Videolaryngoscopy v Standard Direct Laryngoscopy

Jamie Peyton MD, Mary Stein MD, and Melissa Brooks Peterson MD

Original article

Michael F Aziz, Lauren Berkow. Pro-Con Debate: Videolaryngoscopy Should Be Standard of Care for Tracheal Intubation.  Anesth Analg. 2023 Apr 1;136(4):683-688. PMID: 36928154

Editorial

Takashi Asai, Narasimhan Jagannathan.  Videolaryngoscopy Is Extremely Valuable, But Should It Be the Standard for Tracheal Intubation?  Anesth Analg. 2023 Apr 1;136(4):679-682.  PMID: 36928153

Hello fellow PAAD readers!

Your airway gurus here, happy to be writing an informal article away from the ivory towers of medical journals and shared amongst a wonderful community of colleagues (that’s you!).  The conversation about the relative merits of direct and video laryngoscopy – for training, for routine clinical care in and out of the OR, and for patients with difficult tracheal intubations - is one that many of us are regularly having amongst colleagues and friends. In the spirit of robust, informed debate that benefits from a frankness that may be considered impolite in the world of academic publishing, we shall be rather blunt in writing this PAAD. The authors of the Pro-Con debate and accompanying editorial that prompted today’s PAAD are experts in airway management and have done huge amounts to advance our knowledge in both adult and pediatric practice. We have great respect for them, and we enjoy reading their work the vast majority of the time. Here, they address many important points in the conversation including the fallibility of all tracheal intubation techniques necessitating proficiency in a variety of approaches and provide an important discussion of the far reaching implications of labeling a practice the “standard of care”.  However, we found ourselves becoming frustrated with their perpetuation of the narrative describing video laryngoscopy and direct laryngoscopy as warring factions in the battle to perform tracheal intubation.  This is a false dichotomy that makes for nice pro/con debates but doesn’t reflect the realities of our equipment or clinical practice.  We think it bears repeating - Video laryngoscopy and direct laryngoscopy are not mutually exclusive techniques.

With standard Miller or Macintosh blade video laryngoscopy, it is possible for one clinician to perform direct laryngoscopy while allowing the use of the video screen, if desired, by the intubating clinician, by a supervisor, and by others in the room including learners and collaborators. It is also possible for an observer to watch the tube pass through the vocal cords on the screen, does wonders for our heart rates and general stress levels when teaching inexperienced residents to intubate neonates!

We need to move away from this combative narrative and recognize that our technology has advanced away from traditional laryngoscopes. Our energy would be better utilized working on systems within hospitals that prioritize the provision of advanced equipment into the hands of anesthesiologists and other clinicians who manage the airway. The continuation of studies, opinion pieces, editorials, conference sessions, and debates focusing on DL vs VL is a distraction that ignores the basic fact that we are in the midst of a paradigm change regarding basic airway management. The reason this is important is that it places people into artificially divided camps, defending a solitary technique over another, where in real clinical practice, we all recognize that there is no perfect technique and that we must have a plan, and a back up plan, and yet another back up plan – and be able to execute each.  We must be excellent at multiple techinques and cannot allow ourselves to lulled into complacency accepting a single “superior” technique.   Competent airway management that our patients deserve requires redundancies to be built into our plans at every stage. 

Of course – not all video laryngoscopes are created equal!  As the authors note, there are differences in the make / model / size / angle/ “thickness” / “stickiness”  - the list goes on - of VL blades plus differences in clinicians’ experience with these blades. Take home message: one VL blade is not the same as another VL blade – and knowing our airway equipment and our own skills and experience expertly enough to recognize these equipment limitations is critical to our success.  Laryngoscopes – whether used for traditional DL or video systems can all fail.

Failure may be due to the poor view of the larynx obtained, light or power failures, or a patient who cannot open their mouth enough to allow the blade to pass. The difference between a VL system and a traditional laryngoscope is that with the right equipment, one can perform direct laryngoscopy, video-assisted direct laryngoscopy (where the intubating clinician performs DL but is aided by a second clinician observing the video view and/or the intubating clinician uses the view on the screen to improve their direct view), indirect laryngoscopy (where only the video screen view is used to intubate) all within a single laryngoscopy attempt; or change to hyperangulated video laryngoscopy (when a blade designed specifically to look around the natural curve of the airway is used and no direct view is obtained), and attach a flexible bronchoscope that can be used instead of or with the laryngoscopy. With a traditional laryngoscope, you can either perform direct laryngoscopy or use the blade to displace the tongue making way for a flexible scope – and not much else more than that.

We should be focusing on the equipment that we use to ensure that modern video-enabled devices are as reliable as traditional laryngoscopes. We need to drive the prices down – which will occur as their use increases. In pediatrics, we need to push manufacturers to think about the problems we face – there is currently no single system that provides a fully comprehensive set of Miller/Mac blades, hyperangulated blades, and flexible bronchoscopes to cover all the different patients in our care. Often pediatric equipment is simply “scaled-down adult” designs that fail to take into account anatomical differences seen in our smallest patients. We also need to consider how we can aid low- and middle-income countries in increasing the availability of relatively expensive anesthetic equipment; the divide between the haves and have-nots is in danger of becoming even worse as advanced VL systems proliferate in rich hospitals, yet remain beyond the reach of many departments around the world.

We have moved beyond “DL vs VL” by nature of the technology available to us, and future conversations, articles, and lectures should reflect the modern approach to airway management.  We will do our patients a better service, and our community better teaching, if we relegate “VL vs. DL” to the history books and instead shift our mindset to true “Comprehensive Airway Management,” meaning: tools, back up tools, and more back up tools – with clinicians trained to use them in the appropriate settings.

What are your thoughts?  Send your response to Myron who will post in the Friday Reader Response PAAD