Category Archives: Endoscopy

Straightforward AirTraq Intubation

A video example of performing a straightforward intubation using the AirTraq optical laryngoscope, here coupled with the WiFi-enabled camera unit to allow image capture.  Note the optimal positioning (“Rule of 3”):

  1. Epiglottis visible at the top of the screen
  2. Vocal cords central in the vertical axis
  3. Interarytenoid cleft in the lower half of the screen.

This intubation is using a reinforced (“armored”) endotracheal tube, which is sometimes more difficult than a standard ETT, as it is a little floppier.  The AirTraq makes it simple in this instance.  The reinforced ETT was used to facilitate patient positioning for a neurosurgical case.

Is fibreoptic intubation a dying art?

Over the past two weeks, I have been involved in three cases where all means of laryngoscopic intubation failed – including multiple different blades, introducers and highly skilled hands – and the airway could only be intubated with a flexible fibreoptic ‘scope.  These three cases illustrate the type of pathology that can make even video laryngoscopy (VL) difficult or impossible:

  • A morbidly obese patient in traction with a high spinal injury
  • A patient presenting with late-stage, advanced laryngeal carcinoma with both supra- and infraglottic involvement and masses
  • A child with Pierre-Robin Sequence presenting for mandibular distraction surgery.

In an article on the Airway E-Learning site, Dr Matthew Wiles details why he thinks fibreoptic intubation (FOI) is becoming a rare beast, and why we should work hard to maintain excellence in this important skill.

Despite being a huge fan and daily user of VLs, I am completely in agreement with his sentiments.

Overview of the use of fibreoptic bronchoscopy in thoracic surgery

The well-known thoracic anaesthesia guru, Prof Jay Brodsky, has written a succinct and simple overview of the use of fibreoptic bronchoscopy (FOB) in thoracic anaestheisa, which is equally applicable to the modern flexible video endoscopes.   If you are looking for a brief primer (including the appropriate use for placement of bronchial blockers and double-lumen ETTs), read the article on the Airway E-Learning site here.

Importantly, he elucidates the reasons for becoming proficient in the clinical placement and confirmation of DLTs without the use of a FOB, which is of particular relevance here in the developing world.

7 airway questions posed to 6 airway experts

Click the image to go to the article on Anesthesiology News
Click the image to go to the article on Anesthesiology News

This month’s edition of Anesthesiology News features a worthwhile piece from Prof John Doyle, in which he poses 7 questions on the current state of airway management to 6 airway experts from around the world (Abdelmalak, Cooper, Frova, Rosenblatt, Spiegel and Doyle himself), and collates their responses into a dialogue.  Definitely worth reading to determine what some (certainly not all) of the biggest names in the world are thinking on:

  • The place for DL a decade from now
  • The (under)use of bougies
  • What airway algorithm to choose
  • Tracheostomy vs cricothyroidotomy in emergencies
  • The impact of VL on the use of flexible ‘scopes
  • Favourite SGA
  • Favourite VL

You can read the article on the Anesthesiology News site by clicking here or the image above, or download the PDF version here.

For what it is worth, here are my own answers, distilled into one-liners.  I’m very willing to enter into discussions about them!

  • Place for DL in the future: Definitely; just look at the huge needs in the Third World and then ask if (even very cheap) VLs are a priority.
  • Use of bougies: Along with good positioning and mastery of face-mask skills, I think this is one of the most neglected parts of airway training.
  • What airway algorithm: The expert can do what they wish; the trainee should learn something appropriate (like ASA or DAS); the infrequent practitioner should use the Vortex.
  • Trache vs Cric:  Cric all the way; scalpel-finger-bougie
  • Impact of VL in AFOI:  Definitely reducing the use of AFOI, but a flexible scope remains an essential tool, and every airway master should be competent in it’s use.
  • Favourite SGA:  Would love to say the 3gLM, but we need to publish the research first…
  • Favourite VL:  Hasn’t been invented yet, but watch this space.  The C-MAC with Pocket Monitor is my daily workhorse, but I have (and use) GlideScope, McGrath, AirTraq, King Vision, etc.

There are a lot of excellent (and complementary) views expressed in the article, which are worth reading.  Check it out!

Rigid Intubation Scopes

Rigid endoscopes are very valuable tools for intubation in certain difficult scenarios, but are not commonly used in most centres.  The techniques and learning curve differ significantly from normal direct laryngoscopy, requiring independent practice to become proficient.  Pictured here are (left to right) a rigid bronchoscope, Bonfils, Levitan and Shikani optical stylets (rigid intubating endoscopes).

(L to R) Rigid bronchoscope, Bonfils, Levitan and Shikani optical stylets.  Click to enlarge.
(L to R) Rigid bronchoscope, Bonfils, Levitan and Shikani optical stylets. Click to enlarge.

This is the set-up for basic training on an UCT Anaesthesia Airways course.  Which of these devices have you used?  Do you have tricks or comments to share?