- multiple types of video-assisted laryngoscope devices are available
Four step procedure (Mouth – Screen – Mouth – Screen):
- Mouth — look in the mouth as you insert the video laryngoscope (to avoid oropharyngeal trauma)
- Screen — look at the screen to visualise the epiglottis followed by the glottis itself
- Mouth — look in the mouth as you insert the endotracheal tube into the mouth (to avoid oropharyngeal trauma)
- Screen — look at the screen as you pass the tube through the larynx
FOUR KEY TECHNICAL SKILLS
From Levitan: Four Secrets to Video Laryngoscopy
Epiglottoscopy and suctioning
- use video laryngoscope to protract floor of mouth and mandible forward (minimal force) and use Yankauer to suction as you go to avoid putting the video laryngoscope tip in a pool of secretions
- use the Yankauer to drain the fluids and the retractor to lift the epiglottis off the posterior pharyngeal wall (overcome “epiglottis camouflage”)
Lifting to expand the viewing area
- additional jaw distraction and epiglottis control is done with significantly greater force (keep the face plane parallel to the ceiling)
- this opens the hypopharynx, maximizing laryngeal exposure and increases the space for tube delivery.
Tilting the optics toward the ET tube
- if the imaging lens of a hyperangulated device is tilted too close to the target there is no space for tube delivery and no viewing of the tube
- the imaging lens of hyperangulated devices look up toward the larynx, but the trachea follows the cervical and thoracic spine, diving posteriorly; by tilting the imaging toward the ET tube, this angle difference is lessened, making it easier to drive the tip of the tube into the larynx.
Two-stage tube delivery
- advance the tube slowly, until the tip comes into view
- then adjust your insertion angle and direction as needed to get to the second stage of tube delivery (i.e. insertion into the larynx)
- direct-video laryngoscopes like the C-Mac, McGrath Mac, or Glidescope Direct Trainer have tube delivery similar to direct laryngoscopy (straight-to-cuff 35 degree stylet shape, or even no stylet if you prefer)
- if using a hyperangulated stylet then use “STOP, POP and DROP” method — stop stylet insertion after the tip is through the cords — pop the stylet out of the tube, and then — drop the now partially non-styletted tube into the trachea
- Another option is to rotate the hyperangulated stylet to the right 90 degrees (clockwise). Instead of the tip pointing upwards, the tip of the rotated tube now is better aligned with the tracheal axis and can be further advanced before the stylet is withdrawn.
From Levitan: Video + Direct Laryngoscopy
- the original DL/VL device
- standard metal blade has a German Macintosh shape: relatively low proximal flange height, the full flange from base to tip, and a short light-to-tip distance
- also had hyperangulated Dorges (D) Blade (which has more of a Glidescope blade shape)
- video and light source comes through a removal cartridge that slides in and out of the blade handle.
- blade requires cold sterilization and there as of yet no single-use covers, although they too are in the works.
- very bright light and a somewhat closer view of the larynx than the Glidescope Direct Trainer.
- plugs into a separate monitor – also a more portable self-contained small monitor that is part of the camera/light cartridge favailable
C-MAC demonstration (by industry reps)
From Levitan: Four Secrets to Video Laryngoscopy
- Ideal positioning of the larynx using the Glidescope: — larynx kept midline and in the upper part of the monitor, which leaves the lower half of the monitor for visualizing tube delivery. — This positioning of the target lessens the angulation between the video laryngoscope blade and the tracheal axis, which is beneficial for tube insertion into the trachea.
KING VISION(advertising) — only $1100 (see Minh’s review on EMCrit)
References and Links
Journal articles and textbooks
- Chemsian R V, Bhananker S, Ramaiah R. Videolaryngoscopy. Int J Crit Illn Inj Sci [serial online] 2014 [cited 2014 Apr 19];4:35-41.
- Cheyne DR, Doyle P. Advances in laryngoscopy: rigid indirect laryngoscopy. F1000 Med Rep. 2010 Aug 19;2:61. PMC2990653.
- Griesdale DE, Liu D, McKinney J, Choi PT. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth. 2012 Jan;59(1):41-52. PMC3246588.
- Hurford WE. The video revolution: a new view of laryngoscopy. Respir Care. 2010 Aug;55(8):1036-45. PMID: 20667151. [Free fulltext]
- Levitan RM, Heitz JW, Sweeney M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med. 2011 Mar;57(3):240-7. PMID: 20674088.
FOAM and web resources
- EMCrit Podcast 70 – Airway Management with Rich Levitan (2012)
- EMCrit — Brief Review of the King Vision Video Laryngoscope (2011)
- EP Monthly — Levitan: Video + Direct Laryngoscopy (2011)
- EP Monthly — Levitan: Demystifying Pediatric Laryngoscopy (2011)
- EP Monthly — Levitan: Four Secrets to Video Laryngoscopy (2012)
- PHARM — Search for the Sub $100 videolaryngoscope (2012)
- Resus Room — Passing the Tube in Video Laryngoscopy (2012)
- Resus.ME — Video laryngoscope successes and failures (2011)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.