EASY ACCESS There's no arguing that video laryngoscopes have made airway management safer.

The scary part about managing the difficult airway is that you don't always know when you'll be faced with one. About 6% of adults who have normal airway anatomy end up presenting problems, says Richard Cooper, MD, a professor in the department of anesthesia and pain management at Toronto General Hospital in Canada. "Let's call those cases what they are," he says. "If you're performing laryngoscopy for the purpose of seeing the larynx, and you don't see it, the intubation isn't difficult. It's failed." With video laryngoscopes, failure is never an option.

Video laryngoscopes have changed the way Joseph Loskove, MD, practices. The chief of anesthesia at Memorial Healthcare System in Hollywood, Fla., used to fear caring for a patient with a difficult airway. Not anymore. "Now," he says, "I'll go directly to a video laryngoscope or start off with a conventional laryngoscope and switch to video-assisted intubation if need be."

Dr. Loskove tells of a recent experience of working with an anesthesia student to sedate a patient. The student made an attempt with a conventional laryngoscope, but couldn't see much of the airway. Dr. Loskove took over, but the view with the laryngoscope wasn't any better in his experienced hands.

PRACTICE IMPROVEMENT The skill set needed for conventional laryngoscopy doesn't translate directly to video laryngoscopy.

"Fortunately we could ventilate the patient," he remembers. "I asked a nurse to grab a video laryngoscope. Thirty seconds later we put it in, had a perfect view of the airway and intubated the patient. The technology makes those situations much less stressful."

So should the added safety afforded by video laryngoscopes let you take on patients you otherwise wouldn't have because of concerns about their airways? It's a touchy, oft-debated topic.

"Anatomic abnormalities might be easier to handle with a video laryngoscope," says Dr. Loskove, who couches his opinion with the disclaimer that he's a hospital-based provider. "But if you're concerned about patients because they're morbidly obese, and you're not sure you'll be able to intubate them without a video laryngoscope, they might not be candidates for surgery in the outpatient setting."

Pam Wrobleski, DNAP, MPM, RN, CRNA, CASC, administrator of the Southwestern Ambulatory Surgery Center in West Mifflin, Pa., knows firsthand the importance of investing in a video laryngoscope: She's a nurse anesthetist who keeps her anesthesia skills current by filling in regularly at the bedside. Her facility has been using a device for 8 years.

"It's been one of the most significant pieces of equipment we've added to our armamentarium," she says. "It's changed our comfort level in handling various patients, and lets us perform cases we would have otherwise cancelled."

Invest in patient care
Dr. Cooper says most practitioners trained in direct laryngoscopy use video laryngoscopes inappropriately, because the skills of the former don't translate to the latter. He therefore uses video laryngoscopes regularly to keep his skills sharp for when he's faced with a truly difficult airway.

Ms. Wrobleski agrees with the importance of always being prepared for the unexpected. Anesthesia providers at her facility are encouraged to use the video laryngoscope a couple times each month during routine cases to remain competent with its use. "The insertion technique and placement of the endotracheal tube are different than during a regular intubation," she says. "The only way to learn the tricks that improve your technique is through practice. An emergency is not the time to use a device you're not familiar with."

Video laryngoscopes are easier to use than conventional laryngoscopes, says Dr. Loskove, who stops short of calling the devices the standard of care in airway management. "They're relatively more expensive, and therefore have limited availability in most facilities," he explains. "Having said that, you get a dramatically better view of the complete vocal cord structure — a view that's rare with a conventional laryngoscope — that makes intubation straightforward."

Dr. Loskove believes lower price points and user-friendly designs have steadily increased the use of the devices. "From a safety perspective, it's a no-brainer that every facility should have one," he says.

When purchasing her facility's video laryngoscope, Ms. Wrobleski received input from her fellow anesthesia providers and the center's ENT surgeons, who were familiar with difficult airway scenarios. It's a significant capital investment — Ms. Wrobleski's center spent approximately $10,000 for the main component and an additional $15,000 for 3 reusable blades — so you want to make sure the providers who will use the device sign off on its features and importance.

The $25,000 Southwestern Ambulatory Surgery Center spent "is really not that much when you compare the price with equipment that's needed for other specialties," says Ms. Wrobleski, who decided to invest in reusable blades instead of disposables when a crunch of the numbers showed they'd save more over time.

She had the full support to make the investment because all parties involved believed there was absolutely no reason that the facility shouldn't have the video laryngoscope on hand. "You can't put a price on patient safety," she says. "Plus, having the device reduces the number of case cancellations."

SEEING IS BELIEVING Video-assisted laryngoscopy provides direct view of the glottis.

Worth another look
If it's been several years since you've assessed the video laryngoscope market, newer lightweight, ergonomic designs and bright, sharp displays powered by inexpensive batteries you can buy off the shelf demand another look. When shopping the options, don't necessarily settle for the option you think is easiest to use. "That's something that improves with proper training on any device," points out Dr. Cooper. "If you choose a device that matches your experience with a direct laryngoscope, you may end up with a device that has reduced versatility."

Manufacturers offer various blade sizes and designs, which are essentially slight variations of the Macintosh blade, according to Ms. Wrobleski. She suggests you invest in sizes that are appropriate for the patients you host. For example, her facility needed a blade that could be used on children as young as a year old because of the high volume of pediatric cases they schedule.

If you can invest in only 1 blade, buy the largest one you might need, because you can use it in most adult patients with only a slight adjustment in intubation technique, says Ms. Wrobleski.

Dr. Cooper recommends devices with hyperangulated blades, a wide range of blade sizes and the ability to record, capture and store video. He believes recording laryngoscopies is useful from a quality assurance standpoint and will eventually emerge as the standard in clinical documentation that's sent to electronic records.

You'll have to decide between channeled devices — which contain an integrated slot for guiding the placement of the endotracheal tube — and non-channeled devices. Some providers find channeled scopes easier to use, because they don't require the hand-eye coordination to place the endotracheal tube that's needed with direct laryngoscopy. But Dr. Cooper points out that channeled devices are typically bulkier and that you can only maneuver the endotracheal tube by moving the laryngoscope. Some providers might balk at losing independent manipulation, says Dr. Cooper.

Video signals have been upgraded from analog to digital, which has improved image quality and made recording, exporting and storing video easier, according to Dr. Cooper.

"The blades have also become less bulky, which is hugely important," he adds. The height of the blade on the first video laryngoscope Dr. Cooper worked with many years ago was 18 mm. The blade on his current video laryngoscope is 11 mm. It's a reduction in height limited only by the size of the CMOS camera chip in the tip. "The difference between 18 mm and 11 mm is huge," says Dr. Cooper. "The blade can be used on patients with more limited mouth openings or larger chests. It increases the number of potential patients in whom the device would prove useful." OSM