Facilitating tracheal intubation in pediatric patients with the Airtraq® optical laryngoscope

Abstract

To the Editor, The Airtraq optical laryngoscope (Airtraq) (Prodol Meditec S.A., Vizcaya, Spain) is a relatively new disposable tracheal intubation device with an anatomically shaped blade that has two parallel channels, the optical channel and the guiding channel, which accommodates the endotracheal tube (ETT). The Airtraq incorporates a guiding channel to the right of the viewing axis to solve the challenge of passing the ETT through the glottis. However, delivering the ETT through the gap between the end of the guiding channel tube to the glottis may not be straightforward. The guiding channel tube and viewing axis are somewhat incongruent, because the direction of ETT advancement from the guiding channel is defined by the configuration of the guiding channel tube and the ETT angulation. When attempting to advance the ETT through the laryngeal aperture with the Airtraq during tracheal intubation, it has been reported that a posterior tube tip location can be problematic, especially for pediatric patients. On the basis of our cumulated experience with the Airtraq, which includes more than 500 pediatric patients to date, another possible difficulty in advancing the ETT through the glottis, especially in infants and young children with smaller airways, is a left tube tip location. This potential problem arises because the Airtraq is designed with the guiding channel at the right of the viewing axis, and a left-oriented slope at the right side of the distal opening of the guiding channel is devised to direct the tube tip into the glottis in the midline (Figure, Panel A). This design results in ETT advancement from the guiding channel towards the left. Consequently, during advancement of the ETT, the tube tip may move across the midline (Figure, Panel B) towards either the left vocal cord or the left laryngeal vestibule rather than align the ETT towards the midline of the glottis (Figure, Panel C). Whenever this problem arises, our practice has been to withdraw the ETT by approximately 0.5 cm and to exercise one of four available options: 1) slightly rotate the Airtraq in a clockwise direction; 2) advance the Airtraq downwards; 3) gently apply leftwards laryngeal pressure with external laryngeal manipulation, then re-attempt ETT advancement; and 4) in the very rare occasions the above measures fail, withdraw the ETT from the guiding channel and introduce a pediatric bougie into the visualized glottis via the guiding channel. The ETT is then railroaded along the bougie through the larynx, and the Airtraq is used to monitor the progress of the ETT advancement. Over the previous two years, we have used these maneuvers quite successfully to facilitate advancing the ETT into the glottis with the Airtraq device in pediatric patients with uncomplicated and difficult airways alike.