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Canadian Journal of Anesthesia 54:77-78 (2007)
© Canadian Anesthesiologists' Society, 2007

Correspondence

Tracheal intubation using the GlideScope® with a combined curved pipe stylet, and endotracheal tube introducer

Musa Muallem, MD and Anis Baraka, MD FRCA

American University of Beirut Medical Center, Beirut, Lebanon, E-mail: mm08{at}aub.edu.lb

To the Editor:

The GlideScope® (Diagnostic Ultrasound, Bothell, WA, USA) videolaryngoscope provides an enhanced view of the glottis, and increases the likelihood of tracheal intubation compared with direct laryngoscopy in patients with a difficult airway.1 However, it has been well demonstrated that providing a good view of the glottis does not always correlate with successful airway instrumentation. The limitation of the GlideScope® in advancing the endotracheal tube (ETT) through the vocal cords into the trachea has been well described.2,3 The manufacturer recommends using a stylet to curve the ETT and guide it into the larynx, but it remains difficult on occasion to negotiate the ETT through the vocal cords into the trachea. The bevel of the ETT may become stuck at the arytenoids, or impact on the anterior wall of the larynx. It has been suggested that a flexible stylet which would allow for the adjustment of the tube might decrease intubation times and increase the success rate.4

It has been shown previously that the Muallem ETT introducer (METTI; VBM Medizintechnik GmbH, Sulz, Germany), which is characterized by a semi rigid flexible body and a soft curved tip, is effective in guiding the ETT into the glottis and facilitating tracheal intubation.5 A curved brass pipe stylet (5 mm internal diameter) is made through which the METTI size 12 F is introduced. The ETT is slipped over the pipe stylet, thus making an assembly of an introducer, stylet, and tube, as shown in the FigureGo.


Figure 1
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  		FIGURE Assembly of the Muallem endotracheal tube introducer (METTI), pipe stylet, and endotracheal tube.

 
When the glottic inlet is visualized by the GlideScope®, the combined ETT, pipe stylet, and introducer are introduced into the pharynx facing the glottis. The METTI introducer is advanced inside the pipe stylet to target the glottis. Because it has a soft curved tip and semi rigid body, the introducer tip can be easily rotated and pushed via the glottis into the trachea. Once the introducer is pushed deep within the trachea, the ETT is railroaded over the introducer into the trachea. If the ETT becomes stuck at the arytenoids, it can be rotated 90° counter clockwise so that its bevel faces posteriorly, after which it is railroaded over the introducer into the trachea.6

We have successfully used the technique described to facilitate tracheal intubation in four patients with difficult airways (Cormack-Lehane laryngeal grades III and IV). In all four cases, it was easy to visualize the glottis by the GlideScope® and to railroad the ETT over the introducer (METTI) into the trachea.

Footnotes

Accepted for publication September 25, 2006.

References

1 Cooper RM. Use of a new video laryngoscope (GlideScope®) in the management of a difficult airway. Can J Anesth 2003; 50: 611–3.[Abstract/Free Full Text]

2 Doyle DJ, Zura A, Ramachandran M. Videolaryngoscopy in the management of the difficult airway (Letter). Can J Anesth 2004; 51: 95.[Free Full Text]

3 Cooper RM. Videolaryngoscopy in the management of the difficult airway (Letter, reply). Can J Anesth 2004; 51: 95–6.[Free Full Text]

4 Rai MR, Dering A, Verghese C. The Glidescope system: a clinical assessment of performance. Anaesthesia 2005; 60: 60–4.[Medline]

5 Muallem MK, Azar MS, Gerges FJ, Nasr VG, Baraka A. Muallem endotracheal tube introducer (METTI) - an aid for the difficult airway. Middle East J Anesthesiol 2005; 18: 385–9.[Medline]

6 Baraka A, Rizk M, Muallem M, Bizri SH, Ayoub C. Posterior-beveled vs lateral-beveled tracheal tube for fibreoptic intubation (Letter). Can J Anesth 2002; 49: 889.[Free Full Text]





This Article
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