Quality Corner: Video Laryngoscopy

For those of us who began our careers in EMS in the last century, direct laryngoscopy (DL) was the only option for oral endotracheal intubation. The steel, cylindrical, battery-containing handle and light-tipped blade has been the standard for laryngoscopy and endotracheal intubation since the device was first invented by Henry Janeway back in 1913. The only option available to users was whether they preferred the straight (Miller) or curved (Macintosh) blade.

Late in the twentieth century, fiber optics started being used more and more in medicine. Ironically, however, fiber optics became the standard of care in orthopedics, pulmonology, proctology and pretty much all the rest of medicine except for the highest stakes practice of medicine of all—emergency medicine.

One of the EMS agencies I work at recently adopted a facilitated intubation protocol using Etomidate. Unlike conventional intubation, where you manage the patient's airway as you find it, facilitated and rapid sequence intubation requires sedating or completely paralyzing the patient, effectively taking away whatever degree of airway control they may have. This is done to perform intubation earlier in hopes of heading off further deterioration of the patient. However, taking away a patient’s natural airway control places 100% of the burden of managing that airway on the practitioner, and that burden is instantly felt, appreciated and respected by any responsible provider.

One of the advantages of adapting such an aggressive airway management program is that it has a way of re-focusing the participating agency and its providers on the criticality of airway management in general. As part of our facilitated intubation program, we conducted mandatory airway management classes that reviewed the profile of the new drug we were planning on using, basic airway anatomy, management strategies for difficult airways and failed intubation, and a review of both direct and video laryngoscopy (VL).

Every EMS system has a cadre of providers who through experience and personal drive for perfection become the airway management gurus. One of our airway gurus is Scott Henley, deputy chief of Central Bucks Ambulance, a flight medic with Mid-Atlantic Medevac and an EMS instructor. During our airway training Scott preached the concept of making your first intubation attempt your best attempt by doing everything you can to set yourself up for success.

A few years back we purchased the Ranger Glidescope as an optional tool for intubations. Human nature being what it is, most providers opted to stay with the conventional laryngoscope for their initial intubation attempt and only utilize the Glidescope when confronted with a difficult or failed intubation. The most common reasons providers gave for leading off with the conventional laryngoscope were: they were more familiar and comfortable with the older technology they learned to intubate with and they were afraid they would lose the skill of conventional intubation technique if they did not continue to practice it.

Scott’s mantra of making your first attempt at intubation your best attempt struck a chord with me personally, in that it refocused the true goal in intubation—that being to utilize whichever technique is most likely to succeed and in the best interest of the patient, not the technique that will serve as a personal skills fest for the EMS provider.

The biggest difference between direct and video laryngoscopy is exactly what the terminology implies; conventional laryngoscopy with a curved or straight blade creates a direct line of sight from the eye to the glottic opening, except of course in those cases of anterior grade 3 and 4 airways. Video laryngoscopy provides a look around the corner. It's a better view, but that view in and of itself does not create a direct line for advancement of the endotracheal tube. For the tip of the tube to end up where you're viewing, a more acutely angled stylet or a tube channel which follows the angle of the blade is necessary.

Video laryngoscopes provide a clearer view of the larynx and a wider view, including surrounding anatomical structures, which helps to more clearly identify where the user is. It also provides a screen for others to observe the laryngoscopy, which can be beneficial for teaching purposes.

The Glidescope by Verathon was the first video laryngoscope to become commercially available in 2001. The Glidescope incorporates a high-resolution digital camera and light source mounted on the blade and connected to an LCD monitor. The Glidescope has the added advantage of its curved blade being angled 60 degrees anteriorly, which makes it valuable in managing the most common difficult airway problem—the grade 3 or 4 anterior airway.

Several other brands of video laryngoscopes are now also on the market such as the King Vision and the C-Mac. Each video laryngoscope has its own specific design features and selling points, and it goes without saying that cost is also a major consideration for many cash-strapped agencies trying to provide better EMS with less and less money.

Much of EMS has been slow to adopt video laryngoscopy as the primary mode for intubation, for reasons not the least of which include cost. However, after more than a decade most systems have or are now in the process of adopting it. Video laryngoscopy is unquestionably becoming the standard of care for orotracheal intubation in 21st century EMS, for the simple reasons that it makes intubation safer and easier with an improved first-pass success rate.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.