Comparison of Hyperangulated and Standard Geometry Video Laryngoscopy Tracheal Intubation for Prehospital Care in a Manikin: A Randomized Controlled Crossover Trial



      The purpose of this study was to investigate the efficacy of hyperangulated video laryngoscopy (HAVL) versus standard geometry video laryngoscopy (SGVL) in the simulated prehospital environment using a manikin. There is consensus that video laryngoscopy (VL) can be very useful in the emergency department when difficult intubations are predicted. Emergency medical service (EMS) providers are also often faced with difficult, rapidly deteriorating airway management situations that not only involve patient and operator factors but also include challenging unique environmental factors, such as nonoptimized positions in transport vehicles (eg, helicopters and ambulances) or at ground level or entrapped positions. To our knowledge, there has never been a study purposefully investigating the efficacy of hyperangulated geometry versus standard geometry VL techniques in the prehospital environment.


      A single-center, randomized controlled crossover trial was performed using attending physician helicopter EMS providers. Physicians were randomized to perform 5 HAVL or SGVL intubations followed by the subsequent technique. Intubations were performed on ground level and then repeated in the helicopter with the first location also randomized. A manikin airway management trainer was used to simulate intubation in each environment. The time to intubation (primary outcome) as well as first-pass success and the Cormack-Lehane view were recorded for each attempt. Qualitative data were also obtained for physician preference and perceived difficulty.


      There was no statistically significant difference in the time to intubation with HAVL versus SGVL (ground: 15.02 vs. 14.88 seconds, P = .86; helicopter: 16.11 vs. 16.14 seconds, P = .93). First-pass success was 100% for both techniques in both scenarios. More Grade 1 views were obtained with HAVL (147/150 vs. 134/150). Moreover, most physicians preferred HAVL overall and felt that HAVL required less force (9/15 grounded manikin and 10/15 helicopter manikin) and led to the best chance for first-pass success (11/15 grounded manikin and 10/15 helicopter manikin).


      The results of this study are limited because of the static and highly favorable anatomy of a manikin versus the variability and often difficult anatomy of individual patients. Our results suggest that both techniques are efficacious when the patient is both on the ground or in the helicopter, although provider preference does seem to vary.
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        • Bjoernsen LP
        • Lindsay P.
        Video laryngyscopy in the prehospital setting.
        Prehosp Disaster Med. 2009; 24: 265-270
        • Savino BP
        • Reichelderfer S
        • Mercer MP
        • Wang RC
        • Sporer KA.
        Direct versus video laryngoscopy for prehospital intubation: a systematic review and meta-analysis.
        Acad Emerg Med. 2017; 24: 1018-1026
        • Wayne MA
        • McDonnell M.
        Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation.
        Prehosp Emerg Care. 2010; 14: 278-282
        • Jarvis JL
        • McClure SF
        • Johns D.
        EMS intubation improves with King Vision video laryngoscopy.
        Prehosp Emerg Care. 2015; 19: 482-489
        • Boehringer B
        • Choate M
        • Hurwitz S
        • Tilney PV
        • Judge T.
        Impact of video laryngoscopy on advanced airway management by critical care transport paramedics and nurses using the CMAC pocket monitor.
        Biomed Res Int. 2015; 2015821302
        • Trimmel H
        • Kreutziger J
        • Fitzka R
        • et al.
        Use of the GlideScope Ranger video laryngoscope for emergency intubation in the prehospital setting: a randomized control trial.
        Crit Care Med. 2016; 44: e470-e476
        • Naito H
        • Guyette FX
        • Martin-Gill C
        • Callaway CW.
        Video laryngoscopic techniques associated with intubation success in a helicopter emergency medical service system.
        Prehosp Emerg Care. 2016; 20: 333-342
        • Guyette FX
        • Farrell K
        • Carlson JN
        • Callaway CW
        • Phrampus P.
        Comparison of video laryngoscopy and direct laryngoscopy in a critical care transport service.
        Prehosp Emerg Care. 2013; 17: 149-154
        • Burnett AM
        • Frascone RJ
        • Wewerka SS
        • et al.
        Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial.
        Prehosp Emerg Care. 2014; 18: 231-238
        • Strayer RJ.
        Direct vs Video laryngoscopy.
        American Academy of Emergency Medicine Scientific Assembly, New York, NY2014 (direct laryngoscopy. Paper presented at AAEM Feb. 11-15th, 2014)
        • Steuerwald MT.
        Laryngoscopy - a definition of terms.
        March 16, 2015 (Taming the SRU website. Available at:)
        • Brown 3rd, CA
        • Bair AE
        • Pallin DJ
        • Walls RM
        Techniques, success, and adverse events of emergency department adult intubations.
        Ann Emerg Med. 2015; 65 (e1): 363-370
        • Driver BE
        • Prekker ME
        • Moore JC
        • Schick AL
        • Reardon RF
        • Miner JR.
        Direct versus video laryngoscopy using the C-MAC for tracheal intubation in the emergency department, a randomized controlled trial.
        Acad Emerg Med. 2016; 23: 433-439
        • Sakles JC
        • Javedani PP
        • Chase E
        • Garst-Orozco J
        • Guillen-Rodriguez JM
        • Stolz U.
        The use of a video laryngoscope by emergency medicine residents is associated with a reduction in esophageal intubations in the emergency department.
        Acad Emerg Med. 2015; 22: 700-707
        • Sakles JC
        • Mosier JM
        • Patanwala AE
        • Dicken JM
        • Kalin L
        • Javedani PP.
        The C-MAC® video laryngoscope is superior to the direct laryngoscope for the rescue of failed first-attempt intubations in the emergency department.
        J Emerg Med. 2015; 48: 280-286