Video Laryngoscopy

Routine intubation

Rescue for failed direct laryngoscopy

Anticipated difficult intubation (abnormal anatomy, reduced mouth opening, history of difficult intubations, cervical spine precautions, obesity)

Intubation with desire for teaching or supervision of physician trainees

RELATIVE CONTRAINDICATIONS

Brisk bleeding or copious secretions

No oral access (angioedema)

Provider discomfort or lack of training with indirect laryngoscopy and intubation

DEVICES

Multiple devices are available

Devices are broadly grouped into acutely curved blades (GlideScope, King Vision, C-MAC D-blade, Pentax airway scope) or traditionally shaped blades (C-MAC, GlideScope teaching blade)

Traditionally shaped blades can be used as a direct and video laryngoscope to facilitate mechanical memory for direct laryngoscopy

Some devices require free-hand placement of the endotracheal tube (ETT) (GlideScope, C-MAC, McGrath Series 5), while others have integrated ETT channels that require the device and ETT to be inserted together (King Vision, Pentax airway scope)

SUPPLIES

Video laryngoscope system

ETT

ETT stylet (malleable or rigid)

ETT lubricant

10-cc syringe for cuffed ETTs

End-tidal carbon dioxide detector

Tube securing device

Bag-valve mask

Oral and/or nasal airways

Equipment for preoxygenation (facemask oxygen with reservoir)

TECHNIQUE—RAPID SEQUENCE INTUBATION

Preparation

Vascular access

Monitoring: Cardiac monitor, blood pressure monitoring, and pulse oximetry

Suction device

Assemble necessary equipment (see above)

Obtain rapid sequence intubation (RSI) medications

Perform an airway assessment for difficulty

Preoxygenation

Preoxygenate with nonrebreathing mask or bag-valve mask

Nasal cannula for passive oxygenation during intubation, especially for rapid desaturators

Positioning

Cervical spine extension and head elevation if no contraindication

In-line cervical spine neutrality for patients with cervical spine precautions

Perform “Time Out”

Ensure that the team agrees on medications and dosing, devices to be used, and plan for a failed intubation

Administer Induction and Paralytic Agents

Perform Intubation

Traditionally shaped video system blades (C-MAC, GlideScope teaching blade)

Open mouth with a finger/scissor or similar technique

Insert the blade in the right paralingual gutter of the mouth, sweeping the tongue to the left

Advance the blade in traditional technique with the goal of identifying epiglottis first (epiglottoscopy), followed by placement of the tip of the blade in the base of the vallecula

Using an upward motion, lift up on the handle and blade to obtain a view of the vocal cords by manipulating the hyoepiglottic ligament

If an optimal direct view is not seen under direct vision, the operator may attempt optimization maneuvers such as backward upward rightward pressure, or “BURP,” to improve view

Alternatively, the intubator can opt for early recourse to the video screen to assess glottic view and intubate using the video screen

Stylet should be shaped with a gentle curve to approximate the trajectory the blade has taken to the airway

Curved “indirect” video systems (standard GlideScope, C-MAC D-blade, McGrath video laryngoscope, Pentax airway scope, King Vision video laryngoscope)

Open mouth with a finger/scissor or similar technique

Insert the device in the midline, staying opposed to the dorsal surface of the tongue

Advance and rotate the blade around the tongue, staying in the midline, while watching on the video screen to identify key midline airway landmarks (uvula and tip of epiglottis)

Advance until the blade rests in the vallecula

Gently tilt the blade and cranially bring the vocal cords into view on the screen. Do not place the device too close to the glottic inlet as this impedes tube passage.

If the device has a channel to hold and launch the ETT, gently push the tube through the channel and past the vocal cords after first ensuring the vocal cords are in the center of the video screen

If the device requires the use of a stylet, preference should be made for a rigid preshaped stylet as these do not deform during intubation. Malleable stylets should be shaped with a more aggressive curve to mimic the shape of and trajectory taken by the blade.

Place the stylet-loaded tube in the right corner of the mouth with the length of the tube parallel to the ground (3 o’clock position). Advance the tube while rotating the tube in a counterclockwise position until the tube aligns with the curvature of the blade (12 o’clock position). Advance the tube through the vocal cords. If unable to fully pass the tube, withdraw the stylet slightly to allow for more mobility. Withdraw the stylet.

Inflate the cuff (for cuffed tubes)

Proof of Intubation

Confirm tube placement with breath sounds, chest rise, and colorimetric or quantitative end-tidal carbon dioxide

Postintubation Care

Secure the ETT

Order portable chest x-ray

Connect to a mechanical ventilator, if appropriate

Strategy for ongoing sedation

COMPLICATIONS

Failed intubation with hypoxic insult

Need for surgical cricothyrotomy

Esophageal intubation

Airway bleeding and swelling

Damage to vocal cords

Damage to teeth, lips, or tongue

Hemodynamic decompensation following RSI medications

SAFETY/QUALITY TIPS

Procedural

Your eyes should start out looking in the mouth for blade placement, then shift to the screen for optimal blade advancement, then back to the mouth to place the tube near the tip of the blade, then back to the screen to deliver the tube through the cords.

When using video laryngoscopy, do not place the blade too close to the vocal cords as this limits the ability to easily pass the ETT. In practice, this means not trying to get the “best view of the cords” on the screen, rather, keeping a slightly suboptimal view of the cords on the bottom of the screen, which makes tube delivery much easier.

If you are having difficulty passing the tube through the vocal cords, withdraw the stylet and advance the tube

When able, use the proprietary stylet and adjunctive equipment. The proprietary stylets are designed to exactly match the curvature of the blade.

Cognitive

Standard geometry video laryngoscopes will provide an excellent view of the glottis in most cases, can function using direct or indirect technique, and offer comparatively easy tube delivery. Hyperangulated geometry blades provide an excellent view of the cords in almost every case, including cases where standard geometry view is inadequate, but can only be used by the indirect/video approach, and tube delivery can be more challenging.

If the ETT needs to be adjusted, consider doing so under video guidance

Practice with the video laryngoscopy system before using it clinically, especially if the device features a hyperangulated geometry blade

Select the right device for the right patient. Standard geometry video laryngoscopy allows for direct visualization if secretions or blood obscure the screen. Hyperangulated geometry requires less lifting force and may be easier in patients requiring cervical spine immobilization.