Laryngoscopy: Time to broaden our horizon.

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Laryngoscopy Time to broaden our horizon.

• Dr Renu Devaprasath DNB (Anaesthesia)Dept of
  Anaesthesia Jeyasekharan HospitalNagercoilKanya
  kumari District

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LARYNGOSCOPY

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

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LARYNGOSCOPY IN ANESTHESIA

• Unique
• A means to an end
• Objective is usually intubation of the trachea.

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RARELY

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

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TODAYS PRESENTATION

• Techniques, devices manouvres currently
  available to do a successful laryngoscopic
  intubation.

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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.

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LARYNGOSCOPES

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

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DIRECT LARYNGOSCOPES

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

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CURVED STRAIGHT BLADE LARYNGOSCOPE
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CORMACK LEHANE SCORE
Gr I
Gr II
Gr III
Gr IV
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INDIRECT RIGID FIBREOPTIC / OPTICAL LARYNGOSCOPES

• Airtraq
• Bullard
• Wuscope
• Upsherscope
• Truview

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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.

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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.

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AIRTRAQ
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AIRTRAQ
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BULLARD LARYNGOSCOPE
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WUSCOPE
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UPSHERSCOPE
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VIDEO LARYNGOSCOPES

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

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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.

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GLIDESCOPES
Glidescope Ranger
Glidescope cobalt
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GLIDESCOPE COBALT
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ANGULATED VIDEO INTUBATION LARYNGOSCOPE
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McGRATH VIDEO LARYNGOSCOPE
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PENTAX AIRWAY SCOPE
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PENTAX AIRWAY SCOPE IN USE
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OPTICAL STYLETS

• Shikani optical stylet
• Bonfil endoscope

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SHIKANI OPTICAL STYLET (SOS)
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SHIKANI OPTICAL STYLET (SOS)
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BONFIL OPTICAL STYLET
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ADVANTAGES

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

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DISADVANTAGES

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

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FIBREOPTIC ENDOSCOPE
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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 .

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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.

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SET UP
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FOB AIDED INTUBATION UNDER LOCAL IN A PATIENT
WITH CERVICAL FRACTURES
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FOB UNDER TOPICAL TRANSTRACHEAL INSTILLATION
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PATIENT WITH STRIDOR DUE TO TRACHEAL COMPRESSION
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FLEXIBLE FIBEROPTIC ASSISTED AWAKE INTUBATION
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VARIATIONS IN AIRWAY ANATOMY and SIZE OF THE
PATIENT

• Overcome by selection of a appropriate
  laryngoscope .
• Use of pillows and folded sheets.

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LIMITED MOUTH OPENING

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

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LIMITED C-SPINE MOVEMENT PATIENTS

• Direct laryngoscopy with bougie, flexible tip
  blades.
• BURP, OELM
• Indirect fibreoptic scopes
• Video endoscopes
• Optical stylets
• Flexible fibreoptic endoscopes

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VIEW OF GLOTTIC APERTURE

• External laryngeal pressure
• Flexible tip direct laryngoscopes
• Improved immensely by all the newer optical,
  video, flexible fibreoptic laryngoscopes.

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PASSING THE ENDOTRACHEAL TUBE

• Stylet or bougie - shape modification
• Rotation of ETT anticlockwise
• ETT tube / endoscope size

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APPROPRIATE ANALGESIA,ANESTHESIA

• Depth of anaesthesia needed is maximum for direct
  lscopy , 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.

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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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THANK YOU