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Videolaryngoscopes: Design, Purpose and Evidence

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In recent years, video laryngoscopes have become established as indispensable instruments in anesthesia and emergency medicine. They enable improved visualization of the laryngeal structures, thereby increasing the success rate of endotracheal intubation, especially in difficult airway conditions [1].

construction of video laryngoscopes

A video laryngoscope consists of several essential components:

  • Blade: It is inserted into the mouth to push the tongue to the side and allow a view of the glottis. There are different types of spatulas for different applications:
    • Macintosh-like blade (allows direct and indirect vision)
    • Hyperangulated blade (suitable for difficult airway conditions) [2].
    • Miller blade (suitable for use in neonates; see also here: blade overview)
  • Camera: A miniature camera attached to the tip of the spatula transmits the image in real time to a monitor [3].
  • Light source: An LED light source ensures optimal illumination of the airways [4].
  • Monitor: The acquired image is displayed on an external or integrated monitor, allowing precise positioning of the endotracheal tube [5].

Purpose of video laryngoscopes

The main purpose of video laryngoscopes is to perform endotracheal intubation safely and efficiently. The most important areas of application include:

  • Regular intubation: Video laryngoscopes are increasingly used as a standard procedure, especially in anesthesia [6].
  • Difficult airways: The S1 guideline for airway management recommends the primary use of video laryngoscopes in difficult intubation conditions [7].
  • Emergency medicine: Improved visibility of the airway can increase the success rate of emergency intubations [8].
  • Medical training: Due to the real-time display on a monitor, video laryngoscopes are ideal for training anesthesiologists and emergency physicians [9].

Scientific evidence and current guidelines

According to the current S1 guideline “Airway management” of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI) [7], a video laryngoscope should be available at every anaesthesiology workstation. The most important recommendations are:

  • Video laryngoscopes with Macintosh-like blades are suitable as primary instruments for intubation [7].
  • If a difficult airway is expected, hyperangulated blades should be available [10].
  • After unsuccessful direct laryngoscopy, the use of a video laryngoscope is recommended [7].
  • Video laryngoscopy is the preferred method for airway management, particularly in patients at risk of aspiration. [11]

The introduction of video laryngoscopes has significantly improved clinical practice in airway management. Their benefits, especially in difficult situations, are well documented by scientific studies and guidelines. Their routine use is increasingly considered standard, and adequate training is essential to optimally utilize the potential of this technology.

bibliography
[1] Aziz, M. F., Healy, D., Kheterpal, S., et al. (2011). "Routine Clinical Practice Effectiveness of the Glidescope in Difficult Airway Management: An Analysis of 2,004 Glidescope Intubations, Complications, and Failures From a Prospective, Multicenter, Observational Study." Anesthesiology, 114(1), 34–41.
[2] Mosier, J. M., Sakles, J. C., Law, J. A., et al. (2020). "Tracheal Intubation in the Critically Ill: Current Status and Future Directions." The Lancet Respiratory Medicine, 8(8), 754–766.
[3] Cook, T. M., Kelly, F. E. (2017). "A National Survey of Videolaryngoscopy in the United Kingdom." Anaesthesia, 72(8), 1017–1024.
[4] Pieters, B. M., Maas, E., Knape, J. T. A., et al. (2017). "Videolaryngoscopy vs. Direct Laryngoscopy for Tracheal Intubation in Adults with Obesity: A Systematic Review and Meta-analysis." Anaesthesia, 72(6), 691–701.
[5] Myatra, S. N., Jain, R., Gandhi, K., et al. (2013). "Comparison of the C-MAC Videolaryngoscope with the Macintosh Laryngoscope for Routine Airway Management: A Randomised Clinical Study." Anaesthesia, 68(9), 899–907.
[6] Apfelbaum, J. L., Hagberg, C. A., Caplan, R. A., et al. (2013). "Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." Anesthesiology, 118(2), 251–270.
[7] Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI). (2023). "S1-Leitlinie Atemwegsmanagement." AWMF-Registernummer: 001-028. Verfügbar unter: https://register.awmf.org/assets/guidelines/001-028l_S1_Atemwegsmanagement_2023-09.pdf (abgerufen am 04. Februar 2025).
[8] Brown, C. A., Bair, A. E., Pallin, D. J., et al. (2010). "Techniques, Success, and Adverse Events of Emergency Department Adult Intubations." Annals of Emergency Medicine, 56(4), 260–270.
[9] Martin, L. D., Mhyre, J. M., Shanks, A. M., et al. (2011). "3,423 Emergency Tracheal Intubations at a University Hospital: Airway Outcomes and Complications." Anesthesiology, 114(1), 42–48.
[10] Piepho, T., Werner, C., Noppens, R. (2015). "Evaluation of the C-MAC Videolaryngoscope for Nasotracheal Intubation." Anaesthesia, 70(2), 134–138.
[11] Frerk, C., Mitchell, V. S., McNarry, A. F., et al. (2015). "Difficult Airway Society 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults." British Journal of Anaesthesia, 115(6), 827–848.