BACKUP PLAN Video laryngoscopes might not be the first option for intubation, but they've become part of the standard tool kit for airway management.

No one can argue that video laryngoscopes are user-friendly devices that provide direct views of the glottis for easier endotracheal tube placement. But will they become the standard of care in airway management? Our online poll below revealed many of you think they will — at least during challenging intubations.

Difficult becomes routine
Patients with anterior larynxes are challenging to intubate with direct laryngoscopy and are ideally suited for video laryngoscopes, says D. John Doyle, MD, PhD, professor of anesthesiology at the Cleveland Clinic in Ohio. In marginal cases — patients with airways that are slightly problematic, but not obviously so — video laryngoscopy, or direct laryngoscopy with a video scope on standby, are effective alternatives to awake fiber-optic intubation.

"If the patient has a thick or short neck, video laryngoscopy helps tremendously when intubating," says Connie Casey, RN, CNOR, LHRM, administrator of the Northpoint Surgery and Laser Center in West Palm Beach, Fla. "You can see clearly with the scope when you can barely open the mouth."

Providers might try to intubate with a direct laryngoscope before realizing it's much more difficult than they imagined. Instead of making a second attempt with a different direct blade or other technique, they can simply grab a video laryngoscope in the room or ventilate for another 30 seconds until a technician retrieves the device from storage.

"While not needed in most cases, the video laryngoscope has bailed me out of difficulty a great many times," says Dr. Doyle. He believes you should always have one readily available when routine intubations turn out to be anything but, although that doesn't mean you should always use it. Dr. Doyle works at a teaching institution, and understands the importance of keeping direct laryngoscopy skills sharp for routine cases.

Todd Stevens, MD, agrees. "I think traditional rigid laryngoscopes will remain the standard for routine intubations," he says. "However, I do believe that video laryngoscopes have become the de facto backup standard in the event of an anticipated or unanticipated difficult intubation."

CAUTION The scope position that provides the best view of the airway may not provide the best intubation.

When he began as the medical director for anesthesia at the Advanced Orthopaedics Surgery Suite in Richmond, Va., video laryngoscopes became mandatory in airway carts. "They're a huge safety net if you're having difficulty with traditional instruments or you're concerned you might be dealing with a difficult airway," he explains. "They're our standard of practice."

Many of today's patients are sicker, heavier and presenting with more comorbidities than ever, so "having more tools available makes me feel comfortable tackling different anatomy, especially in patients with more anterior laryngeal positions and soft tissue around their airways," says Dr. Stevens. "Every device at your disposal increases successful airway management, service to your patients and patient safety."

The importance of intubating even difficult airways quickly and with relative ease isn't lost on those outside the OR. "When the technology improves the success rate of first-attempt intubation, it saves us time, which in turn saves us money," says Kari Stewart, BBA, BFA, CASC, the administrator of the Pasadena (Calif.) Plastic Surgery Center.

Can you push the envelope?
As a general rule, says Dr. Doyle, you should make 3 attempts at placing the endotracheal tube. If they prove unsuccessful, wisdom dictates you wake up the patient and proceed with fiber-optic intubation.

"Many times I'd get called to the OR when a patient couldn't be intubated, slide in a video laryngoscope, get a really good view of the glottis and put the tube in without difficulty," he says. "That avoided having to proceed with awake intubation or canceling the case altogether." But should video laryngoscopes give providers more confidence in managing the airways of high-acuity patients in the outpatient setting? "That's one of the big debates among anesthesia providers," says Dr. Doyle.

Not long ago, he says, no one in day surgery centers would operate on patients with BMIs over 35. Now many providers argue that intubating those individuals has become easier because of improved airway technologies such as video laryngoscopes.

Dr. Doyle believes assessing how easy or difficult it is to intubate high-acuity individuals oversimplifies a complex issue. "After you extubate these patients," he explains, "many of whom have sleep apnea, questions remain about how long they should be monitored post-operatively in ambulatory settings."

User-friendly features
Compared to other techniques such as fiber-optic visualization, "the proper use of a video laryngoscope is easily learned because the technique is basically the same as performing standard laryngoscopy," says Charles A. DeFrancesco, MD, staff anesthesiologist at Delmont Surgery Center in Greensburg, Pa.

Some providers prefer the portability of small, pocket-sized scopes, but the devices can be a challenge to keep track of and are easy to misplace, says Dr. Doyle. He likes that the viewing units of his hospital's video scopes are housed on stands that roll easily from room to room.

Dr. Stevens recommends scopes with adequately sized viewing screens, especially in teaching institutions or in facilities where MDs supervise CRNAs. "The screen provides better views of the laryngoscopy, thereby facilitating teamwork during intubation," he says. "Since I can see what the CRNA is seeing, I can better assist and offer feedback. It makes me feel more involved, rather than relying on what someone else is seeing, and what they're telling me."

Some video laryngoscopes have channels for placing the endotracheal tube through, but the devices aren't necessarily as easy to use as conventional video scopes, says Dr. Doyle. "With non-channeled devices, providers can independently manipulate the laryngoscope and endotracheal tube," he explains. "That 2 degrees of freedom has a clear advantage over placing the tube through a channeled device, which positions the tube only where the channel directs it."

Dr. Doyle says the scope position that provides the best view of the airway is not necessarily the position that provides the best intubation. "It's frequently wise to pull back from the glottis in order to achieve a more distant view when placing the endotracheal tube," he says. "If you're too close, the trajectory of the tube can be unfavorable, and it tends to hit the anterior tracheal wall."

No magic bullet
Dr. Stevens believes video laryngoscopes have become the go-to tool for many young providers at the first sign of a difficult airway. But he cautions against false confidence when reaching for what they think is a magic bullet for intubation. "Take a step back and realize that video laryngoscopy isn't an airway panacea," he says. "It's not a guarantee that you'll get a great view and get in. Pre-op evaluation of the airway and proper planning are still airway management's essential elements."