The Impact of Airway Technique on Anesthesia Control Time

  • Matthew J. Rowland
  • Richard D. UrmanEmail author
  • Xinling Xu
  • Jesse M. Ehrenfeld
  • David A. Preiss
  • Joshua C. Vacanti
Education & Training
Part of the following topical collections:
  1. Education & Training


Few studies have examined the impact of video laryngoscopy (VL) on operating room efficiency. We hypothesized that VL reduces anesthesia control time (ACT), a metric of anesthesia efficiency, compared with fiberoptic intubation (FOI) in potentially difficult airways, but that direct laryngoscopy (DL) remains more efficient in routine cases. We performed a multi-institutional, retrospective chart review of anesthetic cases from 2015 to 2016. Cases were compared based on choice of airway technique (laryngeal mask airway [LMA], DL, VL or FOI) and ACT. Generalized linear models with gamma distribution and log link were then used to model the data to control for variables including ASA physical status (PS), Mallampati (MP) score, body mass index, and presence of a trainee. ACT was analyzed for 32,542 cases. LMA insertion was associated with a median ACT of 10 min (CI 8–14 min), DL 14 min (CI 11–18 min), VL 17 min (CI 13–21 min) and FOI 20 min (CI 14.5–26 min). Modeling confirmed these results when controlling for variables expected to increase the ACT. However, modeling also revealed that presence of a trainee minimizes the increase in ACT for cases using VL or FOI. Use of VL in patients with a high MP score may improve anesthesia efficiency in the operating room. ASA PS, MP score, and presence of a trainee are all associated with an increased ACT. Trainee presence with both FOI and VL was associated with reduced increases in ACT for these devices.


Anesthesia control time Videolaryngoscopy Laryngoscopy Operating room Efficiency Fiberoptic Intubation 



Anesthesia Control Time


Fiberoptic intubation


Video laryngoscopy


Direct laryngoscopy


Body mass index


Laryngeal mask airway


Mallampati class


Confidence interval


In room to induction complete


Induction start to induction complete


Induction start to intubation


In room to intubation


Certified Registered Nurse Anesthetist


Student Registered Nurse Anesthetist


Compliance with ethical standards

Conflict of interest

None of the authors have any conflicts of interest relevant to this work.


  1. 1.
    Lafferty, B. D., Ball, D. R., and Williams, D., Videolaryngoscopy as a new standard of care. Br. J. Anaesth. 115:136–137, 2015.CrossRefGoogle Scholar
  2. 2.
    Stroumpoulis, K., Pagoulatou, A., Violari, M., Ikonomou, I., Kalantzi, N., Kastrinaki, K., Zanthos, T., and Michaloliakou, C., Videolaryngoscopy in the management of the difficult airway: A comparison with the Macintosh blade. Eur. J. Anaesthesiol. 26:218–222, 2009.CrossRefGoogle Scholar
  3. 3.
    Cavus, E., Thee, C., Kieckhaefer, J., Doerges, V., and Wagner, K., A randomized, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia. BMC Anesthesiol. 11:6, 2011.CrossRefGoogle Scholar
  4. 4.
    Kaplan, M. B., Hagberg, C. A., Denham, W. S., Brambrink, A., Chhibber, A. K., Heidegger, T., Lozada, L., Ovassapian, A., Parsons, D., Ramsay, J., Wilhelm, W., Zwissler, B., Gerig, H. J., Hofstetter, C., Karan, S., Kreisler, N., Pousman, R. M., Thierbach, A., Wrobel, M., and Berci, G., Comparison of the direct and video-assisted views of the larynx during routine tracheal intubation. J. Clin. Anesth. 18:357–362, 2006.CrossRefGoogle Scholar
  5. 5.
    Serocki, G., Neumann, T., Scharf, E., Dorges, V., and Cavus, E., Indirect videolaryngoscopy with C-MAC D-blade and Glidescope: A randomized, controlled comparison in patients with suspected difficult airways. Minerva Anestesiol. 79:121–129, 2013.PubMedGoogle Scholar
  6. 6.
    Silverberg, M. J., Li, N., Acquah, S. O., and Kory, P. D., Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: A randomized controlled trial. Crit. Care Med. 43:636–641, 2014.CrossRefGoogle Scholar
  7. 7.
    Aziz, M. F., Dillman, D., Fu, R., and Brambrink, A., Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology 116:629–636, 2012.CrossRefGoogle Scholar
  8. 8.
    Jungbauer, A., Schumann, M., Brunkhorst, V., Borgers, A., and Gröeben, H., Expected difficult tracheal intubation: A prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients. Br. J. Anaesth. 102:546–550, 2009.CrossRefGoogle Scholar
  9. 9.
    Salama, A. K., Hemy, A., Raouf, A., Saleh, N., and Rady, S., C-MAC video laryngoscopy versus flexible fiberoptic laryngoscopy in patient with anticipated difficult airway: A randomized controlled trial. J Anesthesia Patient Care 1:101, 2015.Google Scholar
  10. 10.
    Lewis, S. R., Butler, A. R., Parker, J., Cook, T. M., and Smith, A. F., Videolaryngoscopy versus direct laryngoscopy for adults requiring tracheal intubation. Cochrane Database Syst. Rev. 11:CD011136, 2016.PubMedGoogle Scholar
  11. 11.
    Kodali, B. S., Kim, K. D., Flanagan, H., Ehrenfeld, J. M., and Urman, R. D., Variability of subspecialty-specific anesthesia-controlled times at two academic institutions. J. Med. Syst. 38:11, 2014.CrossRefGoogle Scholar
  12. 12.
    Chen, Y., Gabriel, R. A., Kodali, B. S., and Urman, R. D., Effect of anesthesia staffing ratio on first-case surgical start time. J. Med. Syst. 40:115, 2016.CrossRefGoogle Scholar
  13. 13.
    Dexter, F., Coffin, S., and Tinker, J. H., Decreases in anesthesia-controlled time cannot permit one additional surgical operation to be reliably scheduled during the workday. Anesth. Analg. 81:1263–1268, 1995.PubMedGoogle Scholar
  14. 14.
    Boggs, S. D., Tsai, M. H., and Urman, R. D., The Association of Anesthesia Clinical Directors (AACD) glossary of times used for scheduling and monitoring of diagnostic and therapeutic procedures. J. Med. Syst. 42:171, 2018.CrossRefGoogle Scholar
  15. 15.
    Hanss, R., Roemer, T., Hedderich, J., Roesler, L., Steinfath, M., Bein, B., Scholz, J., and Bauer, M., Influence of anaesthesia resident training on the duration of three common surgical operations. Anaesthesia 64:632–637, 2009.CrossRefGoogle Scholar
  16. 16.
    Leudi, M. M., Kauf, P., Mulks, L., Wieferich, K., Schiffer, R., and Doll, D., Implications of patient age and physical status for operating room management decisions. Anesth. Analg. 122:1169–1177, 2016.CrossRefGoogle Scholar
  17. 17.
    Dawson, S. R., Taylor, L., and Farling, P., The true cost of videolaryngoscopy may be trainee experience in fibreoptic intubation. Br. J. Anaesth. 115:134–135, 2015.CrossRefGoogle Scholar
  18. 18.
    Kim, K. N., Jeong, M. A., Oh, Y. N., Kim, S. Y., and Kim, J. Y., Efficacy of Pentax airway scope versus Macintosh laryngoscope when used by novice personnel: A prospective randomized controlled study. J. Int. Med. Res. 46(1):258–271, 2018.CrossRefGoogle Scholar
  19. 19.
    Shippert, R., A study of time-dependent operating room fees and how to save $100,000 by using time-saving products. Am. J. Cosmet. Surg. 22:25–34, 2005.CrossRefGoogle Scholar
  20. 20.
    Macario, A., What does one minute of operating room time cost? J. Clin. Anesth. 22:233–236, 2010.CrossRefGoogle Scholar
  21. 21.
    Park, K. W., and Dicerkson, C., Can efficient supply management in the operating room save millions? Curr. Opin. Anaesthesiol. 22:242–248, 2009.CrossRefGoogle Scholar
  22. 22.
    Rothstein, D. H., and Raval, M. V., Operating room efficiency. Semin. Pediatr. Surg. 27:79–85, 2018.CrossRefGoogle Scholar
  23. 23.
    Doll, D., Kauf, P., Wieferich, K., Schiffer, R., and Leudi, M. M., Implications of perioperative team setups for operating room management decisions. Anesth. Analg. 124:262–269, 2017.CrossRefGoogle Scholar
  24. 24.
    Kriege, M., Alflen, C., Tzanova, I., Schmidtmann, I., Piepho, T., and Noppens, R. R., Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: The randomized multicenter EMMA trial study protocol. BMJ Open 7:e016907, 2017.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Department of AnesthesiaBeth Israel Deaconess Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Department of AnesthesiologyVanderbilt University Medical CenterNashvilleUSA

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