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).
Demonstration of an unhurried intubation using a bougie preloaded in the reinforced endotracheal tube in an Airtraq optical laryngoscope with Airtraq Cam video adapter. You can note ideal positioning of the Airtraq (“Rule of 3”) and the steering ability of a coude-tipped bougie.
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:
- 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.
- Quick suctioning of the secretions/saliva/mucus would reduce the risk of losing the view or the patient aspirating.
- An introducer (stylet/bougie) would greatly assist passage of the ETT through the cords.
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.
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.