Let me put my view of video laryngoscopy right up front. Video laryngoscopy is better than direct laryngoscopy. It reliably provides a better view and requires less force than direct laryngoscopy. There’s less trauma to the patient. First-pass intubation success rates are higher and require less time than direct laryngoscopy. Video laryngoscopy is better for our patients and should be the standard of care for oral tracheal intubation.
Wow, Charlie, those are pretty bold statements! I make these statements based on five years of experience with a variety of video laryngoscopes in the field, the operating room (OR) and cadaver labs. I have these views based on the scores of journal articles and studies I’ve reviewed. I have these beliefs from conversations EMS, anesthesia and emergency medicine professionals from the U.S., Canada, Europe, Australia and Asia. Ask anyone who has ever used a video laryngoscope and you’ll find very few who don’t agree with most of my statements. Yep, I’m pretty comfortable with my point of view, but this wasn’t always my position.
I’m a tightwad. Just ask my wife and anyone I’ve worked with. I hate spending money, especially my own. Also, I am a skeptic. I look at new technology with a suspicious eye. I see no reason to change for the sake of change. Imagine my thoughts back in 2006 when I first saw a video laryngoscope. Wow! That’s a lot of money for a camera and some lights. I’ve done just fine intubating patients for over twenty years with my metal sticks, why should I change? It took me at least a year of working with the instrument before I started to believe there was a better way to intubate my patients.
Direct laryngoscopy has changed very little since its implementation in medicine over a century ago. The early ’90s saw several developments in the anesthesia world. In operating rooms, flexible and rigid fiber optic devices were used to place endotracheal tubes in patients with difficult airways. Even seasoned professionals needed extensive practice with these devices.(2) It was incredibly rare for these instruments to find their way to an emergency department, let alone in the hands of EMS providers.
I’d like to tell you that anesthesiologists used fiber optic instruments as the springboard to video laryngoscopy, but I can’t do that. Video laryngoscopy truly had its birth in the profession of surgery; specifically laparoscopic surgery. The earliest patent I could find for a video laryngoscope was issued to Dr. Jonathan Berall in 1998.(3) The first commercially available video laryngoscope was designed by Canadian surgeon, Dr. John Allen Pacey and introduced in 2001.
I have to make a disclosure here. Dr. Pacey is one of my EMS heroes. He’s a soft-spoken man, but vigorously passionate in caring for his patients and developing new technologies. I’ve known Dr. Pacey for years and I’m honored and humbled to call him my friend. Earlier this year, I was privileged to interview him for this website. During the interview, he told the story of how he developed the GlideScope. I’ve heard the story countless times, but each time it’s told, I listen with wonder. Watch the video interview and see what I mean.
It took me a while to understand that video laryngoscopes are not traditional laryngoscopes. I was routinely frustrated and typically unsuccessful because I tried to apply direct laryngoscopy skills. My epiphany came when I finally realized it isn’t a laryngoscope, it’s a camera! With that paradigm shift, I became proficient. It’s the function of every video laryngoscope to place a miniature camera and light in the supraglottic region and transmit the image to a monitor.
A number of instruments are on the market, and they differ in the location of the viewing monitor, shape of the blade and method of inserting the endotracheal tube. Monitors are either attached directly to the laryngoscope handle or at the end of a cable that is connected to the handle. Attached monitors are compact and typically take up less room in gear bags. When you adjust the handle with an attached monitor, you also have to move your head to stay in front of the screen. Detached monitors provide a larger viewing screen and don’t require you to move your head when you adjust the handle.
I’ve seen three blade shapes; a modified Macintosh, an L shape and the proprietary angle of the GlideScope. Remember, the blade is the vehicle used to place the camera and lights in the supraglottic area using the least amount of force. I’ve found the greatest success by using my thumb and two fingers to manipulate the blade; it just doesn’t take much pressure to obtain a view. If you have to apply significant force to obtain a video view, you need to perfect your technique or try different shaped blade.
Two of the L shaped instruments I’ve used with monitors attached to the handles have an endotracheal tube channel on the right side of the blade. Once you have a clear view of the glottis, advance the tube through the channel into the glottis. The other method of placing a tube is manually placing the tube with your right hand. Some of my European friends prefer to place the tube without a stylette, but I’ve had much greater success using one.
Each device offers other features such as video and still recordings, disposable or reusable blades, battery type, air worthiness certificates, ruggedness, size and monitor size. The best way to determine which video laryngoscope is best for you is to put one in your hand. Try as many as possible. Start with manikins, and then move to the cadaver lab and patients. I’ve used pretty much everyone out there, so let me know if you have any questions.
Let’s talk about the elephant in the room; cost. I’ve met very few folks who weren’t impressed with the view, ease of use, and superiority of video laryngoscopes over direct laryngoscopy. I’ve met very few folks who didn’t hesitate when they saw the price tags and I was one of them. While I am still a card carrying tightwad, I do believe you get what you pay for.
How many of you old timers remember using a Porta-Power and Come-Along for vehicle extrication? When Ed Curtrell showed us a new fangled hydraulic tool, a Model 32 spreader, he wanted $5,000 for the system. Show me a rescue unit today without a high pressure hydraulic tool; it’s the industry standard. Last year, the State of Maryland required every ALS unit to have cardiac monitors with 12-lead ECG capabilities. How much did you pay for your most recent monitor? It’s the standard of care.
With all of the recent literature, articles, and editorials questioning EMS providers’ competency to provide endotracheal intubation, I just don’t understand why folks aren’t running to this proven technology. End-tidal carbon dioxide capnography isn’t cheap, but we embraced it and made it a standard of care. Because of adverse court settlements involving direct laryngoscopy, the attorney for a community based emergency physicians group proactively recommended the group drop direct laryngoscopy by its emergency physicians. The group now either intubates in the emergency department via video laryngoscopy or places a supraglottic airway.
The two operational medical directors who have had the greatest impact on my EMS career are Frank M. Yeiser, Jr., MD and Douglas Floccare, MD. Both of these men taught me that same thing; just do what’s best for your patient. Friends, video laryngoscopy is what’s best for your patients.
Take care and be safe.
1. Richard M. Cooper, Can J Anesth. 2003;50:6, 611-613.
2. Clifford Boehm, MD Assistant Professor of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Personal communication, 2008.
3. Jonathan Berall, US Patent 5,827,178, www.uspto.gov.