An Introduction to HAVL
Time 5-8 minutes
(Total completion time 45-60 minutes)
Overview
- Description: Hyperangulated Video Laryngoscopy Training Program
- Creator: Jonathan St George, MD, Chris Root, MD, Sean Runnels, MD
- Includes: Online + Hands-On Curriculum
- Completion Time: 30-40 minutes
- CME & Certificate available: Yes (with site subscription)
Start Course
Ready to roll? Review the learning objectives here and then scroll down to dive in. Once you’ve finished, you’ll be guided to the next poster, with fresh digital content and hands-on training to level up your skills. Mastery of the hyperangulated video laryngoscope is just ahead—let’s get after it.
Critical Knowledge
- Describe the origins, historical development, and conceptual basis of the hyperangulated video laryngoscope.
- Describe the design characteristics and clinical applications of hyperangulated video laryngoscopes.
- Explain the Two-Curve Theory of the airway and its relevance to hyperangulated video laryngoscopy.
- Describe how hyperangulated blades are designed to navigate airway curvature to optimize glottic visualization.
- Explain the relationship between glottic visualization and endotracheal tube delivery during HAVL.
- Describe the role and necessity of a rigid stylet in successful HAVL intubation.
Core Skills
- Demonstrate appropriate gaze management during HAVL
- Demonstrate correct insertion and positioning of an HA blade.
- Use proper progressive VL to identify key anatomical landmarks.
- Obtain a laryngeal view optimized for HAVL. (50/50 view).
- Demonstrate proper insertion, handling, and use of a rigid stylet during HAVL.
- Use the appropriate technique for ETT delivery, the stop–pop–drop technique.
- Apply airway geometry principles to troubleshoot difficulty during HAVL attempts.
- Secure the endotracheal tube and remove the stylet safely following successful HAVL intubation.
The Essentials
Everything changed the day we put a camera on the end of a laryngoscope. No more chasing a straight line of sight. Hyperangulated blades fully embrace this freedom. These devices aren’t built to flatten the airway; they’re designed to follow its natural curves, allowing you to see around obstacles like the tongue, not just over them. That’s their power and their challenge.
To use them effectively, you’ll need to adapt to the curve, not just in the device, but also in the airway itself. That means developing new spatial awareness and a fresh understanding of airway geometry. Add to that a new tool, the rigid stylet, and a few high-impact maneuvers, and you’ll quickly take your airway game to the next level. Ready to master the hyperangulated video laryngoscope? You’re in the right place.
What Is It About HAVL?
The Benefits of HAVL
If you’re looking for a tool that has reshaped modern airway management, hyperangulated video laryngoscopy (HAVL) stands out. HAVL consistently provides enhanced glottic visualization, navigating past anatomical curves that can block the view with standard techniques. This translates into proven performance: studies show HAVL increases first-pass success rates and reduces intubation time compared to traditional Macintosh video laryngoscopy.
What makes HAVL even more compelling is its broad utility across settings. It works just as well in routine cases as it does in the most complex airways, making it a valuable tool for clinicians at all levels of experience. And while it does require some adjustments, its adoption is remarkably straightforward. Once mastered, HAVL becomes not just another device in your toolkit, but one of the most powerful and reliable allies in your airway management practice.
What’s Different: New Design = New Skills
If you’re new to hyperangulated video laryngoscopy (HAVL), you might love it so much it becomes your go-to approach. But fair warning—it’s not just a sleeker version of standard VL. HAVL changes everything: your view, your angles, and especially how you deliver the tube. If you try to wing it with your usual standard geometry technique, you’ll get stuck fast. The fix? The handful of HAVL-specific tricks we’re going to give you here, and once you’ve got them down, it will all click.
Remember, this space is your training ground.
As you move through the digital content and hands-on skills, focus on three high-impact elements that unlock success with HAVL. Once you’re comfortable with them, your intubations will feel smoother, more controlled, and more predictable. Let’s go.
🎧 Deep Cuts
You’ve covered the essentials, solid work. From here, you can move on to the next poster or tap on any of these topics to explore them in greater depth.
The Evidence for Hyperangulated VL
Hyperangulated video laryngoscopy (HAVL) has garnered significant attention in recent years for its potential advantages in airway management, particularly in patients with anticipated difficult airways. Here’s a comprehensive overview of the current medical literature evaluating its benefits:
Enhanced Glottic Visualization and First-Pass Success
A randomized controlled trial involving 182 adults with expected difficult airways compared HAVL (C-MAC D-BLADE™) to Macintosh-style video laryngoscopy. The HAVL group demonstrated a median percentage of glottic opening (POGO) of 89%, significantly higher than the 54% observed with Macintosh blades. The first-attempt success rate was 97% for HAVL, compared to 67% for Macintosh video laryngoscopy.
Another large-scale cluster randomized trial encompassing 8,429 surgical procedures found that HAVL reduced the need for multiple intubation attempts (1.7% with HAVL vs. 7.6% with direct laryngoscopy) and decreased intubation failure rates (0.27% vs. 4.0%).
Improved Outcomes in Intensive Care Settings
In a prospective before-after study conducted in an ICU setting, the universal adoption of HAVL as the primary intubation tool led to a higher incidence of “easy intubation” (92.5% vs. 75.8%) and a significant reduction in difficult laryngoscopy cases (1.5% vs. 22.5%) compared to the period when direct laryngoscopy was standard.
Clinical Implications
HAVL appears beneficial when minimizing head and neck movement is crucial, particularly in patients needing cervical spine precautions or with anatomical challenges. Evidence supporting its adoption as a first-line tool in difficult airway management protocols indicates improved visualization and higher first-pass success rates.
The Desert Island Test?
What airway device would you want if stranded on a desert island? We know it’s not a scientifically validated method for choosing your intubation device, but if you’re @JohnCSakles, legendary airway expert, it’s HAVL. The reason? It works great as a VL workhorse device, but is often chosen for its ability to manage many difficult airway situations. So, if you want to master an approach that will be your “go-to,” HAVL may be a great place to start.
Meet the Inventor
The Bottom Line
Hyperangulated video laryngoscopy (HAVL) offers a decisive advantage: the ability to see around airway structures, not just at them, making it especially effective in difficult airways. But great views aren’t enough. To succeed with HAVL, you’ll need to understand airway geometry and become comfortable using tools such as a rigid stylet for precise tube delivery. The good news? Studies support this: HAVL improves first-pass success, shortens intubation time, and performs well in both routine and challenging scenarios. Mastering HAVL means elevating your airway management skills and enhancing outcomes when it matters most.
Visit the Next Poster
Find Or Click Me
Nice work—you’re through this section! To keep going, scan the QR code on the physical poster at the next station in our pop-up training space to access the next set of digital content. Prefer to stay online? Just click the poster image here to continue your journey.
References:
- Hansel J, et al. “Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airways.” Anaesthesia, 2024.
- Ruetzler K, et al. “Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation.” JAMA, 2024.
- Study on the universal use of HAVL in ICU settings. PubMed, 2024.
- Driver BE, et al. “Comparing Emergency Department First-Attempt Intubation Success With Standard-Geometry and Hyperangulated Video Laryngoscopes.” Ann Emerg Med, 2020.
- Meta-analysis comparing HAVL and Macintosh videolaryngoscopes. Anaesthesia, 2022.
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