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

Anesth Analg 2010; 110:Cover

Takaski Asai, M.D.

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

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

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

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

Traditionally shaped blades

Angulated blades

Channeled blades

CLASSIFICATION VIDEO LARYNGOSCOPES

Verathon® GlideScope® DIRECT INTUBATION TRAINER

Airway management instructors can view

intubation in real-time during direct laryngoscopy

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

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

1)2)

Their precise role in airway management remains to be established.

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.

Law JA, Hagberg CA: Anesthesiology News: Guide to Airway Management. 2008

TEACHING LARYNGOSCOPY THE OLD SCHOOL WAY

Denham Ward, MD, University of Rochester School of Medicine

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

!!!!!!!

¨ 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

!!

!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)

!!

!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)

C-MAC VIDEO LARYNGOSCOPE

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

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

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

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) !

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 !

Text

“I CAN SEE THE CORDS, BUT I CANNOT ADVANCE THE TUBE.”

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  

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

IT’S ALL ABOUT THE STYLET

Almost anyone can get the view

!The skill is advancing the

ETT & stylet

!!

Nestler C, Reske AP, Reske AW, Pethke H, Koch T: Pharyngeal Wall Injury during Videolaryngoscopy-assisted Intubation. Anesthesiology 2012

COMPLICATIONS

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

!!

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

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.

Bettina Schmitz, MD, PhD, Assistant Professor, Texas Tech University Health Science Center

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 !

¨ Flexible FOI preferred technique, particularly when CS unstable

¨ No differences in neurologic injury associated with different laryngoscopy devices.

¨ Well designed comparative research

Charlotte V. Rosenstock, MD, PhD et al, June, 2012

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

VIVID TRAC

Routine/DA management

Better view of glottis Higher intubation success !

Future considerations

Less traumatic/stress?

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

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.

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

OBSTETRIC POPULATION

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

!!

�77