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Home E-Weekly October 1, 2020

New Thinking in Airway Management

Published: October 1, 2020

Video laryngoscopes shine as surgical facilities try to keep both patients and providers safe.

VIEW FROM AFAR VIEW FROM AFAR Video laryngoscopes allow anesthesia providers to intubate patients at a safer distance than the traditional direct approach.

Intubating patients has never been easy, but the presence of a dangerous aerosolized virus has changed the calculus of this delicate and dangerous procedure. After all, anesthesia providers work inches from patient airways to insert laryngoscopes, putting them in the direct path of the airborne coronavirus particles of an infected patient. In addition to the other potential complications of this procedure, there's an added focus on protecting clinicians from patients who might have the virus during intubations.

"COVID-19 has complicated airway management," says Michael Aziz, MD, a professor of anesthesiology and medicine at Oregon Health & Science University in Portland. "Providers must protect themselves with several layers of PPE, which makes the job more physically demanding. Communication is hampered and visualization is more difficult."

Roxanne McMurray, DNP, APRN, CRNA, a clinical assistant professor at the University of Minnesota School of Nursing in Minneapolis, characterizes the pandemic as a reset for anesthesia. "Providers must be more vigilant when securing the airway," she says. "The current challenges will force us to up our game, and that's a good thing."

Rudimentary boxes and shields have been fashioned to protect anesthesia providers during the pandemic, but it’s the usage of video laryngoscopes that might prove to be the lasting difference. Previously viewed by many providers as a luxury or an emergency-use tool for difficult airways, video laryngoscopes now are increasingly becoming standard tools. "The devices were gaining a stronger foothold because clinical evidence shows higher rates of first pass intubation success," says Dr. Aziz. "Some providers had already been using them universally. Many who weren't are now discovering the benefits they provide."

Video laryngoscopes remove the need for the anesthesia provider to put their face directly over the patient to visualize the airway. The provider enjoys a direct view of the glottis from a safer distance to make intubation much easier. These products have been around for about a decade, and they have become more ergonomic and portable over the years, adding high-definition video along the way. They can also accommodate various laryngoscope blade designs.

For Dr. Aziz, screen size and location matter most in a video laryngoscope. "Units with smaller, attached screens are priced competitively, but the visualization and magnification capabilities afforded by larger screens allow for improved intubation performance," he says. "Video laryngoscopes with separate monitors that can be positioned next to the patient let providers stand upright while intubating instead of leaning directly over the airway to perform direct laryngoscopy or manipulate a video laryngoscope with an integrated screen."

As a result of COVID-19, the day may soon come when direct intubations are a relic of the past. "I still teach direct laryngoscopy to new nurse anesthetists, but video laryngoscopes are fabulous tools," says Dr. McMurray. "There's no doubt video laryngoscopy is developing into the standard of care."

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