GUIDING VIEW Video-assisted laryngoscopy lets you navigate difficult airway anatomy.

Video-equipped laryngoscopes were originally designed to help resolve emergency airway situations, but have gained widespread and routine use for intubating even less-than-difficult anatomies. To the anesthesia providers who swear by them, the following considerations can make a big difference when airway management demands a closer view.

1. Ease of use
The video laryngoscope has become the preferred alternative to traditional direct laryngoscopy for emergency endotracheal intubation. It's a choice that providers facing airway difficulties can put into immediate action. The key to its use, then, is ease of use. "Is it straightforward in terms of hooking it up, turning it on and using it in clinical situations?" asks CRNA Jeff Cryder, BS, BSN, MSA. He and his colleagues at Scott & White Hospital in Temple, Texas, have trialed a range of video laryngoscopes on the market, observing also how they fit each patient.

Some devices conveniently approximate how the blade is inserted into the mouth, so it's easier to maneuver and align with the glottic opening, in comparison with a fiber-optic scope or intubating LMA, says Mr. Cryder, adding that others are difficult to get into the mouths of patients with short necks, large breasts or halo traction. A device that offers an assortment of blades — different sizes, types and degrees of curve — will be more adaptable to more anatomical situations, whether that means adults, obese adults or children.

While many video laryngoscopes have a shallow learning curve, don't take the increased safety they deliver for granted. "Make sure everyone managing airways is trained and checked off on the device, so they will know the right way and wrong way to use it," says Mr. Cryder.

In fact, the need for training is a compelling argument for routinely using video laryngoscopes in uncomplicated cases. You can't expect a rapid-response backup plan to succeed if it hasn't been thoroughly practiced.

"The single most important thing is to use these devices to get good," says D. John Doyle, MD, PhD, a professor of anesthesia at the Cleveland Clinic in Ohio. "If you only use them for emergencies, you're not going to be very slick with them." Use them in normal anatomy to develop and maintain competency, he suggests. Practice makes the purchase pay off.

VISION UPGRADE
Video Laryngoscopy's Clear Benefits

LINE OF SIGHT Direct laryngoscopy requires patient and provider manipulation to see the way in.

The advantage of the video laryngoscope, a hybrid of traditional laryngoscope blades and the fiber-optic bronchoscopes used for awake intubation, is that it essentially sees around corners. A camera at the tip of the blade shows the view from around the airway's 90-degree turn without the need for patient-head-tilting or provider-neck-craning.

Compare that to traditional direct laryngoscopy, where the anesthesia provider's point of view is over the handle. The scope's blade has a light at the tip to illuminate the airway, but the patient's anatomy, which makes a 90-degree turn from the tongue to the trachea, doesn't offer a direct sight line.

In order to see through a straight plane, negotiate the airway and achieve intubation, a provider must tilt the patient's head back and lift up the tongue. But obesity, cervical spine abnormalities and other anatomical co-morbidities can complicate these moves, as they do airway management.

"We used to have fully stocked airway carts: LMAs, light wands, a fiber-optic bronchoscope," says Kevin S. Henson, CRNA, MSN, the director of anesthesia services and chief CRNA at Appalachian Regional Healthcare System in Boone, N.C. "Now it's just video laryngoscopes. This is the gold standard for everything we think is likely to be an advanced airway."

He says even the worst possible airways can be successfully intubated without trauma. "The visualization really opens it up," he explains. "You can do so much more, much more safely with it."

The technology has even made its way into the American Society of Anesthesiologists' 2013 update of its Practice Guidelines for Management of the Difficult Airway (tinyurl.com/kdfe9o3). "While it does not name it a standard of care, it does for the first time mention it as a choice," says D. John Doyle, MD, PhD, a professor of anesthesia at the Cleveland Clinic in Ohio.

— David Bernard

2. Image and output
With video laryngoscopes, the quality of the image is an important consideration. Image quality differs from device to device, and depends on the camera's position and resolution, the system's reliability and the laryngoscope's screen, among other factors.

For instance, what sort of image does a device's camera show you? The highest-quality laryngoscopes, says Mr. Cryder, show a wide area of the oropharynx since the camera doesn't sit right on top of the glottic opening. "It's the difference between looking at your finger while holding it 2 inches away from your eyes, or holding it 12 inches away," he explains. "It makes it easier to find landmarks once you're inside the mouth."

Compare this to a view that's too close to the oropharyngeal structures. "It's easier to get lost because you're so close to tissue, and slight movements of the view can throw you off course," says Mr. Cryder.

Also, how well does the screen display the image? On lower-quality systems, displays can lack sharpness and clarity, or can be erratic, occasionally freezing or dropping out, he adds.

Some models feature a mobile-phone-size screen mounted directly onto the laryngoscope handle. On others, the handheld unit connects to an external tablet-computer-sized screen. While screen size may be a factor in image quality, it's not the only factor. "I don't want to say bigger is better," says Kevin S. Henson, CRNA, MSN, the director of anesthesia services and chief CRNA at Appalachian Regional Healthcare System in Boone, N.C. "But a bigger screen means you can pick out more anatomy. A bigger screen means better clarity, more data, better clinical decisions."

A larger, external screen also offers the advantage of letting other surgical team members see what the anesthesia provider can see, to better provide assistance. If the laryngoscope and screen unit are equipped with standard video cable jacks, it opens the door to displaying the airway imaging on surgical monitors or even the big, wall-mounted screen for everyone in the room to see.

FOR ALL TO SEE Dr. Doyle demonstrates the training benefit of an external screen.

3. Availability
How your anesthesia providers intend to use video laryngoscopes can also influence which devices to choose, particularly in terms of their portability, power and reusability.

Compact, self-contained, handheld units travel easily for emergency airway visualization wherever it's needed. But with portability come issues of wear and tear, whether the battery is regularly and sufficiently charged, and even where the instrument is when it's needed, says Mr. Henson. Laryngoscopes with external IV-pole- or dolly-mounted screens are mobile but easy to locate. Their stability offers durability and they can be plugged in for redundant, reliable power.

The proportion of reusable to single-use components varies from product to product, and can involve both budgetary and reprocessing workflow issues. With most, the screen, camera, fiber-optic light source and other electronic components are surface disinfected. Some incorporate an autoclavable or immersible handle and blade, while others slide a camera stick into a disposable blade. Sometimes a disposable plastic cover shields the assembly during use. Some are entirely disposable. What's essential, says Mr. Cryder, is following the manufacturer's directions for turnaround to the letter.

"Cost is a big deal, it'll always be a big deal," says Dr. Doyle, but the rescue technology should be readily available to each anesthesia provider working in each OR at a moment's notice.

The best option for equipping your providers may be seeking out others' opinions. Before arranging hands-on trials with manufacturers, be sure to call the anesthesia and emergency departments at large teaching hospitals in your area. "They usually have 1 or 2 different types and have tried them out," says Mr. Cryder. "How have they liked their devices?"