Tag Archives: VL

Dual endoscopy demo

Here’s a brief clinical example of dual endoscopy using the CMAC VL and VS (video stylet).  This case was performed for teaching purposes, rather than a difficult airway.  Note the endoscopic view appearing as a picture-in-picture is from the editing; the images are on two separate displays.  (It starts a little late due to the author forgetting to press the record button on the device).

 

Dual endoscopy

“Dual endoscopy” refers to using two devices – usually a video laryngoscope and a rigid or flexible endoscope – to manage an airway.  The Bonfils (or Shikani or Levitan) optical stylet is often used in this context.  Performing dual endoscopy provides “three levels of protection”:

  1. If the glottic opening is easily seen with the laryngoscope, the rigid endoscope simply acts as an ideally shaped or steerable stylet to introduce the tube
  2. If the view is poor (CL grade 3 or 4), the laryngoscope can be used to guide the tip of the ETT and endoscope “into the ballpark”, and then the final positioning of the tip of the tube through the vocal cords is achieved with the endoscope.
  3. If the airway is badly soiled or swollen (eg. ongoing bleeding or angioedema), the endoscope can be used as a lightwand for a transillumination technique.  (Remember lightwands, anyone?)

Here’s a brief informal video explaining the first two points, using the CMAC VL/VS:

Another dual endoscopy approach is “VAFI” (video-assisted flexible/fibreoptic intubation), where a VL is used to help place a flexible endoscope, whereafter the rest of the intubation is continued using the flexible.  Several good case reports of this technique are described in the literature.

Here’s a brief clinical example of dual endoscopy using the CMAC VL and VS (video stylet).  This case was performed for teaching purposes, rather than a difficult airway.  Note the endoscopic view appearing as a picture-in-picture is from the editing; the images are on two separate displays.  (It starts a little late due to the author forgetting to press the record button on the device).

 

AirwayHowTo: Clean a CMAC VL

If you work in an environment without constant access to staff to clean and process your video laryngoscopes, you need to know how to do it yourself. This quick video demonstrates pragmatic cleaning of the C-MAC VL (original and latest version) for low-risk patients. Where there is high infection risk, heavy soiling or blood on the blades, high level disinfection may be indicated.

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.

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!