Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy

Background: Videolaryngoscopy has become a popular method of intubation in the Emergency Department (ED), however, little research has compared this technique with direct laryngoscopy (DL). Objective: To compare the success rates of GlideScope (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) and DL in emergent airways with known difficult airway predictors (DAPs). Methods: We evaluated 772 consecutive ED intubations over a 23-month period. After each intubation, the physician completed a data collection form that included: demographics, DAPs, Cormack-Lehane view, optical clarity, lens contamination, and complications. DAPs included: cervical immobility, obesity, small mandible, large tongue, short neck, blood or vomit in the airway, tracheal edema, secretions, and facial or neck trauma. Primary outcome was first-attempt success rates. Multivariate logistic regression was performed to evaluate the odds of failure for DL compared to GVL. Results: First-attempt success rate with DL was 68%, GVL 78% (Fisher's exact test, p = 0.001). Adjusted odds of success of GVL compared to DL on first attempt equals 2.20 (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.51-3.19). After statistically controlling for DAPs, GVL was more likely to succeed on first attempt than DL (OR 3.07, 95% CI 2.19-4.30). Logistic regression of DAPs showed that the presence of blood, small mandible, obesity, and a large tongue were statistically significant risk factors for decreasing the odds of success with DL and increasing the odds of success of GVL. Conclusion: For difficult airways with the presence of blood or small mandible, or a large tongue or obesity, GVL had a higher success rate at first attempt than DL.