SPRING 2010

Video Laryngoscopy: The Wave of the Future

Jeffrey A. Brown DO
Instructor, Anesthesiology
University of Alabama at Birmingham

The ASA difficult airway algorithm states that when placed in a can’t intubate, can’t ventilate situation after two attempts at intubation via direct laryngoscopy, alternate methods for securing a patient’s airway should be sought. Direct video laryngoscopy enables the anesthesia provider a indirect view of the vocal cords often when conventional layrngoscopy has proved futile. We use the GlideScope Laryngoscope for this purpose.

In fact, I have personally used the GlideScope in multiple clinical situations with success:

• Known difficult airway
• Awake (sedated and topicalized) Direct Laryngoscopy
• Unstable cervical spine injury
• Rapid sequence with full stomach
• Esophageal varices in an obtunded patient with copious bleeding
• Floor intubations where the patient has had repeated attempts to be intubated via direct laryngoscopy
• Elective nasal intubations
• Tube exchange in ICU
• Just about anything that a fiberoptic scope is indicated for

For the casual user, I suggest using it on elective cases that are expected to be easy-practice, practice, practice. The GlideScope is not perfect; in fact, I have encountered two key problems and offer solutions for each. Difficulty is often encountered getting the endotracheal tube in the mouth and down towards the vocal cords after the blade has been place in the pharynx. One approach would be to place the endotracheal tube in first! Prior to blade insertion, I carefully place the endotracheal tube in the midline of the posterior pharynx just pass the base of the tongue, taking care not to injure the palate [1]. Depending on the situation I may have an assistant hold it in place while I insert the blade. The second common problem is advancing the endotracheal tube through the vocal cords despite adequate visualization. This is due to the acute angle of the trachea with reference to the tube. I overcome this by lubricating the stylet supplied by GlideScope with surgilube or a small amount of petroleum eye lubricant. While holding the lip of the stylet with my index finger I slide the tube over the stylet with my thumb. This may also be accomplished by having a second operator slide the endotracheal tube off. The learning curve is small and with the above techniques and practice you will be an expert in no time.

Reference

1. A maneuver to facilitate endotracheal intubation using the GlideScope. Can J Anaesth. 2008 Jan; 55(1):56-7.