Printer Friendly

Observations on the assessment and optimal use of videolaryngoscopes.

The use of videolaryngoscopy (VL) has increased with a plethora of publications. There is a predictable chronological trend in published trials: first manikin studies (1,2), then descriptive trials of first clinical applications (3-7), its use in normal airways (8,9), simulated difficult airways (10-13) and actual difficult airways (14,15), leading on to trials comparing performance of one videolaryngoscope against another or against the conventional standard Macintosh blade (16). The prolific data on the burgeoning number of devices can be bewildering to the user. The possible superiority of one VL device over another may not be evident when reviewing the literature, especially for novice videolaryngoscopists with limited experience. We have collated the experiences of several experienced videolaryngoscopists to help guide the assessment and use of these devices. This is not a formal study, therefore the conclusions and recommendations presented should be interpreted in that light.

METHODS

The PubMed database was used to identify relevant videolaryngoscopy papers from 1990 to 2010. The key words for the literature search were videolaryngoscopy and videolaryngoscope. All publications in English were used to provide a list of videolaryngoscopes. Any videolaryngoscopes not available in Australia at the beginning of 2010 were excluded (e.g. McGrath[R] Mac, Aircraft Medical, Edinburgh, UK). The seven most commonly studied types of videolaryngoscopes were selected for appraisal from the generated list. Australian manufacturers or local distributors were contacted to provide their device for trial over a period of at least four weeks. Devices were trialled in normal airways and potential difficult airways (e.g. manual inline neck stabilisation, trauma, retrognathia and patients who had undergone previous radiotherapy for laryngeal carcinoma) by the authors in a number of centres.

The first author (KBG) was responsible for summarising the feedback from the other authors as experts in videolaryngoscopy. No formal data collection to document difficulties was instituted at this initial phase and, therefore, there were no numerators or denominators for specific device problems encountered.

RESULTS

The videolaryngoscopes assessed were:

* C-Mac videolaryngoscope[TM]--Macintosh No. 2, 3 and 4 blades, Miller No. 0, 1, 3 and 'Dorges' or D-blade (Karl Storz, Tuttlingen, Germany),

* Venner AP Advance video laryngoscope[TM]-Macintosh No. 3 and 4 blade and Difficult Airway Blade (DAB)--(Venner Medical, Switzerland),

* C-Trach[TM] (The Laryngeal Mask Company Ltd, Maidenhead, UK),

* Glidescope videolaryngoscope[TM], Glidescope Cobalt videolaryngoscope[TM] and Glidescope Ranger videolaryngoscope[TM] (Verathon Medical Inc., Bothell, WA, USA),

* Pentax-AWS system[TM] ("AirwayScope") (Pentax Corp., Tokyo, Japan),

* Airtraq[TM] (Prodol, Vizcaya, Spain), and

* McGrath Series 5 laryngoscope[TM] (Aircraft Medical, Edinburgh, UK).

The results of the assessments are summarised in Table 1.

TECHNIQUE TO ACHIEVE LARYNGOSCOPY

C-Mac videolaryngoscope and Venner AP Advance video laryngoscope Macintosh 3 and 4 blades sit along the floor of the mouth and displace the submandibular tissues antero-laterally. All other VL devices are passed over the dorsum of the tongue and require little or no elevation of the submandibular tissues for successful laryngoscopy.

Failed laryngoscopy often occurred with the CTrach and Venner AP Advance videolaryngoscope--DAB in patients with severe retrognathia where the curvature of the device did not correspond to the dorsum of the tongue. The Glidescope videolaryngoscope and the McGrath Series 5 laryngoscope have a lower profile, which made it easier to manipulate in this group of patients. However, the 60-degree angulation of the Glidescope videolaryngoscope made insertion of the blade around the tongue difficult in patients with severe retrognathia, short necks, obesity and barrel-shaped chests. This problem was overcome when the upper cervical spine could be extended. The ability to detach the blade from the McGrath Series 5 laryngoscope also overcame this problem in several patients.

It was noted that the Venner AP Advance videolaryngoscope with Macintosh 3 and 4 blades was the same shape as the C-Mac videolaryngoscope with the camera in the same position on the blade. For a limited number of patients the laryngoscopy view on the screen was worse than the C-Mac videolaryngoscope. The authors postulate that the direction of the camera on the C-Mac videolaryngoscope must differ from the Venner AP Advance videolaryngoscope Macintosh 3 and 4 blades.

ADJUNCT REQUIRED FOR SUCCESSFUL TRACHEAL INTUBATION

When considering tracheal intubation, the devices were classified into those which had an inbuilt conduit for the tracheal tube and those that required either a stylet or bougie.

a) In-built conduits (Airtraq, Pentax-AWS system, C-Trach and the Venner AP Advance videolaryngoscope--Difficult Airway Blade)

This group has a 'fixed' curvature. Successful laryngoscopy and intubation occurred when the device's curvature matched a normal or nearnormal oral cavity. The effect of the in-built conduit differed between the Airtraq and the Pentax-AWS system, both within their conduits and beyond in the supraglottic region.

The Pentax-AWS system has a narrower tracheal tube conduit. The tube travels for a short distance almost in line with the blade tip before angling upwards. We found the tip of the Pentax-AWS system needed to be under the epiglottis and close to the glottis for successful intubation. A small number of failures were reported with Pentax-AWS system in patients with long necks where the tip of the blade could not reach the epiglottis. In these cases the tracheal tube tip impacted in the vallecula.

The Airtraq has a wide integrated conduit and the tip of a Magill-shaped tube initially dropped as it exits. It then moved anteriorly following the airway configuration. We found that if the Airtraq was too close to the glottis, the tube tip entered the oesophagus (Figure 1).

Two solutions were helpful in these cases. Either the device was partially removed to allow more room for the tracheal tube to curve upwards to the airway configuration or a bougie was inserted down the tube. The latter elevated the tracheal tip into the larynx. Silicone-based tracheal tubes (e.g. Fastrach) are not pre-shaped and thus failed to negotiate the up-sloping vestibule axis to reach the glottis.

The C-Trach epiglottic elevator bar pushed the epiglottis upwards. This allowed the soft tip of the Fastrach tube to pass through the glottis and along the anterior wall of the trachea.

b) Stylet/bougie required for tracheal intubation (C-Mac videolaryngoscope, Venner AP Advance videolaryngoscope--Macintosh 3 and 4 blades, Glidescope videolaryngoscope and McGrath Series 5 laryngoscope)

These videolaryngoscopes routinely required either a stylet or bougie for tracheal intubation. The devices that flattened the submandibular tissues (e.g. C-Mac videolaryngoscope and Venner AP Advance video laryngoscope--Macintosh 3 and 4 blades) favoured the use of a straight bougie with a short coude tip to manoeuvre through an upward sloping laryngeal vestibule.

[FIGURE 1 OMITTED]

The other devices in this group conformed to the dorsum of the tongue without flattening of the submandibular space (i.e. Glidescope videolaryngoscope and McGrath Series 5 laryngoscope). These devices required a J-shaped styleted tube to manoeuvre around the tongue and enter the glottis. A problem occurred when advancing a polyvinyl chloride tube off the stylet and through the glottis. The tip of the polyvinyl chloride (PVC) tubes often impacted on the anterior wall of the subglottic space.

DEVICE POSITION FOR LARYNGOSCOPY

Laryngoscopy devices are designed for insertion into the upper airway to provide a glottic image by one of two methods: either in the midline over the tongue; or along the floor of mouth with displacement of tongue and flattening of the submandibular space.

These two methods of laryngoscopy are rarely interchangeable between laryngscopes. A device that functions in the floor of the mouth displacing the tongue and compressing the submandibular tissues should not be used over the tongue nor should a device that is designed to pass over the tongue be used along the floor of the mouth. Correct positioning is critical for successful function of these devices during laryngoscopy and intubation. Frequently, operators inexperienced with devices designed for insertion over the tongue attempt to place them along the floor of the mouth. Though this may occasionally provide a view of the larynx, tracheal intubation is often difficult, as the position of the misplaced device now does not match that of the specifically shaped rigid stylet.

MANIPULATION OF THE TRACHEAL TUBE FOR INTUBATION

The ultimate goal of videolaryngoscopy is successful tracheal intubation. Videolaryngoscopes may either have an integrated tracheal tube conduit or require a stylet or bougie for tracheal intubation. The shape of these conduits and stylets should match that of the patient's airway passage. It may be difficult to replicate this shape in such cases as micrognathia or acromegaly with macroglossia (17) to the fixed curvature of a device with an in-built conduit. In these cases a bougie (18,19) or fibreoptic bronchoscope (20) may be necessary to negotiate the airway. In contrast a stylet may have the advantage of being more adjustable (21).

When using a Glidescope videolaryngoscope, the problem of advancing the PVC tube off the stylet with impaction of the tip on the anterior wall of the subglottic space (22) can be solved by the use of a Parker Flex-Tip tracheal tube or a silicone tube (such as the Fastrach tracheal tube). The Parker Flex-Tip tracheal tube has a posterior facing bevel and a curved tip that will slide over the anterior tracheal wall rather than impact on it. Similarly, a silicone tube tip is more pliable than PVC and likely to slide down the trachea. The stylet should not be removed completely from the silicone tube after the tip has passed the glottis as it will tend to buckle in the pharynx. We recommend the stylet be removed from a Fastrach tube in 1 to 2 cm increments as the tube in advanced. After ensuring 4 to 5 cm of the tube is in the trachea, the stylet is removed completely.

Duff and co-workers (23) showed that the Eschmann and Frova bougies had only success rates of 65 and 75% respectively with the Glidescope videolaryngoscope while the 60-degree curved stylet was 100% successful.

Bougies with a short coude tip may be used successfully with the Glidescope videolaryngoscope by any of five mechanisms. The blade may displace a relatively small tongue. Second, the operator uses more force to displace the tongue and submandibular tissues. Both of these techniques create a short laryngeal vestibule and make the use of a bougie more favourable. Third, a curved Magill tracheal tube with a shape similar to the oral cavity may be used as a conduit for the bougie (24) or the shape of the bougie is changed to replicate the shape of the videolaryngoscope blade. Finally, the operator may use a retromolar approach for inserting the bougie therefore bypassing the tongue as with the other group of VL. None of these manoeuvres are universally helpful. Their different roles should be carefully considered during airway training.

The shape of the McGrath Series 5 laryngoscope and the recommended shaping of the bougie and tracheal tube closely resemble those of the Glidescope videolaryngoscope13 with all the same concerns.

The C-Mac videolaryngoscope elevates the mandible and displaces the submandibular tissues antero-laterally. As a result the laryngeal vestibule is relatively short. A short coude tip bougie (25) may be required as an aid for tracheal intubation. The handling of the C-Mac videolaryngoscope during laryngoscopy and intubation is similar to that of the conventional Macintosh blade (26) and should be intuitive to most anaesthetists (27).

A recent study by Cavus (28) of the C-Mac videolaryngoscope D-blade has shown that it can improve Cormack and Lehane laryngoscopy grades from 3 or 4 to 1 or 2a. A 'semiflexible tube guide' was required as part of the intubation technique. This work demonstrated a rapid intubation rate though these results need to be repeated in different clinical scenarios.

VIDEOLARYNGOSCOPY FOR THE OCCASIONAL OPERATOR

Videolaryngoscopy is not currently part of any difficult airway algorithm (29-32). This is likely to change in the future (33); for now it is reasonable to include it as a rescue manoeuvre during difficult intubation when patient oxygenation is well maintained. Given their high success rate at tracheal intubation in failed Macintosh intubations, the videolaryngoscope may well become the alternate blade of choice over others, such as the Miller and McCoy (34-36).

The operator should gain enough exposure and training with the device they plan to use to ensure competence. The extent of this training will probably vary from device to device. Training in laryngoscopy usually starts with the Macintosh blade. This blade is inserted along the floor of the mouth and displaces the tongue and submandibular tissues laterally and anteriorly. It is therefore natural to expect an anaesthetist with only occasional exposure to difficult airways to adopt a videolaryngoscope that replicates this familiar action as this will have a shorter learning curve than some of the other devices.

The C-Mac videolaryngoscope design is based on the Macintosh blade. Several studies have shown that anaesthetists find this device easy to use with a high successful tracheal intubation rate, with or without the use of a gum elastic bougie (3,16,25,37-41). It is possible that the Venner AP Advance video laryngoscope Macintosh No. 3 and 4 blades may produce similar results but there is currently insufficient research with this device.

One common difficult airway scenario is the patient with a normal airway requiring manual in-line neck stabilisation for instability of the cervical spine following trauma or with cervical spine pathology. The occasional operator who has little experience with the Macintosh blade will find the Airtraq and the Pentax-AWS system user-friendly. Their inflexible nature, however, may make it difficult to manage a distorted airway as in severe retrognathia.

Our assessment of videolaryngoscopes fits a previously published airway concept, the Two-Curve theory (42). This theory considers the airway passage as two curves, the primary curve (or oro-pharyngeal airway) and the secondary curve (or pharyngo-glotto-tracheal airway). It also describes how these curves change in different head and neck positions. We feel that such a theory may provide insight into future assessments of these devices.

CONCLUSION

We have examined the function of commonly used videolaryngoscopes based on the technique used to achieve successful laryngoscopy and the adjunct used for tracheal intubation. Some devices follow the dorsum of the tongue while others flatten the submandibular space. The method of laryngoscopy has a direct effect on the appropriateness of the choice of device for successful tracheal intubation.

This approach to videolaryngoscopes considers the effect of airway configuration rather than relying solely on what a specific device may offer the operator. It may provide the foundation for future structured approaches that are based on airway configurations in normal and difficult airway scenarios.

A feature common to all videolaryngoscopes is that the point of view of the glottis is moved to a point within the oropharynx and aimed along the laryngeal vestibule axis to the glottis. They are classified according to both the position of the device in the airway to achieve its line of sight during laryngoscopy and the method required for tracheal intubation.

ACKNOWLEDGEMENTS

The authors would like to thank Dr Phil Allen for his assistance with the preparation of the article.

CONFLICT OF INTEREST DECLARATION

The authors have received the devices reviewed in this article free of charge for assessment from the following companies: Prodol, Vizcaya, Spain (Airtraq [TM]); Pentax Corp., Tokyo, Japan (Pentax-AWS System [TM]); the Laryngeal Mask Company Ltd, Maidenhead, UK (C-Trach [TM]); Venner Medical, Switzerland (Venner AP Advance video laryngoscope [TM]--DAB, Macintosh 3 and 4 blade); Verathon Medical Inc., Bothell, WA, USA (Glidescope videolaryngoscope [TM]); Aircraft Medical, Edinburgh, UK (McGrath Series 5 laryngoscope [TM]); Karl Storz, Tuttlingen, Germany (C-Mac videolaryngoscope [TM]).

Drs K. B. Greenland and M. J. Edwards have not received any financial incentives from any of the companies mentioned in this paper. All devices were provided free of charge to these doctors for a limited time and then returned to the company.

Dr R. Segal has conducted workshops using all the videolaryngoscopes mentioned in this paper. This equipment was provided free of charge for use in these workshops. Dr Segal has also received funding from Karl Storz to attend the 2011 European Society of Anaesthesiology meeting in Helsinki.

Dr C. Acott has received equipment from Karl Storz, LMA PacMed, Coveidin, Abbott Medical Pty. Ltd. and Cook Medical Pty. Ltd. for AusAid work in Papua New Guinea and Fiji.

Dr W. H. L. Teoh has conducted and instructed at airway workshops in the Asia-Pacific region, using the videolaryngoscopes in this paper which were provided free of charge for use in these workshops. Dr Teoh received funding from Karl Storz to attend the 2011 Airway Management Special Interest Group meeting in Coolum, Queensland.

Dr W. P. L. Bradley has not received any financial support from any manufacturers. These companies do supply videolaryngoscopes free of charge on a loan basis for his airway workshops.

REFERENCES

(1.) Malik MA, O'Donoghue C, Carney J, Maharaj CH, Harte BH, Laffey JG. Comparison of the Glidescope, the Pentax AWS, and the Truview EVO2 with the Macintosh laryngoscope in experienced anaesthetists: a manikin study. Br J Anaesth 2009; 102:128-134.

(2.) Sharma DJ, Weightman WM, Travis A. Comaprison of the Pentax Airway Scope and McGrath Videolaryngoscope with the Macintosh blade in tracheal intubation by anaesthetists unfamilar with videolaryngoscopes: a manikin study. Anaesth Intensive Care 2010; 38:39-42.

(3.) Cavus E, Kieckhaefer J, Doerges V, Moeller T, Thee C, Wagner K. The C-MAC videolaryngoscope: first experiences with a new device for videolaryngoscopy-guided intubation. Anesth Analg 2010; 110:473-477.

(4.) Suzuki A, Toyama Y, Katsumi T, Kunisawa T, Sasaki R, Hirota K et al. The Pentax-AWS rigid indirect video laryngoscope: clinical assessment of performance in 320 cases. Anaesthesia 2008; 63:641-647.

(5.) Hirabayashi Y, Seo N. Airway Scope: early clinical experience in 405 patients. J Anesth 2008; 22:81-85.

(6.) Shippey B, Ray D, McKeown D. Case series: the McGrath videolaryngoscope--an initial clinical evaluation. Can J Anesth 2007; 54:307-313.

(7.) Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anesth 2005; 52:191-198.

(8.) Teoh WH, Shah MK, Sia AT. Randomised comparison of Pentax AirwayScope and Glidescope for tracheal intubation in patients with normal airway anatomy. Anaesthesia 2009; 64:1125-1129.

(9.) Fun WL, Lim Y, Teoh WH. Comparison of the Glidescope video laryngoscope vs the intubating laryngeal mask for females with normal airways. Eur J Anaesthesiol 2007; 24:486-491.

(10.) Malik MA, Subramaniam R, Churasia S, Maharaj CH, Harte BH, Laffey JG. Tracheal intubation in patients with cervical spine immobilization: a comparison of the Airwayscope, LMA CTrach and the Macintosh laryngoscope. Br J Anaesth 2009; 102:654-661.

(11.) Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison of Macintosh, Truview EVO2, Glidescope, and Airwayscope laryngoscope use in patients with cervical spine immobilization. Br J Anaesth 2008; 101:723-730.

(12.) Maharaj CH, Higgins BD, Harte BH, Laffey JG. Evaluation of intubation using the Airtraq or Macintosh laryngoscope by anaesthetists in easy and simulated difficult laryngoscopy--a manikin study. Anaesthesia 2006; 61:469-477.

(13.) Savoldelli GL, Schiffer E, Abegg C, Baeriswvl V, Clergue F, Waeber JL. Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia 2008; 63:1358-1364.

(14.) O'Leary AM, Sandison MR, Myneni N, Cirilla DJ, Roberts KW, Deane GD. Preliminary evaluation of a novel videolaryngoscope, the McGrath series 5, in the management of difficult and challenging endotracheal intubation. J Clin Anesth 2008; 20:320-321.

(15.) Asai T, Liu EH, Matsumoto S, Hirabayashi Y, Seo N, Suzuki A et al. Use of the Pentax-AWS in 293 patients with difficult airways. Anesthesiology 2009; 110:898-904.

(16.) Teoh WH, Saxena S, Shah MK, Sia AT. Comparison of three videolaryngoscopes: Pentax Airway Scope, C-MAC, Glidescope vs the Macintosh laryngoscope for tracheal intubation. Anaesthesia 2010; 65:1126-1132.

(17.) Law-Koune JD, Liu N, Szekely B, Fischler M. Using the intubating laryngeal mask airway for ventilation and endotracheal intubation in anesthetized and unparalyzed acromegalic patients. J Neuro Anesth 2004; 16:11-13.

(18.) Takenaka I, Aoyama K, Kinoshita Y, Iwagaki T, Ishimura H, Takenaka Y et al. Combination of Airway Scope and bougie for a full-stomach patient with difficult intubation caused by unanticipated anatomical factors and cricoid pressure. J Clin Anesth 2009; 21:64-66.

(19.) Takenaka I, Aoyama K, Iwagaki T, Ishimura H, Takenaka Y, Kadoya T. Approach combining the airway scope and the bougie for minimizing movement of the cervical spine during endotracheal intubation. Anesthesiology 2009; 110:1335-1340.

(20.) Matioc AA. Use of the Airtraq[R] with a fibreoptic bronchoscope in a difficult intubation outside the operating room. Can J Anesth 2008; 55:561-562.

(21.) Savoldelli GL, Schiffer E. Videolaryngoscopy for tracheal intubation: the guide channel or steering techniques for endotracheal tube placement? Can J Anesth 2008; 55:59-60.

(22.) Dow WA, Parsons DG. "Reverse loading" to facilitate Glidescope intubation. Can J Anesth 2007; 54:161-162.

(23.) Duff E, Junaidu A, Hodzovic I. Video laryngoscope guided tracheal intubation. Comparison of tracheal tube introducer and stylet. Anaesthesia 2008; 63:898-899.

(24.) Budde AO, Pott LM. Endotracheal tube as a guide for an Eschmann gum elastic bougie to aid tracheal intubation using the McGrath or GlideScope videolaryngoscopes. J Clin Anesth 2008; 20:560.

(25.) McElwain J, Malik MA, Harte BH, Flynn NH, Laffey JG. Determination of the optimal stylet strategy for the C-MAC videolaryngoscope. Anaesthesia 2010; 65:369-378.

(26.) Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative Effectiveness of the C-MAC Video Laryngoscope versus Direct Laryngoscopy in the Setting of the Predicted Difficult Airway. Anesthesiology 2012; 116:629-636.

(27.) Butchart AG, Young P. The learning curve for videolaryngoscopy. Anaesthesia 2010; 65:1145-1146.

(28.) Cavus E, Neumann T, Doerges V, Moeller T, Scharf E, Wagner K et al. First clinical evaluation of the C-MAC D-Blade videolaryngoscope during routine and difficult intubation. Anesth Analg 2011; 112:382-385.

(29.) American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98:1269-1277.

(30.) Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-694.

(31.) Heidegger T, Gerig HJ, Henderson JJ. Strategies and algorithms for management of the difficult airway. Best Pract Res Clin Anaesthesiol 2005; 19:661-674.

(32.) Vaida SJ, Pott LM, Budde AO, Gaitini LA. Suggested algorithm for management of the unexpected difficult airway in obstetric anesthesia. J Clin Anesth 2009; 21:385-386.

(33.) Asai T. Videolaryngoscopes: do they truly have roles in difficult airways? Anesthesiology 2012; 116:515-517.

(34.) Amathieu R, Combes X, Abdi W, Housseini LE, Rezzoug A, Dinca A et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology 2011; 114:25-33.

(35.) Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology 2011; 114:34-41.

(36.) Noppens RR, Mobus S, Heid F, Schmidtmann I, Werner C, Piepho T. Evaluation of the McGrath Series 5 videolaryngoscope after failed direct laryngoscopy. Anaesthesia 2010; 65:716-720.

(37.) McElwain J, Malik MA, Harte BH, Flynn NM, Laffey JG. Comparison of the C-MAC videolaryngoscope with the Macintosh, Glidescope, and Airtraq laryngoscopes in easy and difficult laryngoscopy scenarios in manikins. Anaesthesia 2010; 65:483-489.

(38.) van Zundert A, Maassen R, Lee R, Willems R, Timmerman M, Siemonsma M et al. A Macintosh laryngoscope blade for videolaryngoscopy reduces stylet use in patients with normal airways. Anesth Analg 2009; 109:825-831.

(39.) Maassen R, Lee R, Hermans B, Marcus M, van Zundert A. A comparison of three videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesth Analg 2009; 109:1560-1565.

(40.) Meininger D, Strouhal U, Weber CF, Fogl D, Holzer L, Zacharowski K et al. Direct laryngoscopy or C-MAC video laryngoscopy? Routine tracheal intubation in patients undergoing ENT surgery. Der Anaesthesist 2010; 59:806-811.

(41.) Brown CA 3rd, Bair AE, Pallin DJ, Laurin EG, Walls RM. Improved glottic exposure with the Video Macintosh Laryngoscope in adult emergency department tracheal intubations. Ann Emerg Med 2010; 56:83-88.

(42.) Greenland KB, Edwards MJ, Hutton NJ, Challis VJ, Irwin MG, Sleigh JW. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications. Br J Anaesth 2010; 105:683-690.

K. B. GREENLAND *, R. SEGAL ([dagger]), C. ACOTT ([double dagger]), M. J. EDWARDS ([section]), W. H. L. TEOH **, W. P. L. BRADLEY ([dagger][dagger])

Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital and Department of Anaesthesia and Perioperative Medicine, The Alfred, Melbourne, Victoria, Australia; Department of Anaesthesia, Royal Adelaide Hospital, Adelaide, South Australia, Australia and Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore

* MB, BS, MD, FANZCA FHKAM, Consultant Anaesthetist, Wesley Anaesthesia and Pain Management, Wesley Medical Centre; Honorary Associate Professor, Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong SAR; and Senior Lecturer, Burns, Trauma and Critical Care Research Centre, School of Medicine, University of Queensland.

([dagger]) MB, ChB, FANZCA, NBETEeXAM, Staff Specialist, Department of Anaesthesia and Pain Management, Royal Melbourne Hospital.

[double dagger] MB, BS, FANZCA, Staff Anaesthetist, Department of Anaesthesia, Royal Adelaide Hospital.

([section]) BS, MB, BS, FANZCA, PG Dip Echo, Staff Specialist, Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital.

** MB, BS, FANZCA, Consultant Anaesthetist, Department of Women's Anaesthesia, KK Women's and Children's Hospital; Adjunct Assistant Professor, Duke-NUS Graduate Medical School; and Clinical Lecturer, Yong Loo Lin School of Medicine, National University of Singapore.

([dagger] [dagger]) MB, ChB, FANZCA, Specialist Anaesthetist, Department of Anaesthesia and Perioperative Medicine, The Alfred; and Adjunct Lecturer, Academic Board of Anaesthesia and Perioperative Medicine, Monash University.

Address for correspondence: Dr K. B. Greenland, Wesley Anaesthesia and Pain Management, Suite 17, Level 2, Wesley Medical Centre, 40 Chasely Street, Auchenflower, Qld 4066.
Table 1
Characteristics of videolaryngoscopes and recommendations for optimum
use

Airway device Technique to achieve Adjunct required
(Manufacturer, laryngoscopy for successful
City, Country) tracheal intubation *

C-Mac
videolaryngoscope[TM]
(Karl Storz,
Tuttlingen, Germany)

Macintosh No.2, 3 and Blade of device Stylet/bougie with
4 blades and V-MAC placed on floor of coude tip
Storz Berci DCI mouth; operator uses
 the device to lift
 the mandible and
 submandibular tissues

Miller No. 0, 1 Blade of device Stylet/bougie with/
 placed on floor of without coude tip
 mouth; operator uses
 the device to lift
 the mandible and
 submandibular tissues


'Dorges' or D-blade Blade of device J-shaped Stylet
 placed in midline
 over dorsum of tongue
 or on floor of mouth;
 the operator does
 not use the device to
 lift the mandible or
 submandibular tissues

Venner AP Advance
videolaryngoscope[TM]
(Venner Medical,
Switzerland)

Macintosh No. 3 and 4 Blade of device Stylet/bougie with
blade placed on floor of coude tip
 mouth; operator uses
 the device to lift
 the mandible and
 submandibular tissues

Difficult Airway Blade of device Conduit
Blade or DAB placed in midline
 over dorsum of
 tongue; the operator
 does not use the
 device to lift the
 mandible or
 submandibular tissues

C-Trach[TM] (The Device placed in Conduit
Laryngeal Mask Company midline over dorsum
Ltd, Maidenhead, UK) of tongue; the
 operator does not use
 the device to lift
 the mandible or
 submandibular
 tissues.

Glidescope Blade of device J-shaped Stylet
videolaryngoscope[TM], placed in midline
Glidescope Cobalt over dorsum of
videolaryngoscope[TM] tongue; the operator
and Glidescope Ranger does not use the
videolaryngoscope[TM] device to lift the
(Verathon Medical mandible or
Inc., Bothell, WA, submandibular
USA) tissues.

Pentax-AWS system[TM] Blade of device Conduit
("AirwayScope") placed in midline
(Pentax Corp., Tokyo, over dorsum of tongue
Japan) A with the tip lifting
 the epiglottis; the
 operator does not use
 the device to lift
 the mandible or
 submandibular
 tissues.

Airtraq[TM] (Prodol, Blade of device Conduit
Vizcaya, Spain) placed in midline
 over dorsum of
 tongue; the operator
 does not use the
 device to lift the
 mandible or
 submandibular tissues

McGrath Series 5 Blade of device J-shaped Stylet
laryngoscope[TM] placed in midline
(Aircraft Medical, over dorsum of
Edinburgh, UK) tongue; the operator
 does not use the
 device to lift the
 mandible or
 submandibular tissues

Airway device Recommended tracheal Recommendations for
(Manufacturer, tube optimum use
City, Country)

C-Mac
videolaryngoscope[TM]
(Karl Storz,
Tuttlingen, Germany)

Macintosh No.2, 3 and Magill-shaped C-Mac Macintosh, V-MAC
4 blades and V-MAC polyvinyl chloride and Miller blades are
Storz Berci DCI tube used in manner similar
 to the traditional
 laryngoscope blade
 counterparts on which
 they are modeled. They
 are placed on the
 floor of mouth and
 elevate the mandible
 and submandibular
 tissues. A standard
 bougie with small
 coude tip (or
 similarly shaped
 stylet) is appropriate
 adjuncts in many
 difficult airways
 where lift of the
 epiglottis is
 incomplete.

Miller No. 0, 1 Magill-shaped
 polyvinyl chloride
 tube

'Dorges' or D-blade Parker Flex-Tip[TM] The Magill-shaped tube
 tracheal tube is often appropriate
 but changes in its
 curvature may be
 required using a
 stylet to match the
 patient's oro-
 pharyngeal curvature.
 A Parker Flex-Tip[TM]
 tracheal tube avoids
 the problem of the
 standard bevelled tip
 which will impact on
 the anterior wall of
 the subglottic space.

Venner AP Advance
videolaryngoscope[TM]
(Venner Medical,
Switzerland)

Macintosh No. 3 and 4 Magill-shaped The AP Advance
blade polyvinyl chloride Macintosh blades
 tube should function in a
 manner similar to the
 standard Macintosh
 blade. However, more
 work needs to be
 performed before the
 authors can recommend
 further guidelines.

Difficult Airway Magill-shaped The Difficult Airway
Blade or DAB polyvinyl chloride Blade has a high
 tube profile and therefore
 is difficult to insert
 in patients with
 limited mouth opening
 or severe retrognathia
 (where the blade needs
 to be inserted
 cephalically and
 requires extra mouth
 opening).

C-Trach[TM] (The Fastrach[TM] The camera frequently
Laryngeal Mask Company tracheal tube fogs and should be
Ltd, Maidenhead, UK) warmed before
 insertion.
 Fastrach[TM] tracheal
 tubes do not have
 intubation marks to
 indicate depth of
 insertion. The
 operator should be
 aware of the
 possibility that
 endobronchial
 intubation may occur.

Glidescope Parker Flex-Tip[TM] The blade should be
videolaryngoscope[TM], tracheal tube kept in the midline
Glidescope Cobalt over the dorsum of the
videolaryngoscope[TM] tongue.
and Glidescope Ranger
videolaryngoscope[TM] A J-shaped tracheal
(Verathon Medical tube-stylet is the
Inc., Bothell, WA, best shape with the
USA) curvature starting
 approximately 9 cm
 proximal to the tube
 cuff in adults.

 The sniffing position
 is the best position
 to avoid tracheal tip
 impacting on the
 anterior subglottic
 space.

 Parker Flex-Tip[TM]
 tracheal tube with
 posterior facing bevel
 is ideal tube because
 the curved tip slides
 along the anterior
 tracheal wall without
 the frequent problems
 of impaction that
 occurs with standard
 beveled tubes.

Pentax-AWS system[TM] Magill-shaped High success rate but
("AirwayScope") polyvinyl chloride may fail in patients
(Pentax Corp., Tokyo, tube with long necks. In
Japan) A these cases the device
 tip fails to reach and
 elevate the epiglottis
 leading to failed
 intubation. Insertion
 of a bougie down the
 conduit has been
 reported to be
 successful in these
 situations.

Airtraq[TM] (Prodol, Magill-shaped Suitable for use in
Vizcaya, Spain) polyvinyl chloride many circumstances
 tube including paediatric
 patients. The device
 should be kept well
 above the glottis so
 that the Magill-shaped
 tube will curve
 upwards into it after
 it exits the in-built
 conduit. If the tube
 repeatedly enters the
 cricopharyngeus, the
 device should be
 partially withdrawn.

McGrath Series 5 Parker Flex-Tip[TM] Functions like
laryngoscope[TM] tracheal tube Glidescope
(Aircraft Medical, videolaryngoscope[TM]
Edinburgh, UK) with recommended
 J-shaped stylet and
 Parker Flex-Tip[TM]
 tracheal tube.
 Detachment of blade
 for insertion in
 patients with short
 neck and barrel chest
 may be advantageous.

Position of the videolaryngoscopy blade within upper airway to achieve
successful laryngoscopy: midline over dorsum of tongue (i.e. over
tongue largely conforming to the oropharyngealspace); floor of mouth
(i.e. along floor of mouth with lateral displacement of tongue).

Adjunct required for successful tracheal intubation:
conduit-integrated tracheal tube conduit with device's blade;
stylet/bougie with coude tip-standard straight stylet/bougie with
short coude; J-shaped stylet-stylet inside tracheal tube with distal
curve approximating blade of device with distal curvature starting
9 cm proximal to tube tip.

Note: Parker Flexi-tip tracheal tube (Parker Medical, Highlands
Ranch, CO, USA).
COPYRIGHT 2012 Australian Society of Anaesthetists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2012 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:Point of View
Author:Greenland, K.B.; Segal, R.; Acott, C.; Edwards, M.J.; Teoh, W.H.L.; Bradley, W.P.L.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:8AUST
Date:Jul 1, 2012
Words:5380
Previous Article:Anaesthesia for robotic gynaecological surgery.
Next Article:A comparison of pulse contour wave analysis and ultrasonic cardiac output monitoring in the critically ill.
Topics:

Terms of use | Privacy policy | Copyright © 2019 Farlex, Inc. | Feedback | For webmasters