Ah, videolaryngoscopes – wonderful toys increasingly common in operating rooms, intensive care units and emergency departments throughout the world.
After the first video laryngoscope was conceived by New York emergency physician Jon Berall in 1998, commercial success quickly followed with the 2001 Glidescope (designed by a vascular surgeon nonetheless!). Our love of the videolaryngoscope has grown ever since.
Like many anaesthetists and anesthesiologists I've used several different videolaryngoscopes over the past few years. The character that sets apart the videoscopes I like to use from those I do not is how well they enhance airway techniques I use every day rather than requiring a new technique specific to their device.
Overwhelmingly this comes down to how similar the laryngoscope is to a standard Macintosh blade rather than inventing a whole new shape. While there may be theoretical (or even real!) benefits to increasing the angle of the blade or adding extra conduits, when I have a difficult airway I want to augment the tools and techniques I use every day rather than change to something completely different. (When I want to change to something completely different I'll pick up a fibreoptic bronchoscope or something sharp!)
And this the first reason why I love the Storz C-MAC...
1. It uses standard Macintosh size 3 and 4 blades
(and a 'D' blade, if that floats your boat), enhanced by video which typically improves the Cormack-Lehane view by at least one.
In an unexpected difficult intubation my first go-to choice is the C-MAC and a bougie – and it has only let me down once.
This is a key point: the Macintosh-based videoscopes extend existing airway techniques, like tube-over-bougie, rather than inventing something new. A new technique is not necessarily a bad thing, but I'd rather stick with what I know when I'm in the airway vortex.
2. The C-MAC is quick to setup but difficult to loose.
Compared to the theatrical production of setting up a traditional FOB, lightsource and tower, calling for the C-MAC requires it only to be wheeled in and turned on.
Although the separate monitor and stand make it less portable than an all-in-one unit (though still a C-MAC option), the standalone monitor makes the C-MAC harder to loose if forgotten in a distant operating room, radiology or elsewhere.
The monitor can also be used with the Storz video endoscope – very useful in the heat of the moment to quickly swap out one airway weapon for another. It's also much faster to use the CMAC-endoscope de novo compared with a traditional FOB and tower.
3. The C-MAC is great for teaching junior doctors laryngoscopy technique.
"What do you see?" [silence] "What do you see?" [crickets]
Because it is a standard Macintosh blade, junior staff can use it like a normal laryngoscope under direct vision and I can watch on the C-MAC monitor, offering meaningful suggestions and understanding a little better where they might be going wrong.
For junior staff this is a great way to identify laryngoscopy 'threshold concepts' that they might struggle with (blade tip perfectly in the vallecula; vectors of force) – and for senior trainees the perfect way to support their management of a difficult airway without taking over.
While technical skill is a foundational part of difficult airway management, it's the decision making that determines a good or bad outcome. A senior trainee driving a videolaryngoscope allows the supervising clinician to support the decision making process.
The external monitor also allows others to see the airway view: an anesthesia assistant can see the screen and alter BURP as needed, and my surgeons can understand a little better the degree of airway challenge.
4. The C-MAC can be used for awake laryngoscopy.
With careful topicalisation and a co-operative patient, gentle awake laryngoscopy can quickly validate (or not!) the plan in suspicious airways – particularly when an awake FOB intubation is not an option.
5. The C-MAC can be cleaned quickly
Making it ready for use by the next patient, without need for disposables or consumables.
Processing a fibreoptic bronchoscope can easily take 45 minutes – an eternity when you. need. it. now!
The C-MAC is not the only game in town when it comes to Macintosh-videolaryngoscopes, though it has the greatest mindshare in the departments that I have worked in. From the range of videoscopes I have tried, the C-MAC is the one I am happiest with.
The challenge with airway toys is that because there are so many options it's easy to have superficial exposure to many but limited depth in any – and this is what I like about the C-MAC and other Macintosh-based videolaryngoscopes: they leverage the skills I've already earned in wielding Sir Robert's blade.