blade. Some are comparable to Macintosh
and Miller blades and may be used in the
same way. Little retraining is necessary, and
in some cases these blades may be used to
perform conventional direct laryngoscopy.
Other video blades differ from standard
direct laryngoscope blades incorporating
a hyper-angulated curvature. They require
additional training and, in some cases, the
addition of specialized stylets.
VLs also vary in sizes and although not all
VLs can be used in children, manufacturers
continue to introduce separate pediatric-sized
devices or laryngoscope blades for existing
devices. Channel guides are another innovation that vary among video laryngoscopes.
They are fittings that are attached to the
laryngoscope where an endotracheal tube
may be placed. After visualization of the glottis, the ET tube is advanced through the guide
and the cords. Guides limit the size ET tube
that can be used.
Acceptable image size and quality is a
matter of user preference. VLs suitable for
field use generally provide images of sufficient quality for successful endotracheal
intubation. In general, an inverse relationship between image quality and cost exists,
meaning the higher the device costs, the better the image quality. Finally some VLs can be
connected to an external monitor. This permits a trainer or observer to simultaneously
view the picture available to the endotracheal
For more on quality assurance with video
laryngosopy, see the Tucson Fire Department
template in the online version of this article at
Note that children aged 4 years or younger
are particularly challenging. The epiglottis
is at the level of C- 1, not C- 4 as in adults;
there’s a relatively large amount of adenoi-
dal tissue in the airway that’s friable and
prone to bleeding with minimal trauma. In
addition, small children have a rapid meta-
bolic rate and are therefore prone to rapid
desaturation (see Figure 1, p. 35). Thus,
there’s virtually no time of safe apnea for
small children because they begin to desat-
urate immediately on becoming apneic for
Since 2000, many studies of advanced emergency airway management have appeared
in the medical literature. Although most
described patients in the operating room,
intensive care unit or emergency department, studies of video laryngoscopy in
the field are in progress and beginning to
appear in the literature.
Video laryngoscopy provides better views of the glottis, and it permits
more successful intubations with fewer
attempts. Price reductions as more devices,
some specifically intended for EMS, enter
the market will lower the entry costs for
adoption. It is my prediction that in five
years, video laryngoscopy will be the
method of choice for endotracheal intubation in the field.
Terence Valenzuela, MD, MPH, is medical director of
Tucson Fire Department. He can be reached at terry@
Jarrod Mosier, MD, is an assistant professor of
emergency medicine at the University of Arizona College of Medicine Department of Emergency Medicine.
John Sakles, MD, is a professor of emergency medicine at the University of Arizona College of Medicine
Department of Emergency Medicine.
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