1. Great post Minh, and also timely as it seems several of us rural docs in Oz are weighing up pros/cons of various adjuncts for our resus bay and for use at the roadside.

    I wonder how well those Parket tip ETT would work with these devices? Less chance of holdup at the arytenoids?

    Anyhow, off now to make a business case for having these in our local unit….although at the cost, I might just have to buy a brace myself for the prehospital bag.

    Great review, thanks.

  2. No problem Tim. Anything for a fellow rural doc. My sister in law has a house on Kangaroo Island and its nice to know if she ever gets into trouble out there, you and your prehospital bag will be ready !
    Not used the Parker tip ETT but my favourite ETT for anything, especially with a bougie is the Fastrach ETT with the silicone soft tip and wire reinforcement. They are not cheap $70 each I think but worth the money.

  3. Dear Minh,
    Thanks for your review. I got some questions for you:
    1) How is the performance of King Vision scope in airway with soiling (e.g. secretions, blood). From my experience on using airtraq, its camera lens system cannot tolerate just slight more-than-average amount of secretion at the airway and the image from the eye piece was blurred quite often. I wonder if the King Vision scope would out-perform Airtraq in this aspect
    2) Can we use the King Vision scope with non-channel blade like an ordinary direct laryngoscope? For e.g. we could use the C-MAC system like a regular DL if we got perfect line-of-sight to patient’s vocal cord.
    3)It might seem silly question, but I would like to know if the price of the King Vision scope is in Australian Dollars or US dollars


    • Hi Duncan
      Does BR stand for Baton rouge?
      The prices I quote are in Australian dollars
      I would not use any VL as a normal laryngoscope . I would have a good VL and DL separately in the prehospital setting. In Hospital you could just use one system for both but almost no one does as far as I know. Remember the King vision only comes with #3 Mac blades and even they appear shorter and wider than regular #3 Mac blades. If all you had was the King vision then of course you could use it for DL and get a reasonable view but it all depends on your skill with DL.
      Good question about airway soiling, the Achilles heel of VL and optical devices. And FOB for that matter
      My impression is that the King vision would be no better than Airtraq in soiled airway conditions but thats just on inspection of the blade tip camera position. How would it perform in anger? If it looks to be an otherwise easy intubation but the airway is full of vomit,secretions,blood then DL and suction is hard to beat. Airtraq here is not so good as you point out. If it looks to be a difficult intubation as well as soiled airway then I would choose VL first attempt to maximize success, with suction in advance of passage of the VL.I experimented using a suction catheter down the guide channel of the Airtraq a few times to see if it would protect the viewing portal at the tip of the blade but it was hit and miss. It would work great in some soiled airways and not so well in others, depending upon the volume of soiling.

      On a side note,before Kingvision came, my strategy for the soiled airway was :suction first then try place patient in head up position as much as possible(sometimes not possible); then DLwith suction;if not a good view then fastrach ILMA. if good oxygenation then try blind intubation . If that fails then surgical airway under ILMA oxygenation support

  4. Dear Minh,
    Thanks for your reply. BR stands for “Best Regards”…sorry for my laziness. I’m actually coming from Hong Kong

    I also tried passing suction catheter alongside the lumen of the ET tube mounted on airtraq trying to savage poor view because of secretions, but it was unsuccessful.

  5. Re : soiled airway

    I wonder? Non-channelled blade on the KingVision and the ETT-stylet-meconium aspirator- suction contraption described in preceding post. Might work a treat.

    Better to fix a soildd airway than deal with soiled underwear, my first rule of the trauma airway.

    • Or maybe even ETT suction setup with the aspirator, via the guided channel blade of the King Vision to protect camera from fluids and obviate need for stylet.

      Intriguing possibility
      Must build that simulated massive regurgitation and bleeding into airway mannikin idea I have been thinking of to test this!

  6. Any issues with the lens fogging up? When we demo’d the mcgrath we found the lens fogged up prehopsital due to temperature difference in regards to storage then temperature increase in the oral cavity.

    • Great question Jeremy
      You don’t think of these things when you are living in the tropics!
      We did more testing today and it was hot and humid from the cool air conditioning inside to testing outside we did not notice a difference
      I will try to test this further by cooling the device in the fridge then testing outside again on hot humid day and let you’s supposed to have an antifog coating on the camera

  7. re: lens fogging

    Well, I’m down in the south of Australia (rural NSW currently) and so far fogging hasn’t been a problem. Last night took KingVision from car to a case at 11pm – outside temperature about 5 degrees Centigrade. KingVision on for about 15 seconds before intubated. No problems. So based on n=1, this kit still gets thumbs up.

    Intrigued by Minh’s proposal of a massive regurgitation/bleeding into airway mannikin. Could be messy.

  8. Just experimenting with hooking it up to a monitor. Got myself a cheap portable monitor from local hobby shop (TFT screen, colour, 12V power, 12″) and hooked it up to KingVision with the supplied composite video cable

    Sweet! Now have a device which means I can intubate and concentrate on the view in front of me via the screen inbuilt to KingVision handle…and my colleagues n theatre or resus can award points as they watch on the ‘big screen’

    What I like best about this is that (a) can accelerate the learning curve for novices (b) with VL you can deliberately set up a grade III or IV larynx on the screen then practice techniques to ‘get out of trouble’…and if struggling, just change view and reclaim the usual grade I view.

    Got to be good for practicing, given how infrequent grade III/IV views are.

  9. Minh just shared this image:

    Minh States:
    there was a question about using the King Vision from cold into warm environment and fogging.

    I placed the king vision in the freezer for 5 minutes

    then I took it outside in the warm humid air of tropical Queensland. Ambient temperature today is about 30 deg C.

    I tested using a Trucorps mannikin again

    I attach a picture of the King Vision screen during this test. As you can tell no significant fogging.

    When the ambient temp reaches 36-37 C I can retest to try to simulate body temperature but this simple test seems adequate. The image is still more than satisfactory for intubation.

    Now to test it in a simulated bloody airway model!

  10. Quick update as I’ve had several people email me re : monitors to use with the KingVision and video out cable

    My hobby store monitor setup described earlier works well….and I’ll get the maintenace lads at our small rural hospital to secure it to an IV pole and setup a 12v power supply for the monitor.

    Just down in Sydney, NSW on Paul Baker’s excellent airway skills course….put the KingVision head-to-head with the McGrath VL – whilst the latter has an adjustable screen, it is more expensive and the portrait vs landscape screen orientation didnt work for me. Also no video out cable on the McGrath and the KingVision seemed better in sunlight (thanks to Dr liz from Tamworth for trailling this!)

    Last up, Elgato sell a video capture cable/software….so now I can upload video from the KingVsiion to MacBookPro and save as MP3/iTunes/YouTube (works with PC too).

  11. This device is mediocre at best. It doesn’t stand up well to blood/vomit in airway and the blade is very flimsy is you give it much lift. I don’t see it being able to stand up to how rough we are on our equipment. I wasn’t impressed with Airtraq and this isn’t that much different. “Cheap” isn’t always the lowest cost or best thing for the
    patient. It bothers me that medicine has gotten away from using what is best.

    • Sandy-
      This has not been my experience during my trial. These devices are not made to lift the airway structures as you do with a conventional laryngoscope.

      Also, would you mind letting us know if you have any conflicts of interest.

      Much thanks,

    • I had the opportunity to try this device in an airway lab today and while at first skeptical, I was impressed. Granted there are several differences between a mannequin and a human being, but the concept is there. I am curious to hear about someone who may use it in a blood/emesis airway.

      As stated above, from my understanding this device is not made to actually manipulate structures. It simply slides down the base of the tongue. I did however, notice that occasional slight upward-leftward pressure was required to manipulate the ETT around the right arytenoids. I am told that rotating the tube counterclockwise and advancing simultaneously may alleviate this problem though.

      As far as durability, the device seemed of high build quality and with the included protective case, I don’t foresee any durability issues short of you throwing the device across the room.

      Like it or not, healthcare costs are a real issue and a multi-thousand dollar device may not be feasible. Especially with EMS in the United States, current ALS billing does not provide a means to itemize supplies on a bill, so while quality is important, expense of disposables is something real that must be considered to even break even. Forget about making a profit when you start using multiple devices that cost $50-100 per patient.

      While I am sure this is not the last video laryngoscope that will “put the traditional laryngoscope in the trash,” it is definitely a step in the right direction with affordability, ease of use and construction.

  12. Sandy, thanks for your feedback. Have you actually tested the device in any manner at all? I ask because on further testing of the device in terms of the simulated bloody airway, comparing it to the AirTraq, a colleague and I found there appeared to be an advantage with the King Vision. OUr results I believe , will be posted on this site soon so check it out for yourself. The Airtraq I find is a good device for the cost but it failed our simulated bloody airway testing. I agree we should always try to use good quality equipment when we can but I disagree that what is always best is always the most expensive.

    Since writing my original review of the King Vision, the Australian distributor has provided sponsorship of 3 airway courses I am running in 2012 and that is my only conflict of interest to declare on the matter.

  13. We trialled the King Vision at the RBWH in the Anaesthetic Dept.
    The following was fed back to the administration.

    Both the channeled guided and standard (or non-channeled) blades were trialled. The optics are are excellent and the video image is high quality. This aspect places the device in front of many currently marketed devices in this field.
    The significant fault with the device was its length. The device’s screen repeatedly struck the anterior wall of the patient’s chest in patients with retrognathia, large barrel-shaped chests or who required manual in-line stabilisation of the neck. The device could not be inserted in these cases and the procedure was abandoned. Such cases were subsequently handled quite easily with the standard Macintosh blade or the C-Mac videolaryngoscope.
    I discussed this problem with the company representatives at length and they raised the possibility of re-designing the device. It was feasible that the screen may be incorporated into the front of the handle.

    Hope this helps.
    Keith Greenland

    • Keith,

      2 solutions possible:
      The device can be inserted with 90 rotation and then rotated back after the blade is mostly into the mouth–i do the same with my cmac

      with the king, you can insert the blade without the screen and only then attach the screen portion

      • Hi Minh,

        I have been following your blog for some time. Very informative. I just got hold of a kingvision and have been trying it in all of my patients. I practice in a charity hospital and the idea of disposing the blade after a single use is not a good idea. We just clean and sterilize it with cutasept. My problem is that every time I use it the lens always fogs up. Does using the blade several times has something to do with this. Another thing I observe is that there is difficulty in passing the tube in the channeled blade if the the patient is in the sniffing position but none when in the neutral position. I tried also the regular blade for nasotracheal intubation in the sniffing position and my tube gets stuck in the anterior wall of the trachea, I have to rescue this by using the stiff glidescope stylet to push the tip of the tube down and guide it to the glottis. Somebody has to push the tube while I push the ETT tube downwards. Comments please.

        • thanks for questions Nelson
          yes the single use blades will fog up after cleaning as the antifog film on the camera eye gets washed off. thats why they are single use!
          I would advise you review your practice/policy of reusing these single use blades.
          as for the problem of a channeled blade guiding ETT too anterior if patient in sniffing position, it might be because you got the blade inserted too deeply. generally withdrawing the blade a bit may reposition angle better.
          ideally if you have it a pair of macgills forceps will allow you to redirect ETT much easier than as stylet and not need a second person to advance ETT whilst you redirect.

    • Hi Keith! Keith is a senior Anaesthetic consultant and one of the current principal members of the ANZCA Airway SIG. He runs an airway wet lab in Brisbane. hope to see you there in April, mate! I was privileged to host both Keith and Richard Levitan at an airway course in Cairns a couple of years ago and had the rare opportunity to hear both of them talk airway management over dinner. Two masters debating things like airway research methodology and cricoid pressure..golden stuff!

      About the length of the King Vision, I agree we have found the same thing in followup testing. What Scott describes is the technique we adopted after testing. The blade gets inserted first, then the camera unit is attached and switched on. We tested this in a simulated bloody airway mannikin and even witha generous amount of blood coming out of the mouth, onto the testers gloves and the display unit, it appeared to work successfully each time we tested.

  14. The department I work for just purchased these for a primary airway access with ETT. Upon initial training and practice, one would indicate this is the easiest way to achieve an ETT airway where ever your at. Initially I was impressed with this. I did have some reservations in the back of my mind, but was anxious to get an opportunity to use it.

    It sucks for traumatic airways or airways where there is extensive vomit or blood. What are you going to do, wipe the camera on your shirt when it becomes red like blood? I knew it was too good to be true. I do have a design in my head that could fix this issue and then I would reconsider this as being a paramount airway device. Once again, the blade and handle prevail. King has tried for years to develop something fail safe, again, I think they have failed. Don’t get me wrong, it is cool, but not 100% dependable when you need it!

    • We’ve been using the King Vision as our video laryngoscope for our critical care air and ground teams (Metro Life Flight). We are almost exclusively using it when DL has failed or in an anticipated difficult intubation.

      It is really important to realize that there is no ideal intubation device. There will always be situations where one option is superior to another. I don’t necessarily think this is about inventing the better mousetrap but rather a reflection of the diversity of difficult airway issues.

      Note that in Glidescope trials I’ve read the number one rescue device was DL. There are some patients that are exceptionally difficult to get with DL but video devices are easy and vice versa.

      We’ve found for a variety of reasons that it seems to work best to insert the blade first and then attach the video portion afterwards. This greatly reduces the issue of hitting the patient’s chest and also reduces the temptation to torque on the device and try to use it like a laryngscope. We’ve had issues with the handle connection popping off when you pull on the blade too much. It is reflex to try to use it like a standard laryngoscope but that’s not how it was designed.

      The other major pitfall is inserting the device too far into the mouth and ending up too close to the laryngeal inlet. That seems to make it harder both to get a view and also to advance a tube.

      While the device is not perfect it is a pretty darn good tool even when you don’t take into account the affordable price. For our needs it is superior to the glidescope and we would have purchased it even if the pricing difference were not present. The glidescope sometimes poses tube delivery challenges and takes a bit longer to get the tube in than with the King Vision. Hopefully those smaller sized blades for peds will come available soon and increase the flexibility of the device.

      The best way to field the device (learned the hard way from experience) is to get some time with an unembalmed cadaver or two and let your staff experience for themselves the quirks before they are working with a patient. As I said above, this is not a perfect device but it seems to be the best option we have for a crisis video laryngoscope.


  15. Just a quick comment from Perth Australia.

    I would like to highlight that this is a true indirect laryngoscope. It is not in my opinion designed to be used as a MAC 3 blade for direct laryngoscopy. It’s not a tissue lifter as such but it is a only a slider. (I know you have to lift sometimes when you are in but that is not to align the axis)

    If your airway skills are through years of practice and patient experience with a standard macintosh blade, using an indirect blade as your first line is I think a dangerous choice. In some patients an indirect blade can turn an easy intubation into a difficult one. This is more true if you are inexperienced at indirect laryngoscopy as I think many are in Australia.

    I think this is maybe what Sandy Lange was alluding too above??

    If you are an experienced indirect user then this is possibly a good device, in fact we have purchased for use at the Royal Perth Hospital in our nice “clean and clinical” anaesthetic environment.

    I would still never personally, with my skill mix now including a lot of indirect experience, pick up a true indirect blade such as this is as my first line attempt, unless I had a previous documented failure with a mac 3+4 blade .

    This is why the c-mac has proved so popular in, if I can call it, city practice in Perth as it provides a pretty much standard macintosh blade that you can use normally, with the addition of the ability to use the screen to aid if required. There is a minimal learning curve to their use, but unfortunately they are a pain in the backside to clean for the many regional centres in W.A. Roll on a good standard mac bladed videolaryngoscope with a disposable blade!

    To use this indirect sort of blade in anger I think possibly requires taught clinical experience on patients prior to its use in an emergency. This can prove a struggle for the working anaesthetist in Western Australia so I can only imagine it is even harder in many of your followers settings.

    In the United States I understand that true indirect laryngoscopy is a technique that E.D. physicians often use as standard which could lead to a different conclusion entirely!

    Greeting from a wet but still surprisingly warm Perth!

    P.S. I have no conflict of interest

    • Dr. Heard,

      First, let me say it is with great pleasure that I see you posting a comment on the blog. (For those who don’t know, Dr. Heard has done extensive work on difficult airway management and I highly recommend his papers and courses.)

      I agree with all you have written above. To your point re: US folks–I would say Glidescope has stormed the market, at least initially. Most depts that have bought video scopes have glidescopes. I think the transition from glidescope to king is much easier than from conventional laryngoscopes just as you elude to.

      We have the CMAC, which I think is the best device for an academic EM dept b/c you can turn the screen away from the intubator and give them the opportunity to learn conventional laryngoscopy while the supervisor can still see what they are doing. We also have their new D-blade which gives closer to the glidescope experience.

      CMAC has disposable blades coming out in the next month or so. I have trialed them and they are very nice.

      I have no conflicts of interest with any of the above mentioned companies.

      • Hey Scott
        Having had a frustrating time with a three hour turnaround on cleaning of our CMAC size 3 blade yesterday, as I intubated the third patient in a row who that size would have been ideal for, I was wondering if you had heard any more about the disposable blades from Storz? A google search just finds your blog post really! Thanks mate


  16. Any comparison between channelled and standard blade? How is the device holding up (ease of use, durability and usefulness) a year + in the real-life condition?

    Pitfalls, limitation, tips? I gather the blade is $30 each, do box of 10. = ~$ 300?

  17. Hello all! Some observations… First, we are a paramedic EMS service with just under 10,000 runs a year. We tested the King and the McGrath Mac side by side over 2 days with a cadaver. The meds prefered the King 2 to 1 over the McGrath, but it appears that was mostly based on the quality of the video. The cadaver was mostly clean and dry other than surgilube for insertions. The camera held up well with 70+ intubations using a single blade! I was impressed with the durability, as we meds can be brutal on equipment! My instruction on use was brief and mostly about how to use the channel for intubating, I purposely left the “technique” teaching out to see how they would adjust. 80% had no problems and the few that did were do to deep insertion of the blade and their inability to manipulate while watching the screen.
    The McGrath also performed well and I think people were even more successful using it, primarily due to the fact that it operates pretty much like a regular direct laryngoscope.
    My gut is that, had the camera/display been better on the McGrath, they would have chosen that tool.

  18. Our paramedic service has adopted the King Vision as the primary device for all adult intubations. We have over 100 intubations with it now and our experience has suggested several tips for successful use.

    1). We practice inserting the blade without the camera for those large patients or those with continuous compressions ongoing. This works well once practiced.

    2). We train to visualize the epiglottis prior to passing the tube. I started teaching this instead of telling them to use it as a Mac when I realized saying it this way worked better. Our medics were almost always thrilled with the view but complained that they had difficulty directing the tube through the cords. It turns out, they were in too deep. This is prevented if the first part of the procedure is “epiglotoscopy”.

    3) We have suction handy and don’t hesitate to use it simulataneously with intubation. We use only the channeled blade which frees up a hand to suction with. We’ll suction as best as possible and then leave the tip in the oropharynx for continuous suctioning as we insert the device and intubate around the suction tip. Frequently, we can’t even see the suction device. This helps prevent soiling of the lens.

    While this isn’t a full proof device by any means, it has dramatically improved both our first pass success and overall success rates compared with our prior DL experience.

    I have no conflicts to report.


  1. […] issue of ‘which video laryngoscope‘, whilst Minh Le Cong of RFDS Queensland posted a review of the device on EM-crit. Then to top it off I spent the weekend at the NSW proceduralists conference, where […]

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