Rev Esp Anestesiol Reanim.

2019;66(4):177---180

Revista Española de Anestesiología

y Reanimación
www.elsevier.es/redar

EDITORIAL ARTICLE

Is direct laryngoscopy dead? Long live the video

laryngoscopy夽
¿Ha muerto la laringoscopia directa? Larga vida a la videolaringoscopia

M.A. Gómez-Ríos a,b,c,∗ , J.A. Sastre-Rincón a,d , M. Mariscal-Flores a,e

a
Grupo Español de Vía Aérea Difícil (GEVAD), Spain
b
Departamento de Anestesiología y Medicina Perioperatoria, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
c
Grupo de investigación Anestesiología y tratamiento del dolor, Instituto de Investigación Biomédica de A Coruña (INIBIC), A
Coruña, Spain
d
Servicio de Anestesiología y Reanimación, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
e
Servicio de Anestesiología y Reanimación, Hospital Universitario de Getafe, Getafe, Madrid, Spain

Available online 26 March 2019

Ineffective airway management is the main cause of
complications in anaesthesia.1 It has a morbidity and
mortality rate of 1:22,000 and 1:180,000 general anaes-
thesias, respectively,2 and contributes to approximately
40% of anaesthesia-related deaths associated.3 Although
mortality rates have declined in recent years due to tech-
nological advances and improved knowledge and training,
poor airway management still needs to be addressed in
depth.4,5 Because of this, research into airway manage-
ment has increased exponentially in comparison with other
fields of anaesthesiology.6 The 4th National Audit Project
(NAP4) published by the Royal College of Anaesthetists and
the Difficult Airway Society (DAS) has marked a turning
point in this decade. The more than 160 recommenda-
tions derived from the analysis of complications has ushered
夽 Please cite this article as: Gómez-Ríos MA, Sastre-Rincón JA,
Mariscal-Flores M. ¿Ha muerto la laringoscopia directa? Larga vida a
la videolaringoscopia. Rev Esp Anestesiol Reanim. 2019;66:177---180.
∗ Corresponding author.
E-mail address: magoris@hotmail.com (M.A. Gómez-Ríos).
in important changes in clinical practice and improved
patient safety during airway management.7 It is hardly
surprising, therefore, that the NAP4 forms the basis for
the latest DAS guidelines.8,9 The need to limit the num-
ber and duration of attempts to achieve non-traumatic
intubation as soon as possible is one of the core recommen-
dations. The Vortex approach is based on this principle,10
because with each attempt the possibility of success
decreases and the risk of an adverse outcome increases.2
The objective, therefore, should be intubation at the first
attempt.11,12
The Macintosh laryngoscope is perhaps one of the most
successful and long-lasting instruments in the history of
anaesthesiology.13 Since its description by Sir Robert R.
Macintosh in a letter published in The Lancet on February
13, 1943,14 it has remained the gold standard for airway
management.15 However, despite its usefulness, it has sev-
eral disadvantages. Direct laryngoscopy (DL) is a demanding
technical skill that calls for alignment of the oral, pharyn-
geal, and laryngeal axes to visualise the glottis.16,17 This can
cause major haemodynamic changes, cervical instability,
upper airway injury, or inadequate glottic vision, a common
problem and the primary cause of difficult intubation.5,18

2341-1929/© 2018 Sociedad Española de Anestesiologı́a, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights
reserved.
178
Difficult DL is associated with failed intubation and multiple
attempts, which in turn cause airway injury and oedema,
hypoxia, bronchoaspiration or progression to a situation
of ‘‘cannot intubate, cannot oxygenate’’.2,19 Preoperative
planning will enable anaesthesiologists to deal with difficult
DL. However, existing airway evaluation tests are ineffective
in predicting difficulties in up to 93% of cases.20 In addition,
the failure of one technique increases the likelihood of fail-
ure of successive techniques, and the risk of morbidity.5 This
is why it is important to make the first intubation attempt
under the best conditions, using the device with the greatest
likelihood of success.21
Videolaryngoscopy (VL), first introduced with the
Glidescope in 2003, has changed clinical practice.22 Since
then, many different videolaryngoscopes have been devel-
oped. Despite the wide range of devices, they can still be
classified into 3 groups depending on the type of blade
and the presence or absence of a guide channel: devices
incorporating a Macintosh blade, a hyperangulated blade,
or a guide channel. Although their technical specifications
may differ, all these devices share common characteristics.
In addition to5 greater ease of use and a shorter learning
curve,23 they improve glottic vision without the need to
align the axes, and are therefore less traumatic and less
likely to elicit haemdynamic changes.24 Videolaryngoscopes
reduce the incidence of Cormack-Lehane III and IV glottic
view initially obtained with DL, and with it, the risk of intu-
bation failure.25 However, it is important to be aware of their
limitations in order to optimise their performance, since a
good glottic view does not necessarily guarantee success-
ful intubation.26 The success of VL depends on the type of
device used, the operator’s experience, and the character-
istics of the patient.
There is now solid evidence of the superiority of VL
over DL. Different meta-analyses have shown that VL offers
significantly improved glottic vision, increases the first-
attempt intubation success rate, and reduces the number of
failed intubations and DL-related complications.27---29 Guide-
lines recommend that all anaesthetists should be trained
in the use of the videolaryngoscope, and have immediate
access to the device whenever and wherever airway proce-
dures are performed.8,9 Currently, the main indications for
VL are anticipated difficulty airway, as a primary device,
and unforeseen difficult airway, as a rescue device.8,9,30 The
DAS, meanwhile, suggests that VL should be the first choice
device whenever a critical patient is intubated, in order to
avoid multiple attempts and failed intubation.9 Universal
use of the VL as a first line device has many advantages12 :
1. It increases patient safety by decreasing the incidence
of unforeseen difficult airway, the number of intuba-
tion attempts, and instrumentation with other rescue
devices, thus facilitating progression through the airway
algorithm.3,31
2. Unlike sporadic use, universal use facilitates early
acquisition and continuous updating of technical skills,
which maximises efficiency and minimises device-related
complications.
3. The real-time images provided by VLs optimise train-
ing in indirect laryngoscopy, since they allow trainees
to receive indications from an experienced operator
who has access to the novices’ views, thus avoiding
M.A. Gómez-Ríos et al.
the need for a second attempt by the expert.32,33 In
addition, devices with Macintosh blades allow both indi-
rect and direct laryngoscopy, and therefore improve
learning of the latter technique.34 This dual function is
advantageous when the presence of secretions, blood or
gastric contents in the upper airway obstructs indirect
vision.12,35
4. VLs improve teamwork, coordination and communica-
tion, by allowing the entire team to visualise the
procedure.12 They also allow the operator to receive
guidance based on airway findings. This is particularly
beneficial during rapid sequence induction, as it allows
the assistant to adjust cricoid pressure according to glot-
tic view.36
5. With VLs, intubation can be digitally recorded for teach-
ing, legal and clinical purposes, thus facilitating future
interventions.37
6. The use of consumables prevents cross-infection sec-
ondary to residual contamination of multiple-use
material.
7. Operators are able to adopt a more ergonomic body pos-
ture during VL intubation.38
For all these reasons, many experts are now calling for
universal use of VL whenever intubation is required.12,23,37,39
Despite this, the Macintosh laryngoscope is still the first-line
device for ordinary airway management with no predictors
of difficult intubation, and routine use of VL is infrequent.40
Why choose outdated technology when a technically supe-
rior alternative is available? Why not use a smartphone
instead of an obsolete conventional mobile phone?37 The
only factor that has prevented videolaryngoscopy from
becoming the standard of care, besides reluctance to aban-
don deep-rooted practices, is its cost in these times of
budgetary restrictions.5,12,39 However, the design of new
devices and technological advances have overcome this
hurdle.41 In the few studies reporting the experience of
switching from conventional laryngoscopy to VL in a hospital
setting42,43 the change was associated with improved safety
and quality of care, optimised teamwork, and unanimous
support from clinicians. A key factor in ensuring the success
of universal videolarygoscopy is choosing the right device.
Evidence has shown the importance of both the type of vide-
olaryngoscope chosen and the competence and training of
the operator. Indeed, hyperangulated VLs can prolong easy
intubation.44,45 VLs with Macintosh blades allow both direct
and indirect laryngoscopy, and are therefore best suited
to routine practice, while VLs with hyperangulated chan-
nelled or non-channelled blades the latter uses a stylet as
an adjuvant --- are reserved as first-option or rescue device in
difficult airways.9,12 The ideal video laryngoscopes for rou-
tine use are the McGrath MAC (Aircraft Medical, Edinburgh,
United Kingdom) or the C-MAC (Karl Storz, Tuttlingen, Ger-
many) which, aside from portability, have both channelled
and non-channelled blades.21
Since it was first designed, the Macintosh laryngoscope
has been a fixture in operating rooms worldwide, and its
dominance has survived the introduction of new technology.
However, its days as the standard of care in airway manage-
ment may be numbered. Well-designed cost-effectiveness
Is the direct laryngoscopy dead? Long live the video laryngoscopy
studies in VLs will deliver the ‘‘coup de grace’’ to standard
airway management in the foreseeable future.
Funding
None.
Conflicts of interest
None declared.
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