laryngoscopy & complications

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Laryngoscopy and Complications

Laryngoscopy and Complications

Presenter: Dr. Suresh PradhanModerator:Prof. Dr. UC Sharma

LaryngoscopyLaryngoscopy(larynx+scopy) Laryngoscopy may be performed to Facilitate tracheal intubationduringgeneral anesthesiaorCPR or for procedures on the larynxor other parts of the uppertracheobronchial treeExamination of the larynx is carried out for both diagnostic and therapeutic indications.

is a medical procedure that is used to obtain a view of thevocal foldsand theglottis in the larynx2

DiagnosticDiagnostic indications for laryngoscopy include:stridor, either congenital or acquiredsubglottic stenosiscysts or masses causing airway obstructionvocal cord palsyforeign bodies

TherapeuticTherapeutic indications for laryngoscopy include:subglottic stenosisaspiration/injection of mucous cysts, cystic hygromaspapillomaslingual thyroidwebs

Laryngoscopy can be performed by using rigid or flexible instrumentseach of which has certain specific advantages and limitations

Rigid LaryngoscopyA rigid laryngoscopy may be done by using the indirect or direct methodIndirect laryngoscopyperformed by using specially designed laryngeal mirrors in combination with a headlightenables the larynx and the nasopharynx to be visualizedfrequently used in adults, but in children it is often difficult to carry out this procedure

Direct laryngoscopyperformed with handheld curved or straight blade instrumentsalso by using the suspension laryngoscope, which leaves both hands free to manipulate instrumentsthe curved Macintosh blade and the straight Miller blade laryngoscopes are routinely used by anesthetists to intubate patients

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Suspension laryngoscopefrequently carried out by ear, nose, and throat (ENT)surgeonsconsists of a short tubular laryngoscope that is locked to a supporting arm that rests on a base plate lying against the anterior chest wallthis arrangement leaves the surgeons hands free to use instruments

Laryngoscope with different sizes of Macintosh blades

Laryngoscope with different sizes of Miller blades

Parts of a Macintosh Blade

The tip is the distal end of the blade intended for insertion into the patient. The proximal end is the part closest to the handle.The flange projects off the side of the tongue and is connected to it by the web. The flange serves to guide instrumentation and deflect tissues from the line of vision11

Parts of a Miller Blade

decision of whether to use a Macintosh or a Millerblade is multifactorialhowever, the personal preferences and experience of the laryngoscopist is a significant consideration In general, the Macintosh is most commonlyused for adults, whereas the straight blades are typically used in pediatric patients

Preparation for Direct Laryngoscopyproper patient positioning,adequate pre-oxygenation, and the availability and proper functioning of all necessary equipment like laryngoscopes,tracheal tubes,tube stylets,an empty syringe for inflating the tracheal tube cuffa suction apparatus, and the essential equipment for mask ventilation, including an oxygen sourceA skilled assistant should be present to help with external laryngeal manipulation and stylet removal

Adequate preparation is of the utmost importance; as with any airway procedure, the first attempt should be the best attempt15

Positioning of the Patient

Figure A The head is in the neutral position. None of the three visual axes align.

Visual Axis Diagraminvolves the alignment of three anatomic axesoral, pharyngeal, and laryngeal. Positioning the patient in the sniffing position approximates this alignment. 16

Figure B Elevation of the head produces cervical flexion, which aligns the laryngeal axis (LA) and the pharyngeal axis (PA).

Cervical flexion aligns the pharyngeal and laryngeal axes17

Figure C Extension at the atlanto-occipital joint brings the visual axis of the mouth into better alignment with those of the larynx and pharynx.

maximal head extension at the atlanto-occipital joint brings the oral axis closer into alignment

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Conventional laryngoscopy with a Macintosh (curved) blade

A, The laryngoscope blade is inserted into the right side of the mouth, sweeping the tongue to the left of the flange.B, The blade is advanced toward the midline of the base of the tongue by rotating the wrist so that the laryngoscope handle becomes more vertical (arrows)C, The laryngoscope is lifted at a 45-degree angle (arrow) as the tip of the blade is placed in the vallecula. D, Continued lifting of the laryngoscope handle at a 45-degree angle results in exposure of the laryngeal aperture. The epiglottis (1), vocal cords (2), cuneiform cartilage (3), and corniculate cartilage (4) are identified.19

two methods for elevating the epiglottis,depending on whether a straight or curved blade is being used.Straight blade techniqueCurved blade technique

Intubation with a straight laryngoscope blade. The tip of the blade picks up the epiglottis.

Straight blade techniqueblade is made to scoop under the epiglottis and is lifted anteriorly. the vocal cords should be identified. If the blade is advanced too far, it will elevate the larynx as a whole rather than expose the vocal cords.

Intubation with the curved laryngoscope blade. The epiglottis is belowthe tip of the blade.

Curved blade techniqueAfter the epiglottis is visualized blade is advanced until the tip fits into the vallecula.Traction is then applied along the handle at right angles to the blade to move the base of the tongue and the epiglottis forward and upward. The glottis will come into view.A curved blade can also be used as a straight blade, lifting the epiglottis directly, if it is long enough

Flexible laryngoscopyinstruments used for flexible laryngoscopy include the ultrathin bronchoscope, the standard flexible bronchoscope, and the specially designed flexible nasopharyngoscopeultrathin bronchoscope has no suction or instrument channel and is mostly used by anaesthetists for intubation in difficult head and neck casesthe standard bronchoscope has an instrument or suction channel and can be used for therapeutic indicationsthe standard flexible bronchoscope and the nasopharyngoscope are used to evaluate laryngomalacia and vocal cord paralysis

Video LaryngoscopesDr. John Berall, a New York City internist and emergency physician designed a camera screen straight video laryngoscope in 1998The first true video laryngoscope Glidescope was produced in 1999Was commercially available from Dec 2000

The frequent failure of direct laryngoscopy to provide an adequate view for tracheal intubation led to the development of alternative devices

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KARL STORZ Video Laryngoscopes-1st 2nd 3rd 4th generation26

COMPLICATIONS

1. Dental Injurydamage to teeth, gums, or dental prostheses is the most frequentcosmetic disfigurement and discomfort,pulmonary complications if the dislodgedtooth or fragment is aspiratedprofuse bleedingupper incisors are most frequently involvedcondition of each patients teeth should be carefully assessed preoperatively to identify possible problemsa tooth protector may be used

A suture may be placed around a loose tooth to prevent it from entering the airway in the event it becomes dislodged28

Tooth Protectors

2. Cervical Spinal Cord Injuryaggressive head positioning during intubation, especially head or neck extension, has the potential to cause damage in the patient with an unstable cervical spine

3. Damage to Other Structuresreported injuries to the upper airway includeabrasionhematomalips, tongue, palate, pharynx, hypopharynx, larynx, and esophagus lacerationsOsteomyelitis of the mandible has been reportedlingual and/or hypoglossal ner ve may be injuredArytenoid subluxationAnterior temporo manidibular joint (TMJ) dislocationthere is a significant increase in the rate of airway related complications as the number of laryngoscopic attempts increases

A common occurrence is rolling the upper or lower lip between the teeth and the laryngoscope blade as the blade is insertedThe American Society of Anesthesiologists (ASA) Task Force on the Management of the Difficult Airway has recommended limiting to three attempts

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4. Shock or Burnif a laryngoscope light that is left ON contacts the patient, a burn may resulta short circuit can result in the handle and blade rapidly heating the tip of a fiberscope applied directly to the skin may produce a burn

5. Swallowing or Aspirating a Foreign BodyCases have been reported in which the bulb or other part of a laryngoscope was aspirated or swallowed

It is important to make every effort to find these foreign bodies. If they cannot be found in the oral cavity or around the patients head, x-rays of the chest and neck should be taken

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6. Laryngoscope Malfunctionmost common laryngoscope malfunction is light failurea pre-use check will detect most malfunctionsan extra handle and blade should always be immediately available/ kept ready

1. may be the result of a defective power source, lamp, or socket; incorrect assembly; or poor contact between the blade and handle4. Neglecting to observe these precautions could spell disaster, especially when a rapid sequence induction is to be performed

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7. Circulatory Changesmay result in significant increases in blood pressure and heart rate, although these changes are less than those associated with tracheal intubation

8. Disease Transmissionrisk of infection transmission, particularly Creutzfeldt-Jakob disease, via laryngoscopes, is unknown, but is a matter of concern to anesthesiaproviders use of a disposabl