Hermans, B

Lee, R

Maassen, R

Van Zundert, Adrien

English

Ghent University Academic Bibliography

© Acta Anæsthesiologica Belgica, 2008, 59, n° 3Securing a patent airway in patients under -going general anesthesia is routinely performedusing direct laryngoscopy with a Macintosh laryn-goscope blade. However, successive intubationattempt to pass the vocal cords can have a tremen-dous impact on patient outcome. A good laryngealview is often a prerequisite, if not a guarantee, forsuccessful intubation. There are numerous difficul-ties associated with intubation which can have animportant effect on patient morbidity or mortalitysuch as : 1) difficult laryngoscopy (obtaining a non-optimal view of the glottis entrance or no view ofthe vocal cords at all) ; 2) difficult intubation (forwhich extra tools, such as a gum elastic bougie,stylet, Bonfils, Trachlight, fiberoptic intubation,intubating laryngeal mask, ... are required) ; and3) failed intubation. Previously the paradigm for safe intubationhas been built on the foundations of adequate pre-operative measurement of a patient’s airway. Theplethora of metrics for intubation difficulty (i.e.,Mallampati, Cormack Lehane grade, BMI, mouthopening, dentition, thyromental or sternomentaldistances, protruding teeth, overbite, limited neckmovement, are, however, usually very disappoint-ing in predicting difficult cases of intubation.Preoperative metrics that indicate a difficult airwayare not necessarily correct, while patients deemedto have ‘normal’ airways are not precluded frompossibly difficult intubations. Therefore, the ubiquitous assessment of preoperative metrics of apotentially difficult airway by anaesthesiologists, isincomplete at best, but, furthermore, less relevantregarding videolaryngoscopy.The recent introduction of videolaryngoscopesincorporating optics in the tip of the intubationblade has proven advantageous qua improved view-ing of the glottis (Fig. 1). Further, it is assumed inliterature that there are fewer traumas to the patient,with faster intubation times, even in problematiccases (Table 1). Since videolaryngoscopy facilitatesindirect vision of the vocal cords, and it is no longerrequired to visualize the glottic entrance directly,less force is needed to lift the jaw. This has theadvantage that less forces are exerted on the(Acta Anaesth. Belg., 2008, 59, 177-178)Videolaryngoscopy – making intubation more successfulA. A. J. VAN ZUNDERT (*), R. L. J. G. MAASSEN (**), B. HERMANS (**) and R. A. LEE (***)A. A. J. VAN ZUNDERT ; R. L. J. G. MAASSEN ; B. HERMANS ;R. A. LEE.(*) Department of Anesthesiology, ICU & Pain Therapy,Catharina Hospital-Brabant Medical School, Eindhoven,Netherlands, and Ghent University Hospital, Ghent,Belgium.(**) Department of Anesthesiology, ICU & Pain Therapy,Catharina Hospital-Brabant Medical School, Eindhoven,Netherlands, and Maastricht University Hospital,Maastricht, Netherlands.(***) Department of Biomedical Engineering, Faculty ofMechanical, Maritime, and Materials Engineering, DelftUniversity of Technology, Delft, The Netherlands.Correspondence address : Prof. Dr. André van Zundert,Department of Anesthesiology, ICU & Pain Therapy,Catharina Hospital-Brabant Medical School,Michelangelolaan 2, 5623EJ, Eindhoven, The Netherlands.Tel. : +31 40 239 9111. Fax : + 31 40 246 3978. E-mail :zundert@iae.nlFig. 1. — Example of a new videolaryngoscope (C-Mac™,Storz, Tuttlingen, Germany).' Acta Ansthesiologica Belgica, 2008, 59, n¡?3178 A. A. J. VAN ZUNDERT et al. maxillary incisors, relative to classical direct laryn-goscopy, irrespective of anaesthesiologist experi-ence, patient characteristics, or common metrics ofintubation difficulty. This potentially results in lesstrauma to teeth during intubation. Videolaryngoscopes are potentially superioreven for easier patients, but are most beneficialfor use with difficult-to-intubate patients (1).Especial ly in patients where preoperative metricsdo not indicate a difficult airway and the anaesthe-siologist is confronted with an unexpectedlydifficult intubation the videolaryngocope can besuperior to direct classic laryngoscopy.Despite the clear advantages over classicdirect laryngoscopy, there are differences in patientoutcome between the commercially available videolaryngoscopes, Differences exist (e.g. suc-cessful intubation, first pass success, intubationtime, use of extra tools) between the differentdevices. To overcome certain deficits certain manufacturers advocate using a styletted endo -tracheal tube, which may in itself have disadvan-tages. Further studies should investigate strategiesfor optimizing the ergonomic design of the bladesfor videolaryngoscopes. The integration of the videolaryngoscope blade and endotracheal tubegeometry is the most pressing point for furtherdevelopment. CONCLUSIONSuccessful laryngoscopy and subsequent intu-bation depends on the patient’s characteristics andposition during intubation, the intubator’s skills, thetechnique used and the intubation tools. Besidesplacing the patient in an optimal position, wecannot change the patient’s anatomy. The plethoraof methods to predict difficult intubation conditionsyield inclusive results. We, therefore, should focusour attention to technical or procedural improve-ments, especially the design of better laryngo-scopes. Indirect videolaryngoscopy is one suchimprovement, as it offers a better viewpoint of theglottic entrance, often unachievable with directclassical techniques. Videolaryngoscopy is shownto have promising features. We believe that video-laryngoscopy will become standard for all intuba-tions, not only those predicted to be ‘difficult‘.Consequently, the ‘Difficult Airway Algorithm’guidelines have to be adjusted according to thedevelopment of the introduction of new tools in ourpractice, such as videolaryngoscopy.References1. Van Zundert A., Stessel B., de Ruiter F., Giebelen D.,Weber E., Video-assisted laryngoscopy – a useful adjunct inendotracheal intubation, ACTA ANAESTH. BELG., 58, 129-131,2007.Table 1Suggested advantages of videolaryngoscopesCLINICAL – Airway management  Both direct (naked-eye) and indirect (video-assisted) larygoscopy possible  Improved viewing of glottic entrance andsurroundings near perfect view of glottic entrance andsurroundings viewpoint closer to vocal cords wider angle of view better viewing without excessive angula-tion of laryngoscope blade better view of passage of endotrachealtube between vocal cords better evaluation of exact depth of tubeinsertion better view of passage gastric tube intooesophagus reduction in dental damage  Ease of intubation is facilitated less attempts shorter intubation time  seldom need for extra tools  usually no need for external manipulationtrachea/ cricoid  Intubation in (predicted) difficult situationsTECHNICAL  Integrated video display monitor, laryngo-scope and cable  LED lighting further improves better viewingof glottis  Anti-fogging  AC power and DC Lithium-ion battery power  Colour LCD display with CMOS chip  Robustness (stainless steel)  Heat resistant blade (stainless steel)  Portable  Still images and video capturing  SD-card MPEG/JPEG  Reusable (immersable, HDL, Steris)  Different sizes of blades fit on videolaryngo-scopeOTHER APPLICATIONS  Diagnostic tool better view results in more diagnoses ofcysts and tumours other specialists can use it as diagnostictool (e.g. ENT)  Teaching/ educational tool no more “look over the shoulder” both anaesthesiologist and resident cansimultaneously see intubation recording possible for education purposes documented monitoring of tracheal intu-bation possible

Videolaryngoscopy: making intubation more successful

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Videolaryngoscopy: making intubation more successful

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