Review article: Video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management?

Abstract

Background An adequate airway management plan is essential for patient safety. Recently, new tools have been developed as alternatives to direct laryngoscopy and intubation. Among these, video-laryngoscopy has enjoyed a rapid increase in popularity and is now considered by many as the first-line technique in airway management. This paradigm shift may have an impact on patient safety. Principal findings Studies show that video-laryngoscopes are associated with better glottic visualization, a higher success rate for difficult airways, and a faster learning curve, resulting in a higher success rate for intubations by novice physicians. Thus, unanticipated difficult intubations may be less frequent if video-laryngoscopy is used as the first-line approach. In addition, on-screen viewing by the operator creates a new dynamic interaction during airway management. The entire operating room team can assess progress in real time, which enhances communication and improves teaching. However, if video-laryngoscopes become standard tools for tracheal intubation, these more costly devices will need to be widely available in all locations where airway management is conducted. Furthermore, algorithms for difficult intubation will require modification, and the question of selecting alternate devices will arise. If the incidence of difficult intubation decreases, the lack of motivation to teach and learn the use of alternative devices might adversely impact patient safety.

S1 guidelines on airway management

“…Using indirect laryngoscopy the method of video laryngoscopy today represents the most important method for management of an unexpected difficult airway, as after a primary unsuccessful attempt at direct intubation a correct placement of the tube will then often be possible [80]. A rigid or flexible endoscopic intubation is likewise possible in an anesthetized patient with an unexpected difficult airway; however, compared to the procedure for an expected difficult airway the use of a flexible intubation endoscope is frequently more difficult and time-consuming [81].…”

Airway management: judgment and communication more than gadgets

“…Aux yeux de nombreux résidents et jeunes anesthésiologistes, la vidéolaryngoscopie est plus facile à apprendre, a un taux comparable de complications, et donne de meilleures chances de réussite que la laryngoscopie directe. 5 En résumé, elle répond à tous les critères d'une technique de première ligne. Mais alors, que peut-on utiliser comme technique alternative?…”

“…À cet égard, les techniques qui permettent de visionner les voies aériennes sur un écran, comme la vidéolaryngoscopie et la bronchoscopie par fibres optiques, ont un avantage: les informations sont partagées. 5 Avec ces nouvelles directives, la philosophie de la prise en charge des voies aériennes est modifiée; l'exercice n'est plus purement technologique, ce qui indique peut-être que les outils dont nous disposons sont relativement efficaces s'ils sont entre des mains expérimentées. On ne mise plus sur la meilleure technique, mais sur la méthode qui convient le mieux à chaque anesthésiologiste selon les circonstances, avec un jugement sûr quant à évaluer le moment où il faut modifier son plan.…”

“…In the eyes of many trainees and junior anesthesiologists, video laryngoscopy is easier to learn, has a comparable rate of complications, and has a better chance of success than direct laryngoscopy. 5 In short, it fulfills all the criteria of a first-line technique. Then, what should be used as a backup?…”

“…In this respect, techniques that involve displaying the airway on a screen, such as video laryngoscopy and fibre optic bronchoscopy, have an advantage; the information is shared. 5 With the new recommendations, the philosophy of airway management has moved away from a pure technological exercise, perhaps indicating that the tools we have perform reasonably well in experienced hands. The emphasis is no longer on which technique is best but on which method the individual anesthesiologists is most comfortable with in the given circumstances, this combined with sound judgment regarding when to decide to change plans.…”