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How Long Before Video Laryngoscopy Is the New Standard of Care?
With their consistently clear airway views, they make difficult intubations routine.
Thomas Hemmerling
Publish Date: May 13, 2015   |  Tags:   Anesthesia
Thomas M. Hemmerling, MD, DEAA FORWARD-THINKING VIEW Thomas M. Hemmerling, MD, DEAA, believes video-assisted intubation is the future of airway management.

I believe video laryngoscopy is the new standard of care and should be used during every case. In fact, I'd bet that a decade from now video laryngoscopy will be the intubation method of choice. Here's why.

1. Clinical benefits
Video laryngoscopes simplify even the most difficult intubations. You don't have to open the mouth as wide as you do with direct laryngoscopy, meaning there's less risk of damage to teeth and airway anatomy, and less muscle manipulation.

The devices provide a direct view of the glottic inlet, letting you see exactly where you're placing the endotracheal tube. They're especially useful when working around challenging airway anatomy in patients who are obese or who present with previous airway trauma or anatomical abnormalities that turn routine intubations into unexpected challenges.

Every provider has an opinion on video laryngoscopy. Some argue that it takes longer than the 10 to 20 seconds it takes skilled providers to secure the airway with direct laryngoscopy. But I've seen providers who use video laryngoscopes on an every-case basis, and their skills have improved dramatically over time. If you use video laryngoscopy once a month, you obviously won't have the same expertise, but like most skills in the OR, the more you do it, the smoother your motions will be and the faster your intubations will go.

The devices might also provide peace of mind among your anesthesia team, giving them the confidence they need to safely and effectively manage patients with marginal airways, especially considering intubation red flags aren't always apparent during pre-op screenings. When intubation with a direct laryngoscope fails, providers can grab a video laryngoscope to secure the airway instead of making a second attempt with a direct blade. Why not get it done right the first time with video assistance?

video laryngoscopy DIRECT PATH Video laryngoscopy provides views of the glottis, even when maneuvering around challenging airway anatomy.

2. Affordability
Cost is no longer a significant barrier to widespread use of video-assisted intubation. Even just 5 years ago, high-end devices cost between $10,000 and $13,000. Now, similar models can be purchased for as little as $1,000 to $2,000. That low price tag means you can place the devices in each of your ORs. Even when facilities choose not to invest in the technology, the significant drop in cost means individual providers can purchase their own. In fact, some of my colleagues have bought portable devices that they use to intubate patients every time they administer general anesthesia.

3. Airway documentation
When faced with reports of past intubation problems, providers are often left to wonder about the specific issues the previous anesthetist faced. Why was an intubation deemed "difficult?" The definition is often subjective and challenging to communicate to subsequent providers, especially when patients seek surgical care at other facilities perhaps years after the initial incident. Were the past issues because the previous provider lacked adequate intubation skills? Did a resident attempt to secure the airway? Providers are often unsure of the specific issues they'll face when patients' records simply note that their intubations were challenging during previous surgeries.

Although researchers have suggested that anesthetists note the difficulties they faced in a document addressed to future anesthesia providers, a survey of anesthesia professionals revealed most feel that method is insufficient to avoid potential intubation mishaps during subsequent airway management.

Wouldn't it be great to include captured videos of difficult intubations in patients' electronic health records? That way, providers would be able to review digital records of patients' airways to see exactly where the problems occurred — similar to surgeons watching prior surgeries to improve their techniques or review specific cases before operating. In my mind, reviewing digital images of patients' airways could be a component of routine pre-op screening.

4. Transparency
Providing quality anesthesia care is becoming increasingly important as healthcare transparency becomes more prominent in the minds of patients, insurers and lawyers. I would like to record all my intubations, save them on a flash drive and download the videos to my electronic management system. If the intubation was difficult, which can happen unexpectedly, I'd have it recorded for review or to use as a teaching opportunity. Recording and saving all eventful intubations isn't yet standard practice, but I believe that's where anesthesia care needs to go as we work to make it safer.

5. Improved designs
Although the earliest video laryngoscopes were expensive and bulky, newer models boast more streamlined designs and more affordable price tags. If you haven't shopped the latest devices in recent years, the currently available options are worth another look.

Newer platforms are compact and portable, and in some cases can fit in the pocket of your scrubs. The devices come with intuitive controls and feature high-quality video screens for clear, bright views of patients' airway anatomies. More blade sizes are also available, giving providers additional options for securing airways of various shapes.

6. The future of care
The gradual shift to the routine use of video laryngoscopy will resemble the evolution from open to laparoscopic surgery. Younger surgeons are hardly able to do an open procedure, because that's not how they were trained and they don't practice the techniques. As new anesthesia providers learn how to intubate with video laryngoscopy, use of the devices will become more widespread.

Some providers argue that anesthetists who rely solely on video laryngoscopy eventually lose their capacity to perform direct laryngoscopy. That may be true, but would it really matter?

Video laryngoscopes offer a natural progression from standard intubation techniques. Yes, the devices are sometimes difficult to use in patients with a limited mouth opening, but you'd run into the same issue with direct laryngoscopy. Performing an awake fiber-optic intubation through the mouth or nose is a viable option in those circumstances, and a skill that would still be important for providers to master. In my mind, anesthetists should perform video laryngoscopy for every case and have the ability to rely on fiber-optic intubations to manage difficult airways. I get the sense that some providers are the only ones who are pushing back against that idea.

Safety pioneers
Current guidelines call for the use of video laryngoscopes only when direct laryngoscopy has been attempted and failed. Although the overall use of the devices is unknown, the generally accepted 6% rate of difficult intubations provides some indication of how often anesthetists might opt for the technology to secure the airway.

If that ballpark figure is accurate, the rate must increase. Anesthesia care revolves around technology. Providers have long been interested in new devices that make patient care safer. Now's the time to take another big step forward to enhance airway management during the most crucial and dangerous moments of general anesthesia delivery. It's time for anesthesia providers to be pioneers in patient safety and incorporate video laryngoscopy into their daily practice. Intubation is the most dangerous aspect of delivering general anesthesia, and failing to do it successfully puts patients' lives in danger. Why wouldn't anesthesia providers use a tool that makes securing the airway easier and safer?

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