“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”:
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
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.
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.
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.
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.
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: