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Comprehensive VL fellow Videolaryngoscope fellowship Dr Amit Shah

comprehensive understanding of videolaryngoscope
by

vins amit

on 12 November 2016

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Transcript of Comprehensive VL fellow Videolaryngoscope fellowship Dr Amit Shah

When and where to use

Basic steps for the techniques

CLASSIFICATION

2001, Canadian surgeon
John A. pacey
was first to embed a miniature video chip - CMOS and made first true video layngoscopes . Glidescope laryngoscope.
Macintosh(1943) and Miller (1941)

Direct laryngoscopy- Line of sight



Conclusion

Brief description of individual scope

The device should be
intuitive
to an operator skilled in traditional direct laryngoscopy
Our expectations
Video layrnogscope how does it helps ?

Line of sight achieving not necessary
Reduce reliance of proper positioning
No need to give force
Overcome anatomical problems
Achieve successful laryngoscopy every time
Intubation should be under vision


Laryngoscopy – its past and future
Richard M cooper can j anesth 2004

Near Miss experiences provide us with necessary incentives to improve airway management techniques ,
to reduce our chances of reliance on luck and multiple and forceful laryngoscopies

Videolaryngoscope

Video layngoscopy in obese patient


Videolaryngoscopy improves intubation condition in morbidly obese patients.



High risk of difficulty/ known difficulty/ failed DL

Preparation of VL
Technique of intubation with
Non Channeled VL


Laryngeal sighting
Delivering tube to the glottic opening
Advancing the tube beyond glottic opening into trachea

Video laryngoscopy
-
look around the curvature of tongue ,
introduce in midline
Direct laryngoscopy
Laryngoscopy displace the tongue and other structure to achieve direct line of sight
Can be used in difficult airway scenario.
Steep learning curve and longer time to intubate.
Included in German difficult airway guidelines
Bonfil- video stylet

Pentax AWS

Airtraq- optical device,
King vision

GLIDESCOPE

Boogie – rescue alright
Routine recommendation??
Laryngoscopy – its past and future Richard M cooper can j anesth 2004
Flexible Fiberoptic Bronchoscope
Most useful tool and FOI essential skill for all of us
Require special skill and equipment
May not be feasible in emergency
Secretion , bleeding can cause failure
Intubation is essentially blind technique

What we had?

ASA closed claim analysis 1999
- difficult laryngoscopy leads to airway injury

Rose DK, Cohen MM- survey of 18500 pt
If one abnormality present- 34.3% difficult
High chances of desaturation, HT, dental trauma

ASA closed claim analysis 1990 –
Even Non difficult case can result in airway injury


Poor Layngeal exposure – Cormak-Lehane III or IV occur in 1.5-8.5% patient.
crossby et cand jn anesth 1998

Most of this patient get Intubated successfully,
With multiple attempts and force & trauma

Such incidence should be considered “Near Miss”

Near-miss

Review Article:
Video laryngoscopy in paediatric anaesthesia in South Africa
Nienaber LN, South Afr J Anaesth Analg 2011


By providing a superior shared view of the larynx, these airway tools are definitely of value in the management of the difficult pediatric airway.

VL in Pediatric airway

JR Army Med Corps 154 (1): 76-78
Basaranoglu G, et Al, Istanbul,
intubation proficiency with the Airtraq can be achieved quickly and it has a shorter learning curve that fibreoptic endoscopy.

The Cormack-Lehane view was greatly improved with the GlideScope compared with direct laryngoscopy in patients wearing cervical collars. —
Aaron E. Bair, MD
Published in Journal Watch Emergency Medicine December 4, 2009


Technique of intubation with
Channeled VL

Preparation of VL remains same
Tube should be preloaded in to the channel of VL

O’leary et al J clin anesth 2008, walker l et al BJA2009

Macgrath

C-MAC /
V-MAC
storz

Initial development
Fiberoptic technology adapted in rigid laryngoscopes-
First Generation of Video Laryngoscopes
Channel for tube – do not require stylet

Tube delivery beyond the channel to the laryngeal opening may not require stylet , but may have different challenges

Advancing the tube in to trachea
Maassen R, Lee R, Hermans B, et al. 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

Video Laryngoscopes with angled tip ,
( glidescope, c mac D, Mcgrath--
do not displace the tongue,-
Direct laryngoscopy
- displace the structure , make space for line of sight and tube space to deliver it to glottic opening.

Direct laryngoscopy stylet

Glide rite stylet

Glidescope layngoscopy

Conventional layngoscopy

Angle of stylet
Wide field of view approximatley 4-6 cm
The Complexities of Tracheal Intubation With Direct Laryngoscopy and Alternative Intubation Devices .Richard M. Levitan, MD, Annal of emergenc y medicine march 2011 vol 17

Angle of vision & Field of Vision

All these devices can be attached to video display
Richard Cooper clinician’s guide to VL
Anesthesiolgist in canada can j anesth 2002,
Practise pattern in manging the difficult airway be anesthesiologist in US anesth anal 1989
Video laryngoscopes
Non channel video
larynoscopes

video stylets
channel video laryngoscopes
C MAC /
V MAC
MCGRATH
GLIDE
SCOPE
PENTAX
AWS
KING
VISION
BONFIL
LEVITAN
AIRTRAQ

OPTICAL
LARYNGOSCOPE
Evaluation of the
GlideScope
in Patients with C-Spine Immobilization
Airtraq
ln severe ankylosing spondylitis
Comparison of tracheal intubation
Airtraq vs Mc coy laryngoscope
in pt with cervical collar
Marrel J et al, Eur Jn Anesthesia  2007 Dec;24(12):1045-9. Epub 2007 Jul 4.
Anesthesiology news – guide to airway management
Davude Cattano
1.Need hand eye coordination- Variable learning curves; may take longer to intubate

1.Eye and airway need not line up
Advantages
Disadvantages
Is time to shift to Video Laryngoscopy
&
use it more frequently ????
If it is helpful in difficult intubation why not make it use routine?
Less trauma at intubation
padmaja durga IJA vol 56 issue 6 nov dec 2012
Conclusion: airtraq improves the ease fof intubation siginficantly in patient with cervical collar immobilization and manual in line stabilisation simulating the cervical spine surgery

Laryngoscopic failure and near miss events still occurs
Optical fibers in rigid rod which angled 40° at tip, provide 110° view angle.
2, 3.5. 5 mm OD size available
Has ET stabilizer and 1.2 mm working channel for oxygenation
Any light source and camera can be attached to view on screen. Light source can be powered by batter or AC.
Designed to be used for retromolar intubation in case of narrow mouth opening. Can be used in difficult airway scenario.
Learning curve is steep and time required to intubate is longer than other techniques

which one is better ?
channel vs non channel
The Video Revolution:
A New View of Laryngoscopy
William E Hurford MD
Thanks
Video Laryngoscopy as initial approach to intubation

Practice Guidelines for Management of the Difficult Airway
ASA Guideline 2013

Video-assisted Laryngoscopy.
Meta-analyses of RCTs
comparing video-assisted laryngoscopy with direct laryngoscopy
in patients with predicted or simulated difficult airways report
improved laryngeal views,
a higher frequency of successful intubations, and
a higher frequency of first attempt intubations with video-assisted laryngoscopy
(Category A1-B evidence)

Leads to difficulty, Failure
Dependent on many factors
Anatomy,
Anterior complex, posterior complex
Position of head,
Devices
Force


Failure to intubate is really rare
With multiple attempt, use of aids like bougie, manipulations etc.
you intubate most of time
But what if you are not successful next time?
Near miss
All of us have success stories
Poor laryngeal view is common
How to reduce incidence of " near miss" experiences ?
Intubation should be under vision
Classification
Video Laryngoscope
Non Channel
VL
Channel
VL
Video
Stylet
Overcome anatomical problems
Achieve successful laryngoscopy every time
Bullard laryngoscopes
Wu Scope
Upsher scope
Provide superior glottic view even in challenging situations
All require skill acquisition in normal airway
Not a successful devices management choice for difficult airway
The term video laryngoscopy defines a broad range of devices,, in which
a video camera is used in place of line-of-sight visualization to accomplish endotracheal intubation
Many other follow the principle and started using either CMOS or CCD (charged couple device) to capture and transmit the image to the screen
CMOS
CCD
( complimentry metalic oxide semiconductor)
Anti-fog
capability is must
Long lasting
rechargeable battery with AC power source
Image storage capability

Inexpensive
Large
separate view monitor
is must
VL should be lightweight, low profile, easy to maneuver
The device should be
adaptable
for different types of endotracheal intubations – adult ,pediatric, oral , nasal, pre hospital used
Channel VL
Channel VL
Non Channel VL
Non Channel VL
Non Channel VL
Optical fibers in rigid rod which angled 40° at tip, provide 110° view angle.
2, 3.5. 5 mm OD size available
Has ET stabilizer and 1.2 mm working channel for oxygenation
Fiberoptic technology, No camera
Light source of FOB can be used
Retro molar intubation- narrow mouth opening
Hard part is to view the larynx, once you have seen the larynx delivering tube is easy
Hard part is to delivering the tube to trachea, which require understanding of
Laryngeal view is always good,
CL I or II but through indirect imaging
Stylet required in 76% macgrath, 60% glidescope, 10% Cmac of cases
As C mac has less curvature -Tube can reach larynx without stylet
but require some displacement of tongue
1.Clockwise rotation
1.You need to with-draw stylet and advance the tube
Tip impingment
Because view axis and tube track are connected – altering the direction of tube delivery requires manipulating entire device
Tube track and view axis are slightly in congruent.
Standard PVC tube has curved shape ,which turns the tube upward as it immerge in the view
Epiglottis may be obstacle and tip of VL has important roll to keep epiglottis away from the centre of view
We need device which
gives consistently good laryngoscopic view
Steps of Video laryngoscopy

Manipulation is better coordinated than conventional as assistant also has a vision
Less desaturation with experience anesthetist as better 1st time success
Video Laryngoscopy as
first line of management or rescue only ????

The use of guide channel devices, however, appears easy to learn in multiple studies and may be advantageous when cervical spine mobility or mouth opening is limited
Intubation steps remain same except
Achieving best view is essential for ,Tube sliding in to vocal cord. This require maneuvering of the entire VL assembly
Most common problem
Difficulty elevating the epiglottis to visualize the laryngeal inlet
Gr IIb or III view
Change approach and directly elevate the epiglottis
Resistance to insertion beyond vocal cords -Catching on Tracheal Rings
Use of GEB helps
Twist endotracheal tube clockwise 90°
Retract endotracheal tube, twist counterclockwise and advance through vocal cords
Aim blade tip towards the left aryepiglottic fold. Advance ETT 1cm. The endotracheal tube will enter slightly in your field of vision.
Due to the leftward bevel, it is common to catch the right arytenoid or aryepiglottic fold
Then redirect King Vision back towards the interarytenoid notch and advance endotracheal tube.
The leading edge of the endotracheal tube can get caught on the tracheal rings
There may be a few cases where passing the endotracheal tube may be difficult secondary to small anatomy, swollen laryngeal structures, or abnormal anatomy. In these cases, a bougie may be beneficial.
Bougie inside ETT; ensure angled bougie tip is facing upward as it exits the ETT
A bougie has a significantly smaller outer diameter than an endotracheal tube. This allows for easier passage into challenging airways.
When the video laryngoscope is inserted too far, there is limited room to pass the tube, and it can get caught on the right arytenoid.
Tips for Avoiding the Chest During Insertion
1.If not contraindicated, elevate the head or place in a ramped position
2.Scissors the mouth open
3.Use lateral insertion technique
4.Disconnect Display from Blade
A panoramic view should be obtained by withdrawing the scope, which allows for plenty of room to pass the tube.
Too far in
Turn tip of VL towards left aryepiglottic fold
Withdraw device for panaromic view
Counter clock wise roation of ETT
View adequate ??
Rotation of ETT may help
View adequate, Rotation of ETT not helping ??
Rotation of entire laryngoscope assembly helps.
Upward movement of VL not helping to correct the view ??
edema
spontaneously breathing patient
ETT Passage is still not achieved
Curved tip
Small diameter
Trouble shooting
Varies from device to device
Channel VL - King Vision
5.Generally higher success rate, especially in difficult situations
4.Permits sharing of medical information among the team
3.Others can see and help
2.Better view when mouth opening or neck mobility is limited
5.More complicated ,Expensive, Greater processing time and expense
4.Loss of depth perception
3.Fogging and secretions may obscure view
2.Passage of tube may be difficult despite great view; stylet often necessary
Look around the curvature of tongue
Ideal device should have:
Mcgrath
Glidescope
C-Mac
Airtraq
Pentax AWS
3 axis theory and
Adnet's counter argument
Dr Keith Greenland 2 curve theory
Delivering tube to glottic opening
Non Channel VL
Understanding of angle of vision
Tube trajectory
Hand eye coordination

Blade angle
various blades against protractor and 1 cm square field
Looking stright to larynx
Require some force to elevate epiglottis
Epiglottis can block view
Looking up towards larynx
Epiglottis donot block view
Do not require force to elevate epiglottis
Tracheal intubation involves 3 distinct challenges
Angle of blade and camera position -
comparison between channel and nonchannel device
Advancing the tube in to trachea
in case of channel VL

Advancing in to trachea is easy and without impingement most of time.
Once you have central view of larynx and tube advanced beyond vocal cord
Delivering tube to glottic opening for Channel VL
Challenges:
Looking stright to larynx
Channel delivers tube towards glottis
Looking up towards larynx
Epiglottis donot block view
Do not require force to elevate epiglottis
So many devices ?
How do you understand these devices ?
Camera slightly away from glottis
Other fetures you look in Videolayrngoscope before you purchase
Portability
Dr Keith Greenland
Angle of blade
Field of vision
Camera position and angle of vision
Right aryepiglottic impingement
Right aryepiglottic impingement
Right aryepiglottic impingement
Right aryepiglottic impingement
No need to align axis-
- No force
- Proper positioning not mandatory
Look around curvature of tongue
Overcomes Primary curve and look towards secondary curve
Intubation in non channel Video laryngoscope
Delivering tube to glottic opening
Advancing beyond Vocal cord
This requires stylet
.
Tube shape needs to be changed to as per angle of blade to reach the larynx.
----
2. Further only tube advancement also has chances of tracheal ring impingment, because of angle at which it is introduced
3.Use of ILMA - Felxi tip tube
2.Reverse Loading
Chalanges:
Advancing upto larynx
Challenges:
Cost
Vision in day light . etc.
Presence of pediatric options
Resolution of monior
Monitor attached to laryngoscope or separate
Anti fog mechanism of the blade
Intubate
Introduce the ETT
Obtain the best view
Introduce the video laryngoscope inside oral cavity
Preparation of Tube, stylet
Videolaryngoscope
Stylet shape
Tube trajectory in case of non channel
Stylet shape in case of channel
Camera position and angle of vision
How to achieve good laryngoscopic view every time?
channel
Non channel
need to curve distal part ETT like blade of videolaryngoscope
One potential problem is that the tip of the endotracheal tube has to pass a sharp angle to enter the larynx, which increases the risk of contact with the anterior tracheal wall. As a result, the tube cannot be easily advanced into the trachea.
The endotracheal tube stylet should be formed so that its
curve approximates that of the convex side of the GlideScope blade
that will be used.
Common problems encountered:
Channel VL
1. Adequate view- but unable to pass ETT in to laryngeal opening.
2. Not able to get Cormac Lehane I or IIa view
3. Not able to thread ETT beyond laryngeal opening.
4. Difficulty in introducing VL in oral cavity.
5. Nasotracheal intubation - not able to see ETT, magil forcep
6. Difficulty in introducing ETT in oral cavity .
7.

Unable to pass the ETT
Most common problem-
In case of Channel VL- due to rightward position on channel , ETT passage ususally causes - Right aryepiglottic fold impingement.


Most common reason is "too far in"


Withdrawl of layrngoscopic blade under vision , and re introduction of tube again
CL IIa improves the success in such cases

if still not possible
counterclockwise roation of tube will change the trjectory towards left .

If still not possible, entire laryngoscope assembly can be rotated towards left - to direct tube towards left side may also help



Resistance to insertion beyond vocal cords -Catching on Tracheal Rings
Twist endotracheal tube clockwise 90°
The leading edge of the endotracheal tube can get caught on the tracheal rings
Use of GEB
edema
spontaneously breathing patient
ETT Passage is still not achieved
Curved tip
Small diameter
Most common problem
Retract endotracheal tube, twist counterclockwise and advance through vocal cords
Aim blade tip towards the left aryepiglottic fold. Advance ETT 1cm. The endotracheal tube will enter slightly in your field of vision.
Due to the leftward bevel, it is common to catch the right arytenoid or aryepiglottic fold
Then redirect King Vision back towards the interarytenoid notch and advance endotracheal tube.
Too far in
Rotation of entire laryngoscope assembly helps.
Right aryepiglottic impingement
Right aryepiglottic impingement
In case of Non channel VL - introduction of ETT from right side increases the chances of right aryepiglottic fold impingemnt
counterclockwise roation of tube will change the trajectory towards left
Correcting the tube Trajectory
Change approach and directly elevate the epiglottis
Difficulty elevating the epiglottis to visualize the laryngeal inlet
Gr IIb or III view
Not able to get Cormac Lehane I or IIa view
Complete insertion &
Lift the VL assmebly up
CL Gr IIb view
Tube passing posteriorly or interarytenoid impingment-
Videolaryngoscopy troubles

Difficulty in introducing VL in oral cavity.
Adequate view- but unable to pass ETT in to laryngeal opening.
To close to glottis
Most frustrating for newer users
Altering tube trajectory with VL motion
External manipulation
Altering tube trajectory with VL motion
Correcting tube trajectory
Tube passage correction
When the video laryngoscope is inserted too far, there is limited room to pass the tube, and it can get caught on the right arytenoid.
A panoramic view should be obtained by withdrawing the scope, which allows for plenty of room to pass the tube.
CL IIa improves the success in such cases
5. Difficulty in introducing VL in oral cavity.
3. Not able to thread ETT beyond laryngeal opening.
2. Not able to get Cormac Lehane I or IIa view
Correcting tube trajectory
Altering tube trajectory with VL motion
To close to glottis
External manipulation

1. Adequate view- but unable to pass ETT in to laryngeal opening.
External manipulation helps
Clockwise rotation
Reverse Loading
ILMA or Parkerflexitip tube
4. Use of Gum Elastic Bougie
THANKS
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