Category Archives: Endoscopy

Endoscopy, Intubation, Video laryngoscopy

VLVids: Room for Improvement!

Video

This real-life videolaryngoscopy example (RSI of a patient with a head injury for craniectomy) shows some commom errors, and room for improvement. Three major areas that could be better to spot here:

  1. Less-than-ideal positioning of the VL blade. The tip is too deep (over the epiglottis, rather than in the vallecula), which reduces the available space to manipulate both VL and ETT, the field of vision, and the ability to perceive the approach of the ETT.
  2. Quick suctioning of the secretions/saliva/mucus would reduce the risk of losing the view or the patient aspirating.
  3. An introducer (stylet/bougie) would greatly assist passage of the ETT through the cords.

Endoscopy, Intubation, Video laryngoscopy

VLVids: Use an introducer!

Video

A classic example of good videolaryngoscopy technique being thwarted by not always using an introducer (stylet or bougie).  Note the clinician performing the intubation gets perfect, optimised VL view (Rule of 3), but then struggles to pass the ETT anteriorly enough, losing time.  Although this was no problem for the well-oxygenated patient in this case (and the intubation is still under 45 seconds duration), in a critical case it can lead to desaturation, frustration, and possible intubation trauma.

AirwayHowTo, Endoscopy, Flexible scopes, Intubation

Basic fibreoptic/flexible scope skills video

Video

Another quick training video, on the basic techniques of driving a flexible scope (fibreoptic or video) for intubation.  This was made specifically as a primer for people in our own department taking part in a training study, but hopefully it is useful to a larger audience!

Please put your comments and (hopefully constructive) critique below.   As always, you’re welcome to use with attribution!

The permanent page for this video can be found here.

AirwayHowTo, Endoscopy, Equipment, Flexible scopes, Intubation, Supraglottics

Video: Aintree intubation technique

Video

Technique for using the Aintree Intubating Catheter (AIC) to exchange between a supraglottic airway (SGA) and endotracheal tube (ETT).  This is typically required when an airway has been ‘rescued’ with an SGA that is not designed for direct intubation, with a narrow internal diameter or obstructions.  The Aintree has a length of 55cm, internal diameter of 4.8 mm (not 4.2 as stated in the video) and external diameter of 6.0 mm, allowing a paediatric fibrescope or flexible intubating vide endoscope (preferably 4 mm or less) to be passed through the AIC, into the trachea, and then an ETT railroaded after removal of the SGA over the AIC.  If that sounds confusing, watch the video!

Tips/tricks/advice/critique?  Leave a comment!

The Difficult Airway Society (DAS) have a nice poster guide to help you remember how to do this – click the image below to open/download. (Open access).

DAS AIC Guideline - Click image to download PDF directly.
DAS AIC Guideline – Click image to download PDF directly.

AIC_abbreviated_Guide_Final_for_DAS

AirwayHowTo, Endoscopy, Equipment, Intubation, Supraglottics

Video: Flexible endoscopic intubation through SGAs

Video

A description of the technique for intubating through a supraglottic airway that offers a sufficiently large internal bore to allow an appropriate-sized endotracheal tube using an adult fibreoptic or flexible video endoscope.  Take note of the method of providing ventilation during the endoscopy!

As usual, this is an unscripted video, and constructive critique is welcomed to help us improve the educational offering.

Endoscopy, Intubation, Video laryngoscopy

Straightforward AirTraq Intubation

Video

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.

Endoscopy, Intubation

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.

Endoscopy, Equipment

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.