**3.1 Technique of videolaryngoscopy with a channeled videolaryngoscope**

The tube is placed in the dedicated groove of the device (**Figure 7**). The tube or the channel on the device can be lightly lubricated to reduce friction. During this preparation, make sure that the lubricant does not obscure the light source and the outer glass of the screen. The size of the tube should be adjusted to the size of

#### **Figure 2.**

*Storz C-MAC D blade® as an example of the non-channeled videolaryngoscope with a metal reusable blade (own photography).*

#### **Figure 3.**

*Infinium ClearVue® as an example of the channeled videolaryngoscope with a plastic single use blade (own photography).*

**233**

**Figure 6.**

the channel. Namely, these devices differ in size, and the size of the channel is also different. When placing the tube, the top of the tube is displayed on the visible screen as a crescent. The entire device with the tube placed in this way is carefully embedded through the open mouth deep into the pharynx with the dominant hand, paying attention to the structures in the mouth (lips, teeth, and palate). If external resistance

*The screen of the videolaryngoscope on an external monitor (own photography).*

*Videolaryngoscopy, the Current Role in Airway Management*

*An incorporated screen of the videolaryngoscope on a device itself (own photography).*

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

**Figure 5.**

#### **Figure 4.**

*Different single use plastic blades of the videolaryngoscope (A) Macintosh and (B) hyperangular (own photography).*

#### **Figure 5.**

*Special Considerations in Human Airway Management*

**232**

**Figure 4.**

*(own photography).*

**Figure 3.**

**Figure 2.**

*(own photography).*

*(own photography).*

*Infinium ClearVue® as an example of the channeled videolaryngoscope with a plastic single use blade* 

*Storz C-MAC D blade® as an example of the non-channeled videolaryngoscope with a metal reusable blade* 

*Different single use plastic blades of the videolaryngoscope (A) Macintosh and (B) hyperangular* 

*An incorporated screen of the videolaryngoscope on a device itself (own photography).*

**Figure 6.** *The screen of the videolaryngoscope on an external monitor (own photography).*

the channel. Namely, these devices differ in size, and the size of the channel is also different. When placing the tube, the top of the tube is displayed on the visible screen as a crescent. The entire device with the tube placed in this way is carefully embedded through the open mouth deep into the pharynx with the dominant hand, paying attention to the structures in the mouth (lips, teeth, and palate). If external resistance


#### **Table 2.** *Videostylets [23–26].*

**Figure 7.** *Tube placed in a dedicated groove in a channeled videolaryngoscope (own photography).*

is encountered due to large breasts, etc., the device can be turned with the concave side toward the palate firstly, then it can be placed in the mouth and when it reaches the level of the soft palate, it can be rotated to cover the base of the tongue (similar to positioning a Guedel tube). The device is then grasped with the left hand, the eye of the operator is brought closer to the eyepiece or the gaze is directed to the external screen and the whole device is pulled out vertically to the axis of the pharynx so that the glottis is displayed in the middle of the eyepiece or external screen. A slight rotation of the device to the left or to the right by 90 degrees can also help. When the glottis is displayed in the middle of the screen, the tube is carefully pushed through the channel with the free right hand, targeting the glottis. When the tube passes the vocal cords, the tube is displaced from the channel laterally and separated from the whole device carefully. The whole device is carefully removed from the pharynx and the mouth, taking care not to accidentally pull the tube from the trachea.

#### **3.2 Technique of videolaryngoscopy with a non-channeled videolaryngoscope**

The technique of videolaryngoscopy with a non-channeled device largely differs depending on the type of the blade.

If a Macintosh blade (slightly curved) is used (**Figure 8**), the video laryngoscopy technique is similar to direct laryngoscopy with a Macintosh blade, except for watching the progression of the blade and later a tube indirectly on the screen and not directly through the mouth. The mouth is opened, the laryngoscope is taken by the left hand (**Figure 9**), and the tip of the blade is inserted into the right corner of the patient's lip. This step should be watched directly to avoid injuries of the lips and teeth. When the blade is placed in the right corner of the patient's lip, the operator moves his/her gaze toward the screen and from then on keeps watching the screen.

**235**

*Videolaryngoscopy, the Current Role in Airway Management*

*A videolaryngoscope with a Macintoch blade (own photography)***.**

The lateral left side of the blade encloses the patient's tongue, moving it medially from the buccal mucosa. The moment the tip of the blade reaches the base of the tongue, the blade is straightened in the medial line and the operator should try to display the uvula to be positioned in the middle of the lower edge of the screen. The entire laryngoscope is then gently moved up and forwarded at a 45-degree angle to display the epiglottis and glottis, and the tip of the blade is directed into the vallecula. It is important to position the glottis in the middle of the screen, and if possible, to visualize the space around the glottis including the surrounding lateral wall of the pharynx, without getting too close to the glottis. The tube should be performed with a stylet in such a way that the curve of the tube follows the curve of the blade. The preformed tube with the stylet is lowered with the right hand down the groove of the spatula targeting the opening of the glottis. If it is not possible to reach the opening in this way, then the tube is grasped more freely with the right hand and, regardless of the groove of the blade, is directed at any angle to the laryngeal opening. In order to be able to control the direction of the tube beyond the groove and rotate it in different directions if necessary, it is important to have a wider field of view on the screen; that is, in addition to seeing the glottis, it is advisable to see the cavity of the pharynx and the tip of the tube itself. Instead of a tube, a bougie can be used in the described manner, and when it passes the vocal cords, the tube is pulled

*Grasping a videolaryngoscope with the left hand; a tube is handled with the right hand (own photography)***.**

over the bougie according to the principle of the Seldinger technique.

If a Miller (straight) blade is used, the video laryngoscopy technique is similar to direct laryngoscopy with a Miller blade. The mouth is opened, the laryngoscope is taken in the left hand, and the tip of the blade is entered into the right corner of the patient's lip. The lateral left side of the blade encloses the tongue, moving it medially from the buccal mucosa. The moment the tip of the blade reaches the base of the tongue, the spatula straightens in the medial line and tries to display the uvula to be positioned in the middle of the lower edge of the screen. The entire laryngoscope

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

**Figure 8.**

**Figure 9.**

#### **Figure 8.**

*Special Considerations in Human Airway Management*

With flexible tip Rigid and flexible laryngoscope (RIFL)

**Table 2.**

**Figure 7.**

*Videostylets [23–26].*

**Videostylets Name Manufacturer**

With fixed tip Bonfils® Karl Storz, Tuttlingen, Germany

SensaScope® Acutronic

C-MAC® VS Video Stylet Karl Storz, Tuttlingen, Germany

AI Medical Devices Inc., Williamston, MI, USA

Medical Systems AG, Hirzel, Switzerland

is encountered due to large breasts, etc., the device can be turned with the concave side toward the palate firstly, then it can be placed in the mouth and when it reaches the level of the soft palate, it can be rotated to cover the base of the tongue (similar to positioning a Guedel tube). The device is then grasped with the left hand, the eye of the operator is brought closer to the eyepiece or the gaze is directed to the external screen and the whole device is pulled out vertically to the axis of the pharynx so that the glottis is displayed in the middle of the eyepiece or external screen. A slight rotation of the device to the left or to the right by 90 degrees can also help. When the glottis is displayed in the middle of the screen, the tube is carefully pushed through the channel with the free right hand, targeting the glottis. When the tube passes the vocal cords, the tube is displaced from the channel laterally and separated from the whole device carefully. The whole device is carefully removed from the pharynx and

*Tube placed in a dedicated groove in a channeled videolaryngoscope (own photography).*

the mouth, taking care not to accidentally pull the tube from the trachea.

depending on the type of the blade.

**3.2 Technique of videolaryngoscopy with a non-channeled videolaryngoscope**

If a Macintosh blade (slightly curved) is used (**Figure 8**), the video laryngoscopy technique is similar to direct laryngoscopy with a Macintosh blade, except for watching the progression of the blade and later a tube indirectly on the screen and not directly through the mouth. The mouth is opened, the laryngoscope is taken by the left hand (**Figure 9**), and the tip of the blade is inserted into the right corner of the patient's lip. This step should be watched directly to avoid injuries of the lips and teeth. When the blade is placed in the right corner of the patient's lip, the operator moves his/her gaze toward the screen and from then on keeps watching the screen.

The technique of videolaryngoscopy with a non-channeled device largely differs

**234**

*A videolaryngoscope with a Macintoch blade (own photography)***.**

#### **Figure 9.**

*Grasping a videolaryngoscope with the left hand; a tube is handled with the right hand (own photography)***.**

The lateral left side of the blade encloses the patient's tongue, moving it medially from the buccal mucosa. The moment the tip of the blade reaches the base of the tongue, the blade is straightened in the medial line and the operator should try to display the uvula to be positioned in the middle of the lower edge of the screen. The entire laryngoscope is then gently moved up and forwarded at a 45-degree angle to display the epiglottis and glottis, and the tip of the blade is directed into the vallecula. It is important to position the glottis in the middle of the screen, and if possible, to visualize the space around the glottis including the surrounding lateral wall of the pharynx, without getting too close to the glottis. The tube should be performed with a stylet in such a way that the curve of the tube follows the curve of the blade. The preformed tube with the stylet is lowered with the right hand down the groove of the spatula targeting the opening of the glottis. If it is not possible to reach the opening in this way, then the tube is grasped more freely with the right hand and, regardless of the groove of the blade, is directed at any angle to the laryngeal opening. In order to be able to control the direction of the tube beyond the groove and rotate it in different directions if necessary, it is important to have a wider field of view on the screen; that is, in addition to seeing the glottis, it is advisable to see the cavity of the pharynx and the tip of the tube itself. Instead of a tube, a bougie can be used in the described manner, and when it passes the vocal cords, the tube is pulled over the bougie according to the principle of the Seldinger technique.

If a Miller (straight) blade is used, the video laryngoscopy technique is similar to direct laryngoscopy with a Miller blade. The mouth is opened, the laryngoscope is taken in the left hand, and the tip of the blade is entered into the right corner of the patient's lip. The lateral left side of the blade encloses the tongue, moving it medially from the buccal mucosa. The moment the tip of the blade reaches the base of the tongue, the spatula straightens in the medial line and tries to display the uvula to be positioned in the middle of the lower edge of the screen. The entire laryngoscope

is then gently moved up and forward at a 45-degree angle in an effort to display the epiglottis and glottis, and the tip of the blade is directed below the epiglottis to lift it and better display the glottis. The further procedure is as described above.

If a hyperangular blade is used (**Figure 10**), then, unlike the procedures described above, the blade is immediately placed medially in the mouth and progressively directed toward the base of the tongue along the medial line of the tongue. At this point, lifting the base of the tongue attempts to visualize the uvula and place it similar to the one described above by displaying the uvula to the middle of the lower edge of the screen. The further procedure is as described above. To avoid the possible situation of obviously seeing the glottis but not being able to pass the tube through it, it is important to carefully preform the tube according to the hyperangular blade (**Figure 11**). If necessary, a metal stylet can

#### **Figure 10.**

*A videolaryngoscope with a hyperangular blade (own photography).*

#### **Figure 11.**

*Preforming a tube by a stylet to adjust the curve of the tube to the hyperangular blade (own photography).*

**237**

visualization [34, 35].

*Videolaryngoscopy, the Current Role in Airway Management*

be used too (**Figure 12**). And again, instead of a tube, a bougie, which is more plastic, can be used in the described manner, and when it passes the vocal cords, the tube is pulled over the bougie according to the principle of the Seldinger

The primary use of videolaryngoscopy is the intubation guiding after the induction of general anesthesia in operation theaters, intensive care units, and emergency departments. Various specific pathologies that complicate intubation and represent possible situations of difficult airway management have been successfully overcome

Meta-analyses have shown that videolaryngoscopy compared with direct laryngoscopy reduces impossible intubations in expected difficult intubation in adults [27]. Among individual videolaryngoscopes, regardless of the subjective impressions of clinicians, there is no evidence that a single videolaryngoscope is better than others except specifically only the C-MAC Macintosh blade [27]. Evidence further suggests that videolaryngoscope versus direct laryngoscopy facilitates intubation, improves glottis visualization, and reduces the number of impossible glottis visualizations and reduces laryngeal airway trauma [27]. Cochran's 2016 systematic analysis did not prove that videolaryngoscopy reduces the number of intubation attempts. There were insufficient data to establish a temporal comparison of videolaryngoscopy and direct laryngoscopy of the impact of videolaryngoscopy on hypoxia and respiratory complications, the impact of obesity, and the impact of the site and circumstances of intubation (intensive care unit, emergency medicine) [27]. In children, in contrast to adults, the evidence shows that the number of intubation attempts using videolaryngoscopy is increased compared to direct laryngoscopy, the success of first attempt intubation is not increased, and moreover,

Although videolaryngoscopy improves visualization, evidence suggests that traditional direct laryngoscopy is a sufficiently successful method of airway management in intensive care units. Moreover, some evidence suggests that the number of complications when using videolaryngoscopy in intensive care units is higher, especially if used by inexperienced operators [30]. Therefore, for routine airway management in intensive care units, direct laryngoscopy is still recommended as first choice, but videolaryngoscopy is also recommended in a situation of unsuccessful direct laryngoscopy or in the case of expected difficult intubation in the hands of experts [31, 32]. There is a positive trend of using videolaryngoscopy in pediatric ICUs, particularly in older children and those with the positive history of difficult airway. However, there is still no demonstration that this trend has decreased the rate of severe tracheal intubation adverse events or lowered multiple

Videolaryngoscopy can be used successfully for guiding a double lumen tube. Admittedly, according to some, it prolongs intubation time but improves

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

**4. Usage of videolaryngoscopy**

by using videolaryngoscopy.

**4.1 Clinical usage of videolaryngoscopy**

*4.1.1 Single lumen tube orotracheal intubation*

the intubation time is extended [28, 29].

attempts at endotracheal intubation [33].

*4.1.2 Double lumen tube orotracheal intubation*

technique.

**Figure 12.** *A metal stylet (own photography).*

be used too (**Figure 12**). And again, instead of a tube, a bougie, which is more plastic, can be used in the described manner, and when it passes the vocal cords, the tube is pulled over the bougie according to the principle of the Seldinger technique.
