The anaesthetic laryngoscope Airtraq is designed for the difficult airway. This disposable laryngoscope requires minimal cervical manipulation and unlike other common anaesthetic larynmgoscopes contains a channel for the guidance of an endotracheal tube.  This could also be used for diagnosis and biopsy under a general anaesthetic or potentially under a local anaesthetic in an outpatient setting for biopsies or the removal of hypopharyngeal foreign bodies via flexible biopsy forceps obviating the need for a general anaesthetic. Thus Airtraq could be included in the armoury of pre-existing direct laryngoscopes because of its virtue of minimal airway manipulation

Mendis, D

Oates, J

English

Dulani Mendis

John Oates

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The Application of Airtraq (fibreoptic intubation device) to Otolaryngology

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 Short Review:
The Application of Airtraq (fibreoptic intubation device) to Otolaryngology
Dulani Mendis, ENT SpR, West Midlands Deanery, Dept. of ENT Surgery, Birmingham Children’s Hospital NHS Foundation Trust, 
Steelhouse Lane, Birmingham B4 6NH,
John Oates, Consultant Otolaryngologist, Dept. ENT Surgery, Queen’s Hospital, Belvedere Road, Burton-on-Trent, DE13 0RB.
Address for Correspondence:
Dulani Mendis,
ENT SpR, West Midlands Deanery,
Dept. of ENT Surgery,
Birmingham Children’s Hospital NHS Foundation Trust,
Steelhouse Lane,
Birmingham B4 6NH.
E-mail: dulanimendis@yahoo.com
Citation: Mendis D, Oates J. The Application of Airtraq (fibreoptic intubation device) to Otolaryngology. Online J Health Allied Scs.  
2011;10(2):16
URL: http://www.ojhas.org/issue38/2011-2-16.htm
Open Access Archives: http://cogprints.org/view/subjects/OJHAS.html and http://openmed.nic.in/view/subjects/ojhas.html
Submitted: Jun 24, 2011; Accepted: Jul 16, 2011; Published: Jul 30, 2011
Abstract: The anaesthetic laryngoscope Airtraq is designed for 
the difficult airway. This disposable laryngoscope requires min-
imal cervical manipulation and unlike other common anaesthet-
ic larynmgoscopes contains a channel for the guidance of an 
endotracheal tube.  This could also be used for diagnosis and 
biopsy under a general anaesthetic or potentially under a local 
anaesthetic in an outpatient setting for biopsies or the removal 
of  hypopharyngeal  foreign bodies  via  flexible biopsy forceps 
obviating the need for a general anaesthetic. Thus Airtraq could 
be included in the armoury of pre-existing direct laryngoscopes 
because of its virtue of minimal airway manipulation.
Key Words: Difficult intubation; Laryngoscopy
Introduction:
Difficult endotracheal intubation is often associated with a dif-
ficult  direct  laryngoscopy  for  the  Otolaryngologist  and  sub-
sequent poor visualisation of the larynx. A difficult intubation 
is  defined  as  “more  than  three  attempts  to  intubate  in  10 
minutes of time” 1, or whereby “it is not possible to visualise 
any portion of the vocal cords with conventional laryngoscopy” 
or  “intubation  requires  more  than  one  attempt,  a  change  in 
blade, an adjunct to direct laryngoscopy or use of alternative 
devices”.2 The difficult airway is usually assessed as being Cor-
mack and Lehane Grade 3 and 4 or Mallampati Class 3 and 4 
(Figure 1).
Other contributory patient factors may be morbid obesity and 
cervical  spine  pathology  e.g.  trauma  and/or  degenerative 
disease  causing instability  (Rheumatoid  Arthritis).  Successful 
tracheal intubation achieved by obtaining a good glottic view, 
requires alignment  of three optical axes corresponding to the 
oral, pharyngeal and laryngeal planes (Figure 2).
During routine laryngoscopy,  a degree of manipulation of the 
neck is  required to  align  these  axes.  Excessive  manipulation 
due to an unexpected difficult airway can result in delayed in-
tubation  (hypoxia),  cervical  injury,  soft  tissue  injury and  in-
creased risk of  dental trauma.  In patients with cervical  spine 
trauma the concomitant manual in-line axial stabilisation pre-
vents head extension and neck flexion further limiting optimal 
visualisation of the glottis.
Figure  1:  (A)  Mallampati  classification:  Class  1  – 
visualisation  of  the  soft  palate,  Class  2  –  complete 
visualisation of the uvula, Class 3 – visualisation of the base 
of the uvula, Class 4 – soft palate is not visible at all. 
(B) Laryngoscopy according  to the Cormack and Lehane 
classification: Grade I – most of the glottis visible, Grade II 
– only the posterior extremity of the glottis visible, Grade 
III  –  only  the  epiglottis  visible  (none  of  the  glottis  seen), 
Grade IV- neither epiglottis or glottis visible.
Figure  2: Diagram  illustrating  the  oral,  pharyngeal  and 
laryngeal axes, in-order to to obtain an optimal view prior 
to intubation a degree of cervical manipulation is required 
for the alignment of these axes.
Alternative  methods  for  intubating  difficult  cases  include 
awake-fibreoptic  intubation,  with  the  gold  standard  being  a 
fibreoptic  bronchoscope.  This  is  a  skilled  technique  with  a 
steep learning curve. The procedure can take some time and the 
1
This work is licensed under a
Creative Commons Attribution-
No Derivative Works 2.5 India License
Online Journal of Health and Allied Sciences
Peer Reviewed, Open Access, Free Online Journal
Published Quarterly :  Mangalore, South India : ISSN 0972-5997
Volume 10, Issue 2; April-June 2011
view may be compromised by blood and secretions. The instru-
ment  is  weighty  and  expensive,  it  requires  a  separate  light 
source or video stack and the instrument can present as a source 
of infection if not properly sterilised. Awake intubation, is per-
formed in a controlled manner with an expected difficult intub-
ation.  In  the  case  of  a  crash  intubation  the  Otolaryngologist 
may be called upon to intubate with a side splitting Negus-type 
laryngoscope or as a last resort perform an emergency surgical 
airway (cricothyroidotomy or tracheostomy).
Other anaesthetic laryngoscopes for difficult intubations in the 
anaesthetised  patient  are  the  McCoy  levering  laryngoscope 
blade (Penlon Ltd, Abingdon, UK), Bullard laryngoscope (Cir-
con  ACMI,  Stamford,  CT),  the  LMA C-Trach (LMA North 
America, San Diego, CA) and the Glidescope (Saturn Biomed-
ical, Burnaby, British Colombia, Canada). These are essentially 
anaesthetic laryngoscopes, which provide an improved view for 
intubation but not necessarily the equivalent view obtained with 
a direct laryngoscope (Negus, Kleinsessor, Lindholm) required 
in  Otolaryngology  for  biopsy  purposes  or  removal  of 
laryngeal/hypopharyngeal foreign bodies.
The Airtraq laryngoscope, (Inventor:  Pedro Acha, Gandarias, 
produced by Prodol Meditec, Spain) is a new device which has 
recently become  commercially  available  in  the  United King-
dom.  It  is  a  disposable  device  with  an  anatomically  shaped 
blade. This contains a series of lenses, prisms and mirrors that 
transfer the image from the illuminated blade tip to the proxim-
al  viewfinder.  The  blade  incorporates  a  endotracheal  tube 
(ETT) channel on the right side to guide the ETT and any type 
of ETT can be used (standard, reinforced etc.)
The light is battery powered and the battery box is located in 
the main body of the Airtraq device. There are two sizes selec-
ted depending on patient weight and size of ETT to be used; 
regular size - maximum blade thickness of 17.5 mm (ETT 7.0-
8.5) and small  – maximum blade thickness of  15.5mm (ETT 
6.0-7.5), (Figure 3A, 3B). Two further Airtraq versions now ex-
ist  for  nasotracheal  and  double  lumen  endobronchial  intuba-
tions.
Figure 3: (A) Photo of the disposable Airtraq device. 
Figure 3:  (B) Photo demonstrating the detachable view 
finder and battery pack.
There is an anti-fog system and an available clip-on video sys-
tem to allow viewing on to a monitor with a recording facility. 
The device requires 30-60 seconds to reach its maximal light 
and it can be passed, and the patient intubated with the neck in 
a neutral position (no manipulation of the neck is required) and 
so a good view of the glottis is obtained without the need for 
aligning the three axes due to the inherent prism system.
Airtraq has been used in patients with cervical spine trauma3, 
morbidly obese patients4, patients requiring rapid sequence in-
duction5, intubation in the upright position6, awake intubation-
s7 and  intubations  without  muscle  relaxants.  Maharaj,  et  al 
(2006)8 compared the ease of learning intubation with the Air-
traq device with a Mackintosh laryngoscope.  The study con-
cluded that the Airtraq laryngoscope required less operator skill 
to use.  It had a shorter learning curve, was able to provide a 
good view of the larynx with minimal airway manipulation, re-
duced  intubation  time  and  was  associated  with  less  dental 
trauma.
Discussion: Application to Laryngology
The use of the Airtraq device in Laryngology maybe relevant 
for the difficult to intubate patient as the hypopharyngeal/laryn-
geal view is similar to that obtained with a direct laryngoscope 
with  the  additional  advantage  of  less  airway  manipulation 
whilst primarily being used as an intubating tool. To expose the 
glottis the device can either be located at the valecullar or under 
the epiglottis.  Biopsies  of relevant areas could also be taken, 
which is more feasible with shorter versions of flexible biopsy 
forceps (e.g those used for bronchoscopy), in order to follow 
the exaggerated curvature of the laryngoscope (Figure 4). There 
does  not  appear  to  be  a  suitably  curved  rigid  instrument  at 
present.
Figure 4: Photo demonstrating the Airtraq device with the 
use of a flexible biopsy forcep guided through the intuba-
tion channel for the proposed purpose of foreign body re-
moval and biopsies
The device has been described for use in awake patients; this 
could be applied in the outpatient setting for laryngeal biopsies 
and  the  effective  removal  of  hypopharyngeal  foreign  bodies 
with adequate local anaesthesia using flexible forceps and an 
appropriate flexible suction catheter. Mackintosh laryngoscopes 
have anecdotally been used previously for foreign body remov-
al in an awake patient but this is usually a difficult, uncomfort-
able and unsuccessful procedure. This could prevent the need 
for  a general  anaesthetic (especially relevant  to patients with 
multiple  co-morbidities,  American Society of  Anesthesiology 
grade 3 and upwards) and the cost of a hospital admission.
The Airtraq is single use; the plastic viewfinder and battery box 
are detached from the blade, which is disposable.  Disposable 
items although initially expensive when introduced to the mar-
ket are desirable in terms of reducing the risk of transmission of 
prion proteins (Creutzfeldt Jacob disease).
Financially, the four Airtraq variants are costed at £35 exclud-
ing VAT (Fannin UK Limited, Reading). The video system is 
an optional add-on consisting of a clip-on camera and wireless 
receiver. In terms of the curved instruments standard flexible 
bronchoscopy biopsy forceps are costed at £10 each excluding 
VAT in boxes of ten (Diagmed Healthcare, Yorkshire, UK) a 
shorter version of these (currently 110cm in length) would be 
the most appropriate.
2
Conclusion:
Our review comments on the application of a new intubating 
device currently used by Anaesthetists for the difficult airway, 
to Otolaryngology for diagnostic purposes in such cases and on 
its  potential  use  for  the  removal  of  hypopharyngeal  foreign 
bodies in an outpatient scenario, obviating the need for a gener-
al anaesthetic.
We propose the importance of including this device in the ar-
moury of pre-existing direct laryngoscopes because of its virtue 
of minimal airway manipulation.
References:
1. American  Society  of  Anesthesiologists.  Practice 
guidelines for management of the difficult airway. A re-
port by the American Society of Anesthesiologists Task 
Force on Management of the Difficult Airway. Anesthesi-
ology. 1993;78(3):597-602.
2. American  Society  of  Anesthesiologists.  Practice 
Guidelines for Management of the Difficult Airway. An 
Updated Report  by the American Society of  Anesthesi-
ologists Task Force on Management of the Difficult Air-
way. Anesthesiology. 2003;98(5):1269–1277.
3. Maharaj  CH,  Buckley  E,  Harte  BH,  Laffey  JG.  Endo-
tracheal  Intubation  in  Patients  with  Cervical  Spine  Im-
mobilization.  A Comparison  of  Mackintosh and Airtraq 
Laryngoscopes. Anesthesiology. 2007;107(1):53-59.
4. Dhonneur G, Ndoko SK, Amathieu R, Housseini LE, Pol-
liand C, Tual L. A comparison of two techniques for in-
serting  the  Airtraq  laryngoscpe  in  morbidly  obese  pa-
tients. Anaesthesia. 2007;62:774-777.
5. Dhonneur  G,  Ndoko  SK,  Amathieu  R,  Housseini  LE, 
Poncelet C, Tual L. Tracheal Intubation Using the Airtraq 
in  Morbid  Obese  Patients  Undergoing  Emergency 
Cesarean Delivery. Anesthesiology. 2007;106(3):629-630.
6. Ndoko SK, Amathieu R, Tual L, Polliand C, Kamoun W, 
Housseini  LE,  Champault  G, Dhonneur G. Tracheal in-
tubation  of  morbidly  obese  patients:  a  randomised  trial 
comparing performance of Macintosh and Airtraq laryn-
goscopes. British  Journal  of  Anaes-
thesia. 2008;100(2):263-268.
7. Suzuki  A, Toyama Y, Iwasaki  H. Correspondence: Air-
traq  for  awake  tracheal  intubation. Anaes-
thesia. 2007;62:744-755.
8. Maharaj CH, Costello JF, Higgins BD, Harte BH, Laffey 
JG.  Learning and performance of tracheal intubation by 
novice personnel: a comparison of the Airtraq and Mack-
intosh laryngoscope. Anaesthesia. 2006;61:671-677.
3


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The Application of Airtraq (fibreoptic intubation device) to Otolaryngology

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