Chapter

Videolaryngoscopy

17 Lorenz Theiler, Tim Cook and Michael Aziz

Introduction
Videolaryngoscopy has all but evolved to a gold stan-
dard for difficult laryngoscopy and intubation.
A multitude of videolaryngoscope (VL) devices and
designs are available. Videolaryngoscopes can be cate-
gorised into three main types according to their blade
type:
• Macintosh-like blade
• hyperangulated blade
• blade with an integrated tracheal tube-guiding
channel (i.e. a conduit)
Each of the three designs have their indications and each
Figure 17.1 The Bullard scope. (Courtesy of Professor Paul Baker,
requires distinctive training and specialised handling. Auckland Hospital, NZ.)
Related to VLs are video stylets, which are also briefly
described in this chapter.
Videolaryngoscopy provides technical benefits the anaesthesia community quite some time ago.
and significant non-technical benefits to the intuba- A variety of flexible optical bronchoscopes (FOBs)
tion team. Consistently, VLs improve laryngeal view (see Chapter 16) were in use since the 1970s and rigid
compared with direct laryngoscopy. The ability of optical scopes followed afterwards. One rigid optical
other team members (or trainers) to observe what scope, combined with a laryngoscope, is the Bullard
the primary intubator is seeing when using a VL fos- laryngoscope (Figure 17.1). It features important char-
ters enhanced teamwork and learning. acteristics of modern VLs with a hyperangulated blade:
it provides an optical scope, albeit with the eye at the tip
Development of the tracheal tube and not at the tip of the blade, and
Traditionally, laryngeal structures can be visualised a very angulated blade to facilitate intubation around
either indirectly, e.g. by using mirrors, or directly, by anatomical obstacles at the base of the tongue. As such,
the use of standard laryngoscopes. For the last 20 it did not require the alignment of the glottis on the
years, with the recently expanding variety of VLs same axis with the line of sight, which is a prerequisite
available, the anaesthesia community has gradually for direct visualisation of the laryngeal structures.
turned to indirect laryngoscopy as the favourite At the beginning of the twenty-first century, the
means to visualise the larynx. The impact of videolar- concept of placing a camera on the laryngoscope blade
yngoscopy on tracheal intubation is easily comparable started to be marketed. First, on a standard Macintosh
to the introduction of Macintosh’s laryngoscope blade blade equipped with a fibreoptic scope (e.g. Laryflex by
in 1943. It may not be as revolutionary as the intro- Acutronic, Hirzel, Switzerland, Figure 17.2, and Storz
duction of the supraglottic airway device, but it is DCI Videolaryngoscope, Karl Storz, Tuttlingen,
arguably the most important advance in airway man- Germany). The cumbersome assembly and cleaning
agement in recent decades. prohibited widespread use. Dr John Allen Pacey,
The concept of introducing not only light to the a surgeon, introduced a sharply angulated blade with
153
tracheal opening, but also a camera, was introduced to a digital camera in 2001, the GlideScope (Verathon,

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 Section 1: Airway Management: Background and Techniques

Figure 17.2 The Laryflex.

Inc., Bothell, WA, USA, Figure 17.3). This device fea-

tured a CMOS (complementary metal-oxide semicon-
ductor) digital chip and LED (light emitting diode)
light to enable portability and reduced assembly Figure 17.3 The GlideScope Go.
needs. Since then, a wide range of VLs have become
available, with different features and designs. view the intubation procedure provides the oppor-
Studies comparing the success rate of tracheal tunity to evolve the intubation procedure from
intubation between standard laryngoscopy and video- a manoeuvre performed solely by one laryngosco-
laryngoscopy are often insufficient because of incon- pist to a task performed and guided by a team. The
sistent methodology. Hyperangulated blades are very team approach may optimise intubation attempts
different from Macintosh blades and also very differ- (e.g. an assistant providing optimal external laryn-
ent from blades with an integrated tube-guiding chan- geal pressure or adjusting cricoid force) and can
nel (conduit). Regardless of study limitations, there is help prevent errors such as oesophageal intubations,
ample evidence available to confirm VLs are superior as helpful hands and eyes can support the intubation
to standard laryngoscopes in providing an improved procedure. It is also possible to record the intuba-
laryngeal view. tion process for teaching purposes and legal docu-
Compared to standard laryngoscopy, tracheal mentation. The record can now serve to document
tube advancement may be more difficult, especially the ease or difficulty of the procedure and to confirm
with hyperangulated blades. This is most commonly proper tube placement without signs of injury
due to the operator having inadequate knowledge or or aspiration.
experience of videolaryngoscopy technique.
Inadequate training or experience should not be
confused with a limitation of the technique and it
Overview of Different
is important to understand that there is a learning Videolaryngoscopes
curve for all VLs, but particularly for hyperangu- When choosing a VL, the type of blade is the most
lated and conduited devices. When correctly per- important decision (Figure 17.4). Several manufac-
formed, the use of videolaryngoscopy is associated turers offer both hyperangulated and Macintosh blades.
with higher intubation first-attempt success rates, Blades with conduits are routinely hyperangulated.
fewer oesophageal intubations and less sore throat Furthermore, both single-use and reusable sys-
and hoarseness. tems are available. While the performance is similar,
An often-overlooked aspect of the use of VLs is differences regarding financial, logistic, environmen-
154 one of the most important ones: using a screen to tal and hygienic issues guide purchase decisions.

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 Chapter 17: Videolaryngoscopy

Figure 17.4 Overview of

Videolaryngoscopes videolaryngoscope types.

Standard blade: Hyperangulated blade

Macintosh/Miller type

Conduited ‘Difficult Airway’ blade

Use of Videolaryngoscopes with Use of Videolaryngoscopes with

a Macintosh-Type Blade a Hyperangulated Blade
Videolaryngoscopy with a Macintosh-type blade clo- The advantage of using a hyperangulated blade lies in
sely resembles direct laryngoscopy. For practitioners the ability to look around obstacles at the oropharyn-
experienced with standard laryngoscopy who are new geal curve, such as a prominent base of the tongue,
to using VLs, it may be prudent to start with a which would impede or defeat direct laryngoscopy.
Macintosh-type VL blade. The transition is much Hyperangulated blades may be inserted along the side
smoother and the early failure rate may be lower. of the tongue (like a Macintosh-type blade) or in the
Another advantage is the opportunity to readily midline. In either case the tip of the blade should be
switch back to direct laryngoscopy, e.g. in case of placed in the vallecula. Minimal force should be
severe contamination of the lens or the presence needed to place the blade and this is one of its
of ambient light, especially in pre-hospital advantages.
environments. In most circumstances a hyperangulated blade will
A ‘patient–screen–patient’ approach is recom- improve the view of the larynx, compared with direct
mended, just as in regional anaesthesia with ultrasound. laryngoscopy. However, intubation may not necessarily
Thus, the operator looks at the patient when advancing become easier – though this is most commonly due to
or moving the blade and then at the screen to observe the poor operator technique. When passing the tracheal
effect of that movement – while holding the device still. tube, it must pass through the two curves of the upper
Again, when inserting the tracheal tube, the operator airway: first anteriorly to meet the glottic inlet, then
does not look at the screen until the tube is advanced posteriorly to lie along the tracheal axis. This problem
beyond the line of sight at the posterior pharynx. The has been termed as ‘you see that you fail’: the tracheal
advancing of the tube towards and beyond the glottic tube is not passed despite a perfect view of the glottis.
opening may be observed either directly as in standard Successful intubation with a hyperangulated VL man-
laryngoscopy, or by observing the screen. dates a stylet (or another semi-rigid introducer) with an
Intubation may be facilitated by using either angulation resembling the angle of the blade. The man-
a tracheal tube with a stylet inserted or an intubation ufacturers of the GlideScope and C-MAC devices each
aid (a ‘bougie’) (see Chapter 15). market their own rigid stylet with this preformed 155

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 Section 1: Airway Management: Background and Techniques

configuration. Once a tracheal tube has a stylet within it, along the blade in direct contact with the VL blade
it becomes more rigid and if care is not taken, the tube or the tube will reliably enter the glottis. This technique
stylet may injure the posterior wall of the pharynx relies on the fact that the VL camera is ‘looking’
(Figure 17.5). This complication is closely associated straight down the blade and if the blade is optimally
with hyperangulated blades and evidence supports an positioned over the glottis, simple optics mean pas-
expected 1% event rate. The hyperangulated blade sing the tube along the blade will direct it to the
means it is inevitable that the tip of the tracheal tube glottis. In some ways this technique is akin to treating
will pass out of direct sight during insertion. It may not the hyperangulated blade as if it were conduited (see
then appear on the VL screen until it is advanced a little below).
further, meaning there is a ‘blind spot’ when the tube tip Once the tracheal tube reaches the glottis, however
is visible neither directly nor indirectly. In practice this that is achieved, withdrawing the stylet may help
blind spot is very small. Also, if the tip of the tracheal tube facilitate further advancement of the tube down the
is slid along the blade as it disappears from view this tracheal axis as the tube ‘unbends’ and this is essential
should minimise contact with the posterior pharyngeal to minimise risk of injury. Other methods to assist
wall and virtually eliminate the risk of injury. tracheal tube passage include simultaneous rotation
During laryngoscopy itself, placing the VL tip of the tracheal tube as it is advanced and ‘reverse
beyond the epiglottis and lifting directly (‘Miller loading’ of the tracheal tube on the stylet – i.e. insert-
style’) is not advisable, as this may injure the fragile ing the curved stylet against the pre-shaped curve of
epiglottic structure. Also, this technique displaces the the tracheal tube so that when the stylet is withdrawn
larynx further anterior, which makes tube passage the tube naturally projects posteriorly towards the
more difficult. tracheal axis. Choice of tracheal tube type may also
There are several different views regarding opti- impact on success and risk of injury: choosing
mising tube passage with a hyperangulated VL. Some a tracheal tube that is one size smaller than normal,
take the view that when the anterior wall of the tra- one that is not rigidly curved or even is flexible, and
chea becomes visible, the tip of the blade is too close to one that has a bullet tip (e.g. Parker tip) may all assist.
the glottis. In order to facilitate easier intubation, Finally, external laryngeal pressure may help align the
a less than ideal view of the glottic opening is adopted trachea with the direction of the tracheal tube. It is,
by partly withdrawing the blade, i.e. to achieve only however, important to emphasise that with proper
a partial view of the glottic opening. An alternative training and experience, difficulty passing the tracheal
approach is to consider the VL screen to be a 3 × 3 grid tube when using a hyperangulated VL blade should be
and ensure that the glottic opening is in the middle of both very uncommon and readily overcome.
this grid. If the styletted tracheal tube is then slid
Use of Videolaryngoscopes with
a Conduit
Videolaryngoscopes with an integrated guiding
channel are also hyperangulated blades. To ensure
intubation, the glottic opening must be in the mid-
dle of the VL screen to enable advancing the tra-
cheal tube. Thus, positioning of the VL is the
technical part, while intubation itself will be com-
parably easy. These blades may be useful in awake
videolaryngoscopic intubation (see below), and
a bite block is integrated within the blade, protect-
ing the tube. Beginners and incorrectly trained per-
sonnel tend to insert these blades too deep, which
prevents optimal device positioning, making intuba-
tion impossible. The disadvantage of VLs with
Figure 17.5 Pharyngeal injury using a hyperangulated blade with
an inadequately pre-shaped tracheal tube (tube visible at the right
a conduit lies in the fact that the tracheal tube can
156 side of the picture). only be advanced through the channel, alternative

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 Chapter 17: Videolaryngoscopy

approaches to the glottis are not possible (e.g. nasal

intubation). Furthermore, these blades tend to be
a bit bulky, requiring a larger mouth opening.
Of note it is important to use the tracheal tube
recommended by the manufacturer for a given
conduited device. The devices are designed to facil-
itate intubation with the tracheal tube exiting the
conduit aligned with the axis of the channel. If too
small a tracheal tube is used it will ‘cut across the
curve’ of the conduit, tending to exit the conduit
facing posteriorly and intubation will fail. For the
same reason, if intubation with a conduited VL is
difficult, use of a bougie down the channel is unlikely
to help.

Adjuncts to Videolaryngoscopes
and Useful Combinations
Tracheal introducers (bougies) and stylets are dis-
cussed in Chapter 15. Bougies may be used with
high success in a similar manner to that for direct
laryngoscopy. The use of a bougie for videolaryngo-
scopy may be most beneficial with Macintosh-type Figure 17.6 An example of a flexible-tipped stylet. The tip is
flexed/extended by moving the thumb up/down.
blade designs. Bougies are unlikely to be of great
value when using a hyperangulated VL if they are
not malleable. They generally fail to maintain their and tissue distortion to achieve an excellent position
curvature and therefore do not match the curvature of over the larynx. Several studies have observed
the VL blade. Stylets are well suited to use with hyper- equivalent success rates with VLs compared to
angulated VLs: either malleable ones that can be pre- FOBs in awake patients, though in some of these
formed to the required shape or manufacturers’ own studies deep sedation was used meaning they were
devices designed to use with a specific VL (e.g. not strictly ‘awake’ techniques. The topic is discussed
GlideScope and C-Mac). Their use is described further in Chapter 9.
above. Recently a number of bougies which are semi-
rigid or with deflectable (‘steerable’) tips have been
described (Figure 17.6). These may be more suited to
The Use of Videolaryngoscopes
use with hyperangulated VLs than conventional bou- in the Emergency Department
gies, but evidence to support this is awaited. and Out of Hospital
Videolaryngoscopes can easily be combined with
Emergency airway management out of the operating
other optical devices including flexible, rigid or semi-
theatre and out of hospital is challenged by restricted
rigid video stylets. An example is the combination with
time, physiologically compromised patients and often
FOB-guided intubation – video-assisted flexible intu-
the limited experience of the airway practitioners
bation (VAFI) – and this is described in Chapter 19.
involved. While true anatomical difficult airway
per se is relatively rare, difficulties routinely arise
The Use of Videolaryngoscopes from restricted range of motion of the head and
in Awake Patients neck by collars or manual in-line stabilisation and
Awake videolaryngoscopic intubation is an increas- the presence of blood or gastric content in the oral
ingly accepted and taught technique. A variety of cavity. The out-of-hospital environment may also
techniques are described. In most settings hyper- pose difficulties due to intubation at night, in
angulated blades, including those with conduits, the rain, snow or cold and under bright sunlight.
The fundamental principles of airway management 157
will be favoured as they generally require less force

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 Section 1: Airway Management: Background and Techniques

are the same as in the operating theatre, however, and with a hyperangulated system held in reserve. The
VLs are being used with great success in many pre- former will provide some operator and team benefits
hospital services around the world. If available, the VL of videolaryngoscopy while also enabling training of
should be the first-line device, as many factors may novices in direct laryngoscopy and it will not slow
make multiple attempts unsafe. There may be advan- down ‘easy’ intubations. The hyperangulated VL can
tages to initially using a VL with a Macintosh-style be reserved for genuinely difficult cases.
blade, backed up by a hyperangulated blade. The for- When VL is adopted only for predicted difficulty
mer will be more familiar to less experienced opera- and as a rescue device, some experts argue it makes
tors and the user can revert to direct laryngoscopy if little sense to use a Macintosh-type VL as direct lar-
the monitor is rendered useless by blood or secretions yngoscopy will already have failed. A hyperangulated
on the camera or lighting conditions on the screen. VL is a more logical choice as it will provide additional
Because of numerous challenges related to research in proven benefits in the setting of difficult or failed
emergency environments, the literature is not fully direct laryngoscopy.
supportive of videolaryngoscopy in the emergency In addition to difficult airway management, rou-
environment despite robust observational data. tine use of VL has also been adopted in many depart-
Future research is needed to solidify the role of video- ments for the placement of double-lumen tubes and
laryngoscopy in this environment. tubes used for intraoperative neuromonitoring of the
recurrent laryngeal nerve, which require exact place-
Use of Videolaryngoscopes for Routine ment between the vocal cords.
vs. for Difficult and Rescue Use?
There is debate as to whether videolaryngoscopy Rigid Optical Scopes (Video Stylets)
should be a routine and first-line technique or whether Video stylets are very distinctly separate from other
it should be reserved for those predicted or found to be videoscopes and several of them predate bladed VLs.
difficult to intubate. The debate is unresolved, but only The Bonfils rigid optical scope (Figure 17.7a) is one
a small number of institutions have managed to adopt of the more widely known devices and may be used via
routine, or ‘universal’ videolaryngoscopy. a midline or retromolar approach. This can be espe-
Elective and emergency airway algorithms increas- cially useful in patients with limited mouth opening in
ingly emphasise the role of videolaryngoscopy in mana- both asleep and awake patients. There are several closely
ging difficult intubation and failed direct laryngoscopy. related devices available. A less widely known variant is
They also emphasise the importance of operators being the SensaScope (Acutronic, Hirzel, Switzerland, Figure
skilled and experienced in the use of the devices – which 17.7b). It consists of an S-shape rigid scope with
can only be achieved by regular use in easier settings. a flexible tip. The advantage is the possibility to insert
The evidence indicates that most benefit of video- the device beyond the glottis, which makes subsequent
laryngoscopy is in those patients who are predicted or insertion of the tracheal tube easier. Its main disadvan-
known to be difficult during direct laryngoscopy and tage is the unusual handling required, which includes
intubation. However, it also indicates that multiple – a motion similar to a bartender filling a glass of beer.
even as few as two – attempts at intubation may Very recently, Karl Storz introduced the C-MAC Video
increase the risk of harm to patients. Advocates of Stylet (Figure 17.7c), a rigid scope similar to the Bonfils,
universal videolaryngoscopy suggest that routine use but with a flexible tip similar to the SensaScope, which
will ensure that the minimum number of attempts at facilitates tracheal intubation. The C-MAC Video Stylet
intubation are used for each patient, will maximise thus combines the theoretical benefits of both older
operator skills and experience and will ensure the devices. So far, there are no randomised controlled trials
maximum human factor benefits are accrued by the available evaluating this technique. Rigid optical scopes
team. Opponents of universal videolaryngoscopy may may be used with or without a laryngoscope, and also in
consider it unnecessary, costly and overcomplicating – conjunction with a VL. In comparison to FOBs, they
by slowing down easy intubations and requiring have a faster learning curve, including in oncological
adjuncts where these would otherwise not be needed. patients with rigid tissue caused by radiation therapy.
If universal videolaryngoscopy is adopted there is Their main disadvantage that they can only be used via
158 an argument for choosing a Macintosh-type system, the oral route.

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 Chapter 17: Videolaryngoscopy

(a) Figure 17.7 (a–c) Rigid and semi-rigid

video stylets. (a) Bonfils. (b) SensaScope,
upper inset: flexed tip; lower inset:
extended tip. (c) Storz video stylet with
deflectable tip.

(b)

(c)

Documentation on the monitor and via direct laryngoscopy are docu-

mented. Most VLs feature the possibility to directly
Classic grading of intubating conditions used in direct
record the intubation process. Photos and videos docu-
laryngoscopy such as the Cormack and Lehane score
menting successful, smooth intubation may benefit the
may need to be adjusted when using indirect laryngo-
intubating personnel if the tracheal tube dislocates at
scopy, particularly if there is a good view of the larynx
a later stage, raising the question of primary oesophageal
but difficulty intubating. Several scores have been pro-
intubation. Furthermore, videos may be used for teach-
posed, such as the Intubation Difficulty Score, which also
ing purposes.
includes the force applied, external laryngeal manipula-
tions and the position of the vocal cords. The Fremantle
score includes laryngeal view, ease of tracheal tube pas- Further Reading
sage, the device and any adjuncts. Regardless of the score Aziz MF, Brambrink AM, Healy DW, et al. (2016). Success
used, it is vitally important to document whether a VL or of intubation rescue techniques after failed direct
a standard laryngoscope was used, which blade was used laryngoscopy in adults. A retrospective comparative
and whether or not advancing the tube into the trachea analysis from the Multicenter Perioperative Outcomes
posed any difficulties. Ideally, both the view of the glottis Group. Anesthesiology, 125, 656–666. 159

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 Section 1: Airway Management: Background and Techniques

DeJong A, Molinari N, Conseil M, et al. Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. (2016).
(2014). Videolaryngoscopy versus direct Videolaryngoscopy versus direct laryngoscopy for adult
laryngoscopy for orotracheal intubation in the patients requiring tracheal intubation. Cochrane Database
intensive care unit: a systematic review and of Systematic Reviews, 11, CD011136.
meta-analysis. Intensive Care Medicine, 40, Pieters BMA, Maas EHA, Knape JTA, van Zundert AAJ.
629–639. (2017). Videolaryngoscopy vs. direct laryngoscopy use by
Kelly FE, Cook TM. (2016). Seeing is believing: getting the experienced anaesthetists in patients with known difficult
best out of videolaryngoscopy. British Journal of airways: a systematic review and meta-analysis. Anaesthesia,
Anaesthesia, 117(Suppl 1), i9–i13. 72, 1532–1541.

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