Glidescope To The Rescue

[jetproppilot]

We've had a Glidescope on loan for a cuppla weeks now.

I called the rep per a recommendation from a guru past-attending of mine who I'm still in touch with and respect very much. Dr Thomas (guru) said

"You need to try the Glidescope. It may save your a ss one day."

OH HOW RIGHT HE WAS.

So Glidescope Rep Dude brings the scope in a cuppla weeks ago after I call the company. Didn't have an opportunity to use it the first week. Last week was slow and truthfully I wasn't in the mood to mess with something new.

Finally got around to using it a couple times yesterday and actually liked it. Not real sure (yesterday) it was worth the capital investment tho...

Then today rolls around:

56 year old ASA 3 obese male having an anterior cervical fusion (ACF), one level.

My partner was back in the OR starting the case. I had just finished a combined spinal epidural (CSE) in the holding area for a total knee replacement that's to start imminently when my phone rings.

"Jet I've got a bad airway in room 8 and I need help. Bring the Glidescope."

Anytime I get a call from my partner for airway help I know it's bad since, like alotta you rokkstarrs out there,

DUDE CAN INTUBATE AN ANT. ACTUALLY A GRAVID ANT.

"S h i t it's too early for this kinda drama"I mutter to myself as I walk to room 8, Glidescope in tow.

I walk into a very controlled situation where ventilation is not an issue but

uhhhhh we can't do the surgery unless we get the tube in

kinda vibe.

OK I gotta be honest.

Whenever I walk into this situation my first reply, always, is

"Dude, mind if I take a look?"

(I've been in this game a long time. I have proprietary moves laugh that usually work, even if failed laryngoscopy has occurred several times in front of my attempt.

Please note I said usually, not always.)

"Sure! Take a look." my partner replies.

I perform said proprietary moves and....uhhhhhhhhh.....

NO DICE ("uhh can I GET THE CHECK PLEASE?!!! CHECK!!)

Couldn't see S&@T.

Plus dude's gettin' juicy now. Another strike.

Time for Plan B.

I bring the Glidescope screen to my left and, grasping the fiberoptic light secured tightly into a disposable Size Three blade, focus my attention on dude's mouth, inserting the blade like I had done before, remembering to get the blade into position or close to position before looking at the video screen. OK, done. Now, after blade is in I divert my vision to the video screen which from here on out is gonna determine via my motor inputs whether or not a view of the vocal cords or something even close to the vocal cords can be attained.

Keep in mind I've used this device twice before this incident.

After circa 45 seconds or so of blade manipulation

the glottis, the bottom of the vocal cords even, are clearly visible on the screen.

Next is guiding the endotracheal tube there via the special stylettes provided by Glidescope.

I was able to do that too.

The Glidescope saved my a ss today and saved the patient and surgeon from a potential cancellation.

At my previous gig our high tech intubation scope was a Storz (did I spell that right?) Hated it. Never felt comfortable with it. Alotta setup required that if you didnt stay current, essentially rendered it useless in a pinch. I used it a cuppla times. Wasn't impressed. Computer screen with a buncha buttons, gotta white balance, buncha stuff to hook up...

The setup for a Glidescope is

1)Turn it on. One button.

2)Insert disposable blade over fiberoptic moiety

3)Insert blade into dude's mouth.

It's that easy.

Keep in mind, before using it on this difficult intubation today I had literally used the machine TWICE before. That speaks volumes.

Serendipitous how a Glidescope ON LOAN to our boutique hospital saved a buncha people, me included, from a buncha grief today.

We gotta get WANNA THOSE!!!!

---

Members don't see this ad.

 

[btbam]

Glidescope is awesome, although I find the size 3 blade to be too short sometimes. To me, the real learning curve with it is actually getting the tube in. Definitely a different feel from a regular DL.

 

[jetproppilot]

Glidescope is awesome, although I find the size 3 blade to be too short sometimes. To me, the real learning curve with it is actually getting the tube in. Definitely a different feel from a regular DL.

It's funny you say that...about the 3 being too short...

After that case I used the scope generously today...we ran outta 3 blades so I started using 4s...almost seemed easier! But hey I can't say for sure. That was my feeling tho.

Also feel you on the it's hard to just get the tube in the mouth part.

Glidescope rep had a compelling suggestion for our small mouthed patients:

Put the tube in FIRST to occupy said real estate...THEN put the blade in...

sounds like a good idea.

 

[pgg]

The Glidescope saved my a ss today and saved the patient and surgeon from a potential cancellation.

Glidescopes are neat, but isn't that kind of overstating things?

Controlled situation, easy to ventilate --> asleep FOI would've worked too, right?

 

[jetproppilot]

Glidescopes are neat, but isn't that kind of overstating things?

Controlled situation, easy to ventilate --> asleep FOI would've worked too, right?

I dunno man.

FOI is very dependent on a clear field...

no spit...no blood....

ALOTTA SPIT AND BLOOD RENDERS A FIBEROPTIC SCOPE USELESS.

we had a bit of both...

never had a problem with visualization being compromised.

BTW I'm not a paid consultant.

YET.

 

[sethco]

At my previous gig our high tech intubation scope was a Storz (did I spell that right?) Hated it. Never felt comfortable with it. Alotta setup required that if you didnt stay current, essentially rendered it useless in a pinch. I used it a cuppla times. Wasn't impressed. Computer screen with a buncha buttons, gotta white balance, buncha stuff to hook up...

Kinda funny you mention this. If you put a storz and the glidescope next to each other, the differences are pretty obvious. There is the extra anterior tilt of the glidescope that lends it to getting superior views over the storz. Furthermore, there is virtually no difference in the shape of the storz blade and a Mac blade. It adds nothing to the possible difficult intubation except the ability for observers to make comments about how your view of the cords suck. I asked some of the trauma attendings why we even had them in the trauma bay and they admit it adds nothing except teaching purposes for ER residents.

Also feel you on the it's hard to just get the tube in the mouth part.

Glidescope rep had a compelling suggestion for our small mouthed patients:

Put the tube in FIRST to occupy said real estate...THEN put the blade in...

sounds like a good idea.

This is probably the most difficult part, especially for pateints with limited mouth opening. I find it helpful for your tech/assistant/additional anesthesia provider/whoever to stick their finger in the right side of the patients mouth and and make some room. I hear ya, tho.

The funny thing with the glidescope will be if the ASA has to redo the difficult airway algorithm. Usually for anticipated difficult airways, it will tell you to consider awake techniques. However, I find that most attendings (especially with anticipated easy ventilation) will just put the patient to sleep and go straight to glidescope. Some will even admit that it seems like forever since they last used an awake FOI. It seems that the glidescope has revolutionized this arena. However, I don't think it can replace the safety of awake techniques.

 

[Dhanwanthari]

Used the GS for over 100+ intubations ... great for RSI in my obese patients with a potentially difficult DL, risky C-spine, or ****e pulm reserve. (was told, there's no such thing as a RSFOI)*

With the glidescope, I like the idea of putting the tube in first...haven't done that before.

For me it's all about the bend of the tube....

I don't use the stylet provided.

I make the ETT mimic the Glidescope blade's shape.

1st bend: make a right angle bend (true 90 degrees) applied just proximal to the cuff.

2nd bend: line the ETT's right angle bend with the glidescope's distal bend, make another right angle bend at the proximal bend of the glidescopes blade. Tube should look like a "C."

3rd bend, ~5cm distal to adapter end of ETT, 20 degree bend off to right side. This lets me manipulate the tube while keeping the tip midline.

Tube looks like a corkscrew, Stylet's gotta be uber-lubed.

Tube tip drops down and advances as stylet is pulled.

Will post a picture of the bends.

Also, the GS handle isn't the shortest and still can get caught in "Boobage" so get the biguns in a ramp or at least some head up (rev Tberg) or make it tough to get the blade in the mouth.

*I don't 100% agree with the nonexistance of RSFOI (I've seen some attendings FOI as quick as other practitioners w/ DL, but then again these folks are ninjas.

 

[imfrankie]

Glidescopes are neat, but isn't that kind of overstating things?

Controlled situation, easy to ventilate --> asleep FOI would've worked too, right?

I like the light wand too

 

[Ondine]

I REALLY like the Glidescope as well for difficult or anticipated difficult intubations.

I also like to use a MacGrath video laryngoscope as well. I think it has a few advantages over a glidescope:
1. The part of the scope with the blade can be disarticulated from the handle, making it easier to get into big chested patient's mouths.
2. It is a narrower blade in width and height than the Glidescope blades, making it easier to get into someone's mouth with limited mouth opening or not much room.
3. It doesn't need as long of a warmup time for the screen. Just turn it on and go. If you do this with the Glidescope, the camera fogs up pretty bad, so usually it needs to warm up for a coupla minutes - not ideal in an emergency.

I ALWAYS use the Glidescope stylet when using the MacGrath, I guess maybe because of the perfect bend and the stiffness. Doing it both ways, I would prefer to use the Glidescope stylet.

I am not a paid consultant for MacGrath, I'm just a regular guy giving my 2c. Like I said, I love the Glidescope alot, just wanted to add a different perspective to the discussion..

 

[urge]

For me it's all about the bend of the tube....

I don't use the stylet provided.

I make the ETT mimic the Glidescope blade's shape.

1st bend: make a right angle bend (true 90 degrees) applied just proximal to the cuff.

2nd bend: line the ETT's right angle bend with the glidescope's distal bend, make another right angle bend at the proximal bend of the glidescopes blade. Tube should look like a "C."

3rd bend, ~5cm distal to adapter end of ETT, 20 degree bend off to right side. This lets me manipulate the tube while keeping the tip midline.

Yikes!

The glidescope stylette has been fine for me.

 

[btbam]

Remember with the glidescope view, you are seeing the cords and associated structures but essentially passing the tube blindly until it comes into view on the screen. My one major mishap in probably 50 glidescope intubations so far was accidentally pushing the tube through some extraneous mass of soft tissue in an obese pt's posterior oropharynx.

As the tube came into view, it was wedged underneath a band of tissue and everyone in unison said "what the hell is that?" The attending took over and did the same thing, as it had somehow created a new track for the tube to go through...Eventually tube goes in, but since we were going on bypass an ENT surgeon had to come put some stitches in...He said the airway anatomy was "abnormal", but still not my finest moment as a student.

 

[jetproppilot]

Yikes!

The glidescope stylette has been fine for me.

Me too.

Very premature for me to say "Dude, you're over thinking and overreacting."

So I'll speak to you from my heart.

"Dude, you're over thinking and over reacting."

WTF?

You find the need to

REDESIGN SOMETHING THAT WAS SO EASY TO USE

that I used it successfully in a difficult airway today, albeit after only

TWO (2) PREVIOUS ENCOUNTERS WITH THE MACHINE?

I think

OVERTHINKING A SITUATION

is just as detrimental as

underthinking one.

Some of you dudes out there are

TOO SMART FOR YOUR OWN GOOD.

Relax, man.

Light a candle.

Consider moving to California where con bud is legal.

OR, maybe

1)NASA
2)Astrophysics
3)Figuring out if God created the universe

would better suit your train of thought.

 

[psychbender]

At my program last year, we had one case of the glidescope stylet perforating the soft palate before an OMFS case. I tend to use a regular stylet, with the tube shape kind of like the glidescope blade; or if using the glidescope stylet, make sure that the tip does not come out the end of the friggin' tube.

I do like the scope, though, and in my current hospital, we have one in every room (thank you, wasteful government spending). As for getting the blade in for patients with a lot of chest, you can always just disconnect the blade, insert, then reconnect to the fiberoptic source. I have done this a handful of times for intubations in the ICU on patients with TLSO/halo braces.

 

[btbam]

At my program last year, we had one case of the glidescope stylet perforating the soft palate before an OMFS case. I tend to use a regular stylet, with the tube shape kind of like the glidescope blade; or if using the glidescope stylet, make sure that the tip does not come out the end of the friggin' tube.

.

Haha good timing, read my post from 5 min ago

 

[Arch Guillotti]

FOI is very dependent on a clear field...

no spit...no blood....

ALOTTA SPIT AND BLOOD RENDERS A FIBEROPTIC SCOPE USELESS.

we had a bit of both...
]

Indicates that multiple DL's by experienced practitioners is not optimal.

What about an intubating LMA?

 

[psychbender]

Haha good timing, read my post from 5 min ago

Bastard! Submitted that one while I was typing! There needs to be a fist-shaking emoticon.

 

[urge]

At my program last year, we had one case of the glidescope stylet perforating the soft palate before an OMFS case.

Fair number of case reports on that have been published. Pleople look at the screen, not the mouth, when RAMMING the tube in thru the palate. We had a soft palate tear, not full perforation, in my place that I'm aware.

 

[MRW]

We had a Cmac available in the lab during my didactic year. I liked it alot, but that was exclusively on manakins - never used it in the real world. I've used a glidescope many times now and have always been able to find a view quickly even on the most anterior of airways. This morning had an ENT coming in to do a tonsillectomy on a 48yo female with down's and OSA. When the ENT comes in predicting difficult airway, you should listen, but the glidescope sorted it out in about 10 seconds. The thing is gold.

The only difficulties I have had with the glidescope is with getting the blade into small mouth openings.

FWIW, my n is ~ 20.

 

[jetproppilot]

Indicates that multiple DL's by experienced practitioners is not optimal.

What about an intubating LMA?

Another good option, Arch.

Like Shark Week, tho,

well,

it's Glidescope Week at my gig. Or half a week.

Glidescope Rep Dude reclaimed it today.

 

[btbam]

Another good option, Arch.

Like Shark Week, tho,

well,

it's Glidescope Week at my gig. Or half a week.

Glidescope Rep Dude reclaimed it today.

The attendings at a hospital I rotated at in South GA used the glide on everyone, like, everyone. The chief thought it should be a standard of care, what do you think Jet?

 

[MRW]

Glidescope Rep Dude reclaimed it today.

bummer - what is the actual retail price?

 

[tkim]

Used a Glidescope during my EM residency, and have one now in my ED gig. If the situation's going all pear-shaped, I use the glidescope and ETT over bougie. Maybe it's overkill, but I've never needed to more than one attempt with that combo.

 

[RxBoy]

I dunno man.

FOI is very dependent on a clear field...

Thanks to this forum, I brought up the idea of a combined awake FOB and glidescope to my attending last week. Patient with pharyngeal ca s/p radiation with some tracheal narrowing for a mediastinoscopy.

Technique worked like butter. You don't even need to look in the fiberoptic to get to the cords, just manipulate the scope as you watch the glidescope screen. Sprayed the cords a couple of times. Once in, I used the fiberoptic to look within the trachea and made sure my 6.0 was able to pass the narrowing. Its def a 2 man operation, but works like a charm.

 

[Multifidus]

Me too.

Very premature for me to say "Dude, you're over thinking and overreacting."

So I'll speak to you from my heart.

"Dude, you're over thinking and over reacting."

WTF?

You find the need to

REDESIGN SOMETHING THAT WAS SO EASY TO USE

that I used it successfully in a difficult airway today, albeit after only

TWO (2) PREVIOUS ENCOUNTERS WITH THE MACHINE?

I think

OVERTHINKING A SITUATION

is just as detrimental as

underthinking one.

Some of you dudes out there are

TOO SMART FOR YOUR OWN GOOD.

Relax, man.

Light a candle.

Consider moving to California where con bud is legal.

OR, maybe

1)NASA
2)Astrophysics
3)Figuring out if God created the universe

would better suit your train of thought.

While I don't fashion my own stylet, I can vouch for the Glidescope's stylet "failing" sometimes. Once you use it enough, you will have a few airways where you get a great view with the glidescope, but no amount of maneuvering seems to get the styletted tube to pass through the cords (usually just can't get the tube anterior enough). I have seen self-proclaimed "Glidescope experts" get views but abort the technique because of inability to angle the tube correctly. Of course, this is rare, but bound to happen to you if you use it enough. But hey, no device is perfect.

One trick that sometimes helps is to load the ETT upside down on the stylet (against it's natural curve). That way, when you unload the tube off the stylet its natural curve aims it posterior. Works in certain situations.

Most common mistake with the Glidescope is going too deep. This can often be the cause of the difficult ETT passage. As Jet says, best to watch the screen as you are advancing. Once you get the view, stop. It is not a MAC blade.

I tried the C-Mac device the other day. Now this is a MAC blade with a camera at the tip. Worked just fine. Used it on a morbidly obese patient with a history of a difficult airway. Had a trach scar to prove it. But also claimed he had been intubated twice since without difficulty. There is one reason why I liked the C-Mac more than the Glidescope that day. Because it is a Mac blade with a camera, you are able to make an assessment of whether the patient truly is a difficult intubation or not. Used it exactly like a regular MAC blade, had a grade II view with direct visualization. Then I looked at the screen and had a "grade I" view. Now I am able to write in the chart he is easy with a Mac 4. Can't do that with a Glidescope.

 

[jetproppilot]

bummer - what is the actual retail price?

Kinda like being on a

New Car Lot, man.

Started at twelve large quoted but

oh wait a minute....rep "FORGOT" about current incentives since they "wanna move product this month"

so subtract another grand..

Rep said, literal translation, after the "real quote" that included the discount:

"That's a great price. I know you guys want it. If we haffta go any lower it means I haffta go way up the food chain."

Guess that means

If we hold up he will talk to his manager, who will talk with his manager, who will (4 weeks later) speak with

THE

Manager

and we'll eventually get it for

eight large.

What a joke man.

Nothing's easy.

 

[ssmallz]

Now I am able to write in the chart he is easy with a Mac 4. Can't do that with a Glidescope.

IMO that's the biggest failure of the glidescope. We'd use it all the time for intubations on pts that looked difficult (morbidly obese, ACDFs, etc) but then you don't know whether or not it's actually a difficult intubation or just a dude who looks difficult but is actually easy

 

[epidural man]

We've had a Glidescope on loan for a cuppla weeks now.

I called the rep per a recommendation from a guru past-attending of mine who I'm still in touch with and respect very much. Dr Thomas (guru) said

"You need to try the Glidescope. It may save your a ss one day."

OH HOW RIGHT HE WAS.

So Glidescope Rep Dude brings the scope in a cuppla weeks ago after I call the company. Didn't have an opportunity to use it the first week. Last week was slow and truthfully I wasn't in the mood to mess with something new.

Finally got around to using it a couple times yesterday and actually liked it. Not real sure (yesterday) it was worth the capital investment tho...

Then today rolls around:

56 year old ASA 3 obese male having an anterior cervical fusion (ACF), one level.

My partner was back in the OR starting the case. I had just finished a combined spinal epidural (CSE) in the holding area for a total knee replacement that's to start imminently when my phone rings.

"Jet I've got a bad airway in room 8 and I need help. Bring the Glidescope."

Anytime I get a call from my partner for airway help I know it's bad since, like alotta you rokkstarrs out there,

DUDE CAN INTUBATE AN ANT. ACTUALLY A GRAVID ANT.

"S h i t it's too early for this kinda drama"I mutter to myself as I walk to room 8, Glidescope in tow.

I walk into a very controlled situation where ventilation is not an issue but

uhhhhh we can't do the surgery unless we get the tube in

kinda vibe.

OK I gotta be honest.

Whenever I walk into this situation my first reply, always, is

"Dude, mind if I take a look?"

(I've been in this game a long time. I have proprietary moves laugh that usually work, even if failed laryngoscopy has occurred several times in front of my attempt.

Please note I said usually, not always.)

"Sure! Take a look." my partner replies.

I perform said proprietary moves and....uhhhhhhhhh.....

NO DICE ("uhh can I GET THE CHECK PLEASE?!!! CHECK!!)

Couldn't see S&@T.

Plus dude's gettin' juicy now. Another strike.

Time for Plan B.

I bring the Glidescope screen to my left and, grasping the fiberoptic light secured tightly into a disposable Size Three blade, focus my attention on dude's mouth, inserting the blade like I had done before, remembering to get the blade into position or close to position before looking at the video screen. OK, done. Now, after blade is in I divert my vision to the video screen which from here on out is gonna determine via my motor inputs whether or not a view of the vocal cords or something even close to the vocal cords can be attained.

Keep in mind I've used this device twice before this incident.

After circa 45 seconds or so of blade manipulation

the glottis, the bottom of the vocal cords even, are clearly visible on the screen.

Next is guiding the endotracheal tube there via the special stylettes provided by Glidescope.

I was able to do that too.

The Glidescope saved my a ss today and saved the patient and surgeon from a potential cancellation.

At my previous gig our high tech intubation scope was a Storz (did I spell that right?) Hated it. Never felt comfortable with it. Alotta setup required that if you didnt stay current, essentially rendered it useless in a pinch. I used it a cuppla times. Wasn't impressed. Computer screen with a buncha buttons, gotta white balance, buncha stuff to hook up...

The setup for a Glidescope is

1)Turn it on. One button.

2)Insert disposable blade over fiberoptic moiety

3)Insert blade into dude's mouth.

It's that easy.

Keep in mind, before using it on this difficult intubation today I had literally used the machine TWICE before. That speaks volumes.

Serendipitous how a Glidescope ON LOAN to our boutique hospital saved a buncha people, me included, from a buncha grief today.

We gotta get WANNA THOSE!!!!

Glidescope killed the awake FOI.

I have never not seen vocal cords. However, getting the tube in CAN be difficult - as people have pointed out.

The problem is that often the tube hits the below the opening and it is impossible to get the damn tip of the tube anterior to go through the opening, then you bend the stylette, and you get the tip ("just the TIP" yelled archer...hope some of you get the reference) in, but can't pass it.

Recommend - as someone else has pointed out - that on the difficult pass, use a fiber scope as your stylet - not to watch through the fiber, but because it is a completely stearable stylet. This technique (requiring two anesthesiologists) is really slick when you need it.

Soft palate injuries are not uncommon - We have a picture - from one of our cases, of the ETT through the soft palate, into the trachea. It wasn't noticed until time to extubate. Cool picture though.

I think it helps to not look at the screen when placing the tube, until the tube is past the soft palate. (or pre place tube - i love that idea)

By the way Jet, if you guys get one, don't get the Ranger - the portable one. I think they suck, and break easy.

I have never used the disposable blades. How do they compare to the washable ones?

 

[epidural man]

IMO that's the biggest failure of the glidescope. We'd use it all the time for intubations on pts that looked difficult (morbidly obese, ACDFs, etc) but then you don't know whether or not it's actually a difficult intubation or just a dude who looks difficult but is actually easy

I'm not sure.

I think video assisted intubations are the future - not sure why knowing what an intubation grade is by using a MAC or MILLER is helpful in the face of emerging technology.

 

[joshmir]

bougie with the GS is a great combo

you can curve the bougie progressiveley until it angles perfect to get into that anterior airway

 

[FiremedicMike]

We currently have a glidescope demo and a king vision demo on our trucks for trial to pick which one we like better for purchase. While I found the glidescope easier to tube with, the king vision is simpler to put into action and much more forgiving with standard stylets. My personal opinion is that as paramedics we should go straight to one of these methods over old fashioned laryngoscopy, because those of us who aren't to macho will admit we don't do enough tubes to be proficient.

I envy your positions of having time, resources, space, good patient/provider positioning, light, and most important, extensive experience!

 

[sevoflurane]

Yep. Glidescope rocks. I don't use it very often...maybe once every couple of months, but when i do need it....

I AM GLAD I HAVE ONE. We also have 3 Mcgraths. Those suckers are collecting dust.

Great tool. I think they should be one around in every ASC and Hospital.

But... that's cuz I like things that are easy.... (excluding women of course).

You need to know how to drive the snake... it is a skill that every anesthesiologists must know.... even those that don't do thoracic surgery. Intraoperative bronch is part of my maneuvers for hypoxia under GA.

AWAKE FIBEROPTIC may be necessary for some circumstances... ie big ***** mediastinal tumor that may lead to CV collapse from external compression of the grat arteries 20 seconds after induction with prop and roc. Brochoscope is probably better tolerated than a glidescope for those with anxiety.

 

[Dhanwanthari]

Me too.

Very premature for me to say "Dude, you're over thinking and overreacting."

So I'll speak to you from my heart.

"Dude, you're over thinking and over reacting."

WTF?

You find the need to

REDESIGN SOMETHING THAT WAS SO EASY TO USE

that I used it successfully in a difficult airway today, albeit after only

TWO (2) PREVIOUS ENCOUNTERS WITH THE MACHINE?

I think

OVERTHINKING A SITUATION

is just as detrimental as

underthinking one.

Some of you dudes out there are

TOO SMART FOR YOUR OWN GOOD.

Relax, man.

Light a candle.

Consider moving to California where con bud is legal.

OR, maybe

1)NASA
2)Astrophysics
3)Figuring out if God created the universe

would better suit your train of thought.

haha... appreciate the advice...

but there end up being quite a bit of airways where the view comes easy but getting the tube tip in view does not. Keep using it, you will have this issue.

This has actually led to a lot of attendings I've worked with not liking the glidescope -- Showed them the bend (that two attendings who helped develop the glidescope showed me) and they use it now.

It might be overthinking, but it's a "proprietary" maneuver to get the job done when someone else can't. and it works...

Glidescope sees around corners, that means your tube has to be equipped to go around a corner.

 

[Oggg]

1. We wanted a Glidescope but the hospital got us a McGrath. Took a few times to get the hang of passing the tube. I curve my ETT on a regular stylet into a "J", so that is looks like a candy cane, molded to approximate the curve of the McGrath, and then some. If the ETT tip looks like it's too posterior or that it's going to hit the arytenoids, I tug on the stylet and the tube curls anteriorly into the glottis.
2. I used a bougie once with the McGrath and got lucky. Every other time me or one of my partners tries it, they fail, because our bougies will not hold a curve, so we can't get the bougie to go anteriorly into the glottis.

 

[sevoflurane]

This has actually led to a lot of attendings I've worked with not liking the glidescope

Sometimes it's not the proximal bend that makes life difficult... it's the distal one.

You might get a good view but since you are close to 90 degree bend on your tube/stylet, aligning the axis of the ETT to go THROUGH the glottic opening may be a challange.

In extreme cases you may have to bend the TIP of the ETT to guide it in through the vocal cords. This has proven useful a handful of times in my experience.

Good for when you are solo... If you have two people handy... fiberoptic with glidescope (two man technique) is the best of both worlds.

A little exageratted here (the stylet needs to be pulled back 1/4-1/2").... but something to the tune of this:

[/IMG]

 

[jetproppilot]

haha... appreciate the advice...

but there end up being quite a bit of airways where the view comes easy but getting the tube tip in view does not. Keep using it, you will have this issue.

This has actually led to a lot of attendings I've worked with not liking the glidescope -- Showed them the bend (that two attendings who helped develop the glidescope showed me) and they use it now.

It might be overthinking, but it's a "proprietary" maneuver to get the job done when someone else can't. and it works...

Glidescope sees around corners, that means your tube has to be equipped to go around a corner.

Hard to argue with that!

 

[Frank Rizzo]

Your current gig seems pretty good. The group should definitely be able to fork over for one of these things. They're not THAT expensive. Your experience the past few weeks should make it very obvious to the surgeons why you should have one.

Definitely agree about putting the tube in prior for small mouths. Do it regularly. As far as angle goes, if need be, I bend the damn stylet. Yeah, I know, you're not supposed to... big $hit. Its metal, I bend it, then I bend it back. Doing an awake look with a glidescope is a cool move also.

 

[BuddhaCanooda]

For the poster who said the FOB is a steerable stylet that is incorrect. You can NEVER articulate the tube with the FFB. If you don't break your multimode fiber the first time, give it a few tries and you will shear them. Guaranteed, the tensile strength of the FFB is not sufficient to beat the bulk modulus of the ETT.

Using a rigid stylet is old technology. Here is one I did on a tumor case with the GS and Video RIFL (single user, second person required to hit record on the camera). Faster than either of the techniques described above!

HS

 

[proman]

Are you getting one of the single use Glidescopes (like the Cobalt?) I think the Cobalt has a great design and image, with a disposable sheath makes clean up not an issue.

 

[Planktonmd]

At the risk of sounding old fashion and outdated I have to say that in my hands NOTHING is superior to fiberoptic intubation.
The Glidescope is a great toy and we have it at all our locations and we also have to Storz video scope.
There were multiple occasions when neither one did the job and Fiberoptic was the answer.
I understand the issue of blood and secretions disturbing the view but an experienced fiberoptic bronchospist should know how to not dive in a lake of blood and secretions and go for the the right hole every time.
The bottom line, know your strength and weakness ahead of time, and if Glidescope is your strength then go for it, but that does not mean it's the best option in every situation and in the hands of every anesthesiologist.

 

[proman]

At the risk of sounding old fashion and outdated I have to say that in my hands NOTHING is superior to fiberoptic intubation.
The Glidescope is a great toy and we have it at all our locations and we also have to Storz video scope.
There were multiple occasions when neither one did the job and Fiberoptic was the answer.
I understand the issue of blood and secretions disturbing the view but an experienced fiberoptic bronchospist should know how to not dive in a lake of blood and secretions and go for the the right hole every time.
The bottom line, know your strength and weakness ahead of time, and if Glidescope is your strength then go for it, but that does not mean it's the best option in every situation and in the hands of every anesthesiologist.

I agree completely. If I had only 1 tool I'd pick a fiberoptic. My backup intubation method of choice is LMA->FOB/Aintree-> ETT. Glidescope is not very good for the extreme anterior airways. Everything has its limitations.

 

[BuddhaCanooda]

I agree completely. If I had only 1 tool I'd pick a fiberoptic. My backup intubation method of choice is LMA->FOB/Aintree-> ETT. Glidescope is not very good for the extreme anterior airways. Everything has its limitations.

"Anterior" airways is a myth/misnomer. Look at lateral films of patients for proof, it's not as if people walk around with near perpendicular tracheo-esophageal axes. It should be worded "too anterior for the approach", not the airway itself. Or it is likely related to your patient positioning - please say you emphasize that to your residents...

 

[epidural man]

At the risk of sounding old fashion and outdated I have to say that in my hands NOTHING is superior to fiberoptic intubation.
The Glidescope is a great toy and we have it at all our locations and we also have to Storz video scope.
There were multiple occasions when neither one did the job and Fiberoptic was the answer.
I understand the issue of blood and secretions disturbing the view but an experienced fiberoptic bronchospist should know how to not dive in a lake of blood and secretions and go for the the right hole every time.
The bottom line, know your strength and weakness ahead of time, and if Glidescope is your strength then go for it, but that does not mean it's the best option in every situation and in the hands of every anesthesiologist.

Planktonmd,

Have you ever used them in tandem (glidescope and fiberoptic?), it seems to work well.

I agree that nothing really is the best option for every sitiuation

However, I do think that the future is going to be video assisted intubations for almost everything. The form that takes is yet to be seen. Technology will be such that if the patient can pass air from his mouth to the trachea, we should be able to visualize that path rather easily.

Passing a tube may be another issue.

 

[Girevik]

Welcome to the 21st century. We have have been using the glide for years now. Saved my A** a few times. Honestly I thought everyone used them. If you don't have one get one.

I guess when you are a rockstar like Jet you don't need such crutches.

 

[epidural man]

For the poster who said the FOB is a steerable stylet that is incorrect. You can NEVER articulate the tube with the FFB. If you don't break your multimode fiber the first time, give it a few tries and you will shear them. Guaranteed, the tensile strength of the FFB is not sufficient to beat the bulk modulus of the ETT.

Using a rigid stylet is old technology. Here is one I did on a tumor case with the GS and Video RIFL (single user, second person required to hit record on the camera). Faster than either of the techniques described above!

HS

I am confused by your post -

How is a fiberoptic (and by the way, we don't have fiberoptics really, they are LCD cameras) not steerable?

You don't keep the tube on the steerable part - is that what you meant?

Visualizing the fiber scope on the glide scope, you pass the fiber into the trachea. Once confirmed to be in the trachea - by looking at it with the glidscope - and through the fiberscope, you pass the tube down over the fiber.

How do you usually pass the tube when doing a fiber intubation? Do you keep the tube on the end of the fiberscope? That is strange indeed.

 

[BuddhaCanooda]

I am confused by your post -

How is a fiberoptic (and by the way, we don't have fiberoptics really, they are LCD cameras) not steerable?

You don't keep the tube on the steerable part - is that what you meant?

Visualizing the fiber scope on the glide scope, you pass the fiber into the trachea. Once confirmed to be in the trachea - by looking at it with the glidscope - and through the fiberscope, you pass the tube down over the fiber.

How do you usually pass the tube when doing a fiber intubation? Do you keep the tube on the end of the fiberscope? That is strange indeed.

epiduralman,
A fiber optic alone is steerable, with a loaded tube it WILL NOT bend at the tip. It's not designed as such. I use the VR (an articulating stylet) to watch where the ET tip goes. The FFB/GS method is very cumbersome and will require your partner (or attending) to help out. Is this what you usually do?

I still stand by the assertion that 'anterior' airways are misnomers...

HS

 

[seinfeld]

I'm not sure.

I think video assisted intubations are the future - not sure why knowing what an intubation grade is by using a MAC or MILLER is helpful in the face of emerging technology.

I agree. before i end my career there will be one in every OR, Why take a risk with an intubation being difficult when you get 99% of airways without it ever being difficult?

 

[RussianJoo]

yeah the glide scope could be the device that changes the difficult airway algorithm.

To get the blade into people with big chests where the handle keeps hitting the chest i simply turn the blade sideways and once mostly in the mouth turn the blade back. Sort of like you do when inserting an oral airway. Also a few times that I've seen the epiglotis but couldn't see the cords, my attending would just give the stylet/tube a bigger curve and tell me to simply advance it behind the epiglotis, worked every time.

 

[Planktonmd]

epiduralman,
A fiber optic alone is steerable, with a loaded tube it WILL NOT bend at the tip. It's not designed as such. I use the VR (an articulating stylet) to watch where the ET tip goes. The FFB/GS method is very cumbersome and will require your partner (or attending) to help out. Is this what you usually do?

I still stand by the assertion that 'anterior' airways are misnomers...

HS

Why wouldn't a fiberoptic scope be bendable at the tip if an ETT is loaded?
If you are talking about the sideways rotation then you can always do that with your fingers holding the scope close to the patient, you don't need to rotate the whole scope.
Once you enter the trachea with the "steerable" tip you don't need any more steering and the scope becomes a stylet.

 

[Hamhock]

yeah the glide scope could be the device that changes the difficult airway algorithm.

I wouldn't be surprised if you are right...

...but that GS still doesn't help that much in two situations:
1. bloody bloody trauma airway
2. RSI with supraglottic mass or distorted anatomy

I realize that you guys have all kinds of tricks in the OR for #2, but lots of those don't work so well in the ED (ED docs with enough fiberoptic experience are rare) with fresh patients and emergent RSI...although I am a bit off topic now - and I do love the GS - I think there is great utility in keeping skills with other devices, rescue, surgical, etc...

I just don't like the trend I hear around me (EM residents and even young EM attendings) regarding the GS...there's a bit too much confidence with the GS around...until that bloody bloody trauma airway with a supraglottic mass comes in (rare, but it does...happened just two nights ago at my place)

HH

 

[imfrankie]

yeah the glide scope could be the device that changes the difficult airway algorithm.

To get the blade into people with big chests where the handle keeps hitting the chest i simply turn the blade sideways and once mostly in the mouth turn the blade back. Sort of like you do when inserting an oral airway. Also a few times that I've seen the epiglotis but couldn't see the cords, my attending would just give the stylet/tube a bigger curve and tell me to simply advance it behind the epiglotis, worked every time.

I like sitting the patient up, and while facing them (getting the pannus dependent) use the Glidescope. Nice way for an initial look after a gargle of viscous. Then if you can see, on to the syringe(s).

Those little trigger ETTs are nice too. You can stylet them not quite to the end then toggle the tip with the trigger.