Perforation of the soft palate using the GlideScope videolaryngoscope

Difficult tracheal tube passage and subglottic airway injury during intubation with the GlideScope® videolaryngoscope: a randomised, controlled comparison of three tracheal tubes

Difficulty during placement of the tracheal tube is a known problem when intubating with the GlideScope^® , which may lead to subglottic airway injury. This randomised, controlled clinical trial was designed to compare the resistance to passage of PVC (polyvinyl chloride), reinforced or BlockBuster tracheal tubes during intubation with the GlideScope. Secondary outcomes included the time taken to intubate and assessment of subglottic airway injury. One-hundred and seventy-seven patients were included in the data analysis. There was difficult tracheal tube passage (moderate or severe resistance) in 15 (21.4%) patients using the PVC tube compared with 4 (7.4%) and 1 (1.9%) using the reinforced and BlockBuster tubes, respectively (p = 0.003 for PVC vs. BlockBuster). The median (IQR [range]) time taken to intubate was 35 (27-45 [15-115]) s, 25 (20-27 [15-110]) s and 25 (22-30 [16-90]) s, respectively, (p < 0.001 for PVC vs. reinforced as well as PVC vs. BlockBuster). Subglottic airway injury, assessed using a fibreoptic bronchoscope after extubation, was higher with the PVC tube (p < 0.001) and the reinforced tube (p = 0.012) compared with the BlockBuster tube. We conclude that the BlockBuster tracheal tube is a better choice for orotracheal intubation with the GlideScope than PVC or reinforced tubes.

Success of Intubation Rescue Techniques after Failed Direct Laryngoscopy in Adults

Background

Multiple attempts at tracheal intubation are associated with mortality, and successful rescue requires a structured plan. However, there remains a paucity of data to guide the choice of intubation rescue technique after failed initial direct laryngoscopy. The authors studied a large perioperative database to determine success rates for commonly used intubation rescue techniques.

Methods

Using a retrospective, observational, comparative design, the authors analyzed records from seven academic centers within the Multicenter Perioperative Outcomes Group between 2004 and 2013. The primary outcome was the comparative success rate for five commonly used techniques to achieve successful tracheal intubation after failed direct laryngoscopy: (1) video laryngoscopy, (2) flexible fiberoptic intubation, (3) supraglottic airway as part of an exchange technique, (4) optical stylet, and (5) lighted stylet.

Results

A total of 346,861 cases were identified that involved attempted tracheal intubation. A total of 1,009 anesthesia providers managed 1,427 cases of failed direct laryngoscopy followed by subsequent intubation attempts (n = 1,619) that employed one of the five studied intubation rescue techniques. The use of video laryngoscopy resulted in a significantly higher success rate (92%; 95% CI, 90 to 93) than other techniques: supraglottic airway conduit (78%; 95% CI, 68 to 86), flexible bronchoscopic intubation (78%; 95% CI, 71 to 83), lighted stylet (77%; 95% CI, 69 to 83), and optical stylet (67%; 95% CI, 35 to 88). Providers most frequently choose video laryngoscopy (predominantly GlideScope® [Verathon, USA]) to rescue failed direct laryngoscopy (1,122/1,619; 69%), and its use has increased during the study period.

Conclusions

Video laryngoscopy is associated with a high rescue intubation success rate and is more commonly used than other rescue techniques.

Review of videolaryngoscopy pharyngeal wall injuries

OBJECTIVES

Reports of patient injuries associated with videolaryngoscopy are increasing in the literature. There are a wide variety of opinions regarding both safe use of the device and patient care following aerodigestive tract injury. We have seen an increase in videolaryngoscopy-associated injuries in recent years at our institution. Because of this, we wanted to determine if video-assisted laryngoscopy presents a greater risk of injury compared with direct laryngoscopy. Furthermore, we wanted to determine if there were patient and/or surgical factors that could contribute to patient injuries following videolaryngoscopy.

DATA SOURCES

MAMC anesthesia records, PubMed, Ovid.

REVIEW METHODS

We compared rates of injury between videolaryngoscopy to direct laryngoscopy at our institution by searching anesthesia records to identify laryngoscopy procedures that resulted in injury to the soft palate or oropharynx. We also identified 19 published cases in the literature, in addition to our cases, that we reviewed for patient characteristics (e.g., body mass index, age and sex, Mallampati grade), type of videolaryngoscope, location of injury, and type of repair (if any) required.

RESULTS

At our institution, we have a statistically higher rate of injury using videolaryngoscopy compared to direct laryngoscopy. Our data also indicate that women are more commonly injured during videolaryngoscope intubation than men. The right tonsillar pillars and soft palate are the most frequently injured, with through-and-through perforation of the soft tissues being the most common type of injury. The most common repair of injuries required simple closures, and long-term harm was very rare.

CONCLUSION

Our data suggests that using video-assisted laryngoscopy for intubation puts a patient at significantly greater risk for injury compared to direct laryngoscopy. Laryngoscope, 2016 127:349-353, 2017.

Use-Dependent Curvature Changes in the GlideRite® Reusable Intubation Stylet

The Glidescope® is one of the most widely used video laryngoscopes in the market. It is often used with a purpose-built, reusable, "nonmalleable" stainless steel stylet, the GlideRite®. In this study, we investigated whether this stylet retains its original curvature with repeated use and sterilization. To evaluate the shape and curvature of the stylets, high-resolution digital photographs were made of 55 GlideRite stylets (5 new and 50 randomly selected from operating room stock) laid on a grid background and analyzed using Adobe Photoshop®. In a similar fashion, 1 new stylet was inserted into and removed 100 times from an endotracheal tube and photographed every 20 cycles to determine the impact of use on stylet shape. For the 5 new stylets, the handle-to-tip angle was very consistent (23.44° ± 1.04°). The stylets in clinical use varied widely in their configuration. For analysis, they were divided into 3 groups based on the handle-to-tip angle: ±1 SD of the new stylets, those with a shallower angle (straighter), and those with a steeper angle (more curved). The handle-to-tip angles were as follows: 23.07° ± 0.80° (±1 SD), 18.39° ± 2.59° (straighter), and 27.65° ± 2.73° (more curved). Analysis of variance showed that the new and ±1 SD groups were not significantly different, but both the straighter (P = 0.0002) and more curved (P = 0.0048) groups were significantly different from new. The repeated insertion and removal of a new stylet resulted in gradual straightening of the curve of the stylet from 22° at baseline to 19.2° after 100 insertion/removal cycles. Used GlideRite reusable stylets are not reliably equivalent to new ones in terms of their shape or curvature. Given that the repeated insertion and removal of a new stylet from an endotracheal tube resulted in their straightening, it is likely that clinical use has the same effect. Because many used stylets were actually more curved than the new ones, we hypothesize that practitioners likely bend the nonmalleable stylets to improve clinical utility, but often fail to recapture the manufacturer-intended curve. The clinical relevance of the change in shape of the GlideRite stylet remains to be determined; it is that possible intubation may be more difficult than expected compared with the use of new stylets.

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

Palatal and retropharyngeal injury secondary to intubation using the GlideScope® video laryngoscope

INTRODUCTION

There are few reports of injury to the soft palate and retropharynx sustained during intubation with the GlideScope® video laryngoscope. Most reports are of isolated injury to the soft palate.

CASE HISTORY

We describe a patient in whom the retropharynx was injured but the extent of the injury was not observed initially. The patient did not suffer severe sequelae from this injury. However, this injury can cause serious sequelae if it is not recognised (eg development of a retropharyngeal abscess).

CONCLUSIONS

We recommend that any patient who sustains injury to the soft palate during intubation (particularly if the endotracheal tube passes through the soft palate) should be reviewed an otolaryngologist before removal of the endotracheal tube.

GlideScope Use improves intubation success rates: an observational study using propensity score matching

Background

Rigid video laryngoscopes are popular alternatives to direct laryngoscopy for intubation, but further large scale prospective studies comparing these devices to direct laryngoscopy in routine anesthesiology practice are needed. We hypothesized that the first pass success rate with one particular video laryngoscope, the GlideScope, would be higher than the success rate with direct laryngoscopy.

Methods

3831 total intubation attempts were tracked in an observational study comparing first-pass success rate using a Macintosh or Miller-style laryngoscope with the GlideScope. Propensity scoring was then used to select 626 subjects matched between the two groups based on their morphologic traits.

Results

Comparing the GlideScope and direct laryngoscopy groups suggested that intubation would be more difficult in the GlideScope group based on the Mallampati class, cervical range of motion, mouth opening, dentition, weight, and past intubation history. Thus, a propensity score based on these factors was used to balance the groups into two 313 patient cohorts. Direct laryngoscopy was successful in 80.8% on the first-pass intubation attempt, while the GlideScope was successful in 93.6% (p <0.001; risk difference of 0.128 with a 95% CI of 0.0771 – 0.181).

Conclusion

A greater first-attempt success rate was found when using the GlideScope versus direct laryngoscopy. In addition, the GlideScope was found to be 99% successful for intubation after initial failure of direct laryngoscopy, helping to reduce the incidence of failed intubation.

A systematic review of the role of videolaryngoscopy in successful orotracheal intubation

BACKGROUND

The purpose of our study was to organize the literature regarding the efficacy of modern videolaryngoscopes in oral endotracheal intubation, then perform a quality assessment according to recommended external criteria and make recommendations for use.

METHODS

Inclusion criteria included devices with recent studies of human subjects. A total of 980 articles were returned in the initial search and 65 additional items were identified using cited references. After exclusion of articles failing to meet study criteria, 77 articles remained. Data were extracted according to the rate of successful intubation and improvement of glottic view compared with direct laryngoscopy. Studies were classified according to whether they primarily examined subjects with normal airways, possessing risk factors for difficult direct laryngoscopy, or following difficult or failed direct laryngoscopy.

RESULTS

The evidence of efficacy for videolaryngoscopy in the difficult airway is limited. What evidence exists is both randomized prospective and observational in nature, requiring a scheme that evaluates both forms and allows recommendations to be made.

CONCLUSIONS

In patients at higher risk of difficult laryngoscopy we recommend the use of the Airtraq, CTrach, GlideScope, Pentax AWS and V-MAC to achieve successful intubation. In difficult direct laryngoscopy (C&L >/= 3) we cautiously recommend the use of the Airtraq, Bonfils, Bullard, CTrach, GlideScope, and Pentax AWS, by an operator with reasonable prior experience, to achieve successful intubation when used in accordance with the ASA practice guidelines for management of the difficult airway. There is additional evidence to support the use of the Airtraq, Bonfils, CTrach, GlideScope, McGrath, and Pentax AWS following failed intubation via direct laryngoscopy to achieve successful intubation. Future investigation would benefit from precise qualification of the subjects under study, and an improvement in overall methodology to include randomization and blinding.

Video Laryngoscopy in the Prehospital Setting

In the prehospital setting, the emergency care provider must anticipate that some patients will manifest with difficult airways. The use of video laryngoscopy to secure an airway in the prehospital setting has not been explored widely, but has the potential to be a useful tool. This article briefly reviews some of the major video laryngoscopes on the market and their usefulness in the prehospital setting. Studies and case reports indicate that the video laryngoscope is a promising device for emergency intubation, and it has been predicted that, in the future, video laryngoscopy will dominate the field of emergency airway management.

Direct laryngoscopy always should be retained as a primary skill; however, the video laryngoscope has the potential to be a good primary choice for the patient with potential cervical spine injuries or limited jaw or spine mobility, and in the difficult-to-access patient.The role of video laryngoscopes in securing an airway in head and neck trauma victims in the prehospital setting has yet to be determined, but offers interesting possibilities. Further clinical studies are necessary to evaluate its role in airway management by prehospital emergency medical services.

Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope

STUDY OBJECTIVES

To determine whether the first-attempt tracheal intubation incidence using the GlideScope videolaryngoscope is higher in patients with predicted increased risk of difficult laryngoscopy, and to assess the ability of other a priori defined standard risk factors to predict first-attempt intubation success, in aggregate and by forming scores.

DESIGN

Prospective study.

SETTING

Operating room in a tertiary-care academic center.

PATIENTS

357 patients intubated with the GlideScope for nonemergent general anesthesia.

INTERVENTIONS AND MEASUREMENTS

Mallampati airway class was used to create two groups of patients, one with higher and the other, lower, potential difficult laryngoscopy (Mallampati classes 3-4 and 1-2, respectively). Intubation success on the first attempt with the GlideScope videolaryngoscope in patients with a Mallampati class 3 or 4 airway versus those with Mallampati class 1 or 2 airway was tested. We also evaluated the predictive ability of the Mallampati airway class (1 and 2 vs 3 and 4) along with 9 other possible predictors of difficult intubation on first-attempt intubation success: gender, age, body mass index, level of training within our anesthesia residency program (Clinical Anesthesia Resident years 1, 2, and 3), ASA physical status, mouth opening, thyromental distance, neck flexion, and neck extension.

MAIN RESULTS

None of the standard predictors of difficult intubation was significantly associated with outcome after adjusting for other predictors. A multivariable model containing the aggregate set of variables predicted outcome significantly better than a risk score formed as the sum of 10 predictors ("Risk 10"; P = 0.0176).

CONCLUSIONS

With GlideScope-assisted tracheal intubation, Mallampati airway class is not an independent risk factor for difficult intubation. Other standard clinical risk factors of difficulty with direct laryngoscopy also do not appear to be individually predictive of first-attempt success of tracheal intubation.

Endotrol-tracheal tube assisted endotracheal intubation during video laryngoscopy

Video laryngoscopes allow indirect visualization of the glottis and provide superior views of the glottis compared to direct laryngoscopes in patients with both normal and difficult airways, but it may be difficult to advance the endotracheal tube (ETT) through the vocal cords into the trachea, unless a stylet is used. We propose that the Endotrol(®) ETT may be an effective tool to facilitate video laryngoscope-assisted orotracheal intubation without the use of a stylet. After obtaining written and oral informed consent, 60-adult patients scheduled for elective surgery requiring general anesthesia with orotracheal intubation were enrolled. Patients were randomized, respectively, to 1 of 4 groups: Group A(1), (15 patients): McGrath(®) with Endotrol(®) ETT; Group A(2), (15 patients): McGrath(®) with GlideRite(®)-styletted standard ETT; Group B(1), (15 patients): GlideScope(®) with Endotrol(®) ETT; Group B(2), (15 patients): GlideScope(®) with GlideRite(®)-styletted standard ETT. Statistical analysis was performed with Stata (Stata Corp v10, College Station). Mean time to intubation was longer in the Endotrol(®) groups compared to the GlideRite(®) groups: 60.1 (31.6) vs. 44.4 (27.6) s (p < 0.05). It was subjectively more difficult to intubate using the Endotrol(®) than with a GlideRite(®)-styletted ETT (difficulty score median [range] 2 [1-5] vs. 1 [1-3], respectively). Three intubations using the Endotrol(®) were characterized as difficult, whereas there were no difficult intubations with the GlideRite(®)stylet. The Endotrol(®) ETT, as compared to a standard ETT with a non-malleable stylet, is associated with longer intubation times and a subjective increase in difficulty of use. It may, however, still be a clinically viable alternative in video laryngoscope-assisted orotracheal intubation when use of a rigid stylet is undesirable.

The use of the GlideScope® for tracheal intubation in patients with halo vest

OBJECTIVE

GlideScope® provides better laryngoscopic view and is advantageous in tracheal intubation in ankylosing spondylitis patients with difficult airway.

METHODS

This study was performed to investigate the use of the GlideScope® for tracheal intubation in 15 patients wearing halo vests scheduled for elective surgery under general anesthesia. Preoperative airway assessments were evaluated to predict the difficulty of tracheal intubation. Before intubation, all patients were given a modified Cormack and Lehane (MCLS) grade and percentage of glottic opening (POGO) score by the intubating anesthesiologist having resorted to direct laryngoscopy (DL) with a Macintosh Size 3 blade depiction. Then intubation with the GlideScope® was performed, during which the larynx was inspected and given another MCLS grade and POGO score.

RESULTS

Fourteen of the 15 patients had MCLS Grade III or IV by direct Macintosh laryngoscopy and were considered to have a difficult laryngoscopy. Nasal tracheal intubation by the GlideScope® was successful on all occasions. The GlideScope® improved the MCLS grade and POGO score in all patients who had put on a halo vest as compared with those on DL (p<0.01). The GlideScope® also provided a better laryngoscopic view than that by a DL. All of the patients who wore halo vests and presented with suspected difficult airways could be intubated successfully with the GlideScope®.

CONCLUSION

The use of the GlideScope® for tracheal intubation could be an alternative option in patients with a difficult airway, whose surgery was circumscribed under general anesthesia with tracheal intubation.

A randomised controlled trial comparing the McGrath(®) videolaryngoscope with the straight blade laryngoscope when used in adult patients with potential difficult airways

Studies show that both straight blade laryngoscopy and videolaryngoscopy can improve the view of the larynx when compared with the Macintosh blade laryngoscopy. However, no study has compared these two devices. A total of 80 patients with Mallampati grade ≥ 3 were randomly assigned to either have orotracheal intubation with the McGrath(®) videolaryngoscope or the Henderson straight blade. The primary outcome was laryngoscopic view. Time to intubation, number of attempts, ease of intubation and complications were also recorded. Thirty-nine out of 40 patients had grade-1 views in the McGrath group, compared with 29 out of 40 cases in the Henderson group (p = 0.003). There were no statistically significant differences in the secondary outcomes. Two patients suffered from minor oropharyngeal injuries in the Henderson group. Apart from offering significantly more grade-1 laryngoscopic views, the McGrath videolaryngoscope did not improve other clinical outcomes compared with the straight blade, when used in patients with poor Mallampati scores.

A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia

BACKGROUND

The C-MAC® (Karl Storz, Tuttlingen, Germany) has recently been introduced as a new device for videolaryngoscopy guided intubation. The purpose of the present study was to compare for the first time the C-MAC with conventional direct laryngoscopy in 150 patients during routine induction of anaesthesia.

METHODS

After approval of the institutional review board and written informed consent, 150 patients (ASA I-III) with general anaesthesia were enrolled. Computer-based open crossover randomisation was used to determine the sequence of the three laryngoscopies: Conventional direct laryngoscopy (HEINE Macintosh classic, Herrsching, Germany; blade sizes 3 or 4; DL group), C-MAC size 3 (C-MAC3 group) and C-MAC size 4 (C-MAC4 group) videolaryngoscopy, respectively. After 50 patients, laryngoscopy technique in the C-MAC4 group was changed to the straight blade technique described by Miller (C-MAC4/SBT).

RESULTS

Including all 150 patients (70 male, aged (median [range]) 53 [20-82] years, 80 [48-179] kg), there was no difference of glottic view between DL, C-MAC3, C-MAC4, and C-MAC4/SBT groups; however, worst glottic view (C/L 4) was only seen with DL, but not with C-MAC videolaryngoscopy. In the subgroup of patients that had suboptimal glottic view with DL (C/L≥2a; n = 24), glottic view was improved in the C-MAC4/SBT group; C/L class improved by three classes in 5 patients, by two classes in 2 patients, by one class in 8 patients, remained unchanged in 8 patients, or decreased by two classes in 1 patient. The median (range) time taken for tracheal intubation in the DL, C-MAC3, C-MAC4 and C-MAC4/SBT groups was 8 sec (2-91 sec; n = 44), 10 sec (2-60 sec; n = 37), 8 sec (5-80 sec; n = 18) and 12 sec (2-70 sec; n = 51), respectively.

CONCLUSIONS

Combining the benefits of conventional direct laryngoscopy and videolaryngoscopy in one device, the C-MAC may serve as a standard intubation device for both routine airway management and educational purposes. However, in patients with suboptimal glottic view (C/L≥2a), the C-MAC size 4 with straight blade technique may reduce the number of C/L 3 or C/L 4 views, and therefore facilitate intubation. Further studies on patients with difficult airway should be performed to confirm these findings.

Video-laryngoscopes in the adult airway management: a topical review of the literature

The aim of the present paper is to review the literature regarding video-laryngoscopes (Storz V-Mac and C-Mac, Glidescope, McGrath, Pentax-Airway Scope, Airtraq and Bullard) and discuss their clinical role in airway management. Video-laryngoscopes are new intubation devices, which provide an indirect view of the upper airway. In difficult airway management, they improve Cormack-Lehane grade and achieve the same or a higher intubation success rate in less time, compared with direct laryngoscopes. Despite the very good visualization of the glottis, the insertion and advancement of the endotracheal tube with video-laryngoscopes may occasionally fail. Each particular device's features may offer advantages or disadvantages, depending on the situation the anaesthesiologist has to deal with. So far, there is inconclusive evidence indicating that video-laryngoscopy should replace direct laryngoscopy in patients with normal or difficult airways.

Utilization of a Glidescope videolaryngoscope for orotracheal intubations in different emergency airway management settings

OBJECTIVE

To describe the initial experience of a group of emergency department (ED) physicians, utilizing a Glidescope videolaryngoscope (GVL) for orotracheal intubations in the ED.

METHODOLOGY

A 6-month, single center, prospective observational study from 19 Feb 2007 to 18 Aug 2007 was conducted on all orotracheal intubations, which involved utilization of the original GVL in different emergency airway management scenarios.

RESULTS

Overall success of GVL intubation was 15 out of 21 (71.4%) cases. The GVL was able to provide at least Cormack-Lehane grade I or II laryngoscopy views in all cases. All the operators highlighted difficulty in angulating and maneuvering the endotracheal tube for insertion through the glottis as the primary difficulty encountered.

CONCLUSION

We found the GVL to be an effective device in our ED's emergency airway control repertoire. Its role in the anticipated difficult airway in the ED will need further studies.

Pediatric difficult airway management: current devices and techniques

The anesthesiologist confronting the difficult pediatric airway is presented with a unique set of challenges. Adult difficult airway management techniques, such as awake or invasive approaches to airway management, often cannot be applied to children because of inadequate cooperation. Consequently, awake intubation in pediatrics is uncommon; most intubations are performed under general anesthesia or deep sedation. From a physiologic perspective, children have higher rates of oxygen consumption, significantly shortening the period of apnea that can be safely tolerated. Normal developmental anatomic differences of the pediatric airway and the presence of craniofacial dysmorphisms, presents additional challenges to tracheal intubation.

Videolaryngoscopy in the management of the difficult airway: a comparison with the Macintosh blade

BACKGROUND AND OBJECTIVE

Several studies have shown that videolaryngoscopes can provide better laryngeal exposure than conventional laryngoscopy. These studies, however, did not exclusively focus on patients with an anticipated difficult intubation. The aim of the present study was to assess whether a videolaryngoscope would provide better laryngeal exposure than conventional laryngoscopy and therefore facilitate intubation in cases of difficult laryngoscopy.

METHODS

One hundred and twelve patients with an estimated difficult intubation, scheduled to undergo surgical operations, requiring general anaesthesia and endotracheal intubation, were included in the study. Direct laryngoscopy with a Macintosh blade was performed, followed by videolaryngoscopy and intubation attempt(s). The laryngeal views obtained by each method were recorded according to the Cormack/Lehane scale.

RESULTS

The percentage of Cormack-Lehane I and II views obtained by conventional laryngoscopy rose from 63.4 to 90.2% (P < 0.0005) with videolaryngoscopy, whereas Cormack-Lehane III and IV views declined from 36.6 to 9.8% (P < 0.0005). Intubation was successful in 98.2% of the cases.

CONCLUSION

In patients with an anticipated difficult airway, videolaryngoscopy significantly improved the laryngeal exposure thus facilitating endotracheal intubation.

Palatopharyngeal wall Perforation during Glidescope® Intubation

We report a case of palatopharyngeal wall perforation during intubation with a GlideScope® laryngoscope. The likely mechanism was advancing and rotating the endotracheal tube against a taut palatopharyngeal fold. This was missed during the initial laryngoscopy, because there is a potential blind-spot in the oropharynx when attention is focused on the GlideScope® monitor. Fortunately, there were no sequelae other than minor bleeding and a mild sore throat and no surgical intervention was necessary. The use of unnecessary force during the endotracheal tube insertion, the use of too large a laryngoscope blade and the use of a rigid stylet could possibly also have been contributory factors to this complication.

[Lo-Pro Adult Color GlideScope: experience in 350 cases]

BACKGROUND

The aim of this study was to describe our experience in managing the new adult color model of the Lo-Pro GlideScope in a diverse group of patients.

MATERIAL AND METHODS

Prospective, descriptive study of 350 ASA 1-5 patients who underwent oral or nasal tracheal intubation with the Lo-Pro Adult Color GlideScope. Patients whose maximum mouth opening was inadequate were excluded. We recorded the following data: demographic variables, predictors of difficult direct laryngoscopy, Cormack-Lehane grade, presence of morbid obesity, adjusting maneuvers required, intubations in awake patients, intubations with a selective double lumen tube, rescues of failed intubations, oropharyngeal lesions, postoperative sore throat, and failed intubation.

RESULTS

Cormack-Lehane grade was 1 in 80.6% of the cases, 2 in 16.9%, and 3 in 2.6%. There were no Cormack-Lehane 4 patients. Rotation of the tube was necessary when entering the glottis in 38%. There were no significant differences in the incidence of oropharyngeal lesions between oral and nasal intubations. There were no abandoned attempts.

CONCLUSIONS

The rate of successful tracheal intubation is high with the new Lo-Pro Adult Color GlideScope when it is used by trained staff, even in patients with difficult airways. It is also a useful device for intubating awake patients.