Grade 3 view with GS?

[ItBurnsInMyHand]

Patient with acute CHF and hypercarbic respiratory failure (pCO2 98), 473 lbs, electively intubated. Used a GS4 and couldn't quite get anything better than a (at best) grade IIb where I kept getting caught on arytenoids, but otherwise predominantly grade 3 view (with only epiglottis). He had this long floppy, almost omega shaped epiglottis that resembled a pedi airway. Was this view a result of a purely operator dependent issue? An attending had similar luck with it and ended up taking a chance and passing the ETT below the epiglottis. Even after it was placed, it was difficult to ascertain correct placement visually. I'm pretty comfortable with normal DL/GS intubations as a CA2 so I was just wondering in case I encounter this again!

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[deleted9493]

Patient with acute CHF and hypercarbic respiratory failure (pCO2 98), 473 lbs, electively intubated. Used a GS4 and couldn't quite get anything better than a (at best) grade IIb where I kept getting caught on arytenoids, but otherwise predominantly grade 3 view (with only epiglottis). He had this long floppy, almost omega shaped epiglottis that resembled a pedi airway. Was this view a result of a purely operator dependent issue? An attending had similar luck with it and ended up taking a chance and passing the ETT below the epiglottis. Even after it was placed, it was difficult to ascertain correct placement visually. I'm pretty comfortable with normal DL/GS intubations as a CA2 so I was just wondering in case I encounter this again!

Using the glidescope blade tip in the vallecula, yes, I have encountered this type of view. Directly distracting the epiglottis can be necessary, particularly if you're limited by a an unwieldy epiglottis or oral aperture that is limiting your ability to maneuver. I don't know that I would ever recommend it as a go to technique but downsizing the blade and using a portion of the handle in the oropharynx to allow direct manipulation of the epiglottis can be helpful.

 

[ItBurnsInMyHand]

Using the glidescope blade tip in the vallecula, yes, I have encountered this type of view. Directly distracting the epiglottis can be necessary, particularly if you're limited by a an unwieldy epiglottis or oral aperture that is limiting your ability to maneuver. I don't know that I would ever recommend it as a go to technique but downsizing the blade and using a portion of the handle in the oropharynx to allow direct manipulation of the epiglottis can be helpful.

Thank you!

 

[wickedskillz]

did u optimize position beforehand?

 

[Iso4ane]

Patient with acute CHF and hypercarbic respiratory failure (pCO2 98), 473 lbs, electively intubated. Used a GS4 and couldn't quite get anything better than a (at best) grade IIb where I kept getting caught on arytenoids, but otherwise predominantly grade 3 view (with only epiglottis). He had this long floppy, almost omega shaped epiglottis that resembled a pedi airway. Was this view a result of a purely operator dependent issue? An attending had similar luck with it and ended up taking a chance and passing the ETT below the epiglottis. Even after it was placed, it was difficult to ascertain correct placement visually. I'm pretty comfortable with normal DL/GS intubations as a CA2 so I was just wondering in case I encounter this again!

Had a similar situation, at best grade 3 borderline 4 view. Remember the ASA Difficult Airway Pathway. My attending and I were lucky, we had suspicions it would be difficult so we had a fiber-optic in the room. But that was a no go, we shove an LMA in there and luckily it works. So Fiberoptic through that with an Aintree tube exchanger and we get our ETT in.

 

[Shimmy8]

Combo fiberoptic and glidescope works great if planned correctly. So smooth.

 

[Ezekiel2517]

You gotta appreciate there are airways out there that can't be attained with any type of blade, including a glide. Rare but they're out there. Recently had an ankylosing spondylitis patient with a tiny MO. Grade 4 view with glide and 2 other anesthesiologists tried and unable to see anything better. I went fiberoptic by passing the scope thru an ETT placed nasally as a guide.

 

[Ronin786]

I've had that happen on occasion. I can't fully explain it, but lifting up the mandible seems to help sometimes.

 

[MoMoGesiologist]

You gotta appreciate there are airways out there that can't be attained with any type of blade, including a glide. Rare but they're out there. Recently had an ankylosing spondylitis patient with a tiny MO. Grade 4 view with glide and 2 other anesthesiologists tried and unable to see anything better. I went fiberoptic by passing the scope thru an ETT placed nasally as a guide.

Maybe a silly question, but with tiny MO and I'm assuming limited neck extension, why not go straight to awake fiber optic intubation? Or was the airway exam reassuring enough you though you would get a view with DL or glide or mask ventilation?

 

[Ezekiel2517]

Maybe a silly question, but with tiny MO and I'm assuming limited neck extension, why not go straight to awake fiber optic intubation? Or was the airway exam reassuring enough you though you would get a view with DL or glide or mask ventilation?

MO was small but not the biggest issue at all. If you looked at him and did an airway exam, you wouldn't think you'd have an issue with a glide. Extremely rare to not be able to get a view with a glide in PP, so one just doesn't expect an airway like this. First time I've needed to use fiberoptic in a couple years, apart from when surgeon requests an awake intubation

 

[anesthesiadoc]

did u optimize position beforehand?

This!!!

I think people get a false sense of confidence that the video laryngoscopes will be a panacea of sorts for anticipated difficult airway and that it somehow negates the need for optimal positioning. Ramping a patient up and getting a good sniffing position helps with your glide as well. When I give mock orals, it's a sticking point for me when the residents go straight to "I'd have a glide scope in the room" when the stem involves an obese patient with short, thick neck. On the boards (and in real life) that's a dangerous oversimplification of the prep that these patients merit prior to pushing the induction meds.


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[anbuitachi]

Did you try DL w a miller blade

 

[deleted697535]

Patient with acute CHF and hypercarbic respiratory failure (pCO2 98), 473 lbs, electively intubated. Used a GS4 and couldn't quite get anything better than a (at best) grade IIb where I kept getting caught on arytenoids, but otherwise predominantly grade 3 view (with only epiglottis). He had this long floppy, almost omega shaped epiglottis that resembled a pedi airway. Was this view a result of a purely operator dependent issue? An attending had similar luck with it and ended up taking a chance and passing the ETT below the epiglottis. Even after it was placed, it was difficult to ascertain correct placement visually. I'm pretty comfortable with normal DL/GS intubations as a CA2 so I was just wondering in case I encounter this again!

Glidescope is a pain in the ass. It does give a decent view most of the time though.
McGrath is far better imo
There are always exceptions though

I assume it was a 4 blade? Had a similar ish case last week and changing up to a 4 fixed everything. Obviously the nay Sayers will say to start with a 4 for a man but anyway

A glidescope fibreoptic combo is a beautiful technique when you're really stuck though.

 

[Noyac]

Did you try DL w a miller blade

What's a Miller?

 

[Ezekiel2517]

Did you try DL w a miller blade

miller gave grade 4 view. mcgrath gave grade 4 view. multiple blade sizes used, including a size 2 lol. also was a difficult mask with just one person, had to use 2 hands.