Connect with us on Facebook
Brooklyn Sunrise - photo by Stephanie Chia
Video laryngoscopes have become a highly used, frequently relied upon source for managing difficult airways. Even when not in use, it is comforting knowing it’s readily available. While not a new concept, current technology has made their use simple, efficient and highly effective. High resolution cameras, LCD displays, and anti fog mechanism make them a first choice in difficult airway management. While we are all familiar with its use in this regard, I would like to discuss other, more unusual applications. In my current practice I am familiar with the GlideScope, however, I have used other systems successfully as well.
First scenario: That darn OG/NG tube
Just can’t get the OG tube to slide into the stomach? It keeps curling in the mouth and getting stuck in the excessive soft tissue of an obese neck. How many times shall I try before I give up or worse, cause serious trauma to oropharynx? This scenario can be quite frustrating.
Simple solution: Use your video laryngoscope. Insert the blade deep into the pharynx and do a laryngoscopy to retract the excess soft tissue and identify the airway structures as well as the esophagus. Under visualization with your color, high resolution screen, you can easily watch the tip of the OG tube enter the esophagus and continue down without curling. By the way, this technique also works well for difficult TEE probe placement.
Second scenario: Bleeding from the mouth
I have encountered this scenario on several different occasions. Perhaps you notice bright red blood coming from the patient’s mouth after TEE probe removal at the conclusion of a cardiac case. Maybe you notice bright red blood while suctioning a patient after an EGD or bronchoscopy.
Solution: You can use the GlideScope to assess the oropharynx for mucosal tears or trauma. If a small tear to the mucosa is evident, this is reassuring and will usually not require intervention. If there is active bleeding the surgeon should be notified, as this may require cauterization. If there is no evidence of oral or pharyngeal bleeding at this time, there still exists the possibility that the patient has an underlying pulmonary or distal GI pathology (such as esophageal trauma). If rebleeding occurs later in the patient’s hospital course, the patient should be further worked up.
Third scenario: Tube exchange
This is often the most dangerous part of a case. After many hours of hard work, with potential changes to the airway, we are faced with this tenuous and risky proposition. There are times when we must exchange one ET tube for another, such as between double lumen and single lumen tubes. Accomplishing this safely is of highest priority.
Solution: Using a video laryngoscope with a tube exchanger is an elegant way to accomplish this. The key is to maintain constant visualization of the airway anatomy and position of ET tubes and tube exchanger during reintubation. Having someone assist you with this process makes it much easier. One person inserts the GlideScope and takes a look at the anatomy. This will give you information regarding the difficulty of laryngoscopy and the view that you will have if you were to lose the airway. However, this tells you little information regarding the patency of the airway if the current ET tube were to be suddenly removed. The ET tube may be stenting the airway open. The second person inserts the tube exchanger into the current ET tube. With the patient relaxed and on 100% oxygen, the indwelling ET tube is slowly removed. The GlideScope will help to lift the soft tissue away and to visualize the tube exchanger during this process. Care is taken to ensure that the tube exchanger is not inadvertently removed as the ET tube is withdrawn. Finally, while maintaining the laryngoscopy, the new ET tube is threaded over the tube exchanger and visualized as it passes through the vocal cords. Avoiding blind tube exchange can also minimize airway trauma.
Scenario Four: An alternative approach to the difficult airway
A major criticism when using a video laryngoscope is that despite obtaining an adequate view of the vocal cords, one is unable to maneuver the ET tube into the airway. Often times manipulating the curve of the stylet or repositioning the patient will solve this problem. However, these maneuvers sometimes fail.
Solution: To increase your success, use the GlideScope plus fiberoptic scope combination. This combination is a safe and effective approach in situations of truly difficult airways, patients with distorted anatomy, or where manipulating the cervical spine is contraindicated. You get the best of both worlds: the GlideScope’s ability to lift soft tissue and open the airway, with its high resolution, anti fog camera, and the fiberoptic scope’s flexibility. This technique requires two people. One person to hold the GlideScope and another for the fiberoptic scope.
About the Author:
Andre Motie, M.D. is a cardiothoracic-trained anesthesiologist practicing in Fresno, California. He enjoys being continuously challenged, whether in the operating room or out on the golf course. He finally has the time after finishing his rigorous training to invest time into his many interests, such as painting, traveling, and learning Chinese.
