Equipment
Equipment required for video laryngoscopy includes the following:
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Fiberoptic bronchoscope with light source
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Camera with monitor if intubation is to be projected to screen
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Lidocaine 4%
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Nasal trumpets, 28 and 36 French
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Glycopyrrolate 0.2 mg (to be administered intravenously (IV) before start of the procedure)
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Endotracheal (ET) tubes (see Treatment for additional information)
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Warmed saline
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Syringe, 12 mL
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Oral airway
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Carbon dioxide detector
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Antifog solution or an alcohol pad
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Suction tubing
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Oxygen with cannula
Patient Preparation
Anesthesia
This procedure can be performed with the patient either awake or sedated. If the patient is likely to have a difficult airway, perform the procedure when the patient is awake, if possible. In some circumstances, the patient may be given mild IV sedation to make the procedure more comfortable.
For the awake patient, anesthesia should be provided to the following three regions before and during the procedure:
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Nasal cavity (if nasal intubation is to be performed)
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Pharynx
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Larynx
Nasal anesthesia is provided by lightly coating the area around the nasal trumpets with lidocaine 4% jelly. After having the patient inhale phenylephrine 1% or oxymetazoline 0.05% nasal spray, coat a 28-French nasal trumpet with lidocaine 4% jelly and place it in one nasal passage. This should be serially dilated to accommodate a 36-French nasal trumpet, if possible.
Pharyngeal anesthesia is delivered by nebulizer. The patient should inhale nebulized 3 mL of lidocaine 4%.
Laryngeal anesthesia can be delivered in one of the following three ways:
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Apply 1 mL of 4% lidocaine via the fiberoptic scope channel when the scope is positioned directly above the larynx
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A bilateral superior laryngeal nerve block can be performed
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A cotton ball soaked in lidocaine 4% can be used to apply the anesthesia; grasp the soaked cotton back with Jackson laryngeal forceps, then, with the tongue grasped, apply the cotton ball transorally to the epiglottic, hypopharynx, and vocal fold mucosal surfaces
Tracheal anesthesia, though not necessary, can be delivered. This can be done by injecting 2 mL of lidocaine 2% transtracheally.
Positioning
Patients can be seated or supine for fiberoptic intubation. If the patient is being intubated awake, the patient should be seated with the head of the bed elevated almost 90º. If the patient is being intubated under sedation, the traditional supine position with the head in a sniffing position suffices.
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Bronchoscope with endotracheal tube threaded over shaft. Syringe is ready to inflate endotracheal tube cuff.
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Bronchoscope with endotracheal tube threaded along shaft. Oxygen tube is shown above the bronchoscope.
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Tongue is grasped by an assistant. Endotracheal tube is being introduced into the oral cavity without assistance of a guiding oral airway.
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Bronchoscope has been advanced into the trachea.
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With the bronchoscope in the trachea, the endotracheal tube is advanced into the airway.
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Placement of bronchoscope into the oral cavity with endotracheal tube threaded over the shaft of the bronchoscope.
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Intubation being performed with GlideScope. The endoscopist is using the monitor to view the larynx. Patient's head is being held for C-spine precautions.
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GlideScope monitor view. Endotracheal tube is visualized superior to the glottic opening.
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GlideScope monitor view. Endotracheal tube is visualized entering the larynx.
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Ovassapian intubating airway.
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View of the anterior portion of right nasal cavity.
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View of the nasal cavity, passing below the inferior turbinate.
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View of the nasopharynx. Eustachian tube openings are seen bilaterally.
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View of the larynx from the nasopharynx. Arytenoids are seen posteriorly. Base of tongue is seen anteriorly. Soft palate is anterior and tonsillar fossa is lateral.
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View of the larynx.
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Tracheal intubation (fiberoptic-assisted). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
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Tracheal intubation (direct laryngoscopy). Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
