The market for rigid video laryngoscopes (VDLs), valued at $70m in 2009, is forecast to reach $136.4m in 2016 assuming a compound annual growth rate (CAGR) of 10%. The market is expected to be driven by an increasing awareness by healthcare professionals of rigid VDLs, its advantages over traditional laryngoscopes and its increasing use beyond hospital settings. Verathon Medical, Aircraft Medical, Airtraq and Pentax are the leading players in the global rigid VDLs market.
What is VDL?
Video laryngoscopy is a form of laryngoscopy whereby the clinician views the larynx indirectly. Images from VDLs are displayed on a monitor and can be recorded, while the magnification allows for a more detailed examination of the larynx.
Video laryngoscopy is also used with rigid transoral laryngoscopy. Products such as Airtraq, GlideScope and Pentax-AWS are variations of a rigid laryngoscope with a digital camera that allows a view of the larynx on a screen. A rigid VDL has been shown to improve the view of the larynx compared with a conventional laryngoscope. Compared with conventional direct laryngoscopy, rigid VDLs also require minimal head manipulation and positioning.
Tracheal intubation using a laryngoscope secures the respiratory passage in instances where the trachea is blocked or constricted during cardiopulmonary arrest or in surgical operations where the patient is given general anesthesia. Tracheal intubation is done by extending the patient's neck and forcibly separating the upper portion of the palate and the base of the tongue with a laryngoscope. The tube is then inserted while observing the conditions inside the mouth cavity. Tracheal intubation can be a difficult procedure.
A market snapshot
Video laryngoscopy has been shown to improve glottic visualisation in the majority of patients undergoing elective surgery and also serves as an adjunct to facilitate intubation in patients with difficult airways. Its potential use extends to remote locations outside of operating rooms for emergency airway interventions that may take place on hospital floors, intensive care units or cardiac catheterisation suites. Video augmented periglottic visualisation allows VDL adaptation for other airway procedures beyond tracheal intubation.
The GlideScope VDL projects an image of the larynx onto the screen via a cable, and the image is displayed on a large colour LCD screen, which is mounted on a separate stand. GlideScope VDL consists of four disposable blades catering to neonates, paediatrics and adults. It is sold with a malleable stylet with an angle tip of 60°.
The Berci-Kaplan DCI video laryngoscope integrates an endoscopic system within a standard laryngoscope blade. In this system, the camera is incorporated in an ergonomically designed handle. The C-Mac system, meanwhile, is suitable for routine clinical procedures in the operating room, intensive care medicine and emergency hospitalisation as well as preclinical procedures using ground or air-based lifesaving equipment. The D-Blade, a component of the C-Mac system, primarily differs from traditional laryngoscopes in shape, and is characterized by an elliptical, tapering, distally rising blade form. In patients with difficult anatomies, D-Blade can represent a fast and simple solution as all components can be exchanged in seconds. Users can also switch to the D-Blade after initial assessment with, for example, a Macintosh laryngoscope. The device's optimal length and the strong blade curvature allow the intubation of patients with a large, ventrally displaced epiglottis. The closed design of the laryngoscope allows the D-Blade to be processed in the same way as all the other components.
The McGrath is a portable VDL and it has a disposable blade with adjustable length. The McGrath Series 5 VDL is designed to provide a clear view of the vocal cords during intubation with minimal change in laryngoscopic technique. A small camera and light source are located at the distal end of the VDL blade. After obtaining an image of the vocal cords and the surrounding airway anatomy, an endotracheal tube is guided by the clinician through the vocal cords and into the larynx while viewed in real time on the colour video display. Single-use blade tips eliminate the need for sterilisation, while the portable unit has no external cables and operates on a single AA battery.
The Pentax Airway Scope AWS-S100 makes it possible to perform tracheal intubation easily. It has an imaging CCD and LED light attached to its tip, and is paired with an Intlock blade, which has a curved shape. There is no need to extend the patient's neck or apply excessive force using this device. By placing the airway scope under the epiglottis and raising it lightly, it is possible to insert an endotracheal tube into the trachea, and the operator can perform the intubation while watching the LCD monitor. The built-in monitor screen has a wide viewing angle and is visible from behind and from the side of the airway scope, allowing healthcare professionals other than the operator to verify the tracheal intubation status. In addition, the Airway Scope's video output allows the images to be viewed on an external monitor. Also, the angle of the built-in monitor screen can be adjusted, which makes it possible to perform tracheal intubation while viewing inside the patient's mouth cavity from various positions, regardless of if the patient is in a cranial position, on his side, or facing upright.
The AWS-S100 can be used outdoors and also in rainy and wet conditions because it is water resistant. It operates on AA batteries and can be used continuously for about an hour with fresh alkaline batteries. The device has a low-battery alert feature that displays a warning on the monitor screen.
The Airtraq is a portable, disposable battery-powered VDL. It has a screen above the curved laryngoscope handle and a guiding channel. The image is transmitted by a combination of prisms and lenses, and it is designed to provide a view of the glottic opening without aligning the oral, pharyngeal and laryngeal axes. The blade of the Airtraq has one channel acting as the housing for the placement and insertion of the endotracheal tube while another channel terminates in a distal lens. The image is transmitted to a proximal viewfinder through a combination of lenses and a prism, rather than fibre optics, allowing the visualisation of the glottis and surrounding structures, and the tip of the tracheal tube.
The market dynamics
Rigid VDLs are expected to find greater use in the field of emergency airway management. In pre-hospital settings, emergency care providers must anticipate encountering patients with difficult airways, and they may be faced with a rapidly deteriorating airway due to severe facial trauma, neck injury or oropharyngeal edema. Pre-hospital patients frequently have concomitant head injuries, multisystem trauma or presumed cervical spine injuries. A definitive airway should be secured with the safest, most-efficient method with the lowest morbidity rate. Rigid VDL has the potential to be a primary choice for patients with potential cervical spine injuries or limited jaw or spine mobility, and in difficult-to-access patients. Studies and case reports show that the VDL is a promising device for emergency intubation.
VDLs collects electronically processed images and improves the view of the glottis as the camera eye is only centimetres away. This results in improved glottic visualisation compared with a traditional laryngoscope. This is important for medical personnel that infrequently intubate patients. VDLs reduce the need to align the oral, pharyngeal and laryngeal axes or to position the patient in the sniffing position. This results in less cervical manipulation. Spontaneous ventilation preserved during intubation attempts also increases the safety margin in patients with a limited respiratory reserve. By contrast, traditional laryngoscopes require alignment of the oral, pharyngeal and laryngeal axes so that the vocal cords can be seen. This necessitates patient manoeuvres, which require neck flexion, head extension, laryngeal manipulation and other stressful movements to the patient. Traditional laryngoscope may cause significant haemodynamic disturbance, sore throat, airway injury and dental damage, the latter accounting for one-third of all confirmed or potential anesthetic claims in the UK.
Video laryngoscopy allows anesthetists to view the upper airway anatomy on a separate monitor away from infectious secretions. This additional distance, in contrast with traditional laryngoscopy, may protect healthcare professionals from infections. Some video laryngoscopic devices are supplied with disposable blades that reduce the risk of disease transmission between patients. This feature is particularly useful in managing multiple critically ill patients by reducing the turnaround time for equipment sterilisation.
Currently, the majority of hospitals still use traditional laryngoscopes, and about 90% of operating room intubations and about 99% of out-of-operating room intubations are done using the traditional laryngoscope. Out-of-operating room procedures include those inside and outside of the hospital, such as in the emergency medical services, physician offices, clinics, the military and other places where breathing emergencies may occur.
The cost of rigid VDLs is about $10,000, which is expensive when compared with traditional laryngoscopes, which cost less than $500. This huge price difference, coupled with the current economic uncertainty, is leading to the slow adoption of rigid VDLs because healthcare delivery centres are looking for cheaper alternatives.