In the past, direct laryngoscopy (DL) was the only widely available technique for intubation. The ability to perform difficult endotracheal intubation utilizing DL was a highly coveted skill among anesthesiologists. This also led to the development of various laryngoscope blades that had the potential to improve the success of intubation. In the last two decades, there has been an explosive growth of equipment designed to aid airway management. Most of these devices utilize a video camera to view the larynx from inside or outside the endotracheal tube.
Video laryngoscopy (VL): Although many newer airway devices are available, VL is the one used widely by anesthesia providers as well as other health care personnel. VL has increased the success rate and lowered the rate of complications for all practitioners. It has become the primary technique for management of the difficult airway. Learning it is relatively easy, not only for anesthesia providers but even for those who use it only on occasion. This has resulted in reduced utilization and resultant deskilling in other techniques such as DL for management of the difficult airway.
“Patient safety will be compromised if anesthesiologists stop honing their DL and FOB skills.”
Limitations of VL: VLs may be hampered if the airway is compromised by bleeding, vomitus, or other fluids. In many institutions in the U.S., multiple ORs share a limited number of video laryngoscopes. A VL may not be readily available when needed. Ready availability may be even more limited in locations such as the obstetric (OB) suite, ICU, and emergency department. VLs are usually not included with crash carts in rest of the hospital. They may not be available around the hospital during stat intubations for cardiac arrests. Availability of VL is limited even in health care settings outside a hospital. Availability of VL is severely limited in many international locations. Anesthesia practitioners in regions with limited availability of VL should not deskill from techniques such as DL, even if they own a VL.
Pre-intubation airway examination: A detailed examination of the airway is recommended, especially if DL is expected to be difficult. When VL became popular for managing the difficult airway, the importance of detailed airway examination declined. In the era of COVID-19, detailed examination of the airway is risky and often not performed. This can lead to deskilling.
Difficult Airway Algorithm: Since the advent of VL and other video techniques, the number of cases where the Difficult Airway Algorithm is actively used has decreased, leading to deskilling.
Laryngeal mask airway (LMA): It is an alternative to endotracheal intubation and widely used. Placement of an LMA is not difficult in many cases where endotracheal intubation is difficult. LMAs can contribute to deskilling from endotracheal intubation of a difficult airway. On the other hand, VL-assisted intubation has reduced the utilization of LMA for difficult airway, leading to deskilling in such use.
Moderately difficult airway: Many practitioners are choosing to not attempt DL for the moderately difficult airway, instead utilizing VL. Patients with vulnerable dentition or obesity are included in this group. There has been deskilling of anesthesiologists in DL in this group of patients.
Fiberoptic bronchoscopy (FOB): Maintaining spontaneous ventilation is safer while intubating an airway severely compromised by tumor, infection, or trauma. FOB is suitable for this as it reduces stimulation. Video camera-tipped, long flexible scopes have the same functionality and provide better images. Anesthesiologists should avoid deskilling from FOB as it may be the most suitable technique for some highly compromised airways.
Many intubations of potentially difficult but not deformed airways, which were performed by FOB in the past, are now being performed by VL. This can lead to deskilling from FOB. FOB is also being performed by otorhinolaryngologists and pulmonologists. This can contribute to deskilling of anesthesiologists.
Regional anesthesia: Ultrasound guidance has increased the utilization and success of nerve blocks to provide regional anesthesia. This reduces the need to perform difficult airway management, contributing to deskilling in it.
Intubation by non-anesthesiologists: For difficult airways, compared to other health care practitioners, anesthesiologists have a substantially higher success rate and a lower rate of complications. Outside the OR, intubation by non-anesthesiologists is common, especially in urgent or emergent situations. VL is commonly utilized in these cases. Hence, non-anesthesiologists have few opportunities to acquire skills in DL. Airway management in locations such as the ED and in the field may be compromised if VL is not available.
Anesthesiologists’ responsibility: Anesthesia practitioners are expected to intubate virtually every patient, especially in an emergency. DL may be the only equipment available in many emergency settings. DL is one skill that most distinguishes anesthesiologists from other health care providers. FOB may be the most suitable technique for managing a deformed airway. Anesthesiologists should not allow themselves to be deskilled in DL and FOB. Patient safety will be compromised if anesthesiologists stop honing their DL and FOB skills. If in future VL becomes as widely available as DL, deskilling in DL will be acceptable – if the anesthesiologist does not plan to practice outside the U.S.