Category Archives: Video laryngoscopy

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!

C-MAC PM not turning on?

Folks are frequently reporting that our C-MAC Pocket Monitor is not switching on when they plug it in to a blade and want to use it, without realizing that it automatically goes into a hibernation mode if left in the open position for more than 15 minutes. Check out this quick AirwayHowTo video on solving this problem:

Paediatric Bonfils Intubation

Intubation in a young child with a severe submandibular abscess using the paediatric Bonfils rigid intubating endoscope under inhalational general anaesthesia. Direct laryngoscopy showed only severe swelling with a Cormack-Lehane grade 3b view.  A standard laryngoscope was used with the left hand to create an open path for the Bonfils just right of the midline, avoiding the worst of the submandibular swelling.  3.5mm Bonfils allowed intubation with a 4.5 mm uncuffed ETT.  Note that because this is a rigid intubating scope, it is not inserted through the vocal cords, but they are visible through the tube as it is inserted with the Bonfils held steady.

Combination of King Vision VL & AScope for Intrathoracic Goitre

@fibroanestesia comes up with some interesting ideas.  Here they use a combination of the AScope3 (a disposable flexible video endoscope) and the King Vision video laryngoscope to perform a highly controlled intubation in a patient with an intrathoracic goitre.  They have obviously pre-assessed this patient and concluded that the risk of failed intubation or positional loss of the intrathoracic airway due to compression is minimal.

Cormack-Lehane Grading Examples

Here are some real-life examples of Cormack-Lehane classification of laryngoscopic view taken with a video laryngoscope.  Although initially described for direct laryngoscopy in obstetric patients, it is a useful descriptive system in many settings, but is frequently misreported and/or misunderstood.  We will continue to expand the set as we collect good images.

Original and revised (Yentis & Lee, 1998) CL grading:

Click to access the paper in Anaesthesiology, 1998

Cormack–Lehane 1:Cormack-Lehane 1

Cormack-Lehane 2a:Cormack-Lehane 2a

Cormack-Lehane 2b:2014.01.16_08.04.59 Cormack-Lehane 2b (nearly 3)

Cormack-Lehane 3:2014.02.03_10.21.59 Cormack-Lehane 3a

Cormack-Lehane 4:2013.09.20_11.19.39_tongue CL4

See the original article by RS Cormack and J Lehane in Anaesthesia, 1994;(39):1105-1111.

Various modifications to this scheme have been proposed for use with video laryngoscopy (VL), including suggestions by Cook and Fremantle:

cry_redusaabnj

freemantly-vl-grading

 

TotalTrack for Intubation in OSA

The TotalTrack is a new video laryngeal mask that allows intubation through the device without interruption of ventilation.  Recruitment of the first independent clinical trial is well underway in Cape Town, with European studies nearing commencement.  Here is an example video taken with the device, showing intubation in a patient with severe obstructive sleep apnoea (OSA).

Bougie-assisted intubation snagging on arytenoid

This common problem is worst with small bougies, such as in this paediatric example of a child with severe burns and a difficult airway.  The bevel of the ETT allows the tip of the tube to stick out right (laterally) of the bougie and snag on the right arytenoid cartilage.  This can be remedied by withdrawing the ETT slightly (to disengage it from the arytenoid), effecting a one-quarter counter-clockwise rotation of the ETT on the bougie (bringing the bevel and tip of the ETT into a superior midline position snug with the bougie), and then advancing again.