Daniel K. O'Neill, MD, is among a growing number of anesthesiologists who reaches for the video laryngoscope for more and more routine intubations, not just in emergencies or in known or anticipated difficult airways.

"I have a low threshold for using the [video laryngoscope]. I reach for it sooner rather than later for intubation," says Dr. O'Neill, an assistant professor of anesthesiology at the 48-OR New York University Langone Medical Center in New York, N.Y. "In older patients, especially those with limited neck extension, and patients who have excess soft tissue mass in the neck, including obese patients, I tend to use it almost routinely."

As Dr. O'Neill sees it, "If you can do something under direct visualization, you'll have more success than doing it blindly or using excess force to visualize the vocal cords during intubation."

Seeing around the corner
Unlike a traditional laryngoscope, which requires a direct line of sight from the mouth to visualize the vocal cords and trachea, a video laryngoscope with a built-in camera on the blade lets you explore above and beyond airway obstacles, beneath the tongue and under the epiglottis. "Seeing around the corner," many call it.

"I can literally look around the corner compared to seeing only what is directly in front of my blade," says Russell W. Lewis, CRNA, of Lower Umpqua Hospital in Reedsport, Ore., who has intubated more than 4,000 patients using a video laryngoscope. He has a message for those anesthesia providers who resist video laryngoscopy because they want to maintain their intubating skills. "After 30 years of intubating without the video laryngoscope, I want to maintain the skill of using the tool that makes the job safest and easiest."

Many say it's better to first try video laryngoscopy during routine use before tackling difficult situations. "If you reserve video laryngoscopy for high-risk cases," says Dr. O'Neill, "you won't have enough practice to become proficient with it."

William Landess, CRNA, MS, JD, director of anesthesia at Palmetto Health Richland Campus in Columbia, S.C., calls conventional laryngoscopy an invasive procedure and predicts it will soon fall by the wayside. "With the tools available, why continue with this dinosaur approach to securing an airway?" he asks.

As the sole anesthesia provider at an ambulatory surgical center, Charles A. DeFrancesco, MD, the director of anesthesia at Delmont Surgery Center in Greensburg, Pa., says video laryngoscopes let him "successfully intubate patients with unrecognized difficult airways, without needing the assistance of additional skilled anesthesia personnel."

Smart shopping
Video-aided intubations may or may not make direct laryngoscopy obsolete, but there's no disputing that more and more anesthesia providers are routinely incorporating them into daily practice. The obvious reason: They make it easier to intubate all patients. Plus, when you can visualize airway anatomy and tube placement, there's less collateral damage to teeth (chips), laryngeal structures (sore throat caused by trauma to the tender and sensitive airway structures) and cervical spine (minimal head extension), says Dr. O'Neill.

"If you can use less mechanical force to visualize the cords, you decrease the risk of sore throat trauma and injury," says Dr. O'Neill.

Here's what 50 anesthetists told us matters most to them when shopping for a video laryngoscope:

• ease of use.......................60%
• picture quality..................22%
• cost.................................12%
• disposable components.......4%
• monitor size.......................2%

Earlier models of video scopes, like the Bullard and Wu scopes, were cumbersome, says Dr. O'Neill. They required a fair amount of assembly — not exactly what you want to be doing in the throes of a difficult airway — and were just as difficult to reprocess. Some also had sharp edges that could injure tissues.

The curve, angle and shape of today's newer models make insertion easier, Dr. O'Neill explains. As you insert the laryngoscope with the left hand after opening the mouth with the right hand, watch the tip of the blade pass between the uvula and tongue. Then look at the video screen to visualize the vocal cords. Directly watch your right hand manipulate the endotracheal tube to the right of the blade and under the tongue. Then insert it between the vocal cords as you watch the video screen.

Let's not discount good optics. What good is "seeing around the corner" if you can't make out the anatomical landmarks you're supposed to be seeing? "Some scopes have disappointing optics, particularly when you're attempting intubation — which is the exact time when you need to see the vocal cords," says Dr. O'Neill. He and other educators recommend that anesthesia providers trial the devices on mannequins at an airway management workshop or at an anesthesia meeting's exhibit hall. Then, arrange for an in-OR trial for a month or so, he adds. Two desirable features: built-in anti-fogging tips to keep secretions from obscuring the airway view and the ability to record high-definition footage of a procedure to a flash drive.

"Cost was most important with my first video laryngoscope," says Mr. Lewis. "Image capture and storage will be most important with my next unit."

Portability is also a nice feature to have. It's likely too costly to stock a video scope in every OR (video laryngoscopes typically cost $10,000), so look for one that has an on-board miniature camera monitor you can take from room to room. At Langone Medical Center, they either place the monitor next to the patient's chest on a support surface or put it on an IV pole so more people in the room can view it. The image can be "slaved" off a flat-screen monitor so that everyone in the room can view it, says Angel Martinez, senior technical support supervisor of anesthesia at Langone.

Disposable or reusable blades?
Should you use disposable or reusable blades? Mr. Martinez did the math, and found it's more economical to use disposable laryngoscope blades than to reprocess reusable blades. It costs $12 — and takes anywhere from 45 minutes to 2 hours — to reprocess reusable blades and $8 for each disposable blade. "Besides eliminating the aggravation of reprocessing reusable blades, [disposable blades] decrease the risk of cross-contamination and infection," adds Dr. O'Neill.

A video laryngoscope that can record images might be well worth the investment. You might be able to get reimbursed for difficult airways (CPT code 31500 for emergency endotracheal intubation) if you print an image of the difficult intubation and attach it to the operative report. In routine use, the cost of the device is not reimbursed because it's bundled with the procedure code. Still, says Dr. O'Neill, "the cost of having one esophageal intubation or one unnecessarily traumatized airway makes it worth using video scopes."