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.