to the Bonfils or Levitan scopes with the exception that the tip can be manipulated by squeezing a lever at the handle facilitating intubation on anterior airways.  The Video RIFL now improves on this by adding an LCD screen where once there was just an eyepiece. The LCD screen allows for multiple viewers and recording. The tip also features an LED light-source which decreases fogging over standard bulbs.
ETA: Available January 2009 www.aimedicaldevices.com

 
altC-MAC by Storz
The Gist: The C-MAC is Storz’ answer to the Glidescope. It takes their previous fiber-optic mac model and condenses it to a small case and IV pole. The C-MAC has the shape of a standard Mac blade with a small LCD screen attached via a single cable.  This new model allows for multiple people to view and record the airway but also allows the operator to directly record intubation with the simple push of a button in the handle of the blade.  Prior systems required external recording devices and large carts to achieve the same capabilities.
ETA: Available when you read this but expect backorders www.karstorz.com
 
 

Comments   

# Executive Director National Security & Loss Prevention AssociationDave Russell 2009-01-05 20:31
The McGrath is better than all of these, although in the ED it could get lost, dropped, stolen, "Walk", or be broken too easy just like the Ranger / Handheld GlideScope.
As Dr. Ron Walls and Dr. Sackles recommend (Difficult Airway Workshop Gurus) - I would stick with what we know works, the GlideScope System on a Rolling Cart. Plus it is AC or DC unlike most devices, you can alway plug it in and use it if the battery is dead. Plus they have a heating element that prevents fogging built in... Best for Cervical Spine Cases too.
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# Emergency Physician, TechDocJason Wagner 2009-01-05 21:25
I agree with the above points with a caveat. While the GlideScope line is nice in its portability and does a great job with difficult (esp. anterior) airways it does have limitations and there are times when passing the ETT is difficult despite great views. When this happens direct visualization is not possible due to the curvature of the blade. This is when Mac-shaped devices are nice because you can attempt direct visualization when indirect is not working out.

Just to clarify I tried to list items that were offered as either a new device or as a new twist on an older device. This was not meant as a review of all fiberoptics has to offer.

Thanks for the feedback.
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# Emergency Medicine Attending, New York Hospital QueensJose D. Torres, Jr. 2009-01-05 23:02
I have encountered difficult airways in the persons I least expected. No perfect scoring system exists in predicting the difficult airway. I find that all difficult airway intubation devices need active practice to keep skills sharp. These devices will replace the laryngoscope. As prices go down, their use will go up.

I find that you need the stylet that the Glidescope sells, to improve placement of the ett since the view of the airway is taken from an acute angle. The COBALT version with disposable blades is the way to go with that device. It does offer a blade for preterm, neonate, average adult and morbidly obese patient. With a disposable blade, there is not an excuse not to get good at it with every airway intubation opportunity.

The C-mac differs in that is the latest karl storz product that offers a new heating elemet that prevents fogging whereas the old karl storz model did not.

I have used these 2 devices described above only on simulated airway mannequins. Never have used a Rifl so far in my training.

The one I have most proficiency is the Airtraq. I am not a sales representative. This device when you are trained properly with it, since it requires no brute force and all finesse, will save lives. I have used it on all my patients in the ER to train the EM residents I am working with. I do not recommend this device or the other ones listed to be used w/o having gained experience with assumed "easy" intubations. You need to develop the skill to use it. I find 3 times success with it is enough to feel confidence in its use for a difficult airway for the first time. Just need to use your yankeur suction device often for patients with excessive oral secretions, gib, aspiration before inserting and even may need to use it during airtraq use while its in the patient's oropharynx. You just have to remember "Get used to a Better View." You can use it for the upright patient for awake intubation, for patients with cervical spine immobilization, morbidly obese patients. Its portable, has its own battery life, hence doesnt need to be plugged in. Its for one time use only. Its cost compared to the cost for a lawsuit from severe hypoxia, or other complications from a failed airway, is very small. Its price is very affordable, when compared in price to the Glidescope, Rifl, C-Mac mentioned in your article. Its not always the most expensive device that proves to be the easiest to learn with and be successful with.

Certain things need to be emphasized before purchasing these above described devices. Always use these devices with what you are used to, Mac or Miller Blade, next to you. Everyones learning curve is different. Just because one person learned to used it well with one intubation, does not mean the same for another intubator. Always have a combitube, easy tube, i-gel, king lt, lma, or any other supraglottic device available next to you. Keep the patient alive with oxygen. They provide more airway confidence that just Bag Valve Mask ventilation. Less likely to overinflate the stomach and cause aspiration than BVM. These devices will keep the patient alive during a failed intubation airway, not blind attempts or repeated attempts by the same person who failed the initial intubation.
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# egwger 2010-04-01 10:18
hello this is great site, i want to add this site to my favorite nothing ? i hope that will help you
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