difficult laryngoscopy

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I built this presentation using an outline of pre-existing and out-dated material (provided by Carin Hagberg, MD). I conducted both guided and independent literature research and contributed original content (approved by Dr. Hagberg) in addition to designing and creating the slides/media/graphics that compose this lecture in its entirety, as represented here. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.


  • 1.DIFFICULT LARYNGOSCOPY ROLE OF THE VIDEO LARYNGOSCOPECarin A. Hagberg, MD Joseph C. Gabel Professor The University of Texas Medical School at Houston Medical Memorial Hermann HospitalHouston,TX, USA

2. Ane sth A nalg 2010; 110:Cove r 3. Takaski Asai, M.D. 4. UNANTICIPATED DIFFICULT AIRWAY SOCIETIES RECOMMENDATIONS ASA3 intubation attempts, spontaneous ventilation, face mask, alternative approaches (beroptic intubation), awaken patientCanadaOptimize laryngoscopy, alternatives (light stylet, beroptics), awaken patientFrance2 intubation attempts, LMA, beroptics / special blades (2 further attempts), awaken patientUK (DAS)4 intubation attempts, ILMA or LMA, revert to face mask ventilation, awaken patientItalyHelp, 2 intubation attempts, (awaken patient), alternative devices, 2 further(SIAARTI)Germany (DGAI)attempts, LMA / EDIntubation with alternatives, LMA/ILMA, spontaneous ventilation, beroptics, awaken patientHeidegger T, Gerig HJ, Henderson JJ. Best Pract Res Clin Anaesthesiol 2005;19:661-74I 5. Anesthesiology 2013 118:251-70c). 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 beroptic guidance), beroptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation. 6. SUGGESTED CONTENTS SUGGESTED CONTENTS OF THE PORTABLE STORAGE UNIT PORTABLE STORAGE UNIT FOR MANAGEMENT DIFFICULT AIRWAYDIFFICULT AIRWAY MANAGEMENT1. 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. 7. VIDEO LARYNGOSCOPES VS RELATED DEVICES Location Angles, DeviceSize AdultMonitorBatteryCan be usedDefogMonitoType ofSingleof-UseforgerChanner Size,MonitorBladeConventionalRequirl TubeDLedGuideinDegrees(regular Airtraqand small) Naso-95ComingYes (singlesoonuse)N/AUnattachedYesNoNoYes7UnattachedNoYesYesNo7UnattachedNoYesNoNo3.5UnattachedYesPossible, butNoNoNoNoNoYestracheal, Berci -Kaplan DCI C-MACGlideScopedoubleMac 3 & 4 Dorges; all Miller sizes Mac 2,3,4 & D-Blade single Small, midsize,60 80DCI60 80LCD50 60LCDlarge McGrath Pentax Airway ScopeChild, adult35 45LCDSingle size90LCDadult42LCDNeonatal Weiss Angulated Video-(rechargeable) Yes (rechargeable) Yes (Ranger; rechargeable Yes (AA)1.7Attached(Cobalt)notrecommendeYesnotd Possible, but recommendedSmall & TruView EVO2YesYes (AA) Yes (rechargeable)2.4YesNoNoNoYesNoAttached; 5can beOptiona lused withPediatric Single sizeAttachedNoeyepiece 70N/ANoN/AUnattachedYesIntubation C at ta n o D, H a g b er g C A , Vi de o L a r yn gos c opy in Ob e s e P atie nts . A ne s the s iolog y News : Guide to Air way Mana gem ent . 2010; 43-8.No 8. CLASSIFICATION VIDEO LARYNGOSCOPESTraditionally shaped blades Angulated blades Channeled blades 9. Airway management instructors can view intubation in real-time during direct laryngoscopyVerathon GlideScope DIRECT INTUBATION TRAINER 10. VIDEO LARYNGOSCOPYLITERATURE DEVICEARTICLESGlidescopeAirtraqPentax AWSMcGrathBerci-Kaplan DCIC-MAC, D-MACTruView EVO2 29617813036292718 11. LITERATUREREVIEW DEMONSTRATESUNABLETO DEMONSTRATEImproved laryngeal viewsDifference in time to intubationHigher successful intubation Difference in stress Higher frequency of first attempt intubationsAirway (obstruction/ sore throat), trauma lip/gum, dental Difference in degree of cervical spine deviation 12. 1) 2) 13. Their precise role in airway management remains to be established. 14. Clinically,themostrecenttechnologicinnova3onthathaschangedmy prac3cehasbeenthevideolaryngoscopy.Pa3entsthatwereawake berop3cintuba3onscanbedonea=erinduc3onofgeneralanesthesia withthisdevice. 15. Law JA, Hagberg CA: Anesthesiology News: Guide to Airway Management. 2008 16. TEACHING LARYNGOSCOPY THE OLD SCHOOL WAY Denham Ward, MD, University of Rochester School of Medicine 17. DCI VIDEOLARYNGOSCOPESYSTEM Modified standard laryngoscope blades w/ incorporated video system Mac 3&4Miller (all sizes)Doerges !Ability of direct visualization Requires antifog solution Interchangeable w/ FOB, Bonfils Portable Medipack 18. ! ! ! ! ! ! ! Randomized prospective evaluation 200 pts; Berci-Kaplan VL vs DL 18 yr with mouth opening 2 cm, modied Mallampati III/IV, h/o DI (3)2 experienced anesthesiologists 13 yr experience; 3 yr DASupine with head on 7 cm headrest 19. !!!! !!Video vs DirectResults Better visualization Better success rate Shorter laryngoscopy Fewer optimizing maneuvers 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) 20. !!!! !!Video vs DirectSubanalysis III/IV Better success rate Shorter laryngoscopy Fewer optimizing maneuvers 98% vs 78% 53 s vs 105 s 0.8 vs 2.2 (ELM>bougie>positioning) 21. C-MAC VIDEO LARYNGOSCOPE 22. MCGRATH VIDEO LARYNGOSCOPEFully portable video laryngoscope Single-use blade Adjustable3 Sizes !On-board mini-color camera Flat screen monitor mounted on handle Single rechargeable AA battery 23. 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 liftingAwake McGrath may be better than AFOI in certain pts 24. GLIDESCOPE INTUBATION SYSTEMBlade angled upward 60 High-resolution camera LCD light source B&WColor !Embedded antifogging mechanism Adult & pedi sizes ChildNeonate !Portable, easy maintenance 25. GLIDESCOPE COBALTSingle-use GVL Stat blade 60 angulation !Reusable video baton!High-resolution cameraAnti-fogging lens Non-glare color monitor Available in 2 sizes!Large (pts >88 lbs)Small (pts