Laryngoscopy: Time to broaden our horizon. Dr Renu Devaprasath DNB (Anaesthesia) Dept of Anaesthesia Jeyasekharan Hospital Nagercoil Kanyakumari District

LARYNGOSCOPY A procedure wherein the larynx is visualized Performed for diagnostic, therapeutic & intubation purposes by various specialists.

LARYNGOSCOPY IN ANESTHESIA Unique A means to an end Objective is usually intubation of the trachea.

RARELY Visualizing the upper airway & movement of the vocal cords Removing a foreign body Placing a R.T. or TEE Probe

TODAY’S PRESENTATION Techniques, devices & manouvres currently available to do a successful laryngoscopic intubation.

THE VARIABLES INVOLVED IN A SUCCESSFUL LARYNGOSCOPY The laryngoscope The airway anatomy of the patient Neonate, child or adult. Head, neck, body position Movement of cervical spine Mouth opening External laryngeal pressure View of the glottic aperture Placement of the endotracheal tube Appropriate analgesia / Anesthesia Expertise of the anesthesiologist.

LARYNGOSCOPES Direct Rigid laryngoscopes Indirect Rigid laryngoscopes which use fibreoptics, mirrors, prisms, etc. Video laryngoscopes – Rigid, Flexible Optical stylets Flexible fibreoptic endoscopes

DIRECT LARYNGOSCOPES Dominant modality since 1940’s Advantages – quick to use economical , rugged universally available Disadvantage – alignment of the visual , oral & pharyngeal axis is needed.

CURVED & STRAIGHT BLADE LARYNGOSCOPE

CORMACK & LEHANE SCORE Gr I Gr II Gr III Gr IV

INDIRECT RIGID FIBREOPTIC / OPTICAL LARYNGOSCOPES Airtraq Bullard Wuscope Upsherscope Truview

ADVANTAGES Blade shape conforms better to airway anatomy. Lesser mouth opening and neck extension needed. Alignment of oro-pharyngeal axis not necessary. Easy to learn.

DISADVANTAGES Costly. Secretions and blood can impair the view. Difference in angle of vision and glottic aperture. Intubation may be difficult though view of glottis is good.

AIRTRAQ

AIRTRAQ

BULLARD LARYNGOSCOPE

WUSCOPE

UPSHERSCOPE

VIDEO LARYNGOSCOPES Glidescope videolaryngoscopes Glidescope Cobalt Glidescope Ranger Angulated video intubation laryngoscope McGrath video laryngoscope Pentex airway scope Airtraq optical laryngoscope with video

ADVANTAGES Magnified view with a wider angle. The operator and assistant can see the same view and coordinate better. Lesser mouth opening and neck extension needed. Easy to learn and useful for teaching.

GLIDESCOPES Glidescope Ranger Glidescope cobalt

GLIDESCOPE COBALT

ANGULATED VIDEO INTUBATION LARYNGOSCOPE

McGRATH VIDEO LARYNGOSCOPE

PENTAX AIRWAY SCOPE

PENTAX AIRWAY SCOPE IN USE

OPTICAL STYLETS Shikani optical stylet Bonfil endoscope

SHIKANI OPTICAL STYLET (SOS)

SHIKANI OPTICAL STYLET (SOS)

BONFIL OPTICAL STYLET

ADVANTAGES Useful in routine and difficult intubations. Uncomplicated tools. Easily learned. Portable. Simple to prepare.

DISADVANTAGES Short optical depth . Potential for impaired visualization due to fogging or secretions

FIBREOPTIC ENDOSCOPE

ADVANTAGES Laryngoscopic intubation can be done via nasal route also. Neck extension and mouth opening not necessary. Anatomical variations can be overcome. Topical / regional anaesthesia is adequate in the awake patient. Good view of the glottis, larynx, trachea and bronchi .

DISADVANTAGES It is a delicate instrument and needs care. High cost. Takes a little time and practice to learn. Tissue oedema and blood can obscure vision. Cleaning / sterilization takes time.

SET UP

FOB AIDED INTUBATION UNDER LOCAL IN A PATIENT WITH CERVICAL FRACTURES

FOB UNDER TOPICAL & TRANSTRACHEAL INSTILLATION

PATIENT WITH STRIDOR DUE TO TRACHEAL COMPRESSION

FLEXIBLE FIBEROPTIC ASSISTED AWAKE INTUBATION

VARIATIONS IN AIRWAY ANATOMY and SIZE OF THE PATIENT Overcome by selection of a appropriate laryngoscope . Use of pillows and folded sheets.

LIMITED MOUTH OPENING TM Jt ankylosis - fixed Fibreoptic laryngoscopy Pain induced Trismus Trial Direct laryngoscopy after paralysing the patient.

LIMITED C-SPINE MOVEMENT PATIENTS Direct laryngoscopy with bougie, flexible tip blades. BURP, OELM Indirect fibreoptic scopes Video endoscopes Optical stylets Flexible fibreoptic endoscopes

VIEW OF GLOTTIC APERTURE External laryngeal pressure Flexible tip direct laryngoscopes Improved immensely by all the newer optical, video, flexible fibreoptic laryngoscopes.

PASSING THE ENDOTRACHEAL TUBE Stylet or bougie - shape modification Rotation of ETT anticlockwise ETT tube / endoscope size

APPROPRIATE ANALGESIA,ANESTHESIA Depth of anaesthesia needed is maximum for direct l’scopy , lesser for indirect and least for flexible fibreoptic laryngoscopy. Babies & children need sedation or GA. Combative adults also need sedation or GA Flexible endoscopy can be done easily under local on a awake cooperative patient or a sedated ,spontaneously breathing child.

SUMMARY Variety of new laryngoscopes. Familiarization with using two other devices and the fibreoptic endoscope. Meticulous attention to detail in regard to all the variables. A difficult intubation tray.

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