The Evolution of Video Laryngoscopes

‘Airway Jedi’ Christine Whitten shares her thoughts about the latest advances in a critical piece of technology.

Video laryngoscopes are a surgical innovation that have carved out a niche as the go-to tools for managing challenging airways. The enhanced features these devices have added in recent years have increased their capabilities and promise to usher in a new era that promise to redefine airway management practices.

We spoke to Christine Whitten, MD, who writes the popular blog “Airway Jedi,” about the key features of the newest models, and she shed light on the advancements that could potentially revolutionize airway management in surgery centers.

Q: How have video laryngoscopes transformed the management of difficult airways over the years, based on your experience?
A: I started my anesthesia residency in 1980 — before the advent of video laryngoscopes. At that time, managing difficult airways involved procedures like blind-awake nasal intubation or fiberoptic bronchoscopy. These methods had their challenges and could be especially precarious in trauma cases. They were time-consuming, carried risks of airway loss if the patient became too sedated, and posed the potential for complications like vomiting or aspiration. During an intubation or trauma case, encountering a difficult airway heightened the complexity. If it wasn’t handled carefully, there was an increased risk of losing the airway, leading to serious or fatal consequences.

The introduction of video laryngoscopes ushered in a revolution, providing an elective and rescue tool that allowed practitioners to see around corners very easily. The fiberoptic bronchoscope requires a lot of skill and practice to use, especially in an emergency. But with just a little training, a video laryngoscope could easily intubate a difficult airway most of the time.

Plus, with video laryngoscopy, practitioners could anesthetize and perform intubations while patients are asleep, like routine intubations. This approach is not only faster, which is crucial in busy surgical environments, but it also eliminates the struggles associated with awake intubations. Surgeons are happy because their patients are happy, and because they don’t have to wait as long for intubation. Result: A whole group of providers can now skillfully take care of difficult airways. It just revolutionized everything.

Q: They seem to offer so many benefits over traditional methods. Are there any downsides?
A: If there’s a rescue tool that 99 times out of 100 makes it easy, you can get a little cavalier with it. It’s crucial to acknowledge that any tool can fail, and there may be situations where the tool is unavailable. Practitioners must approach each patient with the understanding that any of these challenges could be true. I always tell my students that if you’re paralyzing a patient for intubation, you are betting that patient’s life that you will be able to ventilate them. If you don’t think that’s a good bet, you shouldn’t do it, no matter what your tool is.

Q: Since you’ve seen the evolution of the video laryngoscope from its early start to the modern day, what are some of today’s elements you’ve found to be most beneficial?
A: Today’s video laryngoscopes come in three main categories, and providers often determine which they prefer to work with, depending on their experience and patient demographics. The first features an angulated blade with a significant arc, allowing practitioners to position the camera in the blade tip for better visibility around corners. However, this requires shaping the endotracheal tube with a preformed stylet, which can be challenging and poses a risk of injury. The second type resembles regular laryngoscope blades, lacking a significant arc. While these blades don’t require a stiff stylet, they may necessitate more manipulation of the head and neck to reliably see the larynx. The third type is an optical device with a channel, shaped to curve around the tongue and provide a straight-on view of the larynx. The endotracheal tube (ETT) must be installed into the channel before intubation. If all is aligned, the ETT can be pushed through the channel into the larynx. This design is advantageous for emergency providers with less expertise in intubation, offering a simplified way to line things up and thread the ETT into place.

When working with video laryngoscopes, a clear image is paramount. You need a high-resolution screen with adjustable white balance to ensure optimal visibility during intubation. The size of the screen is also crucial. It must be large enough to see the necessary details without becoming overly bulky. If the camera isn’t working well, intubation becomes challenging. You can also consider the portability you need, though it is a double-edged sword. It offers convenience but also increases the risk of theft, leading to the necessity of secure storage.

Finally, one additional feature I find very helpful is anti-fogging technology. In the old days, you used to have to turn the blade on, and the lightbulb would heat up the mechanism so that the patient’s breath didn’t fog the camera or lens, because once it’s fogged you can’t see anything. Now some of devices have antifogging mechanisms that heat certain areas, so you don’t have to preheat.

Q: Let’s talk about video a little more. What are some of those key features you find important?
A: When evaluating video laryngoscopes, the choice between detached and mounted monitors is crucial. Detached monitors can be larger, sitting on a stand or lying on the bed next to the patient, connected to the laryngoscope with a cable. On the other hand, some models have the monitor mounted on the handle. Both options have their advantages and disadvantages.

Having a monitor on the handle enhances portability, but the size of the monitor can become a drawback, especially when dealing with small, obese, high-chested or pregnant patients. The bulkiness of the handle may pose challenges during intubation in these cases.

It appears video laryngoscopes are becoming the standard tool for intubation rather than just a rescue option for difficult cases.
Christine Whitten, MD

With the monitor off to the side, there’s the option of a larger image, but it comes with a divided view. The practitioner is simultaneously looking at the patient to insert the blade and endotracheal tube while glancing at the video screen to guide the action. This division in focus is akin to using a touchscreen where you draw on the computer screen as opposed to a mouse off to the side. Both methods work, but the skill set required differs.

The decision of monitor placement depends on individual preferences and requirements. Whether one prefers a straight-on view or is comfortable with an off-to-the-side arrangement is a key consideration. Image clarity is paramount, with factors such as frequency of use and the need for separate monitors influencing the selection process. The size and type of monitor, along with how often the device is utilized, play significant roles in ensuring optimal image clarity during intubation procedures.

Q: What considerations should facilities take into account when it comes to the reprocessing?
A: Cleaning can become a major issue with these. Neglecting to close ports or improperly autoclaving blades can lead to leakage into the video components, potentially destroying expensive blades. Facilities need to establish clear protocols for cleaning, ensuring that all staff members are trained to follow the manufacturer’s guidelines meticulously — especially if you have temporary staff coming into contact with them. Additionally, the choice between disposable and reusable components influences reprocessing. While the camera isn’t typically disposable, some models feature disposable blades that slide or attach to the handle. The choice between disposable and reusable components involves tradeoffs, as disposable options offer logistical convenience but may compromise image quality. It’s essential to weigh the cost-effectiveness of disposables against potential reductions in image clarity.

Q: How many blades should a center anticipate needing to have on hand?
A: The number of blades needed depends on the facility’s volume, size and cost considerations. For centers with simultaneous operations across multiple ORs, the volume of intubations should guide the decision on the quantity of blades.

If you’re in an ICU, you might only need one and a backup blade. But if you’re in a 7-8 OR facility that runs simultaneously, you might need two or three. It’s essential to consider the size and shape variations needed. Pediatric populations, in particular, may require smaller and differently shaped blades to accommodate the variations in airway anatomy. Not everyone is the same size, and the size of the laryngoscope blade for someone who is 6’4” is much different for someone who’s 5’2”.

The decision on the number of blades also intersects with cost considerations. Balancing the need for an adequate supply with the associated expenses is crucial. Centers need to assess their usage patterns, comfort levels with specific blade sizes and the financial implications before determining the optimal quantity to have on hand.

Q: For surgical centers considering an upgrade, what advice do you have in terms of evaluating and selecting the most suitable video laryngoscope model for their specific needs and procedures?
A: Surgical centers must carefully assess their needs and procedures. These key considerations should guide the evaluation and selection process:

• Patient Population: Understand the demographics of the patient population being served. It’s especially important to look at your age groups, as pediatric airways necessitate differently shaped blades compared to adults.

• Logistics: Think about the logistical aspects, including ease of assembly and portability. For larger facilities with multiple ORs, consider factors such as the number of units needed and how quickly they can be transported between locations.

• Volume and cost: Consider the center’s volume of intubations and the associated cost implications. Evaluate whether disposable or reusable components are more cost-effective, taking into account the balance between convenience and potential compromises in image quality.

• Training and skill level: Assess the skillset of the providers who will be using the equipment. Some models may be more suitable for emergency providers with less intubation expertise, offering a simpler way to align and thread the endotracheal tube. By carefully considering these factors, surgical centers can make informed decisions when upgrading their video laryngoscope equipment.

Q: What’s next for the video laryngoscope?
A: It appears video laryngoscopes are becoming the standard tool for intubation rather than just a rescue option for difficult cases. I remember being amazed by an early beta model with a viewscreen integrated into a handle, despite its low resolution. To see how far we’ve come — with a high-resolution screen that is both large and lightweight — is amazing. Affordability is crucial for widespread adoption, and I think it will eventually be comparable to the shift seen with cell phones from their initial versions to the current high-resolution smartphones. I can easily envision a future where a small, flexible and easily cleaned handle-mounted monitor costs between $100-200, so it seems plausible that video laryngoscopes will be universally used in every patient scenario. OSM