**5. Limitations and complications of videolaryngoscopy**

Despite the advantages and widespread use of videolaryngoscopy, there are some limitations that may be viewed as absolute or relative contraindications [13]. The only real absolute contraindication for videolaryngoscopy is the significant limitation of opening a mouth which does not allow to insert the blade. In this situation, retromolar intubation with videostylets or fiberoptic intubation, that are comparably smaller devices, may be a good alternative.

Fogging and secretions may obscure view, but they can be solved. Newer devices have additional antifogging adds and one should be aware about it during airway intubation. Adding oxygen may help in antifogging too, while successive early aspiration of secretion may be effective.

The most frustrating situation is when the passage of tube may be difficult despite great view ("laryngoscopic paradox") [13, 24]. However, one must be aware of his/her understanding of the basic videolaryngoscopy concepts. Indeed, as the acute angle is often very sharp, an acutely angled stylet is necessary. In addition, depth perception is lost with a two-dimensional video image, and sometimes, operators may become fixated on the video screen and may not directly observe where the laryngoscope blade or endotracheal tube is being placed [24]. The consequences of this unawareness of the situation are injuries of soft tissues such as soft palate, tonsillar, or pharyngeal wall perforation [65–68]. According to one study female gender, right tonsillar pillars and soft palate were the most frequently injured [69]. The most common repair of these soft tissues' injuries was simple surgical closure with no long-term harm [69].

Additional limitations of videolaryngoscopy are as follows: the need of experience and the time demand for the operator to learn how to use them properly, the rapid deterioration of their display in the presence of a swelling or a secretion, and the fact that they are rather complicated and expensive devices [70].

There are few useful tips that can be practiced to avoid complications. It is particularly important to prepare the tube with the stylet to follow the angle of the blade. As a mnemonic aid, one can remember the abbreviation "CCLL": (1) Choose the right tube, (2) Check the endotracheal tube cuff, (3) Lubricate the stylet and the endotracheal tube (but spare the camera and the light source), and (4) Load the stylet (i.e., band it according to the angle of videolaryngoscopy blade).

To gain great maneuverability with the tube, it is advisable to hold the tube closer to its connector, not to be to too close with the view to the glottis (back it up), and in the case of difficulty, passing through the glottis to use the bougie [71]. In addition, some propose to view videolaryngoscopy as a four-step procedure: First step is to look in the mouth and insert the videolaryngoscopy blade under direct vision. The next step is to look at the screen while gently advancing with the blade toward epiglottis to get the best glottic view. The third step is to move the look again to the mouth while inserting the tube under the direct vision to avoid trauma of soft tissues. And finally, the fourth step, is again to look at the screen to complete intubation. This step will probably need extra rotations and angulations of the tube. It is important that the stylet removal and the tube adjustments are done under direct visualizations [72].

### **6. Conclusion**

Videolaryngoscopy can be used effectively in situations of expected and unexpected difficult airway management. There are several devices for videolaryngoscopy, which differ technically, but with a thorough knowledge of the technical specific details, the success of the use of different videolaryngoscopes in intubation is similar. The choice of a specific videolaryngoscope depends on the individual patient, local resources, and the expertise of the operator. The simplicity and benefits of using videolaryngoscopy lead enthusiasts to entitle videolaryngoscopy as the miracle solution for all possible situations where airway visualization and airway management is required. But, in clinical reality, videolaryngoscopy, like any airway management technique, has its advantages and disadvantages. Its great advantage is that even its shortcomings can be learned faster and more efficiently,

**241**

**Author details**

Tatjana Goranović1,2

**Conflict of interest**

1 University Department of Anaesthesiology, Resuscitation and Intensive Care

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Faculty of Medicine, Josip Juraj Strossmayer University, Osijek, Croatia

Medicine, Sveti Duh University Hospital, Zagreb, Croatia

\*Address all correspondence to: tanjagoranovic@hotmail.com

provided the original work is properly cited.

*Videolaryngoscopy, the Current Role in Airway Management*

because the procedure is widely visible to a larger number of participants gathered in the airway care team in a real time. Therefore, videolaryngoscopy is not only an excellent teaching tool for mastering the airway management with its use but also with other airway devices which can be used as single or in various combinations. In addition, videolaryngoscopy has proven to be a useful technique in other clinical situations besides intubation, such as diagnostics of upper airway and small laryngeal surgeries. Finally, videolaryngoscopy is also an important medicolegal tool for all topics related to airway care as it allows immediate and delayed post-procedure

Nowadays, many societies' guidelines recommend to use videolaryngoscopy early in intubation attempts in order to aim first-pass intubation success. It is possible that even in close future, it will replace direct intubation as the gold standard. However, for such an evolution, it is necessary for the clinicians to master the vide-

Good preparation makes half of the technique. It is important to be aware of the device characteristics, especially technical details such as the resolution and fogging of the screen, the size and the angle of the blade, and the need to use preformed tube by stylet. During the process of videolaryngoscopy, it is advisable to think about it as a four-step procedure with alternately looking in the mouth and at the screen. Direct and indirect visualization of the upper airway should be complemented with customized hand-eye coordination. If accepted, these routine tips can

minimize majority of traumatic complications. Primum nil nocere.

*DOI: http://dx.doi.org/10.5772/intechopen.93490*

analysis by reproducing its recordings.

olaryngoscopy technique by daily practicing.

The author declares no conflict of interest.

#### *Videolaryngoscopy, the Current Role in Airway Management DOI: http://dx.doi.org/10.5772/intechopen.93490*

because the procedure is widely visible to a larger number of participants gathered in the airway care team in a real time. Therefore, videolaryngoscopy is not only an excellent teaching tool for mastering the airway management with its use but also with other airway devices which can be used as single or in various combinations. In addition, videolaryngoscopy has proven to be a useful technique in other clinical situations besides intubation, such as diagnostics of upper airway and small laryngeal surgeries. Finally, videolaryngoscopy is also an important medicolegal tool for all topics related to airway care as it allows immediate and delayed post-procedure analysis by reproducing its recordings.

Nowadays, many societies' guidelines recommend to use videolaryngoscopy early in intubation attempts in order to aim first-pass intubation success. It is possible that even in close future, it will replace direct intubation as the gold standard. However, for such an evolution, it is necessary for the clinicians to master the videolaryngoscopy technique by daily practicing.

Good preparation makes half of the technique. It is important to be aware of the device characteristics, especially technical details such as the resolution and fogging of the screen, the size and the angle of the blade, and the need to use preformed tube by stylet. During the process of videolaryngoscopy, it is advisable to think about it as a four-step procedure with alternately looking in the mouth and at the screen. Direct and indirect visualization of the upper airway should be complemented with customized hand-eye coordination. If accepted, these routine tips can minimize majority of traumatic complications. Primum nil nocere.
