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Techniques for Nasal Intubation
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Techniques for Nasal Intubation

Video and Mirror Laryngoscopes

Glidescope Video Laryngoscope

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The Glidescope Video Laryngoscope (GVL) is a video laryngoscope incorporating a high-resolution miniature video camera positioned on a curved hyper-angulated laryngoscope blade (approximately 60 degrees up from horizontal).

Curvature of Glidescope blade (black, top) compared to American Macintosh blade 

The combination of the blade curvature, camera mounting position, and wide field of view yields a very effective means of imaging the larynx, even in difficult or impossible direct laryngoscopy situations.

 

The device works very well with blood and secretions due to the recessed and protected camera position on the blade.  With vomitus and massive hemoptysis or hematemesis, it is best to suction the patient aggressively prior to insertion.  The image from the Glidescope is looking upward toward the larynx from within the hypopharynx, and is not dependent on patient neck positioning.  A neutral head-neck position, i.e., face plane parallel to the ceiling, helps with jaw distraction allowing more room for tube delivery and intubation (as opposed to atlanto-occipital extension which narrows the hypopharngeal space).

 

The Glidescope is the first alternative airway management technique that has been widely adapted into emergency care settings and used with rapid sequence intubation.  The device originally involved a mobile cart or IV pole attachment, but now the monitor had been ruggedized into a portable version (Ranger) and units with disposable plastic blades (Cobalt and Ranger Single Use), eliminating the logistic difficulties of sterilization between uses. The curved blade shape of the Glidescope is simple to insert, and operators feel comfortable inserting the device and distracting the tongue and jaw, similar to standard laryngoscopy. 

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glidescope

glidescope Ranger

 
cobalt glidescope

Glidescope Video Laryngoscope 4 sizes plus GildeRite Stylet

Glidescope Ranger with Single Use Blades

Glidescope Cobalt showing plastic disposable blade

 

The Glidescope is now offered in four blade sizes GVL 2, 3, 4, 5:

GVL 2:
Patient weight: 1.8 - 10 kg
Blade length (tip to handle): 47 mm
Thickness (height) at camera: 14.5 mm
Width at camera: 18 mm

 

GVL 3:
Patient weight: 10 kg - Adult
Blade length (tip to handle): 82 mm
Thickness (height) at camera: 14.5 mm
Width at camera: 20 mm

GVL 4:
Patient weight: 40 kg – Morbidly Obese
Blade length (tip to handle): 102 mm
Thickness (height) at camera: 14 mm
Width at camera: 27 mm

 

GVL 5:
Patient weight: 40 kg – Morbidly Obese
Blade length (tip to handle): 102 mm
Thickness (height) at camera: 14 mm
Width at camera: 27 mm

 

For novice users of the Glidescope there two subtleties of use that must be understood prior to attempting intubation on an actual patient. The first is that the direct line of sight view down the hyper-angulated curved blade is markedly divergent from the camera’s view.  In other words, the operator has no direct view down the blade.  The blade simply serves to retract tongue and epiglottis and the laryngeal view comes from the camera exclusively. Imaging the target and placing the tube with the Glidescope are entirely different procedures.  In fact, sometimes maximizing the laryngeal view can negatively impact on tube delivery. In many instances, easier tube delivery (intubation itself) occurs when the blade is not fully advanced into the vallecula and the view maximized.  With less full advancement of the blade, the approach angle of the tube is more favorable (discussed below).

 

The second “trick” to the Glidescope is the intubation technique itself, i.e., how the tube is actually delivered into the trachea.  In order to navigate around the curvature of the tongue and hypopharynx, a tracheal tube must be shaped relatively sharply (to match the path the blade creates).  A tube and stylet of 70-90 degrees, however, cannot just be rotated around the tongue and into the trachea.  This severe a bend angle allows entry into the larynx, but hits the anterior trachea at too steep an angle to advance further.  The tip of the tube catches on the first and second tracheal rings.  While rotation of the tube and stylet rightward (clockwise) helps disengage the tube tip from the anterior tracheal rings, tube delivery with the Glidescope is best performed in two-steps.  First the tube and stylet are brought around the curve of the tongue, and only the tip is inserted into the larynx, while watching the insertion on the video monitor.  After the tip of the tube enters the larynx, the stylet is partially withdrawn.   The distal end of the tracheal tube, now without a stiffening stylet, can then be advanced fully into the trachea. 

 

Click here for more information on tube delivery issues with the Glidescope
(and the GlideRite Stylet and Tube)

 

PUBMED CITATIONS ON GLIDESCOPE


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