GlideScope®-assisted Fiberoptic Intubation: A New Airway Teaching Method

Abstract

Cleveland Clinic Foundation, Cleveland, Ohio. doylej@ccf.orgAdditional material related to this article can be found on the Anesthesiology Web site. Go to http://www.anesthesiology.org, click on Enhancements Index, and then scroll down to find the appropriate article and link. Supplementary material can also be accessed on the Web by clicking on the “ArticlePlus” link either in the Table of Contents or at the HTML version of the article.It is well known that “practice makes perfect” when learning fiberoptic intubation (FOI). Although subjecting patients with normal airways to awake FOI for mere teaching purposes is usually inappropriate, it is common to have residents obtain FOI experience in patients with normal airways during general anesthesia. However, conducting FOI in this setting has time pressures that are not present with awake intubation, because special concerns of oxygenation, ventilation, and awakening exist. Complicating this situation is the fact that frequently only the operator can see what is happening, such that the supervisor can only offer limited assistance.The purpose of this letter is to describe a new technique for FOI using the GlideScope® video laryngoscope (Vitaid Airway Management*, Williamsville, NY). After anesthetic induction, a GlideScope® is introduced in the usual manner,1,2followed by introduction of the fiberoptic bronchoscope (FOB). While the resident manipulates the FOB into position, the supervisor monitors the GlideScope® display to see where the tip of the FOB is located. (The resident looks only through the FOB and does not look at the GlideScope® display.) The supervisor then provides verbal feedback to the resident as to the location of the tip of the FOB. When the FOB has entered well into the trachea, the endotracheal tube is passed over the FOB into the glottis. Here, use of the GlideScope® can again be helpful because, should the endotracheal tube get caught on the arytenoids3or other laryngeal structures, it becomes evident on the GlideScope® display, and appropriate corrective action (such as twisting the endotracheal tube) can easily be taken.It should also be pointed out that during general anesthesia, the lumen of the pharynx and the larynx usually becomes smaller as a result of reduced muscle tone. Insertion of the GlideScope® lifts the tongue and the jaw to open up these structures and facilitates the identification of anatomical landmarks by the user of the FOB.Finally, it should be emphasized that this technique would be expected to be useful for other purposes, as in situations where FOI is difficult even for experienced operators, as may occur, for example, in the case of an airway soiled by blood.Based on using this technique in eight anesthetized patients to date, I have found it to be particularly valuable, especially in averting lengthy detours to peripheral structures such as the piriform fossae. It was also my experience that this technique offers a “macro view” that is helpful even when a video bronchoscope is available. Although it is my clinical impression that FOI using this technique can be accomplished in a shorter period and accelerates resident learning, formal studies are needed to test these impressions.Cleveland Clinic Foundation, Cleveland, Ohio. doylej@ccf.org