Are Video Laryngoscopes the New Standard of Care?


Not yet, but some experts say the devices are revolutionizing airway management in outpatient settings.

Will video laryngoscopes become the standard of care for managing difficult airways? Of the 50 anesthesia providers we polled, 62% think they will. Count Russell Lewis, AND, BSNA, CRNA, of the Lower Umpqua Hospital in Reedsport, Ore., among them. "I hear often that some providers prefer not to use (a video laryngoscope) because they want to maintain their intubating skills," says Mr. Lewis. "After 30 years of intubating without the video laryngoscope, I want to use the tool that makes the job safest and easiest." Here's more of what we learned from our survey.

Great visuals, added safety
Standard "laryngoscopes have become obsolete in this new age of video technology," says William Landess, CRNA, MS, JD, the director of anesthesia at the Palmetto Health Richland Campus in Columbia, S.C. "With the tools available, why continue with this dinosaur approach to securing an airway?" He thinks conventional laryngoscopy will fall by the wayside "within this decade, and only be minimally taught as an adjunct and relic of the past."

Video laryngoscopes provide a direct view of the glottic inlet, lead to less muscle manipulation and limit damage to surrounding anatomical structures, says Mr. Landess. The devices are intuitive and user-friendly, meaning most clinicians who've never picked up a video laryngoscope can quickly become proficient in its use. "The technology becomes more efficient the more it's used," says Mr. Landess, who has his providers practice using video scopes during routine cases involving simple airways so they're expert with the devices when confronted with true airway emergencies.

Rigid video laryngoscopes "let you thread the (endotracheal) tube through the trickiest of vocal cords," says Mahlon Forman, BSN, CRNA, of the Texas Institute for Surgery in Dallas

When planning which anesthesia tools to purchase for the now year-old Delmont Surgery Center in Greensburg, Pa., Charles A. DeFrancesco, MD, the center's director of anesthesia, decided a video laryngoscope was a must. "Being the sole anesthesia provider at an ASC, it lets me successfully intubate patients with unrecognized difficult airways, without the assistance of additional skilled anesthesia personnel," he says.

Before Dr. DeFrancesco opted for video technology, he relied on fiber-optic scope intubation to help manage difficult airways. "But I was never really satisfied with that technique," he explains. Once he reached the trachea with the scope, he'd have trouble advancing the endotracheal tube over it and had to deal with troublesome secretions. Plus, he says, intubating with fiber-optic scopes is often a 2-person job, something that's difficult if not impossible to accomplish as the sole anesthesia professional in a busy surgery center. "Intubating with a video scope is something I can do on my own," he says. "Regardless of (the type of facility) where you work, you need a method to bail you out of a difficult airway situation."

The most effective devices are intuitive to use, feature high-quality video images and are highly portable, says Mark Green, CRNA, MSN, who practices at Springfield (Vt.) Hospital. He has ordered a scope with an image display unit slightly smaller than an iPad, making it easy to move from room to room and bed to bed. "It's a compact unit that can be rolled around on a tripod stand," explains Mr. Green. He can easily tote the device from the OR to the intensive care unit of his hospital to perform emergent intubations on patients he has to assume — better to be safe than sorry — have difficult airways.

Reader Survey Results

Do you currently use a video laryngoscope?
Yes: 78%
No: 22%

You use video laryngoscopes because:
It helps you better manage difficult airways: 92.1%
It's a valuable teaching tool: 5.3%
It helps you better perform routine intubations: 2.6%

You do not use video laryngoscopes because:
The technology is too expensive: 58.3%
You do just fine with standard laryngoscope blades: 33.3%
Your case mix doesn't require its use: 8.3%

Would you work more challenging airway cases if you had access to a video laryngoscope?
Yes: 67.5%
No: 32.5%

Will video laryngoscopes become the standard of care?
Yes: 62%
No: 38%

Source: Outpatient Surgery Magazine reader survey, April 2011, n=50

But a new standard?
The wider viewing angle than that offered by standard laryngoscopy equipment greatly increases the ability to visualize airway anatomy and tube placement, explains Mr. Lewis, who says he can literally look around the corners of patients' airways instead of seeing only what's directly in front of his blade.

Mike Morel, CRNA, APRN, MSNA, director of anesthesia services at Volunteer Community Hospital in Martin, Tenn., doesn't believe video laryngoscopes will become the standard of care anytime soon — 99% of airways are secured easily with regular laryngoscopes or LMA-type devices, he says — but he's happy his facility recently added video technology to his arsenal of airway tools. He recalls a pair of difficult airways he recently had to intubate: One in a woman with a healed broken jaw that was stable but still sore, the other in a patient who was 5-foot-2 and weighed more than 300 pounds. Two different difficult airways that a video laryngoscope helped him manage with ease. "I was able to slide it in without much effort or muscle manipulation in either one, which was especially important dealing with the fractured jaw."

Video laryngoscopes are valuable safety nets, says Mr. Morel, but he advises against tucking them in the back of your anesthesia carts. "You need to practice (with the device) on healthy patients so you don't have issues when you actually need to use it."

Dr. DeFrancesco likes that using video laryngoscopes "is just like using a standard laryngoscope, only with a different mechanism. There's something to be said for that."

Mr. Green stops short of calling video laryngoscopes the panacea of difficult airway management, but he does believe the devices enable providers to be more successful in managing challenging airways than any other technique. "I'm beginning to think they could become the standard of care," he says.

Path of least resistance
When faced with a difficult airway, video laryngoscopes are the straightforward solution to getting the vocal cords into view, even when working around challenging patient anatomies, says Mr. Green. "Why wouldn't you use the path of least resistance?" he asks. "When you place the endotracheal tube right where it needs to be, you're a hero."

Handling difficult airways safely and efficiently can also help keep your surgical schedule on track. In a facility like Dr. DeFrancesco's, a busy center hosting many cosmetic procedures stacked back-to-back, a single airway issue can grind patient flow to a halt. "One problem case ruins our efficiency," says Dr. DeFrancesco. "But if I can bail myself out, get a tube in place and proceed with a case, that saves our day."

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