Direct versus Video Laryngoscopy
OVERVIEW
- the advent of video laryngoscopy has led to some experts stating that it should be considered ‘standard of care’ (a loaded term) or at least best practice
- this had led to vigorous and sometimes heated debate, especially in the emergency medicine community
“I will unequivocally state that it is wrong for people to practice direct laryngoscopy in 2012.” — Ron Walls on EMRAP September 2012 (he subsequently softened his stance at Essentials 2012, following a firestorm of responses to the EMRAP podcast)
DIRECT LARYNGOSCOPY PROS AND CONS
Advantages
- tried and tested method
- portable
- inexpensive
- fogging and fluids have less impact on equipment function
- performance in expert hands approaches or is similar to video laryngoscopy
- a perfect view is not necessary for successful intubation
Disadvantages
- approx 1% failure rate
- a very small minority of patients cannot be intubated by this method regardless of of operator skill
VIDEO LARYNGOSCOPY PROS AND CONS
Advantages
- Eye and airway need not line up
- Better view when mouth opening or neck mobility is limited (e.g. c-spine precautions)
- Others can see and help
- Permits sharing of medical information among the team
- Generally higher success rate, especially in difficult situations
- useful for education (e.g. airway anatomy)
- useful for awake intubation
- novices who train with video laryngoscopy also learn direct laryngoscopy faster
- less risk of esophageal intubation
- less oral trauma (conflicting evidence)
- less c-spine movement when c-spine precuations in place (conflicting evidence)
- less haemodynamic response to intubation
Disadvantages
- Variable learning curves
- may take longer to intubate (conflicting data on this)
- Passage of tube may be difficult despite great view; stylet often necessary
- Fogging and secretions may obscure view
- Loss of depth perception
- More complicated
- Potential for equipment failure
- More expensive
- Greater processing time and expense
- may lead to deskilling at direct laryngoscopy over time
- multiple devices available requiring different skill sets
- direct laryngoscopy skills are not directly transferable to use of hyperangulated video laryngoscopes
- many scopes are large in size and difficult to insert in patients with a poor mouth opening (e.g trismus, oropharyngeal abscesses, and tumors)
- video screen may be difficult to visualise in the brightly lit outdoor setting
- rapid acceptance may be an example of ‘gizmo idolatry’
CONCLUSION
- A device such as the Storz C-Mac Video Laryngoscope (no COI to disclose!) offers the best of both worlds – direct laryngoscopy can be performed in the usual way, with the video as an immediately available back up
- critical care doctors need to be expert with both techniques
“All departments should have access to video laryngoscopy equipment”
— Scott Weingart
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
LITFL
Journal articles
- Cheyne DR, Doyle P. Advances in laryngoscopy: rigid indirect laryngoscopy. F1000 Med Rep. 2010 Aug 19;2:61. PMC2990653.
- Herbstreit F, Fassbender P, Haberl H, Kehren C, Peters J. Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students. Anesth Analg. 2011 Sep;113(3):586-90. PMID: 21680859. [Free fulltext]
- Hurford WE. The video revolution: a new view of laryngoscopy. Respir Care. 2010 Aug;55(8):1036-45. PMID: 20667151. [Free fulltext]
- Levitan RM, Heitz JW, Sweeney M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med. 2011 Mar;57(3):240-7. PMID: 20674088.
- Rosenstock CV, Thøgersen B, Afshari A, Christensen AL, Eriksen C, Gätke MR. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: a randomized clinical trial. Anesthesiology. 2012 Jun;116(6):1210-6. PMID: 22487805.
FOAM and web resources
- EMCrit Podcast 70 – Airway Management with Rich Levitan
- EMCrit — Brief Review of the King Vision Video Laryngoscope
- EMRAP — Airway Management! Time for a change?
- EP Monthly — Levitan: Video + Direct Laryngoscopy
- EP Monthly — Levitan: Demystifying Pediatric Laryngoscopy
- EP Monthly — Levitan: Four Secrets to Video Laryngoscopy
- PHARM — Why Video will never kill the direct laryngoscope star!
- PHARM — Search for the Sub $100 videolaryngoscope
- Resus.ME — Video laryngoscope successes and failures
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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