Reusable Laryngoscope Research Articles

Reusable laryngoscope blades: a more eco-responsible and cost-effective alternative

IntroductionConsumption of single-use medical devices has increased considerably, contributing to the excessive wastage produced during surgical procedures. The present study aimed to describe a methodology to assess the transition from single-use blades (SUB) to reusable laryngoscope blades (RUB) and to assess the ecological and economic impact of the switch. MethodsThe ecological analysis was based on the life cycle assessment method. Based on 30 operating rooms in a single tertiary university hospital, the economic analysis compared the usual SUB supplier with four RUB suppliers considering different costs: blade purchasing and depreciation, reprocessing, logistics and waste management. ResultsIn 2021, 17,200 intubations were performed requiring about 147 RUBs. Switching from SUB to RUB led to an annual saving of 26.5 tons of CO2eq (global warming impact), equivalent to 120 000 km by car. It avoids the extraction of 6.6 tons Oileq (petroleum) and 579 kg of copper (mineral resources) per year. This action also leads to a land occupation reduction of 626 m2 per year and water savings of 221.6 m3 per year. The average cost per intubation varies from 3.16 [3.15–3.16] for SUB to 2.81 [2.77–2.85] for RUB, representing an average saving of 0.35 per intubation leading to 5783.50 annual gain [5074.00–6192.00]. RUB are preferable from 3 and 86 uses from an ecological and economic viewpoint, respectively. ConclusionIn a model of 17,200 intubations /year, switching SUD to RUB would save 26.5 tons of CO2eq and 6.6 tons of Oileq with 5783.50 annual gain. RUBs are ecologically and cost-effective after 3 and 86 uses, respectively.

Single-use versus reusable metallic laryngoscopes for non-emergent intubation: A retrospective review of 72,672 intubations

Study objectiveIncreased regulatory requirements for sterilization in recent years have prompted a widespread transition from reusable to single-use laryngoscopes. The purpose of this study was to determine if the transition from metallic reusable to metallic single-use laryngoscopes impacted the performance of direct laryngoscopy at an academic medical center. DesignSingle-site retrospective cohort study. SettingGeneral anesthetic cases requiring tracheal intubation. PatientsAdult patients undergoing non-emergent procedures. InterventionsData were collected two years before and two years after a transition from metallic reusable to metallic single-use laryngoscopes. MeasurementsThe primary outcome was need for intubation rescue with an alternate device. Secondary outcomes were difficult laryngeal view (modified Cormack-Lehane grade ≥ 2b) and hypoxemia (SpO2 < 90% for >30 s) during direct laryngoscopy intubations. Subgroup analyses for rapid sequence induction, Macintosh blades, Miller blades, and patients with difficult airway risk factors (Obstructive Sleep Apnea, Mallampati ≥3, Body Mass Index >30 kg/m2) were performed. Main resultsIn total, 72,672 patients were included: 35,549 (48.9%) in the reusable laryngoscope cohort and 37,123 (51.1%) in the single-use laryngoscope cohort. Compared with reusable laryngoscopes, single-use laryngoscopes were associated with fewer rescue intubations with an alternate device (covariates-adjusted odds ratio [OR] 0.81 95% CI 0.66–0.99). Single-use laryngoscopes were also associated with lower odds of difficult laryngeal view (OR 0.86; 95% CI 0.80–0.93). Single use laryngoscopes were not associated with hypoxemia during the intubation attempt (OR 1.03; 95% CI 0.88–1.20). Similar results were observed for subgroup analyses including rapid sequence induction, Macintosh blades, Miller blades, and patients with difficult airway risk factors. ConclusionsMetallic single-use laryngoscopes were associated with less need for rescue intubation with alternate devices and lower incidence of poor laryngeal view compared to reusable metallic laryngoscopes.

Reusable laryngoscope blades: not a thing of the past but a choice for the future

Reusable laryngoscope blades: not a thing of the past but a choice for the future

Contamination and Disinfection of Rigid Laryngoscopes: A Literature Review.

This article reviews current literature about the contamination of laryngoscope blades and handles, disinfection practices for laryngoscope blades and handles, and environmental effects and costs of reusable and single-use laryngoscopes. This review shows that inadequately processed rigid laryngoscopes may have the ability to transmit infections to patients and health care personnel. Although the laryngoscope handle has been considered a noncritical item that contacts only intact skin, health care team members should consider both the laryngoscope blade and handle as semicritical items and process them by high-level disinfection (HLD) or steam sterilization according to manufacturer's instructions. The fewest environmental effects occur when a reusable stainless-steel laryngoscope is processed by HLD. Laryngoscope costs are lower for processing reusable laryngoscope handles and blades by HLD and highest for single-use laryngoscopes. Evidence-based guidelines are needed to specify and standardize best practices for processing rigid laryngoscopes.

Life Cycle Assessment and Costing Methods for Device Procurement: Comparing Reusable and Single-Use Disposable Laryngoscopes.

Traditional medical device procurement criteria include efficacy and safety, ease of use and handling, and procurement costs. However, little information is available about life cycle environmental impacts of the production, use, and disposal of medical devices, or about costs incurred after purchase. Reusable and disposable laryngoscopes are of current interest to anesthesiologists. Facing mounting pressure to quickly meet or exceed conflicting infection prevention guidelines and oversight body recommendations, many institutions may be electively switching to single-use disposable (SUD) rigid laryngoscopes or overcleaning reusables, potentially increasing both costs and waste generation. This study provides quantitative comparisons of environmental impacts and total cost of ownership among laryngoscope options, which can aid procurement decision making to benefit facilities and public health. We describe cradle-to-grave life cycle assessment (LCA) and life cycle costing (LCC) methods and apply these to reusable and SUD metal and plastic laryngoscope handles and tongue blade alternatives at Yale-New Haven Hospital (YNHH). The US Environmental Protection Agency's Tool for the Reduction and Assessment of Chemical and other environmental Impacts (TRACI) life cycle impact assessment method was used to model environmental impacts of greenhouse gases and other pollutant emissions. The SUD plastic handle generates an estimated 16-18 times more life cycle carbon dioxide equivalents (CO2-eq) than traditional low-level disinfection of the reusable steel handle. The SUD plastic tongue blade generates an estimated 5-6 times more CO2-eq than the reusable steel blade treated with high-level disinfection. SUD metal components generated much higher emissions than all alternatives. Both the SUD handle and SUD blade increased life cycle costs compared to the various reusable cleaning scenarios at YNHH. When extrapolated over 1 year (60,000 intubations), estimated costs increased between $495,000 and $604,000 for SUD handles and between $180,000 and $265,000 for SUD blades, compared to reusables, depending on cleaning scenario and assuming 4000 (rated) uses. Considering device attrition, reusable handles would be more economical than SUDs if they last through 4-5 uses, and reusable blades 5-7 uses, before loss. LCA and LCC are feasible methods to ease interpretation of environmental impacts and facility costs when weighing device procurement options. While management practices vary between institutions, all standard methods of cleaning were evaluated and sensitivity analyses performed so that results are widely applicable. For YNHH, the reusable options presented a considerable cost advantage, in addition to offering a better option environmentally. Avoiding overcleaning reusable laryngoscope handles and blades is desirable from an environmental perspective. Costs may vary between facilities, and LCC methodology demonstrates the importance of time-motion labor analysis when comparing reusable and disposable device options.

Disposable Laryngoscope Blades and Reusable Handles: What Combination Maximizes Light Intensity?

Disposable laryngoscope blades increasingly are used because of infection concerns and convenience. Clinical studies of light intensity through disposable blades have offered conflicting results and are difficult to compare because they used different methods to measure light output. Researchers measured light delivered by nine models of disposable adult-sized plastic and metal laryngoscope blades paired with each of three standard, reusable laryngoscope handles (Vital Signs LED, Heine 2.5 V Xenon, and …

Contamination of the laryngoscope handle

This Invited Commentary accompanies the following original article: Howell V, Thoppil A, Young H, et al. Chlorhexidine to maintain cleanliness of laryngoscope handles. An audit and laboratory study. Eur J Anaesthesiol 2013; 30:216–221. In this issue of the European Journal of Anaesthesiology, Howell et al.1 address the problem of cross-contamination in the operating room associated with the use of non-disposable anaesthesia devices, particularly reusable laryngoscope handles. These authors need to be commended for attracting our attention to a very practical but largely overlooked issue and a simple means of improving patients’ security. The paper challenges our way of thinking in at least three directions. First, the widespread employment of single-use laryngoscope blades – mainly in relation to the risk of transmission of prions – may have reduced our vigilance towards the transmission risks associated with the laryngoscope handle despite the reality of this risk.2 Second, the possibility of severe clinical consequences of such transmission may have been considered as disputable. However, the October 2011 medical alert issued by the UK Medicine and Healthcare products Regulatory Agency (MHRA) proved the opposite. This alert indicates that ‘a patient death was caused by a failure to decontaminate a laryngoscope handle appropriately between each patient use.’ This led to cross-infection and subsequently septicaemia, confirming previous reports (http://www.mhra.gov.uk/home/groups/dtsbs/documents/medicaldevicealert/con129221.pdf.). Third, we trust our institutional decontamination protocols to prevent the possibility of such cross-contamination and delegate this task to the nurses. This again is misleading. Every anaesthesia department, in coordination with the local nosocomial infection prevention committee or the hospital hygiene department, should have a formal, written, updated procedure for decontamination of the laryngoscope handle between each patient use, in the operating room as well as in prehospital and intensive care settings. Such a protocol is not always available3 and, when present, its application depends on individual members of staff recalling the rules or the ‘repaint the fence’ process on a regular basis; it is known from human factors studies that this is not always reliable. Totally disposable laryngoscopes should be discussed in the light of their quality, cost and environmental impact. Improvements in this direction have been published as preliminary reports only,4 combining a disposable shell and a reusable light unit with a LED bubble and batteries. The cost of such a totally disposable one-piece external shell is in the range of the cost of a single-use metal blade. The problem highlighted for the laryngoscope handle is also of concern in relation to other non-disposable pieces of equipment in use in the operating theatre. The fibrescope has a unique place and is not used in every case. Moreover, special decontamination protocols as well as traceability are generally adopted after fibreoscopy. Conversely, less attention is paid to the cross-contamination hazard associated with screens and keyboards, the cuff of non-invasive blood pressure devices, pulse oximeter sensors and ECG cables, all of which are usually reusable.5 A recent survey of bacterial and mycological contaminants showed a 34% incidence of contamination of ECG wires, mainly for cables which had been in use for more than 6 months, possibly in relation to an increase in their surface porosity, allowing for more adhesion of germs.6,7 Finally, the good news in the study by Howell et al. is the immediate and long-lasting antimicrobial efficacy of chlorhexidine. The recommendation to use this agent routinely in addition to cleaning and autoclaving the handle if there is a risk of contamination with Clostridium difficile, and also at regular intervals, makes sense and should be adopted because it has proved to be efficient and cost-effective. Acknowledgements Assistance with the invited commentary: none declared. Financial support and sponsorship: none declared. Conflicts of interest: none declared. Comment from the Editor: this invited commentary was checked by the editors but was not sent for external peer review. PD is an associate editor of the European Journal of Anaesthesiology.

Comparison of plastic and metallic single-use and metallic reusable laryngoscope blades

Plastic single-use laryngoscope blades have been found to increase the difficulty of intubation. Metallic single-use blades may represent an alternative. To compare the rates of intubation failure at first laryngoscopy using metallic single-use, plastic single-use and metallic reusable laryngoscope blades. Randomised, superiority, single-centre, controlled trial. Operating theatres at a University Hospital from January 2008 to August 2009. A total of 1863 adults requiring general anaesthesia. Patients were randomised to one of three laryngoscope blades: metallic single-use, plastic single-use or metallic reusable. The primary end-point was the number of intubation failures at first laryngoscopy. Secondary end-points were glottic exposure and the Intubation Difficulty Scale. The failure rate (absolute difference: 95% confidence interval) at the first attempt was greater for the plastic single-use blades (8.1%) than for the metallic reusable [3.2% (4.9%: 2.2 to 7.6%); P < 0.001] and metallic reusable blades [4.0% (4.0%: 1.2 to 6.9%); P < 0.006]. No difference was found between the metallic reusable and metallic single-use groups (0.9%: -1.3 to 3.1%). Scoring on the Intubation Difficulty Scale [median (interquartile range)] was higher in the plastic single-use group [1 (0 to 2)] than in the metallic groups [metallic reusable: 0 (0 to 1); P < 0.001 and metallic single-use: 0 (0 to 1); P < 0.007] groups. Glottic exposure was significantly better in the metallic reusable group (modified Cormack & Lehane score III and IV: 3.7%) compared with the plastic single-use group (modified Cormack & Lehane score III and IV: 9.4%; P < 0.03). The rates of failed intubation at first laryngoscopy were similar in the metallic reusable and metallic reusable groups, but greater in the plastic single-use group.

Bacterial contamination of re-usable laryngoscope blades during the course of daily anaesthetic practice

Hospital-acquired infections (HAIs) are largely preventable through risk analysis and modification of practice. Anaesthetic practice plays a limited role in the prevention of HAIs, although laryngoscope use and decontamination is an area of concern. We aimed to assess the level of microbial contamination of re-usable laryngoscope blades at a public hospital in South Africa. The theatre complex of a secondary-level public hospital in Johannesburg. Blades from two different theatres were sampled twice daily, using a standardised technique, over a 2-week period. Samples were quantitatively assessed for microbial contamination, and stratified by area on blade, theatre and time using Fisher's exact test. A contamination rate of 57.3% (63/110) was found, with high-level contamination accounting for 22.2% of these. Common commensals were the most frequently isolated micro-organisms (79.1%), but important hospital pathogens such as Enterobacter species and Acinetobacter baumannii were isolated from blades with high-level contamination. No significant difference in the level of microbial contamination by area on blade, theatre or time was found (p<0.05). A combination of sub-optimal decontamination and improper handling of laryngoscopes after decontamination results in significant microbial contamination of re-usable laryngoscope blades. There is an urgent need to review protocols and policies surrounding the use of these blades.

Recycling steel from single‐use laryngoscope blades and Magill forceps

Shelton et al. 1 identified 41% of anaesthetic waste to be recyclable, including single-use stainless steel laryngoscope blades and intubating forceps. The legal position regarding re-use of single use items is clear 2: a single-use item is permitted for one patient during a single procedure. Reprocessing is prohibited; however, the regulations fail to provide any guidance on scrapping. Furthermore, although the 2011 regulations 3 describe the fate of waste laryngoscope blades in terms of incineration or ‘non-burn’ alternative treatment, recycling is not discussed. If steel was sterilised (to minimise the risk to handlers and processors) before scrapping, it could be recycled within the current UK regulations and generate an income of £1000 per tonne. Moreover, since it is no longer discarded into either clinical waste at a cost of £450 per tonne or sharps bins (£750 per tonne) the used metal is worth closer to £1500 per tonne. At University Hospital Southampton (UHS) we initiated a process for collecting and decontaminating anaesthetic room steel, similar to that in place for other surgical items at the end of their natural life The utility costs of washing and decontamination (Steris Cabinet Washer, Mentor, Ohio, USA) followed by sterilisation (BMM Weston P328, Faversham, Kent, UK) are shown in Table 5. The non-urgent nature of decontamination means that it can be undertaken at slack operating times without delaying the processing of urgent instruments. No additional staff need be employed to facilitate this process. The size-4 Macintosh laryngoscope blade weighs 106 g and a pair of adult Magill's intubating forceps 72 g, with scrap values of 10.6 and 7.2 pence, respectively. The maximum number of laryngoscope blades per tray is limited by space and weight to approximately 60. Both washer and steriliser cycles can process up to five fully laden trays containing 300 laryngoscope blades (31.8 kg of steel). Assuming each cycle runs to maximum efficiency, the cost is 1.34 pence per blade. Extrapolating these results to the envisaged use at UHS of 20 000 laryngoscope blades per year, the scrap value is £2120, the saving of not disposing of the waste an additional £1060, less the processing cost of £268. Our Trust stands to save £2912 per annum. Whilst Shelton et al. claim that recycling anaesthetic waste is beneficial in terms of both financial savings and reducing carbon emissions, we believe they have underestimated the environmental impact. The energy expenditure to produce 1 kg of steel from iron ore is over 10 MJ greater than when produced from recycled scrap steel (21.9 MJ vs 11.7MJ) and the carbon footprint associated with producing 1 kg of steel from iron ore is 1.97 kg vs 0.7 kg of CO2 if that steel comes from scrap 4. Almost all single-use laryngoscope blades are manufactured in Pakistan and then transported thousands of miles, to be used once only and for less than a minute. This is reflected in the carbon intensity of disposable items and is currently 600 g CO2 per £GB spent 5, or approximately 3.0 kg per laryngoscope blade. We agree with Shelton et al. and conclude that the process of recycling anaesthetic room steel reduces environmental harm and benefits hospitals economically. Furthermore, we support the authors’ call for clearer guidance on recycling anaesthetic room steel. If we cannot reduce the need for laryngoscopy and re-usable laryngoscope blades have all but been removed, then recycling the steel is perhaps the only sustainable option and steel saves both carbon and money.

Airway management for tonsillectomy: a national survey of UK practice

The emergence of variant Creutzfeldt-Jakob disease (vCJD) prompted guidelines from the Department of Health that stress the use of disposable and protective equipment. This survey explores current methods of airway management for tonsillectomy in the UK and ascertains anaesthetists' current knowledge and opinions of the guidelines and of vCJD. Three hundred and five questionnaires were sent to all Royal College tutors across the UK to explore the current practice and adherence to the guidelines. The tracheal tube was the most frequently used airway across all age groups: 87% for <3 yr old, 79% for 3-16 yr old, and 73% for adults. Of the respondents who intubated, 57% protected the laryngoscope blade with a disposable sheath or used a disposable blade, while others used a reusable laryngoscope blade without protection. Fourteen per cent protected the laryngoscope handle, as recommended. When a reusable classic or flexible laryngeal mask airway was used, 45% reused it after routine sterilization. Thirty-eight per cent of respondents were unaware that any recommendations existed, 55% disagreed with them, and 84% were not fully compliant with them. Compliance rates did not differ between the anaesthetists who agreed or disagreed with the recommendations. Overall full compliance was achieved by only 16% of respondents. The most common reason for non-compliance was the lack of protection of the laryngoscope handle. The survey demonstrates widespread non-compliance with and lack of knowledge of, national guidelines.

Airway management for tonsillectomy: a national survey of UK practice

In 1996 a new variant of Creutzfeldt-Jakob disease (vCJD) was described [1]. Subsequently, the infectious agent was found to be a prion protein. In response to concerns about the prion's infectious nature, its resistance to decontamination and the possibility of asymptomatic carriage of prions in tonsillar tissue, the UK Department of Health and the Royal College of Anaesthetists produced guidelines for airway management of tonsillectomy, stressing the use of disposable equipment [2, 3]. We have conducted a national survey to examine current practice in airway management for tonsillectomy. Several additional questions were asked to explore knowledge both of guidelines and of vCJD. A postal questionnaire was sent to all College Tutors in the UK in July 2005. If the questionnaire was not returned within six weeks, a repeat questionnaire was sent. Microsoft Excel was used to aid the data analysis of the questionnaire. Of the 305 questionnaires sent, 33 replies stated that their hospital did not carry out ENT procedures. Positive replies were received from 183 departments, a response rate of 67%. Not all respondents answered all the questions. The tracheal tube was the most frequently used airway across all age groups: 87% (150/173) for <3 years old; 79% (139/176) for 3–16 years old; and 73% (131/179) for adults). Of respondents using a laryngoscope blade, 57% (96/167) protected the laryngoscope blade with a disposable sheath or used a disposable blade, while 43% (71/167) used a reusable laryngoscope blade without protection of the blade. Only 14% (24/167) protected the laryngoscope handle, as recommended. When a re-usable classic or flexible laryngeal mask airway was used, 45% (20/44) reused it after routine sterilisation. When questioned about the guidelines, 38% (68/180) were unaware that guidelines existed. Only 16% (27/180) were fully compliant with the guidelines. Just under half (45%, 70/154) agreed with the guidelines and of this number 84% (59/70) still did not fully comply with the guidelines. The commonest reasons for not complying were unavailability of equipment or mistrust of disposable equipment. In order to comply with the guidelines published by the Royal College of Anaesthetists, all laryngeal mask airways used should be disposed of whether the device is a disposable type or re-usable; if tracheal intubation is used the laryngoscope blade must either be a disposable blade or the standard metal blade must be covered by a disposable transparent plastic sheath. A clear disposable cover for the laryngoscope handle is also recommended; if bougies or stylettes are used these should also be disposable, and single-use disposable gloves must be worn by the anaesthetist. In this survey we have shown widespread non-compliance with, and lack of knowledge of, national guidelines.

Comparison of Plastic Single-use and Metal Reusable Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia

Comparison of Plastic Single-use and Metal Reusable Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia

Évaluation des pratiques en anesthésie exposant au risque infectieux par transmission croisée

Objective The practice of anaesthesiology has the potential for transmitting a number of infectious agents to the patient. In France, several recent cases have been identified, so that a wide survey on anaesthesiology practice has been enhanced. Methods An anonymous questionnaire, based on the recommendations of the French Society of Anaesthesiology and Intensive Care (Sfar), was send to 8,771 anaesthesiologists and intensive care practitioners and to 2,070 nurses practicing anaesthesiology. Results A total of 1,343 questionnaires were analyzed (response rate of 12.4%). The study shows that some recommendations were routinely applied, such as: availability of alcohol-based hand hygiene solution in operating rooms (94%), use of antimicrobial filters for respiratory circuits (99%), use of single-use laryngoscope blades (77%), aseptic technique for central venous catheterization (99%), hand hygiene after contact with body fluids (96%). In contrast, the study showed that some recommendations were partially applied: hand hygiene practice (52%), wear of gloves when a risk of blood exposure exists (23%), cleaning of reusable laryngoscope blades (19%), and incorrect wear of masks (71%). The reuse of the same syringe for several patients was described in 2% of the responses. Conclusion This results, similar to those previously described in the literature, must be followed by appropriate training and education of anaesthesia personnel, implementation of the recommendations, and evaluation of practices. Reuse of the same syringe for several patients have to be eradicated because of the high risk of viral transmission.

The reliability of laryngoscope lights

The aim of this study is to compare the brightness of laryngoscope light between instruments, and the variability within the same instrument. A secondary aim is to compare the light from a reusable laryngoscope with a single use design. Testing equipment was constructed which provided a qualitative measure of light output from laryngoscopes. Anaesthetists assessed the minimum acceptable brightness for intubation using the intubating mannikin and a variable brightness laryngoscope. Laryngoscopes in anaesthetic rooms around the hospital were then tested repeatedly, and the results were compared to the anaesthetists' opinions. There was considerable intersubject and intrasubject variation in the reusable design, often failing to satisfy the minimum brightness. The single use blades were found to be brighter and more reliable than reusable blades.

Comparison of Plastic Single-use and Metal Reusable Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia

Plastic single-use laryngoscope blades are inexpensive and carry a lower risk of infection compared with metal reusable blades, but their efficiency during rapid sequence induction remains a matter of debate. The authors therefore compared plastic and metal blades during rapid sequence induction in a prospective randomized trial. Two hundred eighty-four adult patients undergoing general anesthesia requiring rapid sequence induction were randomly assigned on a weekly basis to either plastic single-use or reusable metal blades (cluster randomization). After induction, a 60-s period was allowed to complete intubation. In the case of failed intubation, a second attempt was performed using metal blade. The primary endpoint of the study was the rate of failed intubations, and the secondary endpoint was the incidence of complications (oxygen desaturation, lung aspiration, and oropharynx trauma). Both groups were similar in their main characteristics, including risk factors for difficult intubation. On the first attempt, the rate of failed intubation was significantly increased in plastic blade group (17 vs. 3%; P < 0.01). In metal blade group, 50% of failed intubations were still difficult after the second attempt. In plastic blade group, all initial failed intubations were successfully intubated using metal blade, with an improvement in Cormack and Lehane grade. There was a significant increase in the complication rate in plastic group (15 vs. 6%; P < 0.05). In rapid sequence induction of anesthesia, the plastic laryngoscope blade is less efficient than a metal blade and thus should not be recommended for use in this clinical setting.