Airway Gadgets /
Fiberoptic Intubation
D. John Doyle MD PhD
Professor of Anesthesia
Cleveland Clinic
Objectives
At the end of this presentation learners
should be familiar with the following:
• Recognizing situations where intubation will be very
difficult
• The art and science of awake intubation
• Routine and specialized equipment for laryngoscopy /
intubation
Devices to Relieve Airway Obstruction
Techniques for
Difficult Intubation
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Alternative laryngoscope blades
GlideScope
Awake intubation
Blind intubation (oral, digital, nasal)
Fiberoptic intubation (awake, asleep)
Intubating stylet / tube changer
Light wand
Retrograde intubation
Surgical airway
(Modified from ASA Guidelines for Management of the Difficult Airway)
ETT Position
Confirmation
Devices
Stethoscope
Portable Capnograph
TIDAL WAVE Sp™
Handheld Capnograph/
Pulse Oximeter
Easy Cap Disposable
End-tidal CO2 Detector
Changes color from purple to yellow with expired CO2
Ambu Tubecheck - Bulb Model
Ambu Tubecheck - Syringe Model
Video
Laryngscopes
McGrath
MAC
The Venner™ A.P. Advance™ Video Laryngoscope
Koyama J, Aoyama T, Kusano Y, et al. Description and first
clinical application of AirWay Scope for tracheal intubation. J
Neurosurg Anesthesiol 2006; 18: 247– 50
Photograph of the Airway
Scope® with a tracheal tube
in place in the side channel.
A) Front view. B) Lateral
view. The device is held in
the left hand and passed
into the mouth over the
tongue, and the tip is placed
under the epiglottis. C) View
of the glottis of a 33-yr-old
female, which was obtained
during tracheal intubation
using the Air way Scope®.
The target signal shown on
the monitor is aligned with
the glottic opening. D) A
cuffed tube is passed from
its position in the channel
through the vocal cords. E)
The position of the tracheal
tube is confirmed at the
level of the cords.
Canadian Journal of Anesthesia
54:160-161 (2007)
Difference of endotracheal tube (ETT) direction comparing curved and straight
tubes. A) curved reinforced ETT. B) straight reinforced ETT which often passes
posterior to the glottis, potentially resulting in failed intubation.
Canadian Journal of Anesthesia 54:773-774 (2007)
GlideScope
Video
Laryngoscope
GlideScope
Video
Laryngoscope
Case 110
GlideScope Ranger
Photo Courtesy Dr. Richard Cooper,
Toronto General Hospital
INTUBATION DETAILS
“We found that the principal limitation in using the
Glidescope® was not in getting a good view of the
glottis, but rather in manipulating the endotracheal tube
(ETT) through the vocal cords. We also found that
successful ETT placement was usually best achieved
using a stylette formed in the shape of a "hockey stick"
(with a 90° bend) to help ensure that the ETT could be
directed sufficiently anteriorly to enter the glottis.”
D. John Doyle, MD PhD, Andrew Zura, MD and Mangalakaraipudur
Ramachandran, MD. Videolaryngoscopy in the Management of the Difficult
Airway. Canadian Journal of Anesthesia 51:95 (2004)
Sample Video
SARS and Intubation
The GlideScope may offer an advantage in SARS cases
and in other cases of respiratory infections because the
intubator does not have to get close to the patient to intubate.
USING THE GLIDESCOPE IN A
PATIENT WITH AN
UNSTABLE CERVICAL SPINE
E.M Noguera, MD, John Tetzlaff, MD, D. John Doyle, MD PhD
CASE DESCRIPTION [Case 422 Feb 13, 2004]
A 25
year-old female with a 9 year history of
Juvenile Rheumatoid Arthritis (JRA) was
scheduled for debridement of sacral and
ischial decubitus ulcers. Cervical spine xrays suggested that her spine was unstable at
C1-C2.
USING THE GLIDESCOPE WITH CERVICAL SPINE INSTABILITY
CASE DESCRIPTION
She was 164 cm tall, weighed 31 kg
and had no allergies.
Swan neck and Boutonnières
deformity
Maximum flexion of elbows 90 degrees
LIMITED FLEXION
LIMITED EXTENSION
Assessment of the airway
• 3cm mouth opening
• Thyromental distance of 5 cm
• Mallampati I oropharyngeal view
• Limited neck flexion / extension
•Intubation asleep (terrified of awake intubation)
•Immobilization of the neck with semi-rigid neck
immobilizer
•Orotracheal intubation: GlideScope with
fiberoptic bronchoscope ready.
•Induction: Lidocaine 2 mg/kg and Propofol 2
mg/kg. NO RELAXANTS.
•Extubated in the OR with neck immobilizer in
place.
The GlideScope was
particularly suitable in this
case because patients are
generally easy to intubate in
the neutral position with this
system. The alternative of
asleep fiberoptic intubation
might also have been
successful.
Awake Intubation
Awake intubation is
not necessarily
fiberoptic intubation.
Awake Intubation
Will Rosenblatt, ASA Refresher Course 218
The Secrets of Mastering
Fiberoptic Intubation
Andranik (“Andy”) Ovassapian
(1936-2010)
Dr. Ovassapian’s Most
Difficult Airway Case
Preliminaries do count!
• Know your equipment and set it up correctly
• Know your patient and the surgical plan
• Establish a plan for FOBI
– Discussion with patient
– Oxygen (nasal cannula)
– Antisialagogue
(e.g., glycopyrrolate)
– Sedation
(e.g., midazolam, dex)
– Oral vs nasal
– Awake vs asleep
1
2
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Reassurance
Explain need for awake FOBI
Don’t rush patient
Agree to stop / pause when requested
Remember to provide extra topical
anesthesia if needed
3
Pharmacologic Sedation
4
Use two suctions: one for
the Yankauer, and one for
the scope
5
Use standing stools (unless
you are an NBA star)
Correct vs. Incorrect Position
6
Use the biggest scope
available (better image,
better suction). Use a video
scope where possible.
7
Good topical anesthesia is
essential; invasive blocks
are usually not needed.
•
MADgic Laryngo-Tracheal Atomizer
• “Spray as you go”
• Epidural catheter
Wolfe Tory Medical
Transtracheal Block
Retrograde Nasal Intubation In A Case Of Subdural Haematoma With Mandible
Fracture: A Case Report. The Internet Journal of Anesthesiology™
8
http://faculty.washington.edu/pcolley/
9
Use an FOBI airway
(Williams, Ovassapian, ROTIG)
10
Try a Parker Flex-Tip ETT
11
Attend FOBI Workshops
12
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Practice FOBI on Easy Asleep Patients
Standard induction
Williams airway
Jaw thrust
Backup intubation
method readily
available
• Try in conjunction
with GlideScope
Sample Video
Awake Intubation
with the GlideScope
Awake Intubation Technique
Following sedation with midazolam, the
airway is anesthetized with gargled and
atomized 4% lidocaine; superior laryngeal
and transtracheal blocks are not usually
employed. Once a good view of the glottis
is obtained, additional lidocaine is
administered under direct vision, using a
MADgic® atomizer (Wolfe Tory Medical,
Salt Lake City, USA).
MADgic® atomizer (Wolfe Tory Medical, Salt Lake City, USA).
Advantages
There are several advantages of using the GVL for
awake intubation. First, the view is excellent. Second,
the method is less affected by secretions or blood as
compared to fiberoptic intubation. Third, everyone can
view the intubation, while this is the case only for
video bronchoscopes. Fourth, the intubation can be
recorded using a regular camcorder. Fifth, there are
no restrictions on the type of ETT that can be placed,
while this is not the case for fiberoptic methods. Sixth,
the GVL is more rugged than a bronchoscope, and is
less susceptible to damage. Seventh, the GVL is
easily cleaned. Finally, while advancing the ETT into
the trachea over a bronchoscope often fails as a result
of the ETT impinging on the arytenoids, this is not a
problem with the GVL.
GlideScopeAssisted
Fiberoptic
Intubation
GlideScope-Assisted
Fiberoptic Intubation
Case Description:
– 60 yo female with a history of “difficult
intubation” and previous fiberoptic
intubation presents for reversal of loop
ileostomy
– Awake fiberoptic intubation is attempted
orally, then nasally, without success
– Unable to visualize vocal cords
GlideScope-Assisted
Fiberoptic Intubation
• Second physician attempt at fiberoptic
intubation unsuccessful
• After administration of more sedation,
GlideScope introduced, revealing a very
anterior larynx
• Under GlideScope guidance, fiberoptic
bronchoscope redirected 90 degrees
anteriorly and through vocal folds for
successful intubation
Intubation Using the
Aintree Catheter
Fiberoptic bronchoscope (FOB) placed through
the Aintree catheter. The two are then passed
through an LMA™. The last 3 cm of the FOB are
exposed allowing its tip to be manipulated.
Step 1. Introduce a Laryngeal Mask Airway (LMA)™ in the usual manner.
Step 2. Next, a fiberoptic bronchoscope placed through an Aintree
Intubation Catheter, is introduced into the LMA™.
Step 3. The fiberoptic bronchoscope is advanced through the
LMA™, through the vocal cords, and into the trachea.
Step 4. Once visualization of the tracheal rings is confirmed, the
fiberoptic bronchoscope is removed while the Aintree catheter is
left behind.
Step 5. The LMA™ is carefully removed, taking care
not to displace the catheter.
Step 6. One can now “railroad” an endotracheal tube over the Aintree
Intubation Catheter into the patient’s trachea.
Step 7. After the catheter is removed, inflate the endotracheal tube cuff
and begin ventilation. Be sure to check for bilateral air entry and an
appropriate capnogram.
Negative Pressure Ventilation
Negative Pressure Ventilation
Negative Pressure Ventilation
Polio Macintosh Blade
(1950s)
The blade is mounted at 135 degrees to the handle. This equipment was
originally designed to facilitate intubation in patients encased within iron lung
ventilators during the polio epidemic. It is also useful in patients with barrel
chest, restricted neck mobility or breast hypertrophy. These blades are more
popularly used in conjunction with a short ‘stubby’ handle. From
http://www.frca.co.uk/article.aspx?articleid=262
Cuirass
Negative Pressure Ventilation
Negative Pressure Ventilation
A light cuirass
encircles the thorax of
the child from the
clavicles to the upper
part of the abdomen
including the
diaphragm and exerts
successively a
negative pressure
corresponding to
inspiration and a
positive pressure at a
frequency between 4
to 1000 cycles per
minute.
http://picubook.net/parts/lung/NIPPV/text9.html