Disposable laryngoscope handles and blades: "I’m as mad as hell and I’m not going to take this anymore"
Sheila M Rajashekara MD, Diane W Gordon MD, Elizabeth E Hansen MD PhD
The idea of single use laryngoscopes and handles is an abomination and a manifestation of a regulatory environment gone mad. I could add some other words of wisdom (or contempt) to preface today’s PAAD1, but nothing I can say is remotely as visceral as this snippet from the 1976 Academy award winning movie Network. I’ve asked members of SPA’s sustainability group and Project Spruce Green to review this for us. Myron Yaster MD
Original article
Sherman JD, Raibley LA 4th, Eckelman MJ. Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes. Anesth Analg. 2018 Aug;127(2):434-443. doi: 10.1213/ANE.0000000000002683.: PMID 29324492.
Imagine this: a group of seasoned anesthesiologists, accustomed to using their trusty reusable laryngoscopes for years, are told to switch to disposable ones due to concerns they might be cited in a regulatory inspection. This sparks a lively discussion in the break room, with opinions split around convenience, cost, and environmental concerns, specifically that the increased use of disposable medical devices contributes to the growing problem of healthcare-related waste generation. Seeking an evidence-based approach that compares the cost and environmental impact of single use disposable (SUD) laryngoscopes versus reusable laryngoscopes, they find a perfect paper to answer their question.1 In this article, Sherman et al. use life cycle assessment (LCA) and life cycle costing (LCC) to examine the environmental impact and total cost of ownership of reusable vs SUD handles and blades. This article has important conclusions for environmental impact as well as costs related to laryngoscope procurement.
The functional unit for this LCA was 1 laryngoscope handle and blade used for 1 patient so the reusable and SUD products are compared fairly. Reusable handles and blades are rated for 4000 uses, so the authors used 1/4000th of the manufacturing, transportation and disposal impact to compare a reusable laryngoscope to 1 single use disposable (SUD) alternative. The authors conservatively accounted for changes of the fiber optic light every 500 uses and alkaline battery exchanges every 40 uses for the reusable laryngoscopes, while the SUD lithium batteries are discarded after one use.
What were the results? As is elegantly shown in Table 3 below
the SUD handles and blades were by far the worst option from an environmental standpoint in all scenarios, with the SUD handle having 25x the impact of a reusable handle cleaned with high level disinfection (HLD) and the SUD blade having 6-8x the environmental impact of a reusable blade. In addition, even when accounting for the costs of reprocessing of reusable devices, the cost of SUD handles (Figure 3),
was 18x higher than low level disinfection (LLD) of reusable handles and 2-6x higher than reusable blades, depending on which cleaning method was used. Filley et al.2 address the environmental impact of using sterile/sterilized equipment for non-sterile procedures (such as direct laryngoscopy and bronchoscopy), a topic we hope to review in a future PAAD. In total, SUD blades and handles were estimated to cost the hospital (which does 60,000 intubations annually) from $650,000 to $850,000 more per year than using reusable handles and blades.
An important question that the authors bring up in their discussion is the device risk classification - in other words, how should the laryngoscope handle be cleaned? There is inconsistency among professional anesthesia groups, so authority falls to the Centers for Disease Control (CDC).3-5 The CDC actually defers to the device manufacturer’s Instructions For Use (IFU) and The Joint Commission enforces these IFU during accreditation visits. Notably, a reusable laryngoscope handle is now available whose IFU includes LLD, HLD and sterilization– in contrast to older models of reusable laryngoscopes whose IFU only included HLD, which caused the push for disposable laryngoscopes that we’re now facing.
Though SUD recycling wasn’t directly addressed by Sherman et al, we thought it important to address. Manufacturers and vendors of SUD laryngoscopes often tout their recycling programs but may neglect to mention the additional cost of those programs (tens of thousands of dollars annually), the lack of transparency or accountability in their recycling claims, and the fact that if the plastic in the SUD is in fact recycled, it will be processed into plastic pellets to make park benches, etc– not made back into laryngoscopes. Additionally, the lithium batteries used in some SUD laryngoscopes present their own environmental challenges.6 The removal of the battery from the SUD can be extremely challenging (hammer and chisel, anyone?) and lithium batteries should not be disposed of in the trash. If the SUD is going for recycling, the battery may be incinerated (burned to ash, producing toxic fumes) or dismantled into its component parts to be recycled (requiring intensive resources and a dedicated facility). Given the finite amount of lithium on the earth and the energy required to mine it, it is a profligate use of resources to discard a lithium battery after a single use.
Reusable laryngoscopes save considerable money and environmental impact compared to SUDs while producing equivalent clinical outcomes. It's time for anesthesiologists to step up as leaders in the supply chain and advocate for products that reduce costs and harm to the environment.
References:
1. Sherman JD, Raibley LAt, Eckelman MJ. Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes. Anesthesia and analgesia 2018;127(2):434-443. (In eng). DOI: 10.1213/ane.0000000000002683.
2. Filley GI, Kayastha D, Hayes W, Mehra S, Sherman JD, Eckelman MJ. Environmental Impact of a Direct Laryngoscopy: Opportunities for Pollution Mitigation. Laryngoscope 2024 (In eng). DOI: 10.1002/lary.31341.
3. Sherman JD. Reusable vs disposable laryngoscopes. Anesthesia Patient Safety Foundation. February 2019 (https://www.apsf.org/article/reusable-vs-disposable-laryngoscopes/).
4. Gordon D, Sherman JD, Beers R, Hopf HW. Balancing sustainability and infection control: The case for reusable laryngoscopes. Anesthesia Patient Safety Foundation. February 2020 (Patient Safety Foundation Newsletter 33(3): 91. https://www.apsf.org/article/reusable-vs-disposable-laryngoscopes/Hopf H. 2018.).
5. Sherman JD, Hopf HW. Balancing Infection Control and Environmental Protection as a Matter of Patient Safety: The Case of Laryngoscope Handles. Anesthesia & Analgesia 2018;127(2):576-579. DOI: 10.1213/ane.0000000000002759.
6. Reduce, reuse, recycle: Used lithium-ion batteries. In: United States Environmental Protection Agency, ed.