Traoré Ibrahim Alain1, Kaboré Flavien2, Barro Sié Drissa1, Traoré Idriss3,
Ilboudo Serge3, Ouédraogo Nazinigouba2
1Assistant Professor, Anesthesiology & Reanimation Department, The Polytechnic University of Bobo-Dioulasso, Houet, (Burkina-Faso) 2Professor; 3Anesthesiologist
Anesthesiology & Reanimation Department, University of Ouagadougou (UO), BP 7021, Ouagadougou, (Burkina-Faso)
Correspondence:
Dr Traoré Ibrahim Alain, MD, Assistant Professor, Departement of Anesthesiology & Reanimation
Department, The Polytechnic University of Bobo-Dioulasso, Houet, (Burkina-Faso); Mobile: 0022671457580; E-mail:
itraore80@gmail.com
ABSTRACT
Tracheal intubation is the technique of choice for airway management. Occasionally, it may be difficult and result in severe complications including increased morbidity and even fatal outcome. Sometimes the planned surgical operation may have to be postponed. The videolaryngoscope allows a good exposure of the glottis, thus making tracheal intubation easier as compared with a conventional laryngoscope. The gadget is little found in Subsaharan Africa due to its high cost. We report our first experience of successful use of the videolaryngoscope in two cases, which had earlier required postponement of the surgery due to failed intubation.
Key words:
Videolaryngoscope; Videolaryngoscopy; Airway management; Intubation, Tracheal
Citation:
Alain TI, Flavien K, Drissa BS, Idriss T, Serge I, Nazinigouba O. Videolaryngoscope is not a luxury, but a necessity. Anaesth Pain & Intensive Care 2015;19(4):502-504
INTRODUCTION
Tracheal intubation is most frequently done using the conventional Macintosh laryngoscope all over the world. Occasionally it may be found difficult or sometimes impossible in the practice of even experienced anesthesiologists. This situation may result in increased morbidity or a fatal outcome. The planned surgery may have to be postponed.
The videolaryngoscope, developed more than a decade ago, allows a better exposure of the glottis, so making tracheal intubation easier compared with a conventional laryngoscope.1-3 It has found a place in the algorithms of difficult intubation according to international recommendations.4 Still, this new technique of indirect laryngoscopy is little found in Sub-Saharan Africa due to its high cost. We here share our first experience of use of the videolaryngoscope in two known cases of failed tracheal intubation. The aim of presenting the case reports is to stress the need to acquire every possible piece of the latest gadgets for airway management even in underdeveloped countries.
CASE REPORT 1
A 50-year-old patient was scheduled for excision of a right maxillary tumor. He had no other comorbid condition. Three weeks earlier, the patient had been scheduled for the same intervention. Consultation in pre-anesthesia clinic revealed the following indicators of difficult intubation; a Mallampati score 4, limited mouth opening of 2.5 cm and toothless jaws just sparing teeth numbers 31, 41 and 42. Thyromental distance was 6.5 cm. In the operating room, after monitoring (electrocardiograph, noninvasive blood pressure, pulse oxygen saturation) and a preoxygenation with a face mask for 3 min, anesthesia was induced with 120 mg of propofol, 30 mg of suxamethonium chloride and sufentanil. The tracheal intubation was tried by a male nurse anesthetist then a junior anesthetist with a size 4 blade of the Macintosh laryngoscope. During laryngoscopy even the epiglottis could not be visualized despite various external laryngeal manipulations and attempt at intubation failed. After oxygenation and a second dose of suxamethonium 30 mg, was tried three times by a senior doctor anesthetist. The surgery had to be postponed.
Three weeks later, when we received a videolaryngoscope, the patient was rescheduled for surgery. The same monitoring and anesthetic protocol was opted. The laryngoscopy was done by means of Glidescope® (Figure 1) by an anesthesiologist who had never used this device before, under supervision by an anesthesiologist familiar with the videolaryngoscope. Tracheal intubation was successful within one minute with a good vision of the epiglottis as well as the laryngeal opening (Cormack-Lehane Grade 1).
Figure 1: video-laryngoscope (Glidescope®)
CASE REPORT 2
An 18-year-old patient, ASA PS-I was rescheduled for release of burn scars at his neck and face. The patient weighed 50 kg and was 160 cm tall. The patient had reported for surgery two months back. Preanesthetic evaluation revealed features of difficult intubation; a thyromental distance of 5 cm, an oral opening of 2.5 cm and Mallampati score of 3. After routine monitoring, the anesthesia was induced by propofol 100 mg and suxamethonium 50 mg. The intubation was tried thrice by a senior anesthesiologist using a Macintosh blade 4 with no visualization of the glottis. SpO2 dropped to < 90%, so a laryngeal mask airway size 4 was inserted and the surgery postponed. Two months later, the patient was rescheduled for the same surgical operation. A protocol of induction similar to the first intervention was followed. Tracheal intubation was tried by another senior anesthesiologist with a Macintosh blade 4. In spite of 2 attempts and external laryngeal manipulation (BURP maneuver), the laryngoscopy remained Cormack-Léhane grade 4. After oxygenation and reinjection of 50 mg of suxamethonium chlorid, the intubation was easily done within 2 min by the same anesthesiologist by using Glidescope®. With the new device the laryngoscopic view was Cormack-Léhane grade 1.
DISCUSSION
Secure airway during general anesthesia is a major priority for all anesthesiologists, and tracheal intubation with direct laryngoscopy remains the method of choice in most of the cases. However, intubation can be difficult in 1to 4% of the cases and it may fail in 0.05 to 35% of the patients of the general population.5 In case of difficult or failed intubation, may lead to severe complications such as hypoxic brain damage or even death.6
Several alternative techniques in case of difficult intubation have been suggested. Among these techniques, the gold standard is the use of flexible bronchoscope, which is, however, expensive and needs considerable experience before one could attempt it in patients.7 The videolaryngoscopes including Glidescope®, have now become a reliable alternative in case of difficult or impossible intubation. These allow better view of the glottis as compared to conventional laryngoscopy.1,2 In our patients, conventional laryngoscopy showed only Cormack-Léhane grade 4 view, whereas Glidescope® allowed an excellent view of the glottis with a Grade 1. Glidescope®, because of its configuration, does not require a compulsory alignment of the buccopharyngeal axis for the laryngoscopy.8-12 Indeed, the blade of Glidescope®, contrary to that of the Macintosh laryngoscope blade, possesses an additional angulation of 60° upward in distal half. This enables to insert the blade along the median line of the tongue, to follow the airway contour without any tongue movement or necessity of aligning the visual axes. Other studies also demonstrated that Glidescope® reduced the difficulty of tracheal intubation.compared with the Macintosh laryngoscope when used by experienced anesthesiologists as well as by beginners.10,11 In our first patient, Glidescope®, was used by a postgraduate resident. Glidescope® reduced the time required to intubate as well as the risk of dental trauma. The videolaryngoscope is thus a necessity so that tracheal intubation can be done successfully and atraumatically even by less experienced nurse anesthetists or anesthesiologists.
The videolaryngoscope also allows to teach laryngoscopy to nurse anaesthetists, doctors and students in a more effective way. In the coming years, videolaryngoscopes will probably be used as first option for tracheal intubation. The high cost on procurement and maintenance limit their wide spread use. However, due to their positive role in management of difficult airway, all university teaching hospitals need to purchase different videolaryngoscopes.
CONCLUSION
Videolaryngoscopes make tracheal intubation easier even in the hands of less experienced anesthesiologists, in cases with previously failed intubation. At times these may prove to be lifesaving. It is, thus, not a luxury to have one or more of these in our arsenal, but a necessity.
Conflict of interest: None declared by the authors.
Author contribution: All of the authors took part in the management
of this patient and in manuscript preparation.
REFERENCES
Ilboudo Serge3, Ouédraogo Nazinigouba2
1Assistant Professor, Anesthesiology & Reanimation Department, The Polytechnic University of Bobo-Dioulasso, Houet, (Burkina-Faso) 2Professor; 3Anesthesiologist
Anesthesiology & Reanimation Department, University of Ouagadougou (UO), BP 7021, Ouagadougou, (Burkina-Faso)
Correspondence:
Dr Traoré Ibrahim Alain, MD, Assistant Professor, Departement of Anesthesiology & Reanimation
Department, The Polytechnic University of Bobo-Dioulasso, Houet, (Burkina-Faso); Mobile: 0022671457580; E-mail:
itraore80@gmail.com
ABSTRACT
Tracheal intubation is the technique of choice for airway management. Occasionally, it may be difficult and result in severe complications including increased morbidity and even fatal outcome. Sometimes the planned surgical operation may have to be postponed. The videolaryngoscope allows a good exposure of the glottis, thus making tracheal intubation easier as compared with a conventional laryngoscope. The gadget is little found in Subsaharan Africa due to its high cost. We report our first experience of successful use of the videolaryngoscope in two cases, which had earlier required postponement of the surgery due to failed intubation.
Key words:
Videolaryngoscope; Videolaryngoscopy; Airway management; Intubation, Tracheal
Citation:
Alain TI, Flavien K, Drissa BS, Idriss T, Serge I, Nazinigouba O. Videolaryngoscope is not a luxury, but a necessity. Anaesth Pain & Intensive Care 2015;19(4):502-504
INTRODUCTION
Tracheal intubation is most frequently done using the conventional Macintosh laryngoscope all over the world. Occasionally it may be found difficult or sometimes impossible in the practice of even experienced anesthesiologists. This situation may result in increased morbidity or a fatal outcome. The planned surgery may have to be postponed.
The videolaryngoscope, developed more than a decade ago, allows a better exposure of the glottis, so making tracheal intubation easier compared with a conventional laryngoscope.1-3 It has found a place in the algorithms of difficult intubation according to international recommendations.4 Still, this new technique of indirect laryngoscopy is little found in Sub-Saharan Africa due to its high cost. We here share our first experience of use of the videolaryngoscope in two known cases of failed tracheal intubation. The aim of presenting the case reports is to stress the need to acquire every possible piece of the latest gadgets for airway management even in underdeveloped countries.
CASE REPORT 1
A 50-year-old patient was scheduled for excision of a right maxillary tumor. He had no other comorbid condition. Three weeks earlier, the patient had been scheduled for the same intervention. Consultation in pre-anesthesia clinic revealed the following indicators of difficult intubation; a Mallampati score 4, limited mouth opening of 2.5 cm and toothless jaws just sparing teeth numbers 31, 41 and 42. Thyromental distance was 6.5 cm. In the operating room, after monitoring (electrocardiograph, noninvasive blood pressure, pulse oxygen saturation) and a preoxygenation with a face mask for 3 min, anesthesia was induced with 120 mg of propofol, 30 mg of suxamethonium chloride and sufentanil. The tracheal intubation was tried by a male nurse anesthetist then a junior anesthetist with a size 4 blade of the Macintosh laryngoscope. During laryngoscopy even the epiglottis could not be visualized despite various external laryngeal manipulations and attempt at intubation failed. After oxygenation and a second dose of suxamethonium 30 mg, was tried three times by a senior doctor anesthetist. The surgery had to be postponed.
Three weeks later, when we received a videolaryngoscope, the patient was rescheduled for surgery. The same monitoring and anesthetic protocol was opted. The laryngoscopy was done by means of Glidescope® (Figure 1) by an anesthesiologist who had never used this device before, under supervision by an anesthesiologist familiar with the videolaryngoscope. Tracheal intubation was successful within one minute with a good vision of the epiglottis as well as the laryngeal opening (Cormack-Lehane Grade 1).
Figure 1: video-laryngoscope (Glidescope®)
CASE REPORT 2
An 18-year-old patient, ASA PS-I was rescheduled for release of burn scars at his neck and face. The patient weighed 50 kg and was 160 cm tall. The patient had reported for surgery two months back. Preanesthetic evaluation revealed features of difficult intubation; a thyromental distance of 5 cm, an oral opening of 2.5 cm and Mallampati score of 3. After routine monitoring, the anesthesia was induced by propofol 100 mg and suxamethonium 50 mg. The intubation was tried thrice by a senior anesthesiologist using a Macintosh blade 4 with no visualization of the glottis. SpO2 dropped to < 90%, so a laryngeal mask airway size 4 was inserted and the surgery postponed. Two months later, the patient was rescheduled for the same surgical operation. A protocol of induction similar to the first intervention was followed. Tracheal intubation was tried by another senior anesthesiologist with a Macintosh blade 4. In spite of 2 attempts and external laryngeal manipulation (BURP maneuver), the laryngoscopy remained Cormack-Léhane grade 4. After oxygenation and reinjection of 50 mg of suxamethonium chlorid, the intubation was easily done within 2 min by the same anesthesiologist by using Glidescope®. With the new device the laryngoscopic view was Cormack-Léhane grade 1.
DISCUSSION
Secure airway during general anesthesia is a major priority for all anesthesiologists, and tracheal intubation with direct laryngoscopy remains the method of choice in most of the cases. However, intubation can be difficult in 1to 4% of the cases and it may fail in 0.05 to 35% of the patients of the general population.5 In case of difficult or failed intubation, may lead to severe complications such as hypoxic brain damage or even death.6
Several alternative techniques in case of difficult intubation have been suggested. Among these techniques, the gold standard is the use of flexible bronchoscope, which is, however, expensive and needs considerable experience before one could attempt it in patients.7 The videolaryngoscopes including Glidescope®, have now become a reliable alternative in case of difficult or impossible intubation. These allow better view of the glottis as compared to conventional laryngoscopy.1,2 In our patients, conventional laryngoscopy showed only Cormack-Léhane grade 4 view, whereas Glidescope® allowed an excellent view of the glottis with a Grade 1. Glidescope®, because of its configuration, does not require a compulsory alignment of the buccopharyngeal axis for the laryngoscopy.8-12 Indeed, the blade of Glidescope®, contrary to that of the Macintosh laryngoscope blade, possesses an additional angulation of 60° upward in distal half. This enables to insert the blade along the median line of the tongue, to follow the airway contour without any tongue movement or necessity of aligning the visual axes. Other studies also demonstrated that Glidescope® reduced the difficulty of tracheal intubation.compared with the Macintosh laryngoscope when used by experienced anesthesiologists as well as by beginners.10,11 In our first patient, Glidescope®, was used by a postgraduate resident. Glidescope® reduced the time required to intubate as well as the risk of dental trauma. The videolaryngoscope is thus a necessity so that tracheal intubation can be done successfully and atraumatically even by less experienced nurse anesthetists or anesthesiologists.
The videolaryngoscope also allows to teach laryngoscopy to nurse anaesthetists, doctors and students in a more effective way. In the coming years, videolaryngoscopes will probably be used as first option for tracheal intubation. The high cost on procurement and maintenance limit their wide spread use. However, due to their positive role in management of difficult airway, all university teaching hospitals need to purchase different videolaryngoscopes.
CONCLUSION
Videolaryngoscopes make tracheal intubation easier even in the hands of less experienced anesthesiologists, in cases with previously failed intubation. At times these may prove to be lifesaving. It is, thus, not a luxury to have one or more of these in our arsenal, but a necessity.
Conflict of interest: None declared by the authors.
Author contribution: All of the authors took part in the management
of this patient and in manuscript preparation.
REFERENCES
- Cooper RM. Use of a new videolaryngoscope (Glidescope) in the management of a difficult airway. Can J Anaesth 2003;50 :611-3
- Asai T, Shingu K. Use of the videolaryngoscope (letter). Anesthesia 2003;59:513-4.
- Enomoto Y, Asai T, Arai T, Kamishima K, Okuda Y. Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: a randomized comparative study. Br J Anaesth 2008;100:544–8.
- Apfelbaum JL, , Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013 Feb;118(2):251-70.
- Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991;75:1087–110.
- Caplan RA, Posner KL, Ward RJ, Cheney FW.Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology 1990 ;72(5):828-33.
- Kristensen MS, Moller J. Airway management behaviour, experience and knowledge among Danish anesthesiologists-room for improvement. Acta Anesthesiol scand 2001;45:1181-5. [PubMed]
- Rai MR, Dering A, Verghese C. The Glidescope system: a clinical assessment of performance. Anaesthesia 2005;60:60–4.
- Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anaesth 2005;52:191–8.
- Lim Y, Lim TJ, Liu EHC. Ease of intubation with the GlideScope or Macintosh laryngoscope by inexperienced operators in simulated difficult airways.Can J Anaesth 2004;51:641–2.
- Wackett A, Anderson K, Thode H. Bullard laryngoscopy by naïve operators in the cervical spine immobilized patient. J Emerg Med 2005;29:253–7.
- Maharaj CH, Higgins BD, Harte BH, Laffey JG. Evaluation of intubation using the Airtraq or Macintosh laryngoscope by anaesthetists in easy and simulated difficult laryngoscopy – a manikin study. Anaesthesia 2006;61:469–77.