Difficult Laryngoscopy
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DIFFICULT LARYNGOSCOPYROLE OF THE VIDEO LARYNGOSCOPE Joseph C. Gabel Professor
The University of Texas Medical School at Houston
MedicalMemorial Hermann Hospital
Houston, TX, USA
Carin A. Hagberg, MD
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Anesth Analg 2010; 110:Cover
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Takaski Asai, M.D.
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UNANTICIPATED DIFFICULT AIRWAY SOCIETIES’ RECOMMENDATIONS
ASA 3 intubation attempts, spontaneous ventilation, face mask, alternative approaches (fiberoptic intubation), awaken patient
Canada Optimize laryngoscopy, alternatives (light stylet, fiberoptics), awaken patient
France 2 intubation attempts, LMA, fiberoptics / special blades (2 further attempts), awaken patient
UK (DAS) 4 intubation attempts, ILMA or LMA, revert to face mask ventilation, awaken patient
Italy (SIAARTI)
Help, 2 intubation attempts, (awaken patient), alternative devices, 2 further attempts, LMA / ED
Germany (DGAI) Intubation with alternatives, LMA/ILMA, spontaneous ventilation, fiberoptics, awaken patient
Heidegger T, Gerig HJ, Henderson JJ. Best Pract Res Clin Anaesthesiol 2005;19:661-74I
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c). Alternative difficult intubation approaches include (but are not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (e.g. LMA or ILMA) as intubation conduit (with or without fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer,
light wand, retrograde intubation, and blind oral or nasal intubation.
Anesthesiology 2013 118:251-70
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SUGGESTED CONTENTS PORTABLE STORAGE UNIT DIFFICULT AIRWAY MANAGEMENT
1. Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscope
2. Videolaryngoscope
3. Tracheal tubes of assorted sizes
4. Tracheal tube guides. Examples include (but are not limited to) semirigid stylets, ventilating tube-changer, light wands, and forceps designed to manipulate the distal portion of the tracheal tube.
5. Supraglottic airways (e.g. LMA or ILMA of assorted sizes for non-invasive airway ventilation/intubation
6. Flexible fiberoptic intubation equipment
7. Retrograde intubation equipment
8. Equipment suitable for emergency invasive airway access
9. An exhaled CO2 detector
The items listed in this table represent suggestions. The contents of the portable storage unit should be customized to meet the specific needs, preferences, and skills of the practitioner and healthcare facility.
SUGGESTED CONTENTS OF THE PORTABLE STORAGE UNIT FOR DIFFICULT AIRWAY MANAGEMENT
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Cattano D, Hagberg CA, Video Lar yngoscopy in Obese Pat ients . Anesthes io logy News: Guide to Airway Management . 2010; 43-8 .
Device Size Angles, Degrees
Type of Monitor
Battery
Monitor Size,
in
Location of
Monitor
Single -Use Blade
Can be used for
Conventional DL
Defogger
Required
Channel Tube Guide
Airtraq
Adult (regular
and small) Naso-
tracheal, double-
95Coming
soon Yes (single
use) N/A Unattached Yes No No Yes
Berci -Kaplan DCI
Mac 3 & 4 Dorges; all Miller sizes
60 – 80 DCI Yes
(rechargeable) 7 Unattached No Yes Yes No
C-MACMac 2,3,4 &
D-Blade single
60 – 80 LCDYes
(rechargeable)7 Unattached No Yes No No
GlideScope Small,
midsize, large
50 – 60 LCD Yes (Ranger; rechargeable
3.5 Unattached Yes
(Cobalt)
Possible, but notrecommende
d
No No
McGrath Child, adult 35 – 45 LCD Yes (AA) 1.7 Attached Yes Possible, but
not recommended
No No
Pentax Airway Scope
Single size 90 LCD Yes (AA) 2.4 Attached Yes No No Yes
TruView EVO2
Small & adult
Neonatal Pediatric
42 LCD Yes
(rechargeable) 5
Attached; can be
used with eyepiece
No No Optiona
l No
Weiss Angulated
Video-Intubation
Single size 70 N/A No N/A Unattached Yes No Yes No
VIDEO LARYNGOSCOPES VS RELATED DEVICES
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Traditionally shaped blades
Angulated blades
Channeled blades
CLASSIFICATION VIDEO LARYNGOSCOPES
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Verathon® GlideScope® DIRECT INTUBATION TRAINER
Airway management instructors can view
intubation in real-time during direct laryngoscopy
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VIDEO LARYNGOSCOPY LITERATURE
DEVICE
Glidescope Airtraq
Pentax AWS McGrath
Berci-Kaplan DCI C-MAC, D-MAC TruView EVO2
ARTICLES
296 178 130 36 29 27 18
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LITERATURE REVIEW
DEMONSTRATES
Improved laryngeal views
Higher successful intubation
Higher frequency of first attempt intubations
UNABLE TO DEMONSTRATE
Difference in time to intubation
Difference in stress
Airway (obstruction/sore throat), trauma
lip/gum, dental
Difference in degree of cervical spine
deviation
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1)2)
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Their precise role in airway management remains to be established.
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Clinically, the most recent technologic innova3on that has changed my prac3ce has been the video laryngoscopy. Pa3ents that were awake
fiberop3c intuba3ons can be done a=er induc3on of general anesthesia with this device.
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Law JA, Hagberg CA: Anesthesiology News: Guide to Airway Management. 2008
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TEACHING LARYNGOSCOPY THE OLD SCHOOL WAY
Denham Ward, MD, University of Rochester School of Medicine
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DCI VIDEO LARYNGOSCOPE SYSTEM
Modified standard laryngoscope blades w/ incorporated video system
Mac 3&4 Miller (all sizes) Doerges !
Ability of direct visualization
Requires antifog solution
Interchangeable w/ FOB, Bonfils
Portable Medipack
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!!!!!!!
¨ Randomized prospective evaluation 200 pts; Berci-Kaplan VL vs DL
¨ ≥ 18 yr with mouth opening ≥ 2 cm, modified Mallampati III/IV, h/o DI (3)
¨ 2 experienced anesthesiologists ¡ ≥ 13 yr experience; ≥ 3 yr DA
¨ Supine with head on 7 cm headrest
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!!
!Results
¨ Better visualization ¨ Better success rate ¨ Shorter laryngoscopy ¨ Fewer optimizing
maneuvers
!!!
Video vs Direct ¨ I/II 90 vs 64; III/IV 10 vs 36 ¨ 99% vs 92% ¨ 40 s vs 60 s ¨ 0.5 vs 1.2
¡ (ELM>bougie>positioning)
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!!
!Subanalysis III/IV
¨ Better success rate ¨ Shorter laryngoscopy ¨ Fewer optimizing
maneuvers
!!!
Video vs Direct ¨ 98% vs 78% ¨ 53 s vs 105 s ¨ 0.8 vs 2.2
¡ (ELM>bougie>positioning)
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C-MAC VIDEO LARYNGOSCOPE
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MCGRATH VIDEO LARYNGOSCOPE
Fully portable video laryngoscope
Single-use blade
Adjustable 3 Sizes !
On-board mini-color camera
Flat screen monitor mounted on handle
Single rechargeable AA battery
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3 pts with predicted difficult DL with h/o upper airway obstruction Glyco, remi, topical lido
Head up (30o) Well tolerated
No coughing, bucking Minimal lifting Awake McGrath may be better than AFOI in certain pts
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GLIDESCOPE INTUBATION SYSTEM
Blade angled upward 60°
High-resolution camera
LCD light source
B&W Color !
Embedded antifogging mechanism
Adult & pedi sizes
Child Neonate !
Portable, easy maintenance
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GLIDESCOPE COBALT
Single-use GVL® Stat blade
60° angulation !
Reusable video baton
High-resolution camera Anti-fogging lens !Non-glare color monitor
Available in 2 sizes
Large (pts >88 lbs) Small (pts <88 lbs) !
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GLIDESCOPE COBALT
Single-use GVL® Stat blade
60° angulation !
Reusable video baton
High-resolution camera Anti-fogging lens !Non-glare color monitor
Available in 5 sizes
GVL 0,1,2,3,4 !
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“I CAN SEE THE CORDS, BUT I CANNOT ADVANCE THE TUBE.”
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VIDEO LARYNGOSCOPY FAILURE
3.7% failure in a large dataset (early experience)
54% with a Cormack-Lehane Grade 1 or 2 view
3% failure in a large dataset (mixed experience)
35% with a Cormack-Lehane Grade 1 or 2 view
!!Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Rou3ne clinical prac3ce effec3veness of the GlideScope in difficult airway
Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728
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Difficulty or failure w/ VL can be predicted
!Similar predictors to those of difficult direct laryngoscopy w/ the exception of Mallampati score
!Unique scenario of adequate laryngeal view but difficult tube passage
!Device design regarding channel, optics, & stylet have important implications
CONCLUSION
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IT’S ALL ABOUT THE STYLET
Almost anyone can get the view
!The skill is advancing the
ETT & stylet
!!
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Nestler C, Reske AP, Reske AW, Pethke H, Koch T: Pharyngeal Wall Injury during Videolaryngoscopy-assisted Intubation. Anesthesiology 2012
COMPLICATIONS
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PENTAX AWS
Disposable, transparent blade (PBLADE)
ETS 8.5-11 mm Suction port (<4.0 mm suction catheter) !
12 cm cable w/ CCD camera
2.4 in LCD color monitor
Can be adjusted up to 120° Target symbol for accurate alignment w/ glottis !
Cordless, battery-operated
!!
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Disposable optical laryngoscope
2 channels
Guiding Optical !
Built-in anti-fog system
Battery powered light source
3 AAA batteries !
Adult & pedi sizes
Accomodates 4.5-8.5 mm ETS Smaller pedi, nasal & DLT versions now available !
Optional clip-on video system or wireless monitor
AIRTRAQ OPTICAL LARYNGOSCOPE
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Abstract Background: Because algorithms for difficult airway management, including the use of new op3cal tracheal intuba3on devices, require prospec3ve evalua3on in rou3ne prac3ce, we prospec3vely assessed an algorithm for difficult airway management that included two new airway devices. Methods: A=er 6 months of instruc3on, training, and clinical tes3ng, 15 senior anesthesiologists were asked to use an established algorithm for difficult airway management in anesthe3zed and paralyzed pa3ents. Abdominal, gynecologic, and thyroid surgery pa3ents were enrolled. Emergency, obstetric, and pa3ents considered at risk of aspira3on were excluded. If tracheal intuba3on using a Macintosh laryngoscope was impossible, the Airtraq laryngoscope (VYGON, Ecouen, France) was recommended as a first step and the LMA CTrach™ (SEBAC, Pan3n, France) as a second. A gum elas3c bougie was advocated to facilitate tracheal access with the Macintosh and Airtraq laryngoscopes. If ven3la3on with a facemask was impossible, the LMA CTrach™ was to be used, followed, if necessary, by transtracheal oxygena3on. Pa3ent characteris3cs, adherence to the algorithm, efficacy, and early complica3ons were recorded. Results: Overall, 12,225 pa3ents were included during 2 yr. Intuba3on was achieved using the Macintosh laryngoscope in 98% cases. In the remainder of the cases (236), a gum elas3c bougie was used with the Macintosh laryngoscope in 207 (84%). The Airtraq laryngoscope success rate was 97% (27 of 28). The LMA CTrach™ allowed rescue ven3la3on (n = 2) and visually directed tracheal intuba3on (n = 3). In one pa3ent, ven3la3on by facemask was impossible, and the LMA CTrach™ was used successfully. Conclusions: Tracheal intuba3on can be achieved successfully in a large cohort of pa3ents with a new management algorithm incorpora3ng the use of gum elas3c bougie, Airtraq, and LMA CTrach™ devices.
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Bettina Schmitz, MD, PhD, Assistant Professor, Texas Tech University Health Science Center
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1. British Journal of Anaesthesia 100(4):544-8, 2008 Pentax-AWS, a new videolaryngoscope, is more effective
than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study. !
Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y
2. British Journal of Anaesthesia 101(5):723-30, 2008 Comparison of Macintosh, Truview, EVO2®, Glidescope®, and
Airwayscope®, laryngoscope use in patients with cervical spine immobilization. !
Malik MA, Maharaj CH, Harte BH, Laffey JG
3. Korean J Anesthesiol 59(5) 314-8, 2010 Comparison of the laryngeal view during intubation using
Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation. !
Koh JC, Lee JS, Chang CH !
4. Anaesth Intensive Care 33:243-7, 2005 A comparison of the GlideScope® with the Macintosh
laryngoscope for tracheal intubation in patients with simulated difficult airway. !
Lim Y, Yeo SW !
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¨ Flexible FOI preferred technique, particularly when CS unstable
¨ No differences in neurologic injury associated with different laryngoscopy devices.
¨ Well designed comparative research
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Charlotte V. Rosenstock, MD, PhD et al, June, 2012
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Modification of MAC
View tube has distal prism, enables improved viewing by (35o) angle of refraction
!Allows oxygen insufflation
!Slimline Sony T7 color digital camera/endoscope
!Adult & pedi sizes
!
TRUVIEW EVO2
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VIVID TRAC
Routine/DA management
Better view of glottis Higher intubation success !
Future considerations
Less traumatic/stress?
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Video laryngoscopy is here to stay
Routine airway management Difficult airway algorithms
DL vs. VL FOB vs. VL (awake vs. asleep)
Cost should decrease Robust nature !
Traditional direct laryngoscopy should continue to be taught
Not full proof Not there yet !
Future considerations
CONCLUSION
Venner AP
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The many ways to approach the difficult airway, all well substantiated by strong evidence in the medical literature, demonstrate that there is no clear cut, one-size-fits-all answer.
Perhaps more importantly, it demonstrates the complex mastery of medicine that an anesthesiologist must have to successfully practice.
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Routine/DA management
Better view of glottis Higher intubation success !
Future considerations
Less traumatic/stress? !Efficacies of different VLs & elucidate difficulty in their use !Compare w/ DL, other VLs, & other types of intubation devices !Use in difficult pediatric airways !
CONCLUSION
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OBSTETRIC POPULATION
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PEDIATRIC POPULATION
Limited number of VL available
!Limited reports in the literature
!Efficacy of VL in infants without known difficult airway
!Efficacy of VL in children with difficult airways unclear
!!
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