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Trachlight® – More practical solutions to commonly encountered problems

Kasturba Medical College, Manipal, India, E-mail: drumeshg{at}yahoo.co.in

To the Editor:

Over the past few decades, light-guided intubation using the principle of transillumination has proven to be an effective, safe and simple technique. A lighted stylet uses the principle of transillumination of the soft tissues of the anterior neck to guide the tip of the endotracheal tube into the trachea. This technique takes advantage of the anterior or more superficial location of the trachea in relation to the esophagus.

Several tips have been suggested in the literature for improving the success of Trachlight®-guided intubation. These include lifting the tongue with the thumb of the nondominant hand or having an assistant pull the tongue while the intubator continues to provide a jaw thrust, lubricating the wand and the stylet,¹ dimming operating room lights, using smaller size endotracheal tubes, inserting the wand side-on, or providing at least a 90° bend to the wand.² Others have suggested gauging the appropriate "bent length" by measuring the distance from the thyroid prominence to the angle of the mandible.³ Patients with buck teeth may benefit from the addition of another bend to the wand at the level of the buck teeth.⁴

Following repeated use, the internal rigid stylet sometimes assumes a "snake-like" bend that poses difficulty in retraction of the wand. In such situations, it has been suggested that the stylet be straightened, if possible, before reuse, failing which it needs to be disposed. ⁵ We have also encountered a similar situation leading to difficulty in withdrawing the wand along with the rigid internal stylet after successfully negotiating the endotracheal tube-Trachlight® assembly into the trachea. We have noticed that the snake-like bend of the stylet poses a problem when it crosses the endotracheal tube connector, which happens to be not only the narrowest, but also the most rigid portion of the endotracheal tube-connector assembly. We have successfully overcome "hold up" at this level by separating the endotracheal tube connector from the endotracheal tube prior to withdrawal of the wand-stylet assembly. The distal 90° bent portion of the wand-stylet assembly is the other point at which difficulty is encountered during withdrawal of the stylet, especially in the pediatric age group due to the small size of the tube and its connector. Our suggestion provides a solution to this problem also. We therefore recommend that the connector be routinely separated from the endotracheal tube to facilitate smooth removal of the stylet and possibly prolong the life of the stylet. We have applied this technique of removal of the endotracheal tube connector to aid in Trachlight®-guided oral intubation using the Ring Adair Elwyn (Mallinckrodt Medical, Athlone, Ireland) tube also.

In obese individuals, the midline tissues of the neck may be obscured by folds of fat arising either from a double-chin above, or from the anterior chest wall below, posing difficulty in appreciation of the circumscribed glow in front of the neck. Dimming the operating room lights and placing a support under the shoulder to extend the neck often improves success of Trachlight®-guided intubation in obese patients. We have found that having an assistant retract the fold of fatty tissue down and away from the neck so as to avoid formation of skin folds over the neck helps in shortening the time to obtain the classical well-circumscribed midline glow.

Since its introduction in 1959, the lightwand has proven its utility in several clinical situations. Our experience gleaned from the use of the Trachlight® for more than 350 intubations has prompted us to share some of the practical solutions that we have used to overcome problems that we have commonly encountered during its use.

Footnotes

Accepted for publication January 15, 2007.

References

1 Hung OR, Pytka S, Morris I, et al. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea. Anesthesiology 1995; 83: 509–14.[Medline]

2 Djordjevic D. Trachlight^TM- Learning tips. Can J Anesth 1999; 46: 615.[Medline]

3 Chen TH, Tsai SK, Lin CJ, Lu CW, Tsai TP, Sun WZ. Does the suggested lightwand bent length fit every patient? The relation between bent length and patient’s thyroid prominence-to-mandibular angle distance. Anesthesiology 2003; 98: 1070–6.[Medline]

4 Huda W, Khan RM, Ahmad M, Singh M. Yet another bend in the wand! Anesth Analg 2003; 96: 627–8.[Free Full Text]

5 Crosby E. The Trachlight - A few more lessons. Can J Anesth 1999; 46: 297.[Medline]

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