Glidescope fail

[Monty Python]

Until yesterday I had a 100% batting average with the Glidescope on a difficult airway. Yesterday I struck out and it still bugs me.

Normal stature 80 kg, 22 y/o male for elective procedure.

Unanticipated difficult AW. Easy to mask ventilate. Grade 4 view with Mac and Miller DL, could barely see epiglottis. Called for help and AW cart. First person in the room was the dept. chair, whose go-to is the lightwand (and she's VERY good with it). No joy.

Now the AW cart arrives, and within two seconds I have a beautiful view of the cords with the Glidescope, easily pass the bougie beyond the cords. Then I and a partner are both unsuccessful getting the seldinger'ed ETT to quit bumping against the arytenoids and go in despite changes in our body English, angle, choice of epithets, etc.

I was using the single-use disposable Mac 3 blade.

As we mask-ventilated again, the surgeon asked to try. She took one peek with the Miller DL, and said to abort due to worries about AW swelling. We were already thinking it, and she verbalized it about 5 seconds before I was going to.

Does anyone have any pearls for the above scenario? We don't have the "Glideright" ETTs with the cobra-shaped tip.

In the locker room I was armchair-quarterbacking my actions, wondering if the intubating Fast-Track LMA would have been successful. This pt was verrrrry anterior.

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[btbam]

Cool post. I'm not sure if anyone uses the howland lock nowadays, but I know it was the go to for very anterior airways in the past.

What about LMA placement and - assuming easy ventilation - going with fiber optic through the LMA? If fiber optic is a struggle then just wake up.

 

[Monty Python]

Cool post. I'm not sure if anyone uses the howland lock nowadays, but I know it was the go to for very anterior airways in the past.

What about LMA placement and - assuming easy ventilation - going with fiber optic through the LMA?

I actually have a Howland lock in my personal AW ditty bag, which of course yesterday was two stories up in the anesthesia call room on the OB floor.

As soon as the surgeon said "abort" (which I was already thinking) that sealed it for yesterday's attempts on a purely elective procedure. A bloody swollen about-to-occlude AW is difficult to justify on an elective procedure. There's always next week.

 

[Bertelman]

In the locker room I was armchair-quarterbacking my actions, wondering if the intubating Fast-Track LMA would have been successful. This pt was verrrrry anterior.

That technique is tricky, and it sounds like your biggest probl was anatomical alignment, which isnt solved by blindly stabbing an ETT through an LMA.

Have you ever dropped a FOB through an LMA? Slide a 6.0 over the scope, may e visualize what the tube is hanging up on.

 

[BLADEMDA]

n Now, grasp the endotracheal tube at its midpoint and rotate it 90 degrees counterclockwise so the Murphy eye is anterior. This maneuver prevents the tube tip from hanging up on the right arytenoid. Hang-up occurs because the fiberoptic shaft falls posteriorly into the interarytenoid fissure (Figure).

If the tube still hangs up, rotate the tube another 90 degrees counterclockwise.

n Advance the endotracheal tube into the trachea over the bronchoscope shaft until the 22-cm or 23-cm mark on the tube is at the teeth.


http://faculty.washington.edu/pcolley/

 

[sevoflurane]

I don't use a bougie with my glidescope. I use the glidescope stylet or sometimes if that doesn't work, I take a regular stylet and fabricate the angle (anterior angle) that will make it past the cords. With small mouth openings, I put in the Styleted ETT first. I had an anticipated difficult AW yesterday. Micrognathic, huge bugs bunny incisors, small mouth opening, 1.5-2 FB's... anywho... the glidescope stylet failed me and I ended up getting the AW by conforming my own stylet with a very acute/anterior bend and placing the ETT first... retromolar.

 

[BLADEMDA]

http://www.nellcor.com/prod/Product.aspx?S1=AIR&S2=&id=133

I've used this type of ETT tube for intubation over a standard bougie. It's much easier getting past those arytenoids.


Airway ManagementEndotrol® Tracheal Tube with Controllable Tip

Click image for larger view

\

Product Features

• <li class="bodycopyList">Hi-Lo® tracheal tube with directional distal tip control for fast, easy intubation. <li class="bodycopyList">Standard Features:
  • <li class="bodycopyList">High-volume low-pressure cuff<li class="bodycopyList">Full Magill curve<li class="bodycopyList">Hooded Murphy tip with eye<li class="bodycopyList">Tip-To-Tip® radiopaque line
  • Pilot balloon and self-sealing valve
  • Packaged sterile

 

[Monty Python]

That technique is tricky, and it sounds like your biggest probl was anatomical alignment, which isnt solved by blindly stabbing an ETT through an LMA.

Have you ever dropped a FOB through an LMA? Slide a 6.0 over the scope, may e visualize what the tube is hanging up on.

Have previously FOB'ed through the LMA on an anticipated difficult AW; yesterday caught us by surprise. Had this been an emergency case that was a potential next step, but we had already decided to abort on this elective case.

This pt was booked for a pilonidal cystectomy. Our hospital and surgeons do those under spinal most of the time. This particular surgeon is brand-new to us, and ORDERED the anesthesia dept. chair to "never" allow a spinal on her pilonidal cystectomies. Now, I'm all about working in harmony with my surgeons, meeting them more than halfway as long as it's remotely reasonable, but I get a little perturbed over stuff like this. I don't tell the surgeon which suture to use.

 

[Noyac]

I think the problem was the size of your glide scope blade. I always go with the 4 unless I just can't get it in the mouth. I know some people here say the 3 is the way to go but I disagree. Had a flight nurse in the OR the other day for her annual airway requirement. She wanted to play with the glide scope and it was a smaller woman for a pt so she,grabbed the 3. Same thing happened, great view of the cords after I helped her a bit but she couldn't pass the tube. I told her to pull everything out and try with a 4.

It worked perfectly.

 

[BLADEMDA]

In a retrospective review, primary intubation with the Glidescope was successful in 98% of 1,755 cases and rescued failed direct laryngoscopy in 94% of 239 cases.
Altered neck anatomy with presence of a surgical scar, radiation changes, or mass was the strongest predictor of Glidescope failure.


http://journals.lww.com/anesthesiol...linical_Practice_Effectiveness_of_the.17.aspx

 

[Robert Loblaw]

was it a problem twisting the tube up to the glottic opening, or was it tube getting stuck on arytenoids? you could have tried a parker tube, i guess, which i use for tube changes for this reason...

 

[Bertelman]

This pt was booked for a pilonidal cystectomy. Our hospital and surgeons do those under spinal most of the time. This particular surgeon is brand-new to us, and ORDERED the anesthesia dept. chair to "never" allow a spinal on her pilonidal cystectomies. Now, I'm all about working in harmony with my surgeons, meeting them more than halfway as long as it's remotely reasonable, but I get a little perturbed over stuff like this. I don't tell the surgeon which suture to use.

Maybe she'll change her mind now.

But probably not.

 

[BLADEMDA]

was it a problem twisting the tube up to the glottic opening, or was it tube getting stuck on arytenoids? you could have tried a parker tube, i guess, which i use for tube changes for this reason...

Yes. But, I assume a Parker tube or similar ETT was not available. The Parker tube is very similar/identical to the ETT which the Glidescope manufacturer sells. I actually prefer the Parker tube for cost reasons.

 

[Bertelman]

I don't use a bougie with my glidescope. I use the glidescope stylet or sometimes if that doesn't work, I take a regular stylet and fabricate the angle (anterior angle) that will make it past the cords. With small mouth openings, I put in the Styleted ETT first. I had an anticipated difficult AW yesterday. Micrognathic, huge bugs bunny incisors, small mouth opening, 1.5-2 FB's... anywho... the glidescope stylet failed me and I ended up getting the AW by conforming my own stylet with a very acute/anterior bend and placing the ETT first... retromolar.

We used McGrath in residency. Similar to Glidescope, but some differences.

Most of us learned to form the stylet with an acute angle at the end, then load the tube oriented 180 torque from how you normally do, so when the tube is pushed off the stylet, it points down instead of up. Works like a charm with the view and anatomy that a McGrath gives you, but again, never done this with a Glide.

 

[proman]

I wouldn't call this a Glidescope fail. You saw the target, as you said "a beautiful view of the cords". The problem was intubation not laryngoscopy. I rotate the tube as people above mention, or get a smaller tube etc. I'm not sure an Aintree would have worked much better. I definitely wouldn't let the surgeon take a peek given that she's far less experienced than us, and being obnoxious with banning spinals etc.

BTW I've had several cases where the Glidescope shows a target that can't be reached. Was the patient going to be proned? I'm used to doing these in lithotomy with an LMA.

 

[Noyac]

Here is a thread from not too long ago that might help some.

http://forums.studentdoctor.net/showthread.php?t=886943

 

[Noyac]

I wouldn't call this a Glidescope fail. You saw the target, as you said "a beautiful view of the cords". The problem was intubation not laryngoscopy. I rotate the tube as people above mention, or get a smaller tube etc. I'm not sure an Aintree would have worked much better. I definitely wouldn't let the surgeon take a peek given that she's far less experienced than us, and being obnoxious with banning spinals etc.

BTW I've had several cases where the Glidescope shows a target that can't be reached. Was the patient going to be proned? I'm used to doing these in lithotomy with an LMA.

I left the surgeon taking a look part alone earlier for a couple reasons. One was I figured it might have been an ENT surgeon. But a gen surgeon, now that's funny.

We had a guy that was the same way about spinals in these cases. Funny thing is, I've also worked with a different guy that wanted spinals in every case. Just remember, these are not sophisticated creatures you are dealing with.

 

[olaf]

Had this happen a few times. Used the fob with a 7 ett threaded over it to get thru the cords with the glidescope view. The fob is just used as a controllable stylete in the glidescope view.

 

[BLADEMDA]

Had this happen a few times. Used the fob with a 7 ett threaded over it to get thru the cords with the glidescope view. The fob is just used as a controllable stylete in the glidescope view.

Ditto. I've done the same. The Glidescope makes an oral FOB so much easier.

 

[Gern Blansten]

Edit:
Misread the original scenario.

 

[bullard]

I think the problem was the size of your glide scope blade. I always go with the 4 unless I just can't get it in the mouth. I know some people here say the 3 is the way to go but I disagree. Had a flight nurse in the OR the other day for her annual airway requirement. She wanted to play with the glide scope and it was a smaller woman for a pt so she,grabbed the 3. Same thing happened, great view of the cords after I helped her a bit but she couldn't pass the tube. I told her to pull everything out and try with a 4.

It worked perfectly.

I had this same problem the other day. I'm gonna start using the 4. Thanks.

And yeah, I would let an ENT take a look but that's about it.

 

[Noyac]

I had this same problem the other day. I'm gonna start using the 4. Thanks.

And yeah, I would let an ENT take a look but that's about it.

👍

 

[proman]

I had this same problem the other day. I'm gonna start using the 4. Thanks.

And yeah, I would let an ENT take a look but that's about it.

Ditto.

 

[BLADEMDA]

I had this same problem the other day. I'm gonna start using the 4. Thanks.

And yeah, I would let an ENT take a look but that's about it.

Other Suggestions:

Push down on the neck to bring the cords into full view and also make the passage of the ETT easier into the glottic opening.

Try a smaller tube as sometimes a 6.5 goes in easier than a 7.5

ROTATE THE TUBE counterclockwise when using a bougie as an introducer/seldinger

 

[Noyac]

Other Suggestions:

Push down on the neck to bring the cords into full view and also make the passage of the ETT easier into the glottic opening.

I did this for her. Didn't help.

 

[bostonblaz]

When I see what I want and I can't get the tube to slide over the bougie which I think is because it is way to rigid and gets hung up I use one of the reuseable tubes that come with the fasttrach intubating LMA's. They have a smooth playable tip that is made to bang around and slide in the hole. Blaz

 

[urge]

Now the AW cart arrives, and within two seconds I have a beautiful view of the cords with the Glidescope, easily pass the bougie beyond the cords. Then I and a partner are both unsuccessful getting the seldinger'ed ETT to quit bumping against the arytenoids and go in despite changes in our body English, angle, choice of epithets, etc.

Why add a bougie to the mix if you had a good glidescope view? What's wrong with the glidescope stylette?

 

[Noyac]

Why add a bougie to the mix if you had a good glidescope view? What's wrong with the glidescope stylette?

I thought this was odd myself.

 

[Arch Guillotti]

You let the surgeon take a look😀🙂

Just kidding. I have had this happen as well and the fast track LMA worked just fine.

 

[IlDestriero]

When I see what I want and I can't get the tube to slide over the bougie which I think is because it is way to rigid and gets hung up I use one of the reuseable tubes that come with the fasttrach intubating LMA's. They have a smooth playable tip that is made to bang around and slide in the hole. Blaz

The one time I couldn't get the tube back in over a tube changer after a huge case with a DLT, I used the fastrach tube from the difficult airway cart because of it's soft smooth tip. Worked like a charm. That's a good trick of the trade to know about.👍

 

[urge]

The one time I couldn't get the tube back in over a tube changer after a huge case with a DLT, I used the fastrach tube from the difficult airway cart because of it's soft smooth tip. Worked like a charm. That's a good trick of the trade to know about.👍

What do you do now that the pt has the fast track tube in? Do you leave it in and send the pt to the icu? Do you change it to a regular tube? How?

 

[pgg]

You let the surgeon take a look😀🙂

Well, she chose the anesthetic technique, so might as well let her have the airway too. 😀

 

[IlDestriero]

What do you do now that the pt has the fast track tube in? Do you leave it in and send the pt to the icu? Do you change it to a regular tube? How?

We left it in for a few days for the edema, etc to improve and changed it out over a tube changer with a loaded fiber at the ready if needed, watching the whole thing. No problem with the change, though he still had significant edema and getting a good fiber view was not easy.

 

[hippuppy]

That technique is tricky, and it sounds like your biggest probl was anatomical alignment, which isnt solved by blindly stabbing an ETT through an LMA.

Have you ever dropped a FOB through an LMA? Slide a 6.0 over the scope, may e visualize what the tube is hanging up on.

We used a fast track yesterday and passed the FOB through the LMA in this morbidly obese woman with a small mouth opening. Had trouble making the turn to get a good view of the chords and the acute angle of the Fast track did the trick. Unfortunately this wasn't our first approach and she got some decadron.

 

[Idiopathic]

anyone mention a parker tube yet? ive started always using them with video/FO as they are specifically designed to overcome this scenario

parker on the left

 

[PinchandBurn]

anyone mention a parker tube yet? ive started always using them with video/FO as they are specifically designed to overcome this scenario

parker on the left

That looks pretty dangerous....is it just the pick or is it very point at the end. Woudlnt you be concerned about perforating the trachea or the airway....

 

[Idiopathic]

its very flexible and soft at the end, its pointed to show how it hugs the bougie/bronch and wont het caught up on the arytenoids

 

[fakin' the funk]

Nothing truly original to add...

a) doesn't sound like a Glidescope fail to me, sounds like a Bougie that ends up way posterior in the glottis and an ETT that won't slide right. Try a smaller ETT, a larger airway catheter, or FOB, keeping the FOB and the ETT distal ends "matched up"
b) ETT that comes with the Fastrach is way, way softer than a regular one -- it's designed to doink the cords and not destroy them
c) Why are you Bougie-ing with a Glidescope? There's a reason the Glidescope comes with that stylet

 

[Idiopathic]

Cool post. I'm not sure if anyone uses the howland lock nowadays, but I know it was the go to for very anterior airways in the past.

What about LMA placement and - assuming easy ventilation - going with fiber optic through the LMA? If fiber optic is a struggle then just wake up.

i totally need one of these

 

[Bertelman]

anyone mention a parker tube yet? ive started always using them with video/FO as they are specifically designed to overcome this scenario

parker on the left

The photo on the right with a standard ETT is clearly manipulated. They bent the stylet to the left to accentuate the gap.

Reminds me of the Trayvon Martin thread.

Edit- On second look, maybe it's an illusion and my eyes are fooling me. Either way, I wouldn't put it past the advertisers/marketers to pull something like that.

 

[urge]

Cool post. I'm not sure if anyone uses the howland lock nowadays, but I know it was the go to for very anterior airways in the past.

What about LMA placement and - assuming easy ventilation - going with fiber optic through the LMA? If fiber optic is a struggle then just wake up.

Whenever I see a cool old contraption that I have never heard of, I remind myself the reason for that.

It doesn't work.

Why do you think the LMA & Glidescope have spread like fire? They work

The above contraption? Bullard? Lightwand? Funny looking laryngoscope blades with levers, mirrors....? Not so much.

 

[urge]

We left it in for a few days for the edema, etc to improve and changed it out over a tube changer with a loaded fiber at the ready if needed, watching the whole thing. No problem with the change, though he still had significant edema and getting a good fiber view was not easy.

I don't like to leave those tubes in. Patients in the icu bite those reinforced tubes and they don't come back to shape. Changing one crimped tube turned into a disaster one time.

I understand there is not much you can do in your situation. I'm just saying that you are not out of the woods if you have one of those reinforced tubes in. You might have to deal with a difficult tube exchange again in a day or two.

 

[narcusprince]

Until yesterday I had a 100% batting average with the Glidescope on a difficult airway. Yesterday I struck out and it still bugs me.

Normal stature 80 kg, 22 y/o male for elective procedure.

Unanticipated difficult AW. Easy to mask ventilate. Grade 4 view with Mac and Miller DL, could barely see epiglottis. Called for help and AW cart. First person in the room was the dept. chair, whose go-to is the lightwand (and she's VERY good with it). No joy.

Now the AW cart arrives, and within two seconds I have a beautiful view of the cords with the Glidescope, easily pass the bougie beyond the cords. Then I and a partner are both unsuccessful getting the seldinger'ed ETT to quit bumping against the arytenoids and go in despite changes in our body English, angle, choice of epithets, etc.

I was using the single-use disposable Mac 3 blade.

As we mask-ventilated again, the surgeon asked to try. She took one peek with the Miller DL, and said to abort due to worries about AW swelling. We were already thinking it, and she verbalized it about 5 seconds before I was going to.

Does anyone have any pearls for the above scenario? We don't have the "Glideright" ETTs with the cobra-shaped tip.

In the locker room I was armchair-quarterbacking my actions, wondering if the intubating Fast-Track LMA would have been successful. This pt was verrrrry anterior.

What the hell is the surgeon doing trying to intubate your patient. If this was an ENT doc I would be ok with them doing it. If not why does the surgeon think that they can intubate better than you or the attending anesthesiologist. This would never happen at the big house here. Just uncomfortable with this.

 

[urge]

What the hell is the surgeon doing trying to intubate your patient. If this was an ENT doc I would be ok with them doing it. If not why does the surgeon think that they can intubate better than you or the attending anesthesiologist. This would never happen at the big house here. Just uncomfortable with this.

What I wonder is did she see the airway with DL?

I thought trinity had said you couldn't see anything.

Did she see the cords or did she make it up?

 

[Monty Python]

What I wonder is did she see the airway with DL?

I thought trinity had said you couldn't see anything.

Did she see the cords or did she make it up?

Thanks to all for the suggestions and pearls. Truly appreciated.

To answer a few questions asked by others:

1. We couldn't get the ETT to quit bumping against and go beyond the arytenoids.

2. The case was going prone, not lithotomy, thus LMA wasn't considered for the anesthetic. I'm not as brave as the Brits for that.

3. Our very few in number proprietary Glidescope stylettes were down in central processing getting cleaned from recent use. I had great previous success with the bougie and thought it was a good idea here. Next time will try the FOB as a steerable stylette.

4. The general surgeon wanted to take a look just for her own edification and my chief (still in the room) said, "sure help yourself." She was only in the mouth a brief moment, saw the logic in not pursuing any further, and had no problem quickly saying, "cancel." This is a military hospital, and sometimes military senior rank takes precedence in the decision of who-is-going-to-do-what (as long as it isn't completely illogical). 🙄

 

[amyl]

gotta second NP on this one... gen surg does not get a look. once Im staff and not a resident anymore the ER guys won't get "one more try" either 🙂

ive glidescoped and bougied before, it works well. the view is often not the problem w the glidescope. one of the airway gurus here says that the better the view the more trouble you can have passing the tube. bougies steer better so that may help.

if not, then LMA then fiberoptically place the aintree then railroad the ETT over the aintree ventilating all the while... aka the Zura method 🙂

damn NP i WILL miss this place 🙂

 

[BLADEMDA]

I only use the stylets which come with the glide scope. IMHO, pacing a bougie is usually much more difficult than intubating the patent with a standard ETT with the special stylet. All you need to do next time is make sure you have a clean glidescope stylet.

Sure, the lightwand or FOB will work but nothing beats starting the case with the correct stylet in the ETT

 

[urge]

ive glidescoped and bougied before, it works well. the view is often not the problem w the glidescope. one of the airway gurus here says that the better the view the more trouble you can have passing the tube. bougies steer better so that may help.

This airway guru disagrees.

 

[urge]

3. Our very few in number proprietary Glidescope stylettes were down in central processing getting cleaned from recent use. I had great previous success with the bougie and thought it was a good idea here. Next time will try the FOB as a steerable stylette.

Now that your bougie-glidescope combo has fallen from greatness,will you keep trying it?

BTW, thread title should be "bougie fail".

 

[Monty Python]

gotta second NP on this one... gen surg does not get a look. once Im staff and not a resident anymore the ER guys won't get "one more try" either 🙂

🙂

\

Agree in principle. Things are a little different unfortunately when the surgeon is also the Director of Surgical Services, and an O-6, while everybody else in the room (including anesthesia) is south of the O-6 rank.