**3. Advantages and disadvantages of video laryngoscopy**

Regardless of the specific blade or type of device utilized, video-assisted laryngoscopy (VL) increases the rate of successful intubation in elective airways, difficult airways, and those of the critically ill patient [2]. Certain devices allow for recording and capturing of images, which are useful again for teaching purposes or storing of various anatomical findings. The VL view can be saved in the patient's record for future clinicians to observe and thereby provide critical clinical documentation that has historically been very much subject to the interpretation of the laryngoscopist. The VL, with its ability for multiple clinicians to simultaneously visualize the airway, has become a critical device for teaching and other settings where additional assistance may be necessary. Simple prior maneuvers, such as the BURP (backward, upward, and rightward pressure), become significantly more effective when the assistant is able to visualize the effects of the movement on the laryngoscopic view.

Because video-laryngoscopes are designed to allow for visualization of structures that are not within a direct line of sight, VL intubations are often of great benefit in patients with altered airway anatomy or suboptimal positioning, as the oralpharyngeal-largyngeal axes do not need to be aligned for successful intubation. VL may reduce cervical spine motion and allow for lower lift force [3, 4]. It is postulated that VL reduces the stress response to laryngoscopy, though no current studies are available to show significant different hemodynamic differences between VL and DL techniques [5–8].

There are still some opponents of VL technology, though there are fewer now than before due to the improvements in resolution, availability, and clinicians' familiarity with these devices. Arguments against widespread VL use now focus on the cost and time to intubation. The setup of VL is certainly more expensive than DL, with components that may need sterile processing, increasing the yearly cost of airway management. While incidence of successful intubation has been documented, the time to successful intubation, with a maximum apneic limit of 60 seconds, has not been shown to be faster with VL over DL. Thus, the comparative advantage of VL over DL may not be superior. Additionally, the rise in VL use may significantly affect the art and practice of DL, which causes DL technique to suffer.

Videolaryngoscopy is not without potential complication. Reported incidence of videolarynscopy-related otolaryngologic complications is around 1%, with most injuries being minor [9]. Injury most likely with blind introduction of an endotracheal tube through the oropharynx, as the anesthetist is focused on the videolaryngoscope screen. Soft tissue injury may occur at various sites in the aerodigestive tract. While most injuries are minor lacerations, some palate injuries may require intervention by an otolaryngologist. Injuries that are recommended for immediate repair prior to extubation are gaping or perforated injuries with a hanging flap. It is important to evaluate and recognize such injuries in order to prevent potential negative consequences that may include bleeding, infection, retropharyngeal abscess formation, and potentially the inability to safely extubate the patient [10]. Proper training with appropriate visualization during intubation is essential to minimize such soft tissue complications.
