The above three clips illustrate a new technique for teaching fiberoptic intubation (FOI) using the GlideScope . Following anesthetic induction, the GlideScope is introduced in the usual manner, followed by introduction of the fiberoptic bronchoscope (FOB). While the resident manipulates the FOB into position, the supervisor monitors the GlideScope display to see where the tip of the FOB is located. (The resident looks only through the FOB and does not look at the GlideScope display.) The supervisor then provides verbal feedback to the resident as to the location of the tip of the FOB. Once the FOB has entered well into the trachea, the endotracheal tube is then passed over the FOB into the glottis. Here, use of the GlideScope can again be helpful, since should the endotracheal tube get caught on the arytenoids or other laryngeal structures, it becomes evident on the GlideScope display, and appropriate corrective action (such as twisting the endotracheal tube) can easily be taken. Note that this technique is also useful for other purposes, as in situations where FOI is difficult even for experienced operators, as may occur, for instance, in the case of airways soiled by blood.
GlideScope Assisted Topical Anesthesia Using the MADgic Atomizer
(3.43 MB, 39 sec, 15 fps, 320x240)
Following sedation with midazolam, the airway was anesthetized with gargled and then atomized 4% lidocaine.The GlideScope was then introduced. Once a good view of the glottis was obtained additional lidocaine was administered to the vocal cords under direct vision using a MADgic atomizer (Wolfe Tory Medical, Salt Lake City, USA). While we could have easily passed the endotracheal tube directly under GlideScope visualization in this setting, the resident needed experience in awake fiberoptic intubation, so the GlideScope was used only to assist in airway topicalization.
Note, however, that there are several advantages of using the GlideScope for awake intubation. First, the view is excellent. Second, the method is less affected by secretions or blood as compared to fiberoptic intubation. Third, everyone can view the intubation, while this is the case only for video bronchoscopes. Fourth, the intubation can be recorded using a regular camcorder. Fifth, there are no restrictions on the type of endotracheal tube (ETT) that can be placed, while this is not the case for fiberoptic methods. Sixth, the GlideScope is more rugged than a bronchoscope, and is less susceptible to damage. Seventh, the GlideScope is easily cleaned. Finally, while advancing the ETT into the trachea over a bronchoscope often fails as a result of the ETT impinging on the arytenoid cartilages, this is not a problem with the GlideScope.
This patient was a morbidly obese woman scheduled for a gastric banding procedure. Following the induction of general anesthesia, a GlideScope intubation attempt was carried out by a resident inexperienced with the use of the device. When I took over from the resident I was poorly positioned (I was off to the patient's side) and felt rushed (since morbidly obese patients desaturate quickly). Although the view was not great I felt that I was probably in the trachea - a confidence inappropriately bolstered by experience in over 500 GlideScope cases. But it soon became apparent that this was an esophageal intubation.
This 40 year old lady had a large vocal cord polyp. After the induction of general anesthesia she turned out to be fairly hard to ventilate, presumably because of airway obstruction. Although we got a good view of the glottis, despite using a small endotracheal tube (size 5.0 MLT), the tube did not pass all that easily. To see the surgeons chipping away at the polyp click here (6.9 MB 75 second MPEG 4 color video clip).
This 44 year old patient was scheduled for a sinus endoscopy. At a previous anesthetic he was noted to have a Cormack-Lehane grade IV view (epiglottis and glottis not visible). As this clip nicely illustrates,in such cases the GlideScope sometimes offers an excellent view anyway.
This 64 year old patient had really terrible teeth, and we were very worried about knocking out a tooth with intubation. This turned out not to be a problem, and we used the GlideScope to provide a quick video record of the unchanged state of his teeth after intubation.
This is a case where I was called in for assistance since the patient was unable to be intubated. As this clip nicely illustrates, the GlideScope did a nice job in this case.
This is a case where I was called in for assistance. The resident unsuccessfully tried a Macintosh 4 blade, followed by a Miller 3 blade. The staff was unable to see anything either (with a Macintosh 4 blade), and called for the GlideScope. By the time I arrived the patient was still under anesthesia, but the succinylcholine had worn off. The first attempt with the GlideScope was unsuccessful (Part A), but success was subsequently achieved following the administration of succinylcholine (Part B). .
This patient with sarcoidosis could not be intubated using Macintosh 3 and 4 blades. An LMA Fastrach was placed with a view to intubating by this route, by the patient could not be ventialted after placement, so a regular LMA was used temporarily. I was called in for assistance. However, the GlideScope was barely able to enter the oropharynx, the view was terrible, and so further attempts at intubation were abandoned for the moment.
Sometimes the endotracheal tube enters the glottis but hangs up on the anterior tracheal wall. A "twist action" maneuver - whereby the endotracheal tube is rotated while being passed through the cords - can be helpful, as it was in this case.
Case 668
Nasal Intubation
(5.34 MB, 62 sec, 15 fps, 320x240)
Nasal intubation can be achieved using the GlideScope, but special considerations apply. A stylet is not used. In this case Mcgill forceps were not needed. Instead the head of the patient was manipulated so that the glottis was lined up with the endotracheal tube and the tube advanced.
Case 610
Severe Subglottic Stenosis (GlideScope Failure)
(24.5 MB, 265 sec, 15 fps, 320x240)
This patient with severe subglottic stenosis was unable to be intubated using the GlideScope. First a size 6.0 endotracheal tube was tried, then a 4.0 MLT. What saved the day was a DEDO laryngoscope used by the ENT service, which provided a "straight shot" with the 4.0 MLT tube. There was no problem with desaturation, thanks to generous preoxygenation. In retrospect, I probably should have used a bougie or Frova intubation catheter.
Case 663
Cancer Patient Missing Vocal Cords
(7.12 MB, 84 sec, 15 fps, 320x240)
This patient with laryngeal cancer had his vocal cords surgically removed in a previous operation.
