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

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

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

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

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

7. 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.

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

9. 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.

12. CURVED & STRAIGHT BLADE LARYNGOSCOPE

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

14. INDIRECT RIGID FIBREOPTIC / OPTICAL LARYNGOSCOPES
Airtraq
Bullard
Wuscope
Upsherscope
Truview

15. 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.

16. 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.

17. AIRTRAQ

18. AIRTRAQ

19. BULLARD LARYNGOSCOPE

20. WUSCOPE

21. UPSHERSCOPE

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

23. 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.

24. GLIDESCOPES
Glidescope Ranger
Glidescope cobalt

25. GLIDESCOPE COBALT

26. ANGULATED VIDEO INTUBATION LARYNGOSCOPE

27. McGRATH VIDEO LARYNGOSCOPE

28. PENTAX AIRWAY SCOPE

29. PENTAX AIRWAY SCOPE IN USE

30. OPTICAL STYLETS
Shikani optical stylet
Bonfil endoscope

31. SHIKANI OPTICAL STYLET (SOS)

32. SHIKANI OPTICAL STYLET (SOS)

33. BONFIL OPTICAL STYLET

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

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

36. FIBREOPTIC ENDOSCOPE

37. 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 .

38. 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.

39. SET UP

40. FOB AIDED INTUBATION UNDER LOCAL IN A PATIENT WITH CERVICAL FRACTURES

49. FOB UNDER TOPICAL & TRANSTRACHEAL INSTILLATION

51. PATIENT WITH STRIDOR DUE TO TRACHEAL COMPRESSION

52. FLEXIBLE FIBEROPTIC ASSISTED AWAKE INTUBATION

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

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

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

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

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

58. 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.

59. 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.

60. THANK YOU