Video laryngoscopes to help intubation in people with difficult airways

Level of innovation

One specialist commentator confirmed that the technology is innovative when compared with current standard of care (direct laryngoscopy). However, there was a general consensus from all specialist commentators that the technology has been available in the NHS for some time and is evolving, but has not been superseded or replaced. Video laryngoscopes are therefore used as well as the current standard care, but have the potential to replace direct laryngoscopes in the future.

Potential patient impact

All specialist commentators agreed that video laryngoscopes have the ability to provide better visualisation of the larynx (when compared with direct laryngoscopy). This allows the passage of a tracheal tube under improved view more frequently, promoting safer intubation. One specialist commentator considered that the technology would particularly benefit patients with anticipated difficult airways (first-line use). However, 1 described their reservation for paediatric practice, because video laryngoscopes are still rather bulky and can interfere with the placement of nasogastric tubes and pharyngeal packs.

Potential system impact

Specialist commentators described improved training, fewer failed or difficult intubations and reduction in escalation of care (including front of neck access, wake-ups and subsequent postponements of surgery) as associated effects of using video laryngoscopes. One specialist commentator also stated that the use of video laryngoscopes may also provide improved operator ergonomics.

All specialist commentators confirmed that video laryngoscopes are already used in training, with 2 stating that video laryngoscopes ease training because both trainer and trainee see the same view (which does not happen with direct laryngoscopy). Specialist commentators also highlighted differences between video laryngoscopes (for example, in blade shape) that influence training, and are likely not interchangeable between different video laryngoscopes.

Infection control concerns in the use of reusable devices were raised, with 1 describing a general trend towards disposable handles and blades. One commentator also highlighted that power failure would be a concern if a video laryngoscope was the only device available. Another specialist commentator stated the potential for trauma, different to that seen with direct laryngoscopy.

General comments

Three specialist commentators agreed that all tracheal intubations would be eligible for video laryngoscopy. However, 1 specialist commentator stated that they currently only ask for video laryngoscopes to be on standby for about 10% of patients who need to be intubated, as well as standard direct laryngoscopes. Another stated that only 1% to 4% of the 1.5 million intubations done in the UK would be expected to be difficult to intubate with direct laryngoscopy. However, because these cases can be difficult to predict, operators would have to either switch to routine video laryngoscopy (that is, replacing standard direct laryngoscopy) or users would have to become skilled in video laryngoscopy and use frequently enough to stay competent when used as well as standard direct laryngoscopy. This commentator noted a general trend towards video laryngoscopes replacing direct laryngoscopes. Another specialist commentator advised that the incidence of failed intubation and therefore the need for rescue video laryngoscopy varies according to the population and setting, citing around 1 in 1,500 in the elective setting; 1 in 300 during rapid sequence induction in the obstetric setting and 1 in 75 in the emergency department.

All specialist commentators stated that the capital cost would be higher if video laryngoscopes became first choice for all patients. However, 1 specialist commentator stated that the cost differential is reducing. Another commented that unless the price can match direct laryngoscopes, video laryngoscopes should not be used in all patients. This commentator stated that cost assessments should consider both disposable and reusable technologies (including sterilisation).

One specialist commentator described the experience at their trust, in which most of their 40 consultants now use video laryngoscopes regularly, some exclusively. Historically, 5 to 10 patients from 5,000 to 7,000 intubations a year were woken and had their surgery postponed because tracheal intubation was not successful with direct laryngoscopy. Since video laryngoscopes were made widely available in their institution, the rate of unsuccessful intubation leading to wake up and postponement has dropped to 1 to 2 cases per year.