Disclaimer: Unless cited, the contents and conclusions of the following presentation are solely those of the author. The author received funding from Covidien LP, a Medtronic company, for this speaking engagement. The author is responsible for all content and any necessary permissions.
Throughout my career in anesthesiology, I’ve been passionate about airway management, evidence-driven practices, and optimizing patient care. Video laryngoscopy stands out in all three of these areas, and in this article, I’ll share my own experiences and research explaining why.
The evidence surrounding video laryngoscopy (VL) remains paramount for guiding my airway management practice. I’ve participated in many conversations, panels, and webinars about VL, but understanding the benefits may best begin with assessing the myths surrounding its use.
From medical school to residency to private practice and now in my current academic role, I've been introduced to many "truths" about VL. After reviewing the research, many of these points are, in fact, not truths at all. Here are a few easily debunked myths that come up regularly.
Myth: VL is only for difficult airways
Many clinicians feel that simply choosing to use a VL labels a patient’s airway as “difficult.” In reality, many clinicians see VL as the standard of care for routine airway management.1 There are a variety of evidence-based reasons for this shift. For example, VL is associated with improved first-attempt intubation rates2 and a reduction in airway complications in clinical emergency and anesthesia practice.2
Myth: VL always requires a new technique
I also hear the objection from clinicians that they will need to learn a new technique to use VL, and will ultimately lose their direct laryngoscopy (DL) skills if they use VL too frequently. In fact, VLs with Macintosh-shaped blades use a traditional laryngoscopy technique, so you can effectively retain your DL skills.3 VL is also a helpful training tool. Studies show that novices may experience higher intubation success rates using VL, but also when performing DL, after training on a video laryngoscope.4
Myth: VL cannot be used when a patient is vomiting or bleeding
Another myth associated with VL is the inability to use the tool when a patient is vomiting or experiencing airway bleeding. VLs with Macintosh-shaped blades provide optimal glottic visualization and, in the case that blood obscures the video, can easily be used as a direct laryngoscope.5
Myth: All VLs are expensive
Lastly, VL is frequently touted as expensive and not financially sustainable. When I first came across this objection and tried to find existing data to assess its accuracy, I noticed a gap in the literature. We needed a practical assessment of VL cost and the factors that contribute to that cost – which, to my knowledge, didn’t exist – so I took it upon myself to set up an evaluation focused on the cost of VL.
My colleagues — Dr. Dalmar Mohamod, Dr. Andrew Toron, and Dr. Marc Torjman — and I set out to evaluate the data by conducting a retrospective study of the use of VLs in relation to operational expenses and cost savings.6 We examined 52 hospital locations within a single, large university hospital. Most of those locations were hospital operating rooms. Our objective was to determine the entire cost behind video laryngoscopy by comparing the cost effectiveness of two popular choices currently on the market.
For this study, we analyzed the costs and usage associated with two common VLs: the McGRATH™ MAC VL from Medtronic and the GlideScope™* VL from Verathon. Cost information was calculated for the equipment, blades, batteries, and repairs, and subsequent analysis was performed to determine cost differences between these two devices.
The study spanned a 24-month period. During that time, 34,600 endotracheal intubations were performed with 11,345 using video laryngoscopes. This was further broken down between devices, with 48.5 percent of intubations using the McGRATH™ MAC and 46.8 percent using the GlideScope™* device. During the first 12 months of the study, the GlideScope™* VL was used more frequently, but at the onset of the Covid-19 pandemic, the McGRATH™ MAC surpassed the GlideScope™* VL use with a 61 percent increase for all VL cases.
Related: What are the direct and indirect costs associated with the intubation practices and technologies you choose? Take a look at this infographic to see how your choice may impact your facility’s costs and patient outcomes.
During the course of the 24-month period, we found that the overall costs of using the McGRATH™ MAC were 55.5 percent lower than the GlideScope™* VL, equating to a savings of $181,093. Most of the cost differences were attributed to equipment and blade purchases, which were 65 percent higher with the GlideScope™* VL.
To arrive at this number, the following variables were compared in the retrospective analysis: number of endotracheal intubations performed each month with breakdown between video laryngoscopy and flexible bronchoscopy airways, frequency of use for each type of laryngoscope, blades used, and equipment costs for use of each laryngoscope. Hospital cost estimates for both the McGRATH™ MAC and GlideScope™* laryngoscopes included batteries, handles, blades, and the devices themselves. Cost data were also collected on frequency of device failure, maintenance, and replacement of parts and lost equipment.
Lastly, we reviewed the number of failures of both the McGRATH™ MAC and the GlideScope™* VL. The results uncovered no failures for the McGRATH™ MAC video laryngoscope, while three baton replacements were required among the GlideScope™* VL device.
During and following our retrospective study, our facility began using the McGRATH™ MAC video laryngoscope more frequently and for routine intubations. We have been able to directly cut departmental expenses by using a more cost-effective device for intubations without compromising safety and efficacy.
While there’s still work to be done evaluating cost differences between video laryngoscopy and other intubation options, this study is an important step in understanding the economics of VL.
And we’ve already put our research into action.
We now have a McGRATH™ MAC in every operating room. Pairing performance and cost savings, the McGRATH™ MAC has become our preferred intubation device for routine use.
For more information on this topic, listen to my full webinar recording, where I discuss several topics related to airway management including cost effectiveness.
1. Samuels, Jon D., et al. Adoption of video laryngoscopy by a major academic anesthesia department. Journal of Comparative Effectiveness Research 10.2 (2021): 101-108.
2. Kriege M, Noppens RR. Evaluation of the McGRATH™ MAC and Macintosh laryngoscope for tracheal intubation. British journal of anaesthesia. 2020;125(1):e209.
3. Berkow LC, Morey TE, Urdaneta F. The Technology of Video Laryngoscopy. Anesth Analog. 2018 May:126(5):1527-1534. Doi:10.1213/ANE.000000000000Z 490. PMID: 28961559.
4. Myantra, Sheila N., Doctor, J. Use of videolaryngoscopy as a teaching tool for novices performing tracheal intubation results in greater first pass success in neonates and infants. Indian J Anaesth. 2019 Oct; 63(10): 781-783.
5. Kristensen, M. S., & McGuire, B. (2020). Managing and securing the bleeding upper airway: a narrative review. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 67(1), 128-140.
6. Thaler A, Mohamod D, Toron A, Torjman MC. Cost Comparison of 2 Video Laryngoscopes in a Large Academic Center. Journal of Clinical Outcomes Management. 2021 July;28(4):174-179.
This retrospective study was performed from June 2018 through May 2020 at Thomas Jefferson University Hospital under exemption from the Thomas Jefferson University Institutional Review Board. Electronic medical records containing demographic data and information related to endotracheal intubation procedures, with monthly breakdowns between GlideScope™* and McGRATH intubations, were reviewed. Cost information calculated for equipment, blades, batteries, repairs, and subsequent analysis performed to determine cost differences between those 2 instruments during the COVID-19 period.
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