Cheryl K. Gooden, MD, has performed hundreds of tracheal intubations - some with unique challenges like the recent case of a 4-year-old with a Pierre Robin Sequence. Just one year earlier, anesthesiologists cracked some of the patient's teeth in their unsuccessful attempts to intubate with a direct laryngoscope. But using a video laryngoscope, Dr. Gooden pltaced the tube with a clear view of the airway despite the child's displaced tongue and small lower jaw.
"I've had a number of emergency situations when I've been able to rescue an airway where someone else failed, particularly the more difficult airways with craniofacial abnormalities," said Dr. Gooden, associate professor of anesthesiology and pediatrics at Mt. Sinai Medical Center in New York. "Video laryngoscopy has improved our ability to secure these airways by offering an expanded view so we can better appreciate the overall anatomy."
In just under a decade, the video laryngoscope has become a go-to device for difficult airways. Its built-in camera lets specialists explore beyond obstacles in the airway unlike traditional laryngoscopes that require direct line of sight. Video laryngoscopy's path for the future looks clear, despite cost concerns and a need for more research.
"Our surgical colleagues have been using video technology since the early 1980s, and we are just coming on board now," Dr. Gooden said. "Video laryngoscopy is here to stay. I don't think it will totally replace direct laryngoscopy, but it's becoming more routinely incorporated into daily practice."
Considering the options
Various evolutions of the video laryngoscope have hit the market since the first device became available in 2001. "Over time we're seeing the technology getting even better with higher resolution, better digital imaging, and more options," Dr. Gooden said.
For instance, some devices now feature built-in anti-fogging tips to keep excess secretions from obscuring the airway view. And some of the latest generation models can record high-definition footage of a procedure to a USB flash drive or SD card. Dr. Gooden has used these images to take a closer look at anatomy with her students and review abnormalities in the airway with her surgical team.
By design, some video laryngoscopes have a straight or curved blade with a slightly angulated camera to provide a more interior view.
"It's not quite as direct a shot so you have to curve the tube more with a stylet to get it into the airway," said Michael Bigham, MD, a pediatric intensivist and medical director of pediatric transport at Akron Children's Hospital in Akron, Ohio. "By nature, it requires far less manipulation of the lower jaw and tongue because it provides a view around the curve rather than having to straighten out the curve to get a better view."
Other disposable optical devices have a curved design with a guide channel in which the endotracheal tube is placed prior to placing the laryngoscope. With this setup, you put the device in the pharynx, center the glottic opening on the lens, and then slide the tube along the channel.
Studies generally have confirmed the value of video laryngoscopy, but few have looked at which devices specifically are associated with fewer problems advancing the tube into the trachea.
"I don't have a device that I think is a panacea for managing routine or difficult airways," said John E. Fiadjoe, MD, clinical assistant professor of anesthesiology at Children's Hospital of Philadelphia (CHOP). "The answer to which device is best will have to come out of prospective randomized data; however, I suspect that we'll find different types of anatomy are amenable to different devices."
Intubating infants and peds
More research and clinical experience also are needed to determine which of these devices work best in pediatric and neonatal patients. "The technique of inserting the blade is the same with any patient, but the depth is a lot shallower in pediatrics and neonates," Dr. Gooden said. "In terms of the blade sizes, they're becoming more available in various sizes to fit the very smallest preemies all the way up to the adolescents and beyond."
Some newer blades also feature a somewhat narrower design so that it is easier to get into the mouth and maneuver around obstacles created by craniofacial abnormalities like micrognathia.
But before tackling these difficult situations, most clinicians recommend trying video laryngoscopy during routine use first. "I support doing some intubations in a more controlled environment like an operating room specifically with pediatric patients just because the large size of the blades and the small oral aperture of the child is really quite challenging," Dr. Bigham said.
Clinicians at CHOP had the same idea when they recently launched a trial comparing video versus standard laryngoscopy in children with normal airways who present for routine anesthetics and intubation.
Working with normal airways allows clinicians to familiarize themselves with the major differences in the infant anatomy such as the higher location of the glottic opening and to devise an appropriate approach.
"Make sure you have enough space to pass the styleted tube without causing injury," Dr. Fiadjoe said. "You have to be very careful with the little patients because your margins of error are very small and your working space is very small."
Looking at the cost and benefits
As the technology continues to develop and new patient populations are garnering the benefits of video laryngoscopy, cost remains a hindrance. Disposable optical laryngoscopes cost about $80, and conventional laryngoscopes range from $200 to $300, while video laryngoscopes typically cost $10,000.
Most clinicians argue that you cannot put a price on patient safety. "One rescued airway is a significant advantage of these devices because if you lose a patient because you just don't have the equipment, that cost is much higher than the cost of these devices," Dr. Fiadjoe said.
When considering how the price compares to standard devices, it also is important to take into account the additional expenses that come into play with direct laryngoscopy. Hospitals must process blades in a sterilizing system between patients. During that time, some blades are temporarily unavailable because they are not in circulation, while others need to be replaced or repaired because their light bulbs have died out during sterilization.
"There's a significant cost in processing," Dr. Fiadjoe said. "I suspect if you factor in all the costs of sterilizing blades, going to one of the newer technologies where you have a disposable blade may actually be more cost-effective. I also think the cost of these devices is going to decrease significantly as the technology becomes more ubiquitous."
And clinicians are hopeful that as video laryngoscopy becomes more prevalent, reimbursement will improve too. Right now, the best way to get reimbursed is by using CPT code 31500 for emergency endotracheal intubation. In routine use, the cost of the device is not reimbursed because it is bundled in with the procedure code. But that could change as video laryngoscopy becomes more prominent in hospitals.
"I have a sense that video laryngoscopy is going to play a bigger and bigger role in anesthesia practice and intubation," Dr. Fiadjoe said. "I think that it's important that critical care practitioners become familiar with these devices because they are going to be significant tools for airway management."
Contact Colleen Mullarkey at firstname.lastname@example.org.