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* From the Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario;
Saturn Biomedical Systems,
Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; and
the Departments of Anesthesiology and Medicine, University of Washington and Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA.
Address correspondence to: Dr. Richard M. Cooper, Department of Anesthesia and Pain Management, Toronto General Hospital, 200 Elizabeth Street, 3 EN-421, Toronto, Ontario M5G 2C4, Canada. Phone: 416-340-3242; Fax: 416-340-3698; E-mail: richard.cooper{at}uhn.on.ca
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Abstract |
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Methods: Five centres, involving 133 operators and a total of 728 consecutive patients, participated in the evaluation of a new video-laryngoscope [GlideScope® (GS)]. Many operators had limited or no previous GS experience. We collected information about patient demographics and airway characteristics, Cormack-Lehane (C/L) views and the ease of intubation using the GS. Failure was defined as abandonment of the technique.
Results: Data from six patients were incomplete and were excluded. Excellent (C/L 1) or good (C/L 2) laryngeal exposure was obtained in 92% and 7% of patients respectively. In all 133 patients in whom both GS and direct laryngoscopy (DL) were performed, GS resulted in a comparable or superior view. Among the 35 patients with C/L grade 3 or 4 views by DL, the view improved to a C/L 1 view in 24 and a C/L 2 view in three patients. Intubation with the GS was successful in 96.3% of patients. The majority of the failures occurred despite a good or excellent glottic view.
Conclusions: GS laryngoscopy consistently yielded a comparable or superior glottic view compared with DL despite the limited or lack of prior experience with the device. Successful intubation was generally achieved even when DL was predicted to be moderately or considerably difficult. GS was abandoned in 3.7% of patients. This may reflect the lack of a formal protocol defining failure, limited prior experience or difficulty manipulating the endotracheal tube while viewing a monitor.
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Introduction |
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Rigid fibreoptic laryngoscopes offer the advantage of providing a non-line-of-sight view of the airway and visual control of ETT advancement. Examples include the Bullard laryngoscope (ACMI, Circon, Santa Barbara, CA, USA), the WuScope (Achi Corporation, Freemont, CA, USA) and the Upsherscope Ultra (Mercury Medical, Clearwater, FL, USA). It has been demonstrated that success of one of these devices was unrelated to traditional predictors of difficulty,4 however despite this, they are not widely used.5,6 It would appear that these useful techniques have a learning curve which results in frustration and abandonment by many prospective operators before they acquire competence.
Recently, miniature video-chips called "charge coupled devices" (CCD) have become widely available. A robust, high-resolution fog-resistant camera is small enough to be embedded into a laryngoscope blade. This allows for the transmission of a video-image to a monitor, enabling the operator to visualize an object not necessarily in the line-of-sight. The operation of this laryngoscope is sufficiently similar to conventional laryngoscopy that we anticipated easy adoption by new operators. We hypothesized that even novice users would obtain a better laryngeal view compared with DL. We compared the laryngeal views provided by the video-laryngoscope with historical data and a limited number of side-by-side comparisons. We also determined the ease and rate of successful tracheal intubation.
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Methods |
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). The view obtained is oriented anteriorly and the camera is sufficiently remote from the glottis to provide a wide visual field. Two light emitting diodes adjacent to the video-chip provide adjustable illumination. A black and white image is displayed on a dedicated lightweight 7-inch (17.8 cm) monitor (Figure 2) and can also be displayed on other devices or recorded using a standard video output port (NTSC). Following a controlled clinical evaluation by two of the authors (J. A. P. and R. M. C.) or under their direct supervision, the GS was made available to anesthesiologists at The University Health Network (consisting of Toronto General Hospital, Toronto Western Hospital and Princess Margaret Hospital, Toronto, ON, Canada), Burnaby Hospital (Burnaby, BC, Canada) and Veterans Affairs Puget Sound Health Care System (Seattle, WA, USA) for use in their clinical practice.
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Instruction was available if requested, although it was not provided in a standardized fashion. During the early stages of this evaluation an experienced user, if available, offered suggestions about the GS technique. The recommended technique was as follows: an ETT was prepared with a malleable stylet, using a 60° curvature or a Parker Flex-ItTM stylet (Parker Medical, Englewood, CO, USA); (Figure 3). The patient was positioned according to the preference of the user. Following preoxygenation, general anesthesia and neuromuscular blockade were induced if clinically appropriate; a rapid sequence technique was utilized if indicated; the GS was inserted in the midline; the uvula was identified and used as the first landmark to ensure the blade was in the midline and correctly oriented; the blade was preferentially introduced into the vallecula or posterior to the epiglottis if the latter obscured the glottis. After advancing the tip of the ETT through the vocal folds, the stylet was withdrawn. In some cases, slight rotation of the ETT was required after removing the stylet to facilitate passage into the trachea. The GS was withdrawn after visual confirmation of tracheal placement. Auscultation and capnography were performed as additional tests of appropriate tube placement.
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The user was requested to describe the intubation as "easy," "awkward" or "failed." Failure of GS intubation was not defined by protocol – the technique was regarded as a failure if it was abandoned in favour of an alternative method. In a few cases, an alternative technique was resorted to if the first GS attempt was unsuccessful. No recommendations were provided regarding the number of recommended or permitted GS attempts.
All attempted GS intubations between November 2001 and March 2003 were included. Data were excluded when the user or outcome information could not be determined from the care-provider or datasheets. Statistical analysis was performed using a statistical software program (SAS version 8.20, SAS Institute, Cary, NC, USA). Data are expressed as mean ± SD.
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Results |
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Patients
Between November 2001 and March 2003, data were collected on 728 consecutive GS laryngoscopies. Outcome data (laryngeal view or success of tracheal intubation) or user identification were unavailable in six instances and these data have not been included in the analysis. The patient demographics were as follows (mean ± SD): age 54.4 (± 15.5); body weight 70.3 (± 18.8) kg; height 168.1 (± 11.3) cm and body mass index 27.8 (± 6.2) kg•m–2. The airway characteristics are displayed in Table I. Operators provided their prediction of difficulty had DL been used for 617 (85%) patients. DL was expected or known (based on previous records) to be easy in 351 (57%) cases, slightly difficult in 166 (27%), moderately difficult in 82 (13%) and very difficult in 18 (3%).
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, GS videolaryngoscopy resulted in C/L views of grade 1 or 2 in 99% of the patients studied. More specifically, the 115 patients with Mallampati oropharyngeal class III views had C/L grade 1 or 2 glottic views in 91.3% and 8.7% of cases respectively (Table II). In the 27 patients with Mallampati class IV views, GS videolaryngoscopy resulted in a C/L grade 1, 2, 3 and 4 views in 21 (78%), three (11%), two (7.4%) and one (3.7%) patients respectively.
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compares the laryngeal view in the 133 patients in whom both DL and GS laryngoscopy were performed. Overall, DL resulted in a C/L grade 1 view in 48.9% vs 85.7% using G/S. More importantly, in the 35 patients in whom no glottic exposure was achieved by DL, a grade 1 or 2 view was obtained 77% of the time with the GS.
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Thirty morbidly obese patients (body mass index > 40 kg•m–2) underwent videolaryngoscopy. A C/L grade 1 or 2 view was obtained in all but two and an alternative intubation technique was required in one.
Intubation
Inability to perform tracheal intubation with the GS occurred in 26/ 722 patients (3.7%). Failure however was defined as abandonment of the technique, which occasionally occurred after a single attempt. In two cases, it was not possible to insert the videolaryngoscope. Fourteen of the 26 failed intubations (54%) occurred despite achieving a C/L 1 view. Generally, failures resulted from the inability to direct the ETT toward a clearly seen larynx. In six cases, a grade 3 or 4 view was obtained. All patients who could not be intubated by videolaryngoscopy were successfully intubated using a variety of devices according to the operator’s preference. These included DL, an articulated laryngoscope, lightwand, gum elastic bougie or a flexible FOB.
The laryngeal views and success rates for tracheal intubation in specific clinical settings are summarized in Table IV.
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Discussion |
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The current study describes the early experience with a new videolaryngoscope (GS) at five hospitals involving 133 operators and 722 consecutive uses. There was no formalized training and, in many cases, the operators had little or no prior experience with the GS. Patients were selected according to the preference of the operator and the availability of the device. Most operators familiar with DL found the transition to the GS relatively seamless. In fact, shortly after the device became available, the GS was often requested to manage patients expected to be difficult or very difficult to intubate.
Although specific data were not collected, the investigators had the impression that naïve laryngoscopists were very successful at visualizing the larynx and intubating the trachea. This contrasts with the learning curve for conventional (Macintosh) DL among first year anesthesiology residents. Konrad et al. observed that such trainees required a mean of 57 attempts before achieving a 90% success rate.10 Another study of novice intubators, previously exposed to extensive manikin training and attempting to intubate only patients with no suggestion of a potential difficulty, found that a 90% success rate was achieved after about ten intubations though 47 attempts were required to achieve a "good intubation" 90% of the time.11 By contrast, at one of our participating institutions (VA Puget Sound HCS) 15 intubations were performed by operators with no prior GS experience. All were successful, and all but one operator achieved a C/L 1 view. At the same centre, medical students performed four of the intubations and all were achieved on the first attempt. All four students found the GS easier to use than the Macintosh laryngoscope.
GS laryngoscopy was considered a failure when the technique was abandoned, which occasionally happened after a single attempt. Most studies of DL would not have regarded this as a failure; comparisons of our failure rate with published reports of DL failure are therefore misleading. A variety of definitions are used to define difficult laryngoscopy or failed intubation: a C/L 3 or 4 view obtained using DL has an incidence of up to 8.5%;2 two unanticipated, unsuccessful attempts at DL has an incidence of up to 0.9%;12 "failed intubation" defined by greater or equal to three or more attempts at DL has an incidence of 1.15 to 3.8%.2 A standardized intubation difficulty score13 might have provided a better reflection of the degree of difficulty encountered with the GS and the need for additional maneuvers to achieve success. It would also afford a better comparison between published DL and the current GS experience. Nonetheless, the above-mentioned study limitations are likely to be relevant to other new users.
We asked the laryngoscopists to estimate the degree of difficulty they would anticipate had DL been chosen. Most operators likely formulate a subjective assessment based upon specified objective observations. We know that "objective measurements" suffer from significant inter-observer variability,14 but we suspect most airway managers routinely make such assessments rather than employing complex predictive schemes. Both subjective assessments and complex scores are imperfect and result in unanticipated difficult laryngoscopies. In 16% of cases, the operators stated that they expected DL would be moderately or very difficult. These expectations were confirmed in all the patients in whom DL was performed (10/10). We did not determine whether DL had been performed to confirm a clinical suspicion or as the first choice, which proved to be unsuccessful. Compared with other studies,15,16 a significantly higher proportion of patients in our study had a modified Mallampati oropharyngeal view of III or IV. El Ganzouri et al. observed that 21% of such patients had C/L class 3 or 4 views while in our study, GS laryngoscopy resulted in only 2% (3/142) incidence of such views. Indeed, using the GS 88% (125/142) of these patients had a C/L grade 1 view.
While the primary purpose of laryngoscopy is to achieve tracheal intubation, in the strict sense, laryngoscopy that fails to visualize the larynx is a failed laryngoscopy whether or not intubation is successful. However, successful visualization that does not result in intubation is of limited value. Even among inexperienced users, GS laryngoscopy resulted in a higher incidence of good or excellent laryngeal views compared with DL, however, the intubation failure rate in our study was higher than most studies of DL. This may have resulted from i) insufficient familiarity with or confidence in the device; ii) lack of an agreed upon definition of failure; iii) a higher percentage of patients with difficult airways; and iv) a separate skill required to advance the tracheal tube toward and through the glottis. We attempted to collect the data resulting from each clinical use. A large number of operators had no or very limited prior experience. Since some inexperienced operators lacked confidence in the device or in their skill, they abandoned it early, rather than risk patient injury by persevering. A significant proportion of failed intubations occurred despite good or excellent glottic visualization. Indeed, 14/26 failures occurred despite a C/L grade 1 view. During the study, some operators repeatedly found intubation challenging while others experienced no such difficulty. It is possible that this results from the unfamiliar technique of manipulating the ETT while viewing the events on the monitor. It is also consistent with our observation subsequent to the study that most operators successfully acquired the skill and the problem of manipulating the ETT was virtually extinguished.
Laryngeal exposure was rarely the cause of a failed intubation, but the inability to deliver the ETT to a visualized larynx is both frustrating and largely avoidable. The GS should be inserted in the midline. It is helpful to identify the uvula and ensure that it is centered on the monitor before advancing the scope around the tongue. We recommend advancing the laryngoscope anterior to the epiglottis. Efforts to maximize glottic exposure may place the blade too close to the glottis, demanding greater precision in placing the ETT. In addition, this tends to elevate the superior glottic structures thereby increasing the angle of incidence between the advancing ETT and the axis of the larynx. We strongly recommend the use of a malleable stylet or a device like the Parker Flex-ItTM directional stylet since the ETT must be presented to the glottis, which may not be in the line of sight. The shape of the stylet can determine the success or failure of this maneuver, though many operators have successfully employed shapes other than the 60° curvature we have recommended. Insertion and advancement of the ETT may result in distortion of the malleable stylet. Placement of the ETT/stylet in the midline, beneath the phalange of the GS will minimize contact with the teeth which can distort the stylet. If the larynx is anterior to the ETT, four possible corrections can be considered: i) the curvature of the stylet can be increased; ii) external laryngeal pressure can be applied; iii) the laryngoscope blade can be slightly withdrawn which tends to reduce tilting of the laryngeal axis; or iv) very rarely, a gum elastic bougie can be introduced into the visualized trachea. If a bougie is used, the GS should be used to monitor the progress of the ETT as it is "railroaded" through the larynx. This differs significantly from intubation over a flexible fibreoptic scope wherein ETT advancement is usually not visualized.
The clinical role of the GS requires validation. This study would suggest that it could easily be incorporated into routine clinical practice. Compared with DL, GS laryngoscopy consistently affords a comparable or better glottic view, even in patients in whom DL is challenging.17 Although obtaining an excellent glottic view requires minimal practice, success with intubation may improve with prior manikin experience. Early clinical experience should be acquired in patients expected to be easily intubated by DL. The GS may prove to be particularly useful in the unanticipated difficult airway as a rescue device or when airway secretions make fibreoptic intubation difficult. The CCD camera is resistant to fogging and secretions do not appear to interfere with the glottic view. In addition, bariatric surgery, obstetrical surgery and cervical spine restrictions18 are specific settings where GS laryngoscopy may offer advantages over other techniques. Videolaryngoscopy is useful in the demonstration of airway anatomy or the direct supervision and monitoring of the progress of students19–22 though videolaryngoscopes requiring the identical technique may be better suited for teaching DL. The role of the GS in patients known to have a difficult airway appears very promising but should be determined by experienced operators under controlled settings.17,23
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Acknowledgments |
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Footnotes |
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Conflicts: J. A. P. is the developer of the GlideScope® and CEO of Saturn Biomedical Systems, its manufacturer. R. M. C. is a consultant to and investor in Saturn Biomedical Systems. R. M. C. has received travel subsidies from Saturn.
Accepted for publication August 5, 2004. Revision accepted November 8, 2004.
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E. Falco-Molmeneu, F. Ramirez-Montero, R. Carregui-Tuson, N. Santamaria-Arribas, T. Gallen-Jaime, and M. Vila-Sanchez The modified Eschmann guide to facilitate tracheal intubation using the GlideScope(R). Can J Anesth, June 1, 2006; 53(6): 633 - 634. [Full Text] [PDF]
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S. O. Bader, J. W. Heitz, and P. B. Audu Tracheal intubation with the GlidesScope(R) videolaryngoscope, using a "J" shaped endotracheal tube. Can J Anesth, June 1, 2006; 53(6): 634 - 635. [Full Text] [PDF]
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C. K. Gooden Successful first time use of the portable GlideScope(R) videolaryngoscope in a patient with severe ankylosing spondylitis Can J Anesth, August 1, 2005; 52(7): 777 - 778. [Full Text] [PDF]
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