Video-Laryngoscopy in EMS

An emerging trend this year is the explosive growth of video-laryngoscopy. The buzz at this year’s ASA Conference in San Diego is that in 10 years we will all look back on the blade & handle visual laryngoscope as a primitive instrument. With a video-laryngoscope more than one person sees the tube goes between the vocal cords. It makes the difficult anterior airway easier to see, particularly when the head and neck are motion restricted.

A video-laryngoscope is defined as an instrument for performing endotracheal intubation which displays the target anatomy on a screen or monitor. The first were big and cumbersome. But now they come in many flavors and styles, from small hand-held devices to those that can even display on a big external screen.

In recent years we have seen many reports of problems with pre-hospital endotracheal intubation. Some EMS systems have started using more supraglottic rescue airways and fewer ET tubes. Nobody ever said a properly placed ET tube is not the definitive advanced airway. It is just that without much help and few resources, the risks in some areas were starting to outweigh the rewards. Video-laryngoscopy is one heavy weight to drop down on these scales.

This technology holds the promise to make intubation easier and safer, with fewer complications. It could re-focus our efforts back on what was always the gold standard of airway care. We are now seeing only the beginnings of these devices adoption by EMS providers, but they have become commonplace in hospital anesthesia departments.

Verathon makes the industry leading Glidescope, including a pre-hospital and military version called the Ranger. You will probably find a Glidescope in the majority of large hospital anesthesia departments. They are the ones that really started video-laryngoscopy.

We also saw the recent introduction of many new models of video-laryngoscope and improvements to older ones this year. Karl Storz who makes the C-MAC Video Laryngoscope and is now appearing at many leading EMS conferences intoduced the D-Mac blade, for difficult intubation. Ambu now offers the Pentax Airway Scope, LMA has the McGrath Series 5 Video Laryngoscope and King Systems the new King Vision, Aircraft Medical the new McGrath Mac, and the new Truview PCD is from Truphatek (whom on disclosure I work for).

Some of these devices use a more traditional blade and handle with screen approach. The advantage of this style is the basic mechanics. You hold the video-laryngoscope in your left hand and place the tube with your right, just like traditional laryngoscopy. Using an old and well-developed motor skill is always easier than learning a new one. Others have a J-shaped insertion member with screen at the top, which into which you load a lubricated ETT.

The J-shaped devices all in some measure great or small, owe their design success to the Augustine Guide. The Augustine Guide was the first device to demonstrate that on most normal airways this style tube delivery system can work very well. The Augustine Guide was invented by the same brilliant anesthesiologist Scott Augustine, that invented the world’s best known patient warming system the Bair Hugger.

The Airtraq was the first of this type device to really achieve widespread popularity and they now have a video option for it too. The key to using any of this style device is to keep the vertical member vertical. Don’t tilt the top of the device back. Lift up and push forward towards the patients feet to open the epiglottis.

In the case of the Glidescope or the Truview PCD, the view is one that is tilted anterior. This makes easier viewing of the more anterior airway possible. Reducing the grade or difficulty by even 1 grade can spell the difference between life and death. The Glidescope has the patented feature of mounting the camera at the end of the blade at a 60 degree angle.

In the case of the Truview PCD, the distal lens on the optical view tube is a prism. It looks 47 degrees anterior, also making those impossible airways viewable. But the Glidscope and Truview are but a few of the many choices now available. They are just two of many new video devices for intubation.

Now with 10 years of history and clinical trial behind them, video-laryngoscopes are proving to have a vital role. They can help make the difficult airway manageable. It is only a matter of time now before the reliability goes up enough and the prices come down enough to make these devices viable in EMS. Frankly, a few of them already are quite viable. Some more progressive EMS agencies are already using them.

About Dan White

I'm a retired Paramedic and EMS Instructor with 35 years EMS and emergency medical product experience. I love canoes, cars and EMS. I write about EMS Technology on the Paramedic Blog, the Insights on Innovation column for EMS1.com, on AmbulanceWorld.com and Multibriefs.com. I work for Intersurgical, Inc. managing EMS sales and distribution. I can be reached directly at 573-240-0002. Follow me @Paradan on Twitter
This entry was posted in EMS Equipment, EMS Technology, New EMS Products. Bookmark the permalink.

8 Responses to Video-Laryngoscopy in EMS

  1. John says:

    I honestly believe that you hit the nail on the head in the last paragraph when you touched on pricing coming down. The fact of the matter is that in this economy a private ambulance company will not spend the kind of money required to outfit every single ALS unit with a video laryngoscope. It’s just not cost effective from a business standpoint. That being said, nobody is contesting the clinical benefit. It would obviously be better to have one on the unit than the regular laryngoscope. Perhaps in the old days (prior to the economic depression) the fire departments would be able to splurge and purchase these in bulk, but even those guys are pinching pennies now! Who saw that one coming?!? Anyway, I believe eventually we will all find a way to fit these into our budgets but until then it will be the old fashioned laryngoscope! Thanks for the article.

  2. John Wales, MD says:

    The true market for all of these video larygoscopes are the many EMS crews and first responders across the world. Price point below $1000 is important (below $500 for sure), and reusables or disposables under $20 a piece would bust this market wide open. The days of $10-15,000 for this equipment is over. Technology for the masses!

    • john moyers says:

      Doctor
      THANK YOU and I would hug you if I were near you. My name is john moyers DVM, PHD, EMT-B, EMT-Paramedic (I became a paramedic after fiance died in car crash in 2006 and I retired from research director of lab at UK college of medicine, then recovered) and I LOVE being a paramedic! I have looked EVERYWHERE for the price of this device (having done 5000 animal intubations I have only done 11 humans as I am still a “rookie” here. Yours is first site to actually tell the price of this device;; I have seen them at seminars, but never even could get a “range”! I will buy my own, EMS services are financially strained enough!
      ANywhere I can find to order one that actually lists price?

  3. Brandon, EMT says:

    Agreed. Pricing is going to be a factor that can’t be argued. We have tried the Ranger, Pentax, Airtraq and most recenlty the Vision. We love the Airtraq due to its price, but would like a screen that we can take in the field. The Vision is under 1000.00, so that is the way we are leaning.

    I would also recommend checking out the new McGrath if your budgets are higher – pretty cool device.

  4. John Wales, MD says:

    The King Video Larygoscope comes in around $895 plus about $25 per disposable. Quick and easy. Also has channel along side for passing tube and without channel.

    The new McGrath device runs about $4000 plus about $8 per disposable. Just out and made in Scotland. The break even is at around 190 intubations……then the disposables for the McGrath make it more affordable. Am waiting to get my hands on it to demo it.

    I expect more devices to come forward at a lower price point as well. Having more than one person able to view the intubation is helpful, not having all the positioning for patient and provider shouls also help provide better care and higher first attempt success.

    • phillydan says:

      They already have. The new Truview PCD ranges from about $3,600 to $8,000. It is built mainly from stainless steel and is entirely re-usable, with your only per use cost a re-charge and some Cidex. http://truphatek.us

      More importantly, it offers some of the same advantages as the industry leading Glidescope. Specifically the ability to look anterior at the difficult airway and the ability to mitigate fogging. Glidescope does it differently than Truview, but these are the only two that do.

      Last but certainly not least, the Truview PCD does constant oxygen insufflation. This reduces the rate of desaturation allowing more time to pass the tube safely.

      I think most of the above mentioned devices are all quite good. With every generation they improve and the price comes down.

  5. Jon Haller, EMT says:

    Yes, the question is price…certainly. An Airtraq at under 80 bucks is amazing – although no screen (yet). The King VIsion in my mind is a great device, as we just trialed this one. For under 900 bucks it is pretty slick. I’d love a glidescope, but our budget won’t support one. I did hear that the Co-Piolt isn’t too bad, and at a better price point.

    Having a screen that is right on/ attached to the device is something that I would prefer.

    It will be interesting as these toys seem to get less expensive, with more bells and whistles every year.

    Cheers!

    Jon

  6. Easier to work, especially for difficult intubations.

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