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Correspondence |
University of Rochester, Rochester, USA., E-mail: Mirsad_Dupanovic{at}URMC.Rochester.edu
To the Editor:
Obtaining a view of the glottis using the GlideScope® videolaryngoscope (GSVL) is easier than delivery of the endotracheal tube (ETT) to the glottis and its subsequent placement into the trachea.1–4 Various malleable stylet configurations have been described to facilitate ETT insertion.1–3,5 A recently published letter describes insertion of a gum elastic bougie using the GSVL with subsequent guiding of the ETT into the trachea.4 We would like to describe an alternative stylet configuration, the technique of ETT insertion, and an alternative use of a tube introducer that we have successfully employed while intubating with the GSVL.
We use a styleted ETT bent to a 90° angle in the sagittal plane at the proximal cuff, a "straight to the cuff" configuration. The proximal end of the stylet is bent 90° to the right to form a "handle" (Figure A
). The GSVL blade is inserted per manufacturer’s guidelines.5 Once a satisfactory view of the glottis is obtained, while holding "the stylet handle" like an automobile gear shift lever, the tip of the ETT is inserted via the right corner of the mouth past the right side of the GSVL blade. If necessary, the GSVL blade can be displaced slightly to the left in order to provide more space for the ETT. Once the ETT tip is in front of the GSVL camera, while observing the screen, the intubator maneuvers the handle and drives the ETT tip passed the arytenoids and then toward the glottis in order to align the axis of the ETT tip and the laryngeal axis. Once these axes are aligned, the right thumb pushes the ETT off the stylet, through the glottis, and into the trachea (Figure B). This maneuver allows the tip of the ETT to have enough flexibility to be advanced into the trachea at a minimal angle of incidence (Figure C). Slight clockwise rotation of the ETT-stylet assembly often makes this maneuver smoother. Misalignment of the ETT tip and its impaction on the anterior comissure is the most common difficulty encountered. To solve this problem, we readjust the bend on the ETT to a more favourable angle (usually less than 90°). If the tip has entered the glottis, but the ETT cannot be advanced into the trachea, indicating contact with the anterior tracheal wall, we remove the malleable stylet and gently attempt advancing the tube alone in a twisting motion. If that maneuver fails, an assistant inserts a lubricated cudé-tipped tube introducer through the ETT into the trachea (15 Fr, Sun-Med, Largo, FL, USA). The ETT is subsequently guided over the introducer, all under direct vision on the GSVL screen.
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In our experience, a malleable stylet bent to a 90° angle usually allows easy glottic insertion of the ETT. However, it may be more difficult to pass the ETT into the trachea in this configuration. To date, we have employed this technique on adult patients for numerous elective endotracheal intubations, a few emergent airway rescues, and fourteen awake intubations of patients with known or suspected difficult airways. We have successfully intubated all patients in elective situations when we have visualized the glottis, and the ETT was of adequate size for insertion of the 15 Fr tube introducer.
Footnotes
Accepted for publication October 26, 2005.
References
1 Rai MR, Dering A, Verghese C. The GlideScope® system: a clinical assessment of performance. Anaesthesia 2005; 60: 60–4.[Medline]
2 Doyle DJ, Zura A, Mangalakaraipudur R. Videolaryngoscopy in the management of the difficult airway (Letter). Can J Anesth 2004; 51: 95.
3 Cuchillo JV, Rodriguez MA. Considerations aimed at facilitating the use of the new GlideScope® videolaryngoscope (Letter). Can J Anesth 2005; 52: 661.
4 Heitz JW, Mastrando D. The use of a gum elastic bougie in combination with a videolaryngoscope (Letter). J Clin Anesth 2005; 17: 408–9.[Medline]
5 GlideScope® Video Intubation System. System Operation & Service Manual, Saturn Biomedical Systems Inc., Burnaby, BC, Canada.
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