Advice
The technology
The technology
Video laryngoscopes incorporate an integrated camera and display monitor. These provide indirect visualisation of the upper airway to help placement of a breathing tube between the vocal cords and into the trachea, to maintain the airway. Record and display features of the technology are also useful for teaching intubation techniques, particularly in people with difficult airways.
A video laryngoscope consists of 4 main components:
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Interchangeable reusable or single-use blades of various shapes and sizes for different airway anatomy; blades can be curved (Macintosh), angulated or straight (Miller). Some blades are available with a channel to guide the introduction of appropriately sized endotracheal breathing tubes. Blades can have an anti-fog coating or warming feature to prevent moisture from affecting the camera lens.
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A high-resolution small camera at the distal tip of the device, with a light source to illuminate the airway.
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An integrated (attached) or stand-alone (cart-based) monitor with colour display and adjustment controls to view images of the airway. Integrated monitors can be angled, rotated or flipped to improve the airway view. Monitors can incorporate a video output port to connect an external monitor and a USB or memory card to download and save images and recordings.
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Single or multiple internal power sources (rechargeable or non-rechargeable batteries) are used to power the camera, light source and display monitor. A separate charging unit is used for rechargeable components.
Video laryngoscopes may comprise reusable (monitor and camera) and disposable components (blades) when used in acute settings but can also be fully disposable for use in remote locations and emergency situations.
This briefing focuses on 11 video laryngoscopes that are used to help intubation in people with difficult airways. Other similar technologies may be available but are not included in this briefing (for example, if they were not identified, or the company chose not to take part). Video laryngoscopes may also be used in routine intubations, but this is outside the scope of this briefing.
Five of the 11 included video laryngoscopes can also be used as standard, direct view laryngoscopes and have been identified in table 1, along with their key technical features.
Table 1 Summary of key features of included video laryngoscopes
|
VL Device |
Camera: |
Monitor: |
Blades: |
Power: |
|
King Vision aBlade |
2 types of video adapter (depending on blade size) with 640×480 pixel VGA, CMOS technology and LED light source. |
Integrated 2.4 inches, 320×240 pixel TFT-LCD; video output. |
Non-sterile, single-use: sizes 1 (infant), 2/2c (paediatric), |
3×AAA size, non-rechargeable alkaline batteries; 90 minutes. |
|
C-MAC System with C-MAC monitor |
Reusable blades have an integrated camera; 640×480 pixel CMOS technology with white LED light source. |
Stand-alone 7 inches, 1,280×800 pixel TFT-LCD; HDMI video output, SD memory card and USB port. |
Reusable: Macintosh #4, #3, #2, #0; Miller #1, #0; D-Blade and D-Blade Ped. Direct view functionality. |
Rechargeable 3.7V lithium-ion battery; 120 minutes. |
|
Single-use blades fit to 1 of 2 C-MAC S reusable imagers (depending on blade size); both use 640×480 pixel CMOS technology with white LED light source. |
Non-sterile, single-use: Macintosh #4, #3; Miller #1, #0; Direct view functionality. |
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C-MAC System with C-MAC pocket monitor (KARL STORZ) |
Reusable blades have an integrated camera; 640×480 pixel CMOS technology with white LED light source. |
Integrated 3.5 inches 640×480 pixel TFT-LCD with optional extension cable for remote viewing. |
Reusable: Macintosh #4, #3, #2, #0; Miller #1, #0; D-Blade and D-Blade Ped. Direct view functionality. |
Rechargeable 3.7V lithium-ion battery; 90 minutes. |
|
Single-use blades fit to 1 of 2 C-MAC S reusable imagers (depending on blade size); both use 640×480 pixel CMOS technology with white LED light source. |
Non-sterile, single-use: Macintosh #4, #3; Miller #1, #0; D-Blade. Direct view functionality. |
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|
Marshall VL |
1,600×1,200 pixel, CMOS technology with LED light source. |
Integrated 3.5 inches 640×480 pixel LCD; HDMI video output and 4GB SD memory card. |
Sterile, single-use: Macintosh sizes 3 or 4; Direct view functionality. |
Rechargeable lithium-ion battery; 120 minutes. |
|
McGrath MAC (Medtronic; UK supplier: Healthcare 21) |
CMOS technology with LED light source. |
Integrated 2.5 inches 240×320 pixel LCD. |
Sterile, single-use: Macintosh sizes 1, 2, 3 or 4 and X3 hyper-angulated blade. |
Proprietary non-rechargeable 3.6V lithium battery pack; 250 minutes. |
|
Airtraq Avant (Prodol Meditec; |
640×480 pixel VGA, Wi-fi CMOS camera with LED light source and proprietary wireless image transmission to additional remote display (PC, phone or tablet). |
Wi-fi camera has integrated 2.8 inches, 320×240 pixel, touch-screen TFT-LCD; Mobile phone adapter to use phone camera and display with 'Airtraq Mobile' iOS/Android app. |
Reusable optics with 2 single-use disposable adult regular #3 or small #2 blades. |
Avant reusable optics: rechargeable 3.7V lithium-polymer battery, 15×10 minute intubations. Wi-fi camera and display: rechargeable 3.7V lithium-polymer battery, |
|
Airtraq SP |
640×480 pixel VGA, Wi-fi CMOS camera with LED light source and proprietary wireless image transmission to remote display (PC, phone or tablet). |
Wi-fi camera has integrated 2.8 inches, 320×240 pixel, touch-screen TFT-LCD; Mobile phone adapter to use phone camera and display with 'Airtraq Mobile' iOS/Android app. |
Non-sterile, SP model with combined optics and blades in 6 sizes (adult regular #3, small #2, paediatric #1, infant #0, nasal and double lumen). |
SP combined optics and blades: Wi-fi camera and display: rechargeable 3.7V lithium-polymer battery, 120 minutes. |
|
APA |
3 camera modules: MAC, MIL (small) and MIL (large) with CMOS technology and LED light source. |
Integrated 3.5 inches, 320×240 pixel TFT-LCD; video output. |
Non-sterile, single-use: MAC 3 or MAC 4 (with Oxy Blade oxygen assist options); MIL 1 or MIL 2; Difficult airway blades (DAB) (channelled or unchannelled); Direct view functionality. |
Camera module: |
|
GlideScope Go |
Single-use spectrum blades have an integrated camera with 640×480 pixel CMOS technology and LED light source. |
Integrated 3.5 inches, 320×240 pixel LCD; USB port. |
Sterile, single-use spectrum blades in 6 sizes: LoPro S1, S2, S3, S4 and DirectView MAC S3 and MAC S4; Direct view functionality. |
Rechargeable 3.7V lithium-ion battery; 100 minutes. |
|
GlideScope AVL |
GVL Stats fit to 1 of 2 reusable video batons with 320×240 pixel CMOS technology and LED light source. |
Stand-alone 6.4 inches, 640×480 pixel TFT-LCD; HDMI video output port and USB port. |
Sterile, single-use GVL Stats in 6 sizes: 0, 1, 2, 2.5, 3 or 4. |
Rechargeable 3.7V lithium-ion battery; 90 minutes. |
|
GlideScope Spectrum single use |
Single-use spectrum blades have an integrated camera with 640×480 pixel CMOS technology and LED light source. |
Stand-alone 6.4 inches, 640×480 pixel TFT-LCD; HDMI video output port and USB port. |
Sterile, single-use Spectrum blades in 6 sizes: LoPro S1, S2, S3, S4 and DirectView MAC3 and MAC4; Direct view functionality. |
Rechargeable 3.7V lithium-ion battery; 90 minutes. |
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GlideScope Titanium reusable |
Reusable Titanium blades have an integrated camera with 640×480 pixel CMOS technology and LED light source. |
Stand-alone 6.4 inches, 640×480 pixel TFT-LCD; HDMI video output port and USB port. |
Sterile, reusable Titanium blades in 4 sizes: LoPro T3, T4 and MAC T3, T4. |
Rechargeable 3.7V lithium-ion battery; 90 minutes. |
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Abbreviations: CMOS, complementary metal-oxide semiconductor-based image sensor chip; GB, gigabyte; HD, high definition; HDMI, high definition multimedia interface; LCD, liquid crystal display; LED, light-emitting diode; PC, personal computer; SD, secure digital; SP, single patient; TFT-LCD, thin film transistor liquid crystal display; USB, universal serial bus; V, volt; VGA, video graphics array; VL, video laryngoscope. |
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Innovations
A conventional direct laryngoscope moves the tongue to create an unobstructed, direct view of the glottic entrance, to help placement of the tracheal tube. However, it can be challenging to see the vocal cords in some patients. Video laryngoscopes are designed to improve visualisation of the glottis, with the aims of: a shorter time to successful intubation; higher first-attempt intubation success rate; higher overall intubation success rate; reduction in applied force; and reduction in intubation-related complications.
Current care pathway
The current NHS pathway for intubation varies according to setting and user, such as pre-hospital (ambulance, paramedic), emergency (hospital, emergency clinician) and critical care, anaesthetic rooms or operating theatres (hospital, anaesthetist). Users may have the choice of direct or video laryngoscopes according to local provision.
The Difficult Airway Society (DAS) guidelines for management of unanticipated difficult intubation in adults 2015 state that video laryngoscopy should be immediately available wherever intubation is done and that anaesthetists should be trained in the technique (Frerk et al. 2015).
The DAS Paediatric difficult airway guidelines state that, for unanticipated difficult tracheal intubation during routine induction of anaesthesia in a child aged 1 to 8 years, more research is needed in the use of newer airway devices such as video laryngoscopes, in paediatric clinical practice.
The following NICE guidance and advice have been identified as relevant to this care pathway:
Population, setting and intended user
Video laryngoscopy would be most likely to be used in people with an anticipated difficult airway in emergency or secondary care settings. They would be used by anaesthetists, non-clinician practitioners in anaesthesia, emergency medicine clinicians and paramedics in the hospital and pre-hospital settings. Video laryngoscopy is different to the conventional intubation technique. Therefore, human factors such as training, experience, device design, usability and control can affect patient outcomes.
Costs
Technology costs
The list prices, excluding VAT, for all included video laryngoscope components and accessories are shown in table 2. Most companies offer training as needed as part of post sales service. Although video laryngoscopes do not need routine calibration, some companies offer maintenance contracts, for example to cover accidental damage.
Table 2 Cost of included video laryngoscopes
|
Company |
Device |
Main components, consumables and accessories |
List price |
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Ambu Ltd |
King Vision aBlade |
King Vision display |
£750 |
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Video adapter (aBlade 3/3c) |
£299 |
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aBlade size 3 or 3c, box (20) |
£199.80 |
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Video adapter (paediatric) |
£375 |
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aBlade size 1, 2 or 2c, box (5) |
£60 |
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aBlade kit (display, video adapter, 4×channelled and 2×standard aBlades, case, batteries and USB) |
£895 |
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King Vision display and video adapter (aBlade 3/3c) |
£849 |
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Case |
£12 |
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KARL STORZ |
C-MAC System |
C-MAC monitor |
£4,418 |
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Connecting cable |
£475 |
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C-MAC pocket monitor set |
£3,399 |
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C-MAC PM charging unit |
£586 |
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Reusable blades |
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Mac #4 |
£2,754 |
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Mac #3 |
£2,755 |
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Mac #2 |
£2,696 |
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Mac #0, Miller #1 or #0 |
£3,492 |
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D-Blade or D-Blade Ped |
£3,750 |
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C-MAC S Imager |
£3,164 |
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Disposable blades (Adult): |
£160 |
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C-MAC S Paediatric Imager |
£3,399 |
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Disposable blades (Paediatric): |
£206 |
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Marshall Airway Products Ltd |
Marshall VL |
VL system kit (video laryngoscope, USB power lead, UK mains cable, HDMI video lead and metal case) |
£1,200 |
|
Mac blades 3 or 4, box (10) |
£29.50 |
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Medtronic; |
McGrath MAC |
Video laryngoscope |
£1,600 |
|
Disposable blades: |
£6.50 each |
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X3 difficult airway |
£18 each |
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Prodol Meditec; |
Airtraq Avant / Airtraq SP |
Avant reusable optics |
No charge |
|
Docking station charger |
No charge |
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Avant single-use blades, box (50) |
£495 |
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SP single-use laryngoscope (all sizes), box (6) |
£283.67 |
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Wi-fi camera |
£235 |
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Wi-fi kit |
£259 |
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Universal smart phone adaptor |
£20 |
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Phone protection sleeve |
£10 |
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AAM Healthcare |
APA |
Video viewer and charger |
£2,000 |
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Video viewer charger |
£160 |
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Handle |
£750 |
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MAC camera module |
£880 |
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MIL (small) camera module |
£850 |
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MIL (large) camera module |
£880 |
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MIL 1 or 2 blade, box (10) |
£70 |
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MAC 3 or 4 blade, box (10) |
£75 |
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MAC 3 or 4 O2 blade, box (10) |
£85 |
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DAB or Unchannelled-DAB, box (10) |
£480 |
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Video cable (3m) |
£105 |
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Verathon Medical UK Ltd |
GlideScope |
GlideScope Go monitor kit |
£2,300 |
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AVL single-use system: |
£8,050 |
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GlideScope video monitor, video baton 1-2, premium cart and 2 boxes of Stat blades |
£8,800 |
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Video baton 3-4 kit or 1-2 kit |
£2,600 |
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GVL Stat 0, 1, 2, 2.5, 3 or 4, box (10) |
£120 |
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Spectrum single-use system: |
£8,400 |
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LoPro S1 or S2, box (10) |
£310 |
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LoPro S3 or S4, box (10) |
£270 |
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DirectView S3 or S4, box (10) |
£270 |
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Spectrum smart cable |
£2,790 |
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Titanium reusable system: |
£9,530 |
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LoPro T3 or T4 |
£3,141 |
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MAC T3 or MAC T4 |
£2,982 |
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Titanium video cable |
£332 |
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Costs of standard care
The NHS Supply Chain Online Catalogue lists 1,141 items under the search term 'laryngoscope' (23 August 2018). Removing video laryngoscope and fibre-optic laryngoscope devices and consumables leaves 363 items across 14 suppliers to the NHS. These 363 devices and consumables provide a range of costs for the following categories of direct laryngoscopes (delivery included and 20% VAT excluded):
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reusable handle with disposable blade ranges from £10.05 to £88.98 per device
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single-use handle with disposable blades ranges from £4.34 to £79.39 per device
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single-use handle and blade set ranges from £2.60 to £39.69 per device
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reusable handle with reusable blade ranges from £16.95 to £28.16 per device.
Resource consequences
The resource consequences of adopting video laryngoscopy instead of direct laryngoscopy would include any price differential in purchasing the device, accessories and consumables and the need for additional training in the use of the video technologies. Based on the information provided by companies for this briefing, the prices of video laryngoscopes range from £245 to £7,149 per unit for integrated display models and from £7,589 to £13,003 per unit for cart-based models (exclusive of VAT). Therefore the cheapest video laryngoscope is about 3 times the price of the most expensive direct laryngoscope.
Although list prices for video laryngoscopes are substantially more expensive than standard laryngoscopes, flexible pricing options can make device costs more comparable. For example, 1 manufacturer offers the reusable and rechargeable components of their system free of charge, only charging for disposables.
A recent NHS national survey (Cook and Kelly 2017) reported that 92% of respondents had video laryngoscopes available in at least 1 clinical area in their hospital. Of all clinical areas represented by the responses, 52% reported availability of a video laryngoscope, with some degree of restriction of use reported in 32% of anaesthetic departments, 58% of intensive care units and 78% of emergency departments. Of the 131 respondents who described elective use of video laryngoscopy in the operating theatre, none reported routine use, less than 33% reported regular use, and 10% reported rare use. For those surgical cases where direct laryngoscopy proves to be difficult or impossible, a readily accessible video laryngoscope may allow surgery to proceed as planned with no extra anaesthetic complications. Without a video laryngoscope in theatre, a patient with an unanticipated difficult airway and failed direct laryngoscopy would either be woken up and their operation would be postponed, or their operation would proceed with an increased risk of anaesthetic complications (which could be minor, intermediate or life-threatening).
No cost-effectiveness studies were identified in the evidence searches for this briefing, but potential improvements in patient outcomes could reduce time spent in higher cost intensive care units and overall hospital length of stay.