Combination of Glidescope with Fiberoptic Bronchoscope for the Optimization of Difficult Endotracheal Intubation. A Case Series of Three Patients.
The unique feature of the Glidescope (GS) is a miniature video camera which allows 60o blade angulation and detailed image visualization on a monitor. These features significantly improve glottic view but occasionally endotracheal intubation remains difficult. To facilitate endotracheal intubation, the combination of Glidescope with fiberoptic bronchoscope (FOB) has been applied using the following algorithm. When Cormack-Lehane grades one or two are obtained with GS, the FOB is guided into the glottis solely under GS view as a stylet with controlled flexible tip. If grades three or four views are obtained with the GS, the FOB is advanced until glottis is displayed on a FOB monitor. We describe the successful application of this technique in three patients with suspected difficult airway. We discuss the advantages, limitations and future directions of this technique.
The recently developed Glidescope (GS) (Original model, Laerdal Medical Corporation, New York, NY) consists of a similar to Macintosh blade with a miniature high resolution wide angle video-camera attached to its inflection point. The addition of the video camera allows for a more pronounced 60o blade angulation and detailed image visualization on a video monitor, which significantly improves the view of the glottis and endotracheal intubation rate in comparison with the standard Macintosh laryngoscope (1-4). Cooper et al, (3) however, were not able to intubate the trachea in 26/722 (3.7%) patients using the GS. In the majority of these cases, failure occurred due to the inability to direct the endotracheal tube (ETT) into the trachea. In six cases, intubation failed because grade three or four Cormack-Lehane views were obtained with the GS. After failure to intubate using the GS, all 26 cases were successfully intubated using other devices including the fiberoptic bronchoscope (FOB). These failures suggest that the GS may not replace fiberoptic intubation (FOI) as the “gold standard” tool in difficult intubation. On the other hand, FOI is not free of limitations, including difficulties keeping the upper airway open, shortsighted, narrow-angle views, and complete view obstruction that may be caused by the presence of blood or heavy secretions. These disadvantages may make FOI a less desirable technique, especially in emergency situations (5). In order to limit the disadvantages of both the GS and video-FOI, we have started to use a combination of both methods in potentially difficult airways. In the following report, we describe three cases of successful airway management in patients with suspected difficult airway using the above mentioned technique.
A 49-yr-old male presented with cervical spinal cord compression, for C5-C6 corpectomy, and C4-C7 fusion with allograft and anterior plating. The patient was admitted to the hospital with osteomyelitis of the cervical spine at the C5-6 level, kyphotic deformity and myelopathic symptoms. Gardner-Wells tongs were placed for cervical spine extension for three days prior to surgery. Following discussion with the neurosurgeon of risks related to cervical spine instability, we decided not to remove Gardner-Wells tongs and to maintain neck extension during induction of anesthesia and trachea intubation. After topicalization of the oropharynx with cetacaine (benzocaine 14%, butamben 2% and tetracaine 2% combination), propofol was titrated to the loss of consciousness (50 mg) while spontaneous ventilation was maintained. Then, the first operator inserted the GS blade in the patient’s oropharynx and visualized the soft palate. No attempt was made to improve visualization in order to avoid dislocation of the cervical spine. The second operator inserted the FOB loaded with size 8.0 Parker ETT, advanced the FOB under soft palate using GS visualization, and identified the glottis on the FOB display. Next, the FOB was advanced to the patient’s trachea followed by the ETT placement during inspiration. ETT position was confirmed with the FOB. The patient was followed through the early postoperative period. No complications were identified.
A 52-yr-old female presented for emergency exploratory laparotomy. The patient was admitted with symptoms of small bowel obstruction confirmed by computer tomography. The patient had undergone gastric bypass surgery for morbid obesity one year prior to the current admission. She stated that breathing tube placement was difficult. No documentation of the previous trachea intubation was available. Past medical history was significant for asthma and obstructive sleep apnea. Physical examination revealed body mass index of 39, wide mouth opening, airway Mallampati Class: 3, large tongue, thick neck, mandible-hyoid distance = 4.5 cm. and full range of motion of the neck. Rapid sequence induction of general anesthesia was performed with propofol 200 mg, succinylcholine 100mg, and fentanyl 100 mcg. GS laryngoscopy revealed a Cormack-Lehane grade one view. FOB loaded with 7.5 size Parker ETT was advanced and positioned in the trachea under Glidescope visualization.
The endotracheal intubation was performed by a junior resident and took about 30 seconds. There was no complication of the procedure.
A 70-yr-old female patient with recurrent pleural effusion presented for pleurodesis. Her past medical history was significant for coronary artery disease, status post myocardial infarction, non-insulin dependent diabetes mellitus and hypertension. An airway examination revealed a Mallampati Class: 3, short mandible-hyoid distance (3.5 cm) and full range of motion of the neck. General anesthesia was induced with fentanyl 150 mcg, propofol, 150 mg, and rocuronium, 50mg. GS laryngoscopy revealed a Cormack-Lehane grade 2 view. A FOB, loaded with 37G Robertshaw double-lumen ETT (DLT) tube through the bronchial lumen, was inserted through the glottis and advanced into the left main stem bronchus. The ETT was successfully inserted and correct endobronchial placement was confirmed by FOB. There was no complication of the procedure.
Laryngoscope-assisted orotracheal FOB intubation has been described in anesthesia literature (6,7). The laryngoscope helps to open the oropharynx and to guide the FOB to the point where the glottis can be visualized by the FOB operator. With a conventional laryngoscope, however, it is not possible to observe the laryngoscopic and FOB views simultaneously because in order to obtain the laryngoscopic view the person performing the procedure must look directly into the patient’s mouth. The addition of a video monitor to the laryngoscope eliminated this disadvantage. Greif et al (8) successfully intubated 16 patients with a combination of Storz video-laryngoscope and Storz FOB (Karl Storz, Tuttlingen, Germany). The Storz video-laryngoscope utilizes a blade very similar to the standard Macintosh blade in combination with a video-monitor but does not have the benefits of steep blade angulation. The steep angulation of the GS significantly improves glottic visualization but occasionally makes ETT placement difficult. Several solutions have been proposed to solve this problem including the use of different types of stylets (9,10) and using a transillumination device (11) in combination with GS. In comparison to other devices, the FOB provides additional flexibility due to its controllable tip. The use of the FOB scope as a stylet in GS-assisted intubation has been reported (12). Xue et al successfully used GS -FOI combination for awake trachea intubation in 13 patients (13). Our current experience consists of more than 50 successful GS-assisted tracheal intubations all performed in anethetized patients. We developed the following algorithm using the combination of GS with FOB. When Cormack-Lehane grades one or two are obtained with GS, the FOB is guided into the glottis solely under GS view as a stylet with controlled flexible tip (Figure 1). If only grades three or four views can be obtained using the GS, the FOB is advanced until glottis is displayed on a FOB monitor using the GS for optimal positioning. The FOB then can be advanced through the glottis and ETT can be placed. In case of resistance, gentle rotation of the ETT under GS visualization can help to find an appropriate angle and avoid airway trauma.
An additional benefit of the described method is in its usefulness as an educational tool for FOB intubation. Doyle (14) used the GS view to monitor resident manipulation of the FOB scope. The resident was not allowed to use the GS view. Subsequently, feedback was given to the resident. We believe that using this combined technique can help residents develop FOI skills while allowing them the opportunity to look at the GS monitor and direct the flexible tip of bronchoscope during FOB manipulation. We believe that this procedure can improve the skills of residents.
Limitations and future directions.
In our opinion, combination of GS with FOI is an important step in the management of difficult airways and can improve the rate of successful intubation. However, this method of endotracheal intubation has to be used with caution, especially in situations where successful ventilation is not assured. Limited mouth openings (less than 18 mm) and abnormal upper airway anatomy resulting from disease or surgical intervention are other contraindications to this method. When in doubt, it is very important to maintain spontaneous ventilation or have the ability to return to spontaneous ventilation as quickly as possible. A further significant limitation of this method is the necessity to have a second operator in order to accomplish endotracheal intubation. The development of a controllable optical stylet to be manipulated by the operator’s right hand in combination with a GS-type device used by the left hand of the same operator would overcome this limitation. Combining both laryngoscopic and FOB images on the same screen would make this technique more user-friendly. Further clinical studies are necessary to evaluate this technique in difficult airway management.
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Mikhail R. Sukernik ,M.D, PhD.
Associate Professor of Anesthesiology
(Sadly, the first author Dr Mikhail Sukernik passed away 07/07/2008)
Dmitri Bezinover, M.D, PhD.
International Assistant Professor of Anesthesiology
Barbara Stahlman, MS
Clinical Research Regulatory Coordinator
Sonia J. Vaida, M.D.
Associate Professor of Anesthesiology
Director, Obstetric Anesthesia
Leonard Pott, M.D.
Associate Professor of Anesthesiology
Department of Anesthesiology
Pennsylvania State University College of Medicine
Penn State Hershey Medical Center
Hershey, Pennsylvania, USA
None of the authors has commercial or non-commercial interests that may be considered a conflict of interest in this work.
Copyright Priory Lodge Education Limited 2009
First Published January 2009