Category Archives: Endoscopy

Endoscopy, Equipment, Rigid scopes, Video laryngoscopy

VLVids: Dual endoscopy intubation with compressive thyroid mass

Here’s a great example of using a dual endoscopy technique not only to manage a potentially difficult airway, but also to give more insight into the pathology itself. This short video shows the intubation of a patient who presented for thyroid surgery with a large mass compressing the trachea, as well as some other predictors of difficult intubation: slightly limited mouth opening, a short neck, and potentially challenging dentition. We wanted to see the position and degree of tracheal compression present before advancing the tracheal tube, but also to place the modified tube with nerve monitoring sensor precisely at the right depth.

Video laryngoscopy with a Mackintosh-style blade provided good access to the airway, and allowed us to spray the vocal cords and trachea with local anaesthetic, avoiding neuromuscular blockers. We could then place the tip of the tube through the vocal cords and observe the trachea and subglottic space using the Bonfils optical stylet. Both images are displayed side-by-side to coordinate view. It’s a good tip to put the device in your left hand on the left side of the screen (and corresponding right-handed device on the right) to promote good orientation.

If you’ve tired dual endoscopy for a clinical case, pop a description or brief story in the comments!

, , , , , , , , , fficult airway
Endoscopy, Equipment, Intubation, Rigid scopes, Video laryngoscopy

Split-screen dual endoscopy

Some new devices/monitors such as the Glidescope Core or Storz CMAC 8404 now allow viewing two video feeds on one display, either as a “picture-in-picture” or side-by-side display. Here is a demo of split-screen dual endoscopy with Macintosh-blade VL and optical stylet:

Dual endoscopy using split screen. It would have been good to have warmed the optical stylet (right) to prevent fogging of the lens. Orienting the VL on the left and stylet on the right improves coordination between left and right hands holding the devices.

For more discussion on dual endoscopy, see the original post from 2018 here on OpenAirway which is being updated over time.

Endoscopy, Rigid scopes, Video laryngoscopy

Dual endoscopy demo

Video

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, Endoscopy, Rigid scopes, Video laryngoscopy

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).

 

Some of the newest devices (eg. CMAC 8404; Glidescope Core monitors) allow both images to be displayed on the screen simultaneously, either as a “picture in picture” view, or side by side. If using the latter, orientating the images so that the VL is on the left and endoscope on the right is convenient, as this matches the two hands being used. Here’s an example, again in a patient with an easy airway, but simulating CL3 view:

Dual endoscopy using CMAC3 and Bonfils. It would have been good to have warmed the Bonfils before starting, to prevent the fogging of the distal lens.
AirwayHowTo, Endoscopy

Airway topicalisation: How to make the GSH mix

There are many ways to adequately topicalise an airway, which depend on personal and institutional experience, and the available drugs in different parts of the world.   This is a step-by-step set of instructions on how to make the “GSH Mix” in use at Groote Schuur Hospital, Cape Town, South Africa.  Note that we don’t have access to certain ingredients which are commonly available elsewhere (such as viscous lignocaine or Moffett’s solution).

End product:  4 % (or 5%) lignocaine with 20 mcg/ml adrenaline.

You’ll need:

  • Three 10 ml syringes
  • Needles to draw up drugs
  • Syringe labels and marker pen
  • 5 ml 10% lignocaine (‘Remicard 10% in SA)
  • 1 mg/1 ml adrenaline (1:1000)
  • Two 10 ml normal saline ampoules to dilute
  • Nebuliser mask

Label the syringes clearly:  100 mcg/ml adrenaline (1:10 000) and 4 % lignocaine with 20 mcg/ml adrenaline:

Draw the adrenaline (1 mg/1 ml) into the adrenaline syringe, and dilute with saline to 10 ml (100 mcg/ml, or 1:10 000 solution):
Transfer 2 ml (200 mcg) of the dilute adrenaline into the mix syringe: Add 4 ml of the 10 % lignocaine solution to the mix syringe (use all 5 ml if you want to make a 5 % solution rather than the usual 4 %): Add saline to the mix syringe to a total volume of 10 ml.  You now have 4 % (or 5 %) lignocaine with 20 mcg/ml adrenaline: Put 5 ml of the mix into the nebuliser mask, ready to commence topicalisation by neb: Split the remaining 5 ml mixture into two 10 ml syringes (using your third syringe) to be used for spray-as-you-go through the scope if needed:
Put the rest of the adrenaline solution somewhere safe (or discard it), and draw back the plungers on the mix syringes all the way.  This introduces air which then blows the local mix through the scope when you do spray-as-you-go.  Don’t forget to give the neb plenty of time to work (15-20 minutes, until complete). Don’t forget to use adjuvant strategies to improve your topicalisation, such as gargling, atomised spray, or topical gel/paste, and enter your cases into a registry such as TheAirwayApp so that we can build worldwide experience with different techniques!

Endoscopy, Equipment, Simulation

Nairobi Airway Course 2017: Photos

Some photos of the action at the Nairobi Surgical Skills Centre this week. Many thanks to the local faculty from the University of Nairobi and other institutions, the companies that supported use of the facilities and equipment, and the enthusiastic delegates!



Resources and notes from the course are available on the course page here. 

Endoscopy, Intubation, Video laryngoscopy

VLVids: Intubation in Spinal Immobilisation

Video

Clinical video demonstrating a collection of techniques to facilitate elective intubation for a patient with an unstable cervical spinal injury in caliper traction.  Note the sideways introduction of the VL blade due to limited space for the VL handle, optimisation of the view (‘Rule of 3’), use of a coude-tipped bougie (introducer), and the 3-part technique to advance the endotracheal tube when it catches on the arytenoid cartilage (pull tube back to disengage, rotate 90 degrees counterclockwise, advance tube).