TRY IT, YOU'LL LIKE IT When you factor in cost, portability and ease of use, there's no reason not to have a video laryngoscope in every OR.

Having a video laryngoscope sitting in the operating room is like having a shiny sports car parked in the garage. If it's around, you're going to want to take it for a spin. And once you try it, you're going to love it so much that you'll never want to go back to your standard direct laryngoscopy blades. Or your minivan. Which begs the question: Should you use video laryngoscopes for all intubations, or just reserve it for difficult ones?

Some anesthesia providers would argue no, that while video laryngoscopes are a nice tool to have, they often have a better view with a standard Miller blade, its straight blade directly lifting up the epiglottis and providing a clear view of the glottic opening. They might also argue that their intubation skills will atrophy if they rely solely on video laryngoscopy. What if they're in the cath lab, MRI lab or some other off-site location that doesn't have a video scope and there's an airway emergency? They'll be in a world of trouble if they need to do an emergency intubation.

Let me address that last point first. True, video laryngoscopy is easier to learn and perform, but performing direct and video laryngoscopy is similar in style and technique. The only difference is you're looking at amazing anatomic views on a video screen, not crouching and using one eye to look down someone's mouth to align the oral—pharyngeal—laryngeal airway axes for an optimal view of the glottis. With a camera at the end of the blade, as close as possible to where you're trying to get to, video laryngoscopes give you the best view you can possibly get. I'm not sure how anyone could argue that the view is better with direct laryngoscopy. Video scopes provide a better view of the anatomy and of the endotracheal tube passing through the vocal cords, making the procedure safer for the patient.

Backup no more
Video laryngoscopes were traditionally used as a backup to standard direct laryngoscopy blades. And it's true that you can intubate 90% of your patients with a standard blade. But here's the main reason to use them on every patient: It's impossible to predict a difficult intubation.

Things might seem routine before the patient goes to sleep, but then you encounter a big tongue, a stiff neck, loose teeth or a narrow mouth opening. You won't have the time to scramble to find the video laryngoscope. If you could start with the laryngoscope that gives you the best success when unexpected difficult intubations occur, why wouldn't you always have one at your elbow?

Cost was the main obstacle to having a video laryngoscope in every OR. Maybe you'd be able to purchase 1 or 2 to cover all your ORs. Thankfully, that's all changing as prices continue to drop.

A couple years ago, a video laryngoscope cost about $10,000. Now you can purchase one for about $2,000 to $3,000 (the price of ours just dropped from $2,500 to $1,800!). Our disposable plastic blades, which come in boxes of 50, cost $10 each. By comparison, it costs about $12 to use a standard disposable laryngoscope: $9 per disposable handle and $3 per disposable blade. So we're saving $2 per intubation using the disposable plastic replacement options versus the standard disposable laryngoscope handle-blade. Plus, disposable blades that pop off after use decrease the risk of infection and make cleaning the device extremely simple.

The reduction in size and portability has also been a huge attraction for the newer models. Today's video laryngoscopes are small enough to fit in your pocket, have fold-up screens and are completely battery operated (our batteries last for 250 minutes). We store the scopes either in the door of the anesthesia machine or in the drawer of the anesthesia cart. It's a good idea to label them with an OR room number so that a provider who uses one in ICU knows to return it to the OR.

Regardless of cost and convenience, video laryngoscopes are an inexpensive investment if they minimize the potentially catastrophic risk for even one lost airway that could easily lead to a multi-million-dollar lawsuit.

Instantly hooked
A quick story to end. Not long ago, my hospital had only 1 video laryngoscope for the whole department: 12 ORs and 4 endoscopy suites. It was attached to a big pole that you had to wheel around.

But anesthesia is changing from a lower-tech, higher-touch specialty to a higher-tech, lower-touch specialty. We now have a video laryngoscope in every OR. After a few months of daily use, even those anesthetists who were hesitant to try them became hooked and didn't want anything but the video scopes. They'd get upset if for some reason there wasn't a video scope in their room when they arrived in the morning. They've come off the bench and into our starting lineup to become our first choice for all intubations. OSM