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VideolaryngoscopyWhy go blind
if you can see?
André van Zundert, MD, PhD, FRCA, EDRA, FANZCA
Professor & Chairman Discipline of Anesthesiology
The University of Queensland & Royal Brisbane & Women’s Hospital
Chair University of Queensland ‘Burns, Trauma, Critical Care Research Centre’
Chair University of Queensland ‘Centre of Excellence & Innovation in Anaesthesia’
Brisbane QLD Australia
Royal Brisbane and Women’s Hospital
Metro North Hospital and Health Service
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Prof André van Zundert
The most challenging aspect for the anaesthetist is the insertion of a
tracheal tube.No other anaesthetic gesture is this
important. Failure to succeed can ultimately lead to a life-or-death situation
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Problems with Airway Management
• Endotracheal Tubes• Laryngoscopy: classic laryngoscopy fails (Cormack-Lehane grade III-IV = blind intubation)
• Tracheal intubation (NAP4 Report – UK)• Failed: 1 in 1-2,000 pts (elective surgery) – 1:250 (OB pts) – 1:50-100 (ICU/DEM)
• Failed: difficult or failed tracheal intubation is low (1:2,000 to 1:50 cases)
• CICO: 1:5,000 cases
• Laryngeal Masks• Downfolding of the epiglottis: incidence: >50% - 90%
• Glottis (slightly) obstructed by epiglottis
• Epiglottis seen in bowl of laryngeal airway mask
• LEAK & OBSTRUCTION – inadequate ventilation
• Vocal cords not always visible during fibreoptic scopy
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Be PreparedDanish Airway Registry: 93% of difficult tracheal intubations are unpredicted! Anaesthesia 2015
Preoperative Evaluation Airway
Correct Position on Operating Table
Have Airway Equipment Ready ad Hand
Teeth Protection‘Dental Guards’
Plan A
Plan B
Plan C
Plan D
RAMPED
position
HELP
Head
Elevated
Laryngoscopy
Position
Plan A
Plan B
Plan C
Plan D
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Mallampati-Gatt Score
Grade I Grade II Grade III Grade IV
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Tenaceous secretions/saliva/pus Aspiration!
Clear the airway!
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250 million operations/yr
General anaesthesia
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1940s 2015
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RAMP POSITION
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Van Zunder A. et al. Br J Anaesth 2012
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Alignment tracheal – laryngeal - oral axes
Greenland et al.Van Zunder A. et al. Br J Anaesth 2012
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Van Zunder A. et al. Br J Anaesth 2012
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10 Major Advantages of VLS over Classic Direct LaryngoscopyImproved glottic view & less failed laryngoscopies (CL III-IV)
C-L I C-L II POGO C-L III
Direct: 90% good laryngoscopySuccessful Intubation
VLS99% success
Direct: Up to 10% failed laryngoscopyDifficult Airway Management
Prediction of a difficult airway = inexact scienceOverall patients with a difficult airway were NOT predicted by preoperative parameters
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10 Major Advantages of VLS over Classic Direct LaryngoscopyClear differentiation between trachea & esophagus
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Reduced hemodynamic response during tracheal intubation
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
GlideScope® Storz® McGrath®0
20
40
60
80
100
La
ryn
go
sco
pie
s (
%)
Reduced need for adjuncts (e.g. rigid stylet)
Van Zundert et al. Anesth Analg 2009 Maassen-van Zundert Anesth Analg 2009
Normal Airways Difficult Airways
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Less trauma to upper incisors + soft tissue
0 5 10 15 20 25 30 35
0
10
20
30
40
50
60
Time (s)
Fo
rce
(N
)
Forces during intubation of an obese patient with
both classic and video laryngoscope
Classic
Video
1
23
1
Lee, van Zundert Anesth Analg 2009;108:187-91
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Less trauma to upper incisors + soft tissue
Rigid stylet
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Trauma to Palatopharyngeal Wall Rigid stylet
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10 Major Advantages of VLS over Classic Direct LaryngoscopyMore successful intubations in NORMAL + DIFFICULT AIRWAYS
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10 Major Advantages of VLS over Classic Direct LaryngoscopyMore successful intubations in NORMAL + DIFFICULT AIRWAYS
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10 Major Advantages of VLS over Classic Direct LaryngoscopyMore successful intubations in NORMAL + DIFFICULT AIRWAYS
Acute EpiglottitisActa Anaesthesiol Belg 2010;6167-70
Bonfils + C-MAC
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10 Major Advantages of VLS over Classic Direct LaryngoscopyMore successful intubations in NORMAL + DIFFICULT AIRWAYS
Cervical fracturesfixation
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10 Major Advantages of VLS over Classic Direct LaryngoscopyMore successful intubations in NORMAL + DIFFICULT AIRWAYS
• Orogastric/nasogastric tubes
• Temperature probes
• Gastroscopes/esophagoscopes
• Double lumen tubes
• Laryngeal masks
• Facilitate surgeons (ENT)
Videolaryngoscopes facilitates safe insertion ThyroidectomyCorrect insertion depth NIM tube
Neural Integrity Monitor
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10 Major Advantages of VLS over Classic Direct LaryngoscopyMore successful intubations in NORMAL + DIFFICULT AIRWAYS
Limited Lip/Mouth OpeningVan Zundert et al. J Anesth 2012;26:468-9
Giant Tonsils / Kissing Tonsils CL- IV / Long epiglottis
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10 Major Advantages of VLS over Classic Direct LaryngoscopyMore successful intubations in NORMAL + DIFFICULT AIRWAYS
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Improved initial intubation success rate of novice intubators and paramedics
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
More successful tracheal tube exchange procedures under continuous glottis visualization
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10 Major Advantages of VLS over Classic Direct Laryngoscopy
Better teaching, learning and monitoring tool
Van Zundert et al. Minerva Anestesiol 2013
Videolaryngoscopy is easy to learn!
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Major Advantages of VLS over Classic Direct Laryngoscopy
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What will the future hold for videolaryngoscopy?
• Preop. transnasal evaluation of airway be prepared
• Videoclip/still image laryngoscopy/TT
in patient’s records = Better Informed Anesthesiologists
For education/courses/research = Better Teaching Options
• Telemedicine/Tele-intubation:
Remote advice to jr (night shift problem) & snr (remote hospital)
• Difficult airway alert / bracelet /identification document
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Videolaryngoscopy: Time to change our practice!
We have now the tools available to
facilitate successful, fast, accurate,
atraumatic tracheal intubation in patients:
– Normal airway
– Anticipated difficult airway
– Unanticipated difficult airway
– ALL Patients undergoing Anesthesia
– Elective & Emergency Surgery
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Videolaryngoscopy: Time to change our practice!
Videolaryngoscopyshould become the
rulenot the exception!
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Editorial
Minerva Anestesiologica
2015
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