Glidescope To The Rescue

[RussianJoo]

the pt's don't get freaked out when you tell them what you want to do? I don't think my patient population would tolerate me sticking a glide scope in their mouth when they're a wale. but maybe i'll try it on myself one night on call... ,

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[Arch Guillotti]

Give some decent sedation and some decent blocks/topicalization and an awake glidescope can be great.

 

[imfrankie]

the pt's don't get freaked out when you tell them what you want to do? I don't think my patient population would tolerate me sticking a glide scope in their mouth when they're a wale. but maybe i'll try it on myself one night on call... ,

Learn to do some awake intubations. Don't get burned being afraid to do an awake look. The key is patient buy-in. Let them know you intend to do what is safest for them. Safest isn't roll the dice and hope you can ventilate or intubate.

Now an added benefit of sitting them up and facing them, is that the exam is not so unlike the doctor taking a look with a tongue depressor. It's a nice technique. Check it out.

There is an outstanding fairly recent Audio Digest lecture by Benumof I encourage you to listen to. The difficult airway. Audiodigest.com

 

[proman]

"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...

I agree. I also think the whole "lining up the axis" is a myth. But the vernacular is easily understood. There are plenty of airways that you can see a part of with the Glidescope or traditional DL but just can't get the tube in.

 

[BuddhaCanooda]

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.

Plankton, you cannot bend the ETT with a FFB. THat is what I meant by when it is loaded. You are doing a railroad technique. When you push the tube off it is still a blind advancement since you cannot see where the tube goes until it passes the tip of the FFB.

If you don't believe me then try to bend the ETT with the FFB. I bet you will lose your FFB privileges...

 

[Multifidus]

Plankton, you cannot bend the ETT with a FFB. THat is what I meant by when it is loaded. You are doing a railroad technique. When you push the tube off it is still a blind advancement since you cannot see where the tube goes until it passes the tip of the FFB.

If you don't believe me then try to bend the ETT with the FFB. I bet you will lose your FFB privileges...

Dude, you see the where the tube is going by looking at the Glidescope screen. He isn't saying that he uses the fiberoptic to bend the ETT. He uses the fiberoptic to steer through the cords first, then passes the ETT over the fiberoptic.

 

[Impromptu]

We have the C-MAC at our place. Pretty good device. However, I did have trouble on a dude with some radiation in the neck. Could not lift that epiglottis out of the way. We only have MAC blades and an even more curved blade. Grabbed my Miller for a DL and got a grade 1 view. You can be sure that that was noted in the electronic record. Hopefully will save the next guy some grief (if he does a quick look at the record).

I do like Fiberoptic intubation. Controlling it is a lot like playing Halo or similar games.

 

[RxBoy]

You are doing a railroad technique. When you push the tube off it is still a blind advancement since you cannot see where the tube goes until it passes the tip of the FFB...

Seeing the FOB tip advance through cords on a glidescope monitor, then passing your tube over the FOB watching the glidesope monitor as the tube passes the cords then looking through the FOB to verify position is pretty damn far from blind. Sure its an indirect view, but its sure as hell reassuring.

Blind is when you push a tube through someones nose and prey it goes through the glottis.

 

[fakin' the funk]

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)

+1



(But yea the GS is awesome)

 

[C.P.]

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.

I've worked at a few different hospitals and have been equipment manager at one of them, and in the process worked with a lot of different equipment (C-mac, video fast trach, macgrath, bullards, airtrach, lightwands, straight up fiberoptics, and glidescopes).
I'm a big fan of the glidescope because of its simplicity, durability, and easy portability.

For those considering one, I have a recommendation: If you've got a smaller OR setting and are just going to buy one with a couple blades, go for it.
If you're looking at the potential for a little more use (i.e. needing it quickly in another room), if you haven't gotten the blade cleaned you may be S.O.L.
Check out the Cobalt. It looks different, but gives you the same access, but the nice thing is it's using a disposable (and hence reloadable in a second) cover, that makes it more flexible in giving you a quick turnover or switching to different sizes.
I'm no rep and get no kickbacks, I just like things that are simple since I've found any number of idiots will sooner or later break my fiberoptic scopes or lose vitally important dongle A which is necessary to utilize piece of expensive equipment B.

 

[pgg]

I have an adult with Turners Syndrome coming up, known difficult airway which caused some drama during a CABG a year ago. I didn't do her preop visit but the note says she's micrognathic, small mouth, short neck (no MP listed) ... recs having a Glidescope in the room.

I haven't laid eyes on her yet of course, but I'm thinking she probably deserves a FOI and that'll be general anesthesia plan A from the start.


Just curious if anyone has had experience using the Glidescope in patients with actual anatomic abnormalities, particularly micrognathia as that's a common theme in a lot of congenital syndromes.

 

[MRW]

Just curious if anyone has had experience using the Glidescope in patients with actual anatomic abnormalities, particularly micrognathia as that's a common theme in a lot of congenital syndromes.

Used the GS on a 48yo downs patient with an "ENT predicted" difficult airway a few days ago. Negotiating the GS through the mouth opening was the big challenge. Visualising and entering the very anterior airway was not.

Retro/micrognathia scares me more than macroglossia.

 

[Planktonmd]

I have an adult with Turners Syndrome coming up, known difficult airway which caused some drama during a CABG a year ago. I didn't do her preop visit but the note says she's micrognathic, small mouth, short neck (no MP listed) ... recs having a Glidescope in the room.

I haven't laid eyes on her yet of course, but I'm thinking she probably deserves a FOI and that'll be general anesthesia plan A from the start.


Just curious if anyone has had experience using the Glidescope in patients with actual anatomic abnormalities, particularly micrognathia as that's a common theme in a lot of congenital syndromes.

If I feel that Ventilation is not going to be a problem (most likely) I would go for FOI asleep.
If she appears difficult to ventilate then good topical, good sedation (possibly Droperidol + Fentanyl or maybe precedex), transtracheal block, then awake FOB.

 

[sevoflurane]

I have an adult with Turners Syndrome coming up, known difficult airway which caused some drama during a CABG a year ago. I didn't do her preop visit but the note says she's micrognathic, small mouth, short neck (no MP listed) ... recs having a Glidescope in the room.

I haven't laid eyes on her yet of course, but I'm thinking she probably deserves a FOI and that'll be general anesthesia plan A from the start.


Just curious if anyone has had experience using the Glidescope in patients with actual anatomic abnormalities, particularly micrognathia as that's a common theme in a lot of congenital syndromes.

Hey man.... I've been in some very challanging airways during residency (for some reason... not that many in PP). Peds heavy place (now with a children's hospital) with all sorts of pierre-robin, treacher-collins, goldenhars syndrome, cornelia deLange, cranio facial syndromes, etc, etc... Later in life, they would come back to get taken care of at the big house.
Anyways... I remember one particular AW I shared with my attending (foramaly in PP for 15 yrs.) at 3:00am. I think it was a Beckwidth-Wideman syndrome. Adult size. Anywho... it took us a good 1.5 hours to secure the AW (prolly should of just gotten trached but we were maintaining good mask ventilation). Started out with DL x 4. Intubating LMA, fiberoptic alone and thorugh LMA and then glidescope. Best view was definately with the glidescope, but getting through the cords was just as challanging as getting a view.

Anywho... we ended up securing the AW with a combined approach (glidescope/fiberoptic).... next step would have been a surgical AW. One of those intubations you never forgett (you know you've been at it too long when the roc wears off....)


Here is a case report that came up on my google search:

http://www.pedsanesthesia.org/meeti.../submissions/abstracts/casereports/CSF146.pdf

ASA editorial:

http://journals.lww.com/anesthesiol..._R__Intubation_Assisted_by_Fiberoptic.47.aspx

There are a number of studies that demonstrate that glidescope + FO can facilitate intubation in certain patient populations.

I find that FO is better for some patients, but overall... I likethe glidescope's ease of use + sometimes better AW tool.

 

[sevoflurane]

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

Dude... I don't know what you are saying. The FOB IS A STYLET.... just a flexible one.... and one that CAN be steared. That is it's purpose. To stear us into the glottis. Like with anything we do in anesthesia... if you are using force you ain't doing it right.


It is you who is incorrect:

Glidescope + Fiberoptic is a well described method of securing the AW. My anesthesia department was publishing papers on this 4yrs. ago.

 

[deleted9493]

Dude... I don't know what you are saying. The FOB IS A STYLET.... just a flexible one.... and one that CAN be steared. That is it's purpose. To stear us into the glottis. Like with anything we do in anesthesia... if you are using force you ain't doing it right.


It is you who is incorrect:

Glidescope + Fiberoptic is a well described method of securing the AW. My anesthesia department was publishing papers on this 4yrs. ago.

I did this just yesterday. Patient had a small mouth opening and ability to sublux was non-existent. Grade III with Mac/Miller. Glidescope an easy view but w/ the small mouth opening couldn't get the tip anterior enough--regardless of how I contorted the tube. Used a fiberoptic scope as a stylet to direct the tube under glidescope visualization anteriorly to glottic opening. Definitely a two user technique but very powerful.

I find the bougie with the glidescope to be not nearly as powerful as the bougie with the standard video laryngoscope--simply because it does not approximate the shape of the former, nearly as well as the latter and getting the bougie anterior enough with the glidescope can be impossible in some cases.

Took care of a 200kg woman w/ Stevens Johnsons, no neck (sloughing her airway and aspirating blood) and an interincisor distance of maybe 2cm. I don't think I could have manipulated a Glidescope in her but the C-Mac w/ its slimmer profile worked like a champ and allowed a bougie through her swollen larynx.

 

[jdh71]

FWIW, and this probably doesn't surprise any of the airway professionals on this board . . . we really like the glidescope in the MICU, especially overnight or weekends at a VA which usually only has a CRNA on homecall. I like it, and I've found that if you use their stylet, it seems to help if you pop it out some after getting the tip of the tube through the cords, inserting a little more, and then taking it the rest out. The airways I couldn't get that way have been either bougieable or obtained with some creative regular stylet bending.

 

[RussianJoo]

Learn to do some awake intubations. Don't get burned being afraid to do an awake look. The key is patient buy-in. Let them know you intend to do what is safest for them. Safest isn't roll the dice and hope you can ventilate or intubate.

Now an added benefit of sitting them up and facing them, is that the exam is not so unlike the doctor taking a look with a tongue depressor. It's a nice technique. Check it out.

There is an outstanding fairly recent Audio Digest lecture by Benumof I encourage you to listen to. The difficult airway. Audiodigest.com

cool thanks

 

[proman]

Plankton, you cannot bend the ETT with a FFB. THat is what I meant by when it is loaded. You are doing a railroad technique. When you push the tube off it is still a blind advancement since you cannot see where the tube goes until it passes the tip of the FFB.

If you don't believe me then try to bend the ETT with the FFB. I bet you will lose your FFB privileges...

You seem to have an axe to grind with any device that's not a stylet. You wouldn't happen to have a conflict of interest would you?

 

[urge]

Just curious if anyone has had experience using the Glidescope in patients with actual anatomic abnormalities, particularly micrognathia as that's a common theme in a lot of congenital syndromes.

Peds attendings swear by it for Pierre Robin and other micrognathic disorders.

 

[imfrankie]

Peds attendings swear by it for Pierre Robin and other micrognathic disorders.

Yes, they have pedi blades now. I still like the Bullard though. Same diff cept thinner.

 

[ssmallz]

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?

And if this were the case it wouldn't matter what the airway looked like w/a mac or miller but unfortunately in the practice environment we live in, macs and millers are everywhere in every airway box in the hospital while glidescopes are still mostly found in the OR and there's only a few on site in each hospital. I feel it is important to know the view w/a standard D/L blade so that if someone tries to intubate this pt in the future, they will have more information on how to be proceed b/c they may not have access to a glidescope all the time.

 

[amyl]

huge glidescope fan, but I always DL first unless they are documented to have failed -- if the pt goes somewhere they don't have a glidescope i hate to destine them to awake FOI -- and honestly now i seem to bring the glidescope in the room (just in case to ward off the evil forces) and never use it.... positioning, etc. seems to do the trick. would love to see them make a smaller glidescope version that would facilitate DLT placement... that would rock.
we have had a number of injuries though. i can't stress enough what was said above... when you put the tube with the stylet (that needs to be behind the murphy hole) look at the mouth! not the screen. once you can no longer see the tip of the tube then look at the screen to drive. i think all the injuries we have seen (and we glidescope ALOT) have been ill placed stylet and/or looking at the screen when you place the tube in the mouth.