From video laryngoscopes to supraglottic airways, advanced airway devices have made intubations and sedations safer than ever — assuming that your anesthesia providers are comfortable using them. You know what they say about assuming.

“We have lots of fancy airway devices and toys that have improved first-pass success and safety of intubation, but staying proficient on all the many different devices can be a challenge when there are 10 different video laryngoscopes,” says University of Florida College of Medicine professor of anesthesiology Lauren Berkow, MD, FASA, who’s also president of the Society for Airway Management.

Calling video laryngoscopes “the biggest innovation in routine airway management in the last 20 years,” Richard P. Dutton, MD, MBA, chief quality officer at U.S. Anesthesia Partners in Dallas, Texas, notes a gradual shift toward intubation via video laryngoscope as the standard of care.

“We still teach direct laryngoscopy, but more and more, the routine practice is turning to video laryngoscopy because it’s a little bit easier and more reliable,” says Dr. Dutton.

Over the years, the screens, optics, size, shape and form on video laryngoscopes have improved so much that, “with a little bit of training, you can turn everybody into someone who can successfully intubate 90% of the American public,” says Tom Losasso, MD, staff anesthesiologist with Summit Anesthesia/Orthopedics in Eagan, Minn. “Every [outpatient facility] should have a video laryngoscope because it makes everybody more effective.”

Emerging disposable video laryngoscopes could make economic sense for smaller facilities as opposed to buying a single reusable scope that costs thousands of dollars and requires maintenance and cleaning, says Dr. Berkow, while larger facilities with dozens of ORs may be better served buying multiple $15,000 reusable scopes rather than hundreds of disposable ones.

Supplemental oxygen devices are gaining favor in response to treating older, heavier patients with several comorbidities.

“You can be really facile with a video laryngoscope,” says Dr. Berkow. “but if your patient starts to desaturate the minute you give sedation, you also need a plan to oxygenate and ventilate”

One such plan uses a device that delivers humidified nasal oxygen at up to 30 liters a minute that’s “surprisingly well-tolerated by patients,” says Dr. Berkow, adding it’s proven effective on patients with some airway stenosis or ENT lesions.

Another is a CPAP-like device that fits over the nose and hooks up to high-flow oxygen. “It stents the airway open, so they’re really valuable for patients with morbid obesity or obstructive sleep apnea,” says Dr. Berkow. “You can put these devices on before they go to sleep and leave them on during airway management, because they’re delivered through the nose.”

High-flow nasal oxygen could let your providers sedate more patients with an uncontrolled airway rather than intubating or placing a laryngeal mask airway along with a general anesthetic. Says Dr. Dutton, “It’s quite possible that in a few years we’ll look at [obese patients] and say, ‘We can do this with some sedation and be reasonably confident the patient will stay saturated on high-flow oxygen.’” One important caveat: High-flow oxygen increases fire risk.

Dr. Berkow says these devices address a vital safety issue for ambulatory facilities: patients with severe sleep apnea who require CPAP. “Being able to better oxygenate them immediately upon extubation may shorten their throughput through the recovery room in an outpatient environment,” she says.

Dr. Losasso believes we don’t yet have the tools to definitively determine how big a risk a particular high-BMI patient may be. While you likely have a magic BMI cutoff, “BMI by itself is not necessarily indicative of the ability to care for [patients] effectively,” says Dr. Losasso, who points to football players whose BMIs are high due to muscle rather than fat. “The question is, what’s the magic metric that’s more specific than BMI that indicates an airway problem?”