The Case for Expanded Video Laryngoscope Use

A multitude of benefits make frequent usage of these devices ‘the expectation of care’ at top facilities.

There’s no question the invention of video laryngoscopes changed the way providers tackled the critical issue of airway management. But for years after these game-changing devices hit the market, usage was limited only to those challenging cases, the ones involving “difficult” airways. Now, with providers seeing plenty of benefits beyond just the difficult airway cases, we’re witnessing another shift. “With the recognition of their role in airway management, and the increasing familiarity and popularity as well as the decrease in cost, some difficult airway guidelines now recommend the use of video laryngoscopy for all patients,” says Basem Abdelmalak, MD, FASA, an anesthesiology professor at the Cleveland Clinic Lerner College of Medicine. “These devices should be given consideration as the first-line laryngoscope to be used in certain marginally potentially difficult airway cases.”

Whenever the adoption of a certain technology or technique becomes commonplace in the OR, the standard of care question is bound to come up. But maybe that’s not the best way to look at expanded video laryngoscope usage. While Dr. Abdelmalak cites the ASA 2022 Practice Guidelines for the Management of Difficult Airways that lists video laryngoscope as a suggested content for standard anesthetizing location and says usage is getting closer to the standard of care, he also acknowledges a core truth about universal usage of the equipment. “The challenge with video laryngoscopy is that it isn’t feasible for some facilities due to the cost,” he says.

So if video laryngoscopy isn’t merely a rescue technique for difficult airways, but it isn’t quite the standard of care, how should we categorize the usage of these devices in the world of surgery? “I would call it the ‘expectation of care,’” says Ashish Sinha, MD, PhD, DABA, MBA, FASA, a professor at the University of California Riverside and designated institutional official and program director of anesthesiology at UC Riverside/Riverside Community Hospital. Dr. Sinha says the video laryngoscope frequency increases at larger teaching facilities like Mount Sinai. “If you were to go into training there, you’d be given a video laryngoscope and that’s yours for the duration of your training there, and they want you to do every [intubation] on it,” he says. “You go in the morning, and you get the blade that you need for that day.”

Indeed, the teaching potential of video laryngoscopes alone is almost reason enough to expand usage to cases well beyond those traditionally difficult airway cases. “That’s one of the greatest advantages of video laryngoscopy,” says Dr. Sinha. “You can teach a lot easier because if I’m teaching you, both you and I can look at the same image on the video screen, and I can tell you how to correct for it.”

Function over flash 

TEACHING TOOLS Video laryngoscopes improve training because both the instructor and the student are viewing the same image on the video screen, making it easier for the instructor to explain how to correct problems quickly.  |  Irene Osborn

Whether you’re purchasing a video laryngoscope for the first time or adding to the arsenal you already have on-site, there are certain factors that will play a role in the purchasing decision. Obviously, the upfront cost plays a factor, but both market competition and technology advances have helped prices drop, and though top-of-the line video laryngoscopes with all the bells and whistles can cost up to $30,000, newer models are in the $10,000-and-below price range — with smaller, portable video scopes coming in as low as $2,000 or lower. Beyond the price-point, talk to your anesthesiologists and anesthesia providers about what they like in a product and use that information as a purchasing roadmap. For instance, Dr. Abdelmalak understandably places a premium on the design comfort and convenience of a device. “The most important features for me are functionality, ease of use and rate of intubation success,” he says, adding that a low-profile blade to increase the laryngoscope’s usability in patients with a small mouth plays a key role and decreases airway trauma. In terms of the blades themselves, there are several variables to consider. Dr. Abdelmalak says the curvature and design of the blade (hyper-angulated, channeled vs. unchanneled, etc.) are important. “You also want to consider whether it’s a reusable or disposable blade,” he says, noting ASC leaders should directly weigh the ease of cleaning (i.e., contamination risk, cost), storage and maintenance of the reusable blades against the cost and environmental impact of disposable blades.

Video laryngoscopes have improved visualization of the larynx, increased the success of intubation in many populations and situations, and while they have not eliminated the challenge of the management of the ‘difficult airway,’ they have helped quite a bit.
Basem Abdelmalak, MD, FASA

When it comes to the design, Dr. Abdelmalak tends to avoid bulky blades. “They limit access to the mouth and the space for inserting the breathing tube safely,” he says. “By the same token, I do not appreciate the devices you need to use a stylet with to accomplish the intubation due to the blade angulation. While the incidence is very low, stylets can cause airway trauma with significant injury.” 

Size and storage components also come into play, and while many providers, including Dr. Abdelmalak, prefer the portability of smaller, battery-operated video laryngoscopes with small screens that make storage, transportation and cleaning much easier for staff, that’s not always the case. “The configuration of the screen, whether attached to the device — usually a small screen — or separated from the device to be mounted on a pole or connected to a big wall screen, makes a difference on how different practitioners prefer one over the other,” Dr. Abdelmalak says. “Some love the details on the big screen, but the awkwardness of looking at a screen far away from the mouth and trying to maneuver the tube in the patient’s oropharynx limits the enthusiasm for this variety,” he says, adding that some providers prefer the small, attached screen because it is closer to the mouth and face — or closer to the traditional way of performing direct laryngoscopy. “However, small screens limit the airway details and, for aging clinicians, visualizing details in those nearby screens is challenging.” 

Maintain multiple techniques

Like all innovative technologies in the OR, video laryngoscopes aren’t meant to replace other skills and techniques providers rely on to safely secure patients’ airways. As Dr. Abdelmalak points out, though issues and failures are rare with video laryngoscopes, they do still occasionally happen. “Sometimes when a video laryngoscope fails, what works is direct laryngoscopy,” he says, adding that providers still need to maintain their skills and practice with other devices like supraglottic airways and flexible intubation scopes. Still, anesthesiologists and anesthesia providers overwhelmingly laud the many benefits of video laryngoscopes. “It’s one of the most impactful innovations in airway management,” says Dr. Abdelmalak. “Video laryngoscopes have improved visualization of the larynx, increased the success of intubation in many populations and situations and, while they have not eliminated the challenge of the management of the ‘difficult airway,’ they have helped quite a bit.” 

To illustrate just how much they have helped, Dr. Sinha tells a simple but compelling story using statistics. When you take all factors into account, he says the first-pass success rate among anesthesia professionals is around 95%, which is outstanding. But the first-pass success rate jumps to 98% when you use video laryngoscopy. 

“Put another way, if you have a 95% rate, you have a one in 20 failure rate,” he says. “But if you have a 98% success rate, your failure rate drops to one in 50. Which one would you rather have?” OSM