"Videolaryngoscopy for all intubations?" Dr. Ranko Bulatovic (PGY3) and Dr. Ravi Taneja respond to recent article in BJA

March 20, 2015

Videolaryngoscopy - for all intubations?

Bulatovic R, Taneja R

In Response to "Videolaryngoscopy as a new standard of care." Zaouter C, Calderon J, Hemmerling TM. Br J Anaesth. 2015. 114(2):181-183.

Dear sir,

We read with interest Dr. Zauter's editorial on the evolving role of videolaryngoscopy in anesthestic care (1). Overall we do agree with the authors that videolaryngoscopes will and should be available freely in the foreseeable future. As anesthetists working in a teaching hospital, we already note that residents often choose these as their first-choice for laryngoscopy in anticipated difficult intubations.

However, with increasing availability of new technology such as this, we must acknowledge that trainees will progressively lose their skills with conventional laryngoscopy. This may have safety implications for patients needing anaesthesia in remote locations where videolaryngoscopy may not be the norm. Hence, our younger colleagues having to provide anaesthetic services in such settings may find themselves underprepared or unable to secure an airway.

Furthermore, do not believe that videolaryngoscopes should be used for all intubations indiscriminately. Even though their use is associated with improved glottic visualization (2), the process of placing an endotracheal tube takes longer and is more difficult with videolaryngoscopy (3,4) Thus, one might choose to perform a conventional laryngoscopy for a patient who needs rapid sequence induction (for an anticipated easy airway that has a high risk for aspiration). Additionally, reports exist of intubations which failed using videolaryngoscopy but were subsequently successful with direct laryngoscopy by the same operator (5). Pediatric intubations, which are challenging even for experienced laryngoscopists, have not been extensively studied but preliminary evidence points to a higher degree of difficulty and longer time to intubate with videolaryngoscopy (6). Lastly, equipment malfunction may on occasions necessitate reverting back to conventional laryngoscopy. Limited training and experience with the back up technique in that instance seems worrisome.

We can assume that the availability of standard laryngoscopes is likely as uniform as the availability of endotracheal tubes across all major health care facilities in the world. With the advent of newer videolaryngoscopes, each with their own nuances, learning curves, and proprietary equipment, exceptional challenges and difficulties would be placed on any anesthesia providers entering a work environment which employs devices they are unfamiliar with. Securing an airway remains the most essential skill in anesthesia, particularly in difficult scenarios. We must avoid creating a culture wherein future generations may find themselves struggling should their videolaryngoscopes fail. To quote King Lear, "striving to better, oft we mar what's well".

We support the use of new technology since it cannot be ignored. However, we believe that it can be accepted wholeheartedly only after we have assurance of expertise with the tried and tested techniques.

Ranko Bulatovic, MD,

1. Zaouter C, Calderon J, Hemmerling TM: Videolaryngoscopy as a new standard of care. Br J Anaesth 2015;114(2):181-3.
2. Cavus et al. A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia. BMC Anesthesiol. 2011 Mar 1;11:6.
3. Turkstra TP, Jones PM, Ower KM, Gros ML: The Flex-It stylet is less effective than a malleable stylet for orotracheal intubation using the GlideScope. Anesth Analg 2009;109:856-9.
4. Platts-Mills TF, Campagne D, Chinnock B, Snowden B, Glickman LT, Hendey GW: A comparison of GlideScope video laryngoscopy versus direct laryngoscopy intubation in the emergency department. Acad Emerg Med 2009;16:866-71.
5. Cavus et al. The C-Mac videolaryngoscope for prehospital emergency intubation: a prospective , multicentre, observational study. Emerg Med J 2011;28:650-653.
6. Kim HJ, Kim JT, Kim HS, Kim CS, Kim SD. A comparison of glidescope videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children. Ped Anes 2011;21(4):417-421.

Conflict of Interest
None declared

Copyright © 2015 the British Journal of Anaesthesia

Read the letter in BJA