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Methods to Improve Success With the GlideScope Video Laryngoscope

Methods to Improve Success With the GlideScope Video Laryngoscope. Darrell Nemec, DNAP CRNA Edward Hines, Jr. VAMC. Objectives. The learner will be able to: Identify characteristics of the difficult airway Understand the mechanism and use of airway blocks

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Methods to Improve Success With the GlideScope Video Laryngoscope

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  1. Methods to Improve Success With the GlideScope Video Laryngoscope Darrell Nemec, DNAP CRNA Edward Hines, Jr. VAMC

  2. Objectives • The learner will be able to: • Identify characteristics of the difficult airway • Understand the mechanism and use of airway blocks • Discuss methods/tools to improve success with GVL • Create a detailed intubation plan when confronted with a difficult airway scenario, including the use of available tools and techniques for success

  3. Introduction • Lack of planning • Inadequate patient preparation • Inc. morbid obesity past 3 decades • Deaths • ~ 33% are 2/2 to airway mismanagement (closed claims report)

  4. The Difficult Airway • Be proficient at difficult airway management • Your career depends upon it • “ Do one thing every day that scares you” Eleanor Roosevelt • Develop self-confidence

  5. You can’t hide, the problem remains

  6. Predictors of Difficult Mask Ventilation: The Basics • Age sunken cheeks • BMI > 26 Kg/M2 • Beard • Edentulous- use mask straps, oral airway to create a better seal

  7. Predictors of Difficult Endotracheal Intubation • Short TMD • Malocclusion/ protruding front teeth • Large tongue • Short neck • Brodskya • Neck circumference @ 40 cm ~5% probability • Neck circumference @ 60 cm ~35% probability • Riadb • Independent predictors of difficult mask ventilation & difficult intubation • Micrognathia • XRT head/neck a Brodsky JB, Lemmens HJM, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. AnesthAnalg. 2002;94:732-736. doi:10.1097/00000539-200203000-00047. bRiadW, Vaez MN, Raveendran R, et al. Neck circumference as a predictor of difficult intubation and difficult mask ventilation in morbidly obese patients. Eur J Anaesthesiol. 2016;33:244-249. doi:10.1097/EJA.0000000000000324.

  8. The difficult airway What can it look like?

  9. Case report I was on late call and there are 2 on-going cases in the main operating room after hours. I was paged to the medical ICU (MICU) for an emergency intubation. Upon arrival in the MICU I found a patient in severe respiratory distress and semi-conscious, thrashing about in the bed. PMHx: + DVTs and pulmonary emboli (he is on a heparin drip), + Respiratory failure + OHS/Pickwickian Syndrome Wt : 780lbs (355 KG) + Stable CAD + Currently receiving Dobhofftube feedings

  10. Ask yourself: • How should I proceed to intubate in this scenario? • Though rare, this situation can occur in clinical practice. • As a CRNA, you need to be able to handle this situation in a comprehensive manner. • How many of you have already encountered a difficult airway/intubation scenario in your clinical practice?

  11. Don’t Panic – Mind Your Head

  12. Distribution of the nerve supply to airway

  13. The Nervous System of the Airway • V2 Maxillary division, Trigeminal Nerve (Sphenopalatine Nerve) • IX Glossopharyngeal Nerve • X Vagus (SL, IL, RL) Nerves

  14. Use of regional blocks • Sphenopalatine ganglion

  15. Glossopharyngeal nerve – 2% Xylocaine jelly

  16. Superior Laryngeal Nerve Block

  17. Transtracheal Block

  18. Alternative intubation techniques • Blind nasal intubation • Indications • Contraindications • GlideScope intubation • Stylet: 60° GlideRite™ • Stylet: 90° Malleable • Studies • Turkstraa • Cooperb • Intubating Laryngeal Airway (ILA)/Laryngeal Mask Airway (LMA) • Rescue ventilation • Facilitate tracheal intubation aTurkstra TP, Harle CC, Armstrong KP, et al. The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use. Can J Anaesth. 2007;54(11):891-896. bCooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anaesth. 2003;50(6):611-613.

  19. Alternative intubation techniques • Awake/sedated GlideScope intubation (airway blocks or Spray & Go technique) • Awake/sedated FOI (airway blocks or Spray & Go technique) • GlideScope-assisted FOI • Gum-elastic bougie technique

  20. Doctoral paper http://www.aana.com/newsandjournal/20102019/glidescope-1215-p389-397.pdf

  21. The Problem Defined • Occasionally, intubation is difficult while using a GVL • Problem • Inability to guide OETT into glottis, or pass OETT into trachea despite a CL grade I view

  22. Materials and Methods • PICO question (population, intervention, comparison, outcome) :  guiding search for evidence In patients undergoing video laryngoscopy with the GVL where there is adequate visualization of the glottic opening, what additional maneuvers help improve intubation success?

  23. Literature Search Strategy • Search engines (2001-2014) PubMed, Cochrane Library, SUMSearch, GVL operator and service manual (Verathon Medical) • Keywords/keyword strings Difficult intubation, failed intubation, GlideScope video laryngoscope, difficult intubation techniques using GlideScope, Parker Flex-Tip OETT, GlideScope-assisted fiberoptic intubation • Inclusion criteria Systemetic reviews (SRs), randomized controlled trials (RCTs), case series, case reports - all published in English language. Lower-level evidence as case series and case reports included because of nature of problem • Hierarchy of evidence From Level I ( SRs) to Level VII (expert opinion)

  24. Search Results • 250 sources found • 25 met inclusion criteria (Tables 1 and 2 in paper) • All techniques described in Table 2– reported to be successful • 7 RCTs (total 750 subjects: from 58-196 per study) • 4 descriptive studies (over 1,029 subjects: from 16-500 subjects in each study) • 8 case series (41 subjects, from 4-13 per study) • 6 case reports

  25. Search Results • Strong evidence • 7 RCTs15,17-21,23 All investigators randomly assigned subjects to control or intervention groups • In 2 studies19,21 Investigators used a randomized block design (dividing subjects into subgroups-blocks). • Variability within blocks is less than variability between blocks. • Subjects in each block are randomly assigned to treatment conditions; equal to stratified random sampling.

  26. Search Results • Weaker evidence: • 4 – Descriptive studies13,14,16,22 • 8 – Case series24-31 • 3 – Interventions include using GVL with FOB16,24,28 • 3 – GVL22,25,26 with a malleable stylet • 4 – GVL13,29-31 with intubation guide rather than the GRS™

  27. Search Results • Weaker evidence • 6 – Case reports32-37 • Intubation guides • 4 – C-shaped ET tube introducer employed23,29-32,37 (gum elastic bougie) • Different manufacturers (Frova, Cook, SunMed) • Narrow gauge • Malleable/flexible nature of tool • Oxygenate through Cook • GlideScope-assisted FOI/“Smart stylet” concept

  28. Special Techniques Introducers (Cook, Frova, Sun Med ) Endoflex Parker Flex-Tip “Reverse camber” loaded ETT-posterior placement

  29. Cook Introducer

  30. Sun Med Introducer

  31. Tube Exchanger

  32. Endoflex endotracheal tubeafor GVL intubations aPhua DSK, Wang CF, Yoong CS. A preliminary evaluation of the Endoflex endotracheal tube as an alternative to a rigid styletted tube for GlideScope intubations [letter]. Anaesth Intensive Care. 2009;37(2):326-327.

  33. Results • Endoflex endotracheal tube (N = 60 subjects) • Malleable distal tip in “J” shape • Review in 2009 • Mean time to intubation (TTI) – seconds • GRS™: 40 secs • Endoflex: 48 secs • Mean TTI • Only significant difference between 2 groups (P = .08) • Successful intubations • GRS™: 30 • Endoflex: 28 (2 converted to GRS™ after failure to intubate)

  34. Parker Flex-Tip Endotracheal Tubea aRadesic BP, Winkelman C, Einsporn R, Kless J. Ease of intubation with the Parker Flex-Tip or a standard Mallinckrodt endo- tracheal tube using a video laryngoscope (GlideScope). AANA J. 2012;80(5):363-372.

  35. Endotracheal tube cambera • The authors measured TTI – 2 angles of ETT • 60° or 90° • 90°best angle • “Forward camber” or “reverse camber” did not affect TTI • BUT: • Most important • “reverse camber” directs distal ETT tip posteriorly upon stylet retraction • Guides ETT directly into trachea a Jones PM, Turkstra TP, Armstrong KP, et al. Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope. Can J Anaesth 2007; 54 (1): 21-27.

  36. Intubating Solutions • Parker Flex-Tip-Radesic found • Ease of tube placement • GlideScope-assisted FOI • Under MAC or GA • Malleable Stylet (MS) vs GRS™: Turkstra discovered • Both equally effective • Operator dissatisfaction: 43% against GRS™; 13% against MS (favored more) • Dupanovic : Intubation success with angle of ETT bent proximal to cuff • 60° bend: 51/60 success • 90° bend: 59/60 success • Jones noted: “reverse camber” ETT  guides tube posteriorly

  37. Pearls • Planning • Preparation • Don’t burn a bridge: Muscle Relaxants Keep Calm Your GlideScope™ & FiberOptic Scope is on

  38. Apfelbaum JL, Hagberg CA, Caplan RA, et al; American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251-270. Rai MR, Dering A, Verghese C. The Glidescope system: a clinical assessment of performance. Anaesthesia. 2005;60(1):60-64. GlideScope GVL and Cobalt Quick Reference Guide. Bothwell, WA: Vera- thon Medical Inc; 2009-2011. Cooper RM. Use of a new videolaryngoscope (GlideScope) in the management of a difficult airway. Can J Anaesth. 2003;50(6):611-613. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Can J Anaesth. 2005;52(2):191-198. Sun DA, Warriner CB, Parsons DG, Klein R, Umedaly HS, Moult M. The GlideScope Video Laryngoscope: randomized clinical trial in 200 patients. Br J Anaesth. 2005;94(3):381-384. MarrelJ, Blanc C, Frascarolo P, Magnusson L. Videolaryngoscopy improves intubation condition in morbidly obese patients. Eur J Anaesthesiol. 2007;24(12):1045-1049. Kaplan MB, Hagberg CA, Ward DS, et al. Comparison of direct and video-assisted views of the larynx during routine intubation. J ClinAnesth. 2006;18(5):357-362. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39(11):1105-1111. Glick DB, Cooper RM, Ovassiapian A, eds. The Difficult Airway: An Atlas of Tools and Techniques for Clinical Management. New York, NY: Springer Publishing Co; 2013. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well- built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123(3):A12-A13. MelnykBM, Fineout-Overholt E. Evidence-Based Practice in Nursing and Health Care: A Guide to Best Practice. Philadelphia, PA: Wolters Kluwer; 2011. Falco-MolmeneuE, Ramirez-Montero F, Carregui-Tuson R, Sant- amaria-Arribas N, Gallen-Jaime T, Vila-Sanchez M. The modified Eschmann guide to facilitate tracheal intubation using the GlideScope. Can J Anaesth. 2006;53(6):633-634. Kramer DC, Osborn IP. More maneuvers to facilitate tracheal intubation with the GlideScope [letter]. Can J Anesth. 2006;53(7):737-740. Jones PM, Turkstra TP, Armstrong KP, et al. Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope. Can J Anaesth. 2007;54(1):21-27. GreibN, Stojeba N, Dow WA, Henderson J, Diemunsch PA. A combined rigid videolaryngoscopy-flexible fibrescopy intubation technique under general anesthesia [letter]. Can J Anaesth. 2007;54(6):492-493. TurkstraTP, Harle CC, Armstrong KP, et al. The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use. Can J Anaesth. 2007;54(11):891-896. References

  39. Phua DSK, Wang CF, Yoong CS. A preliminary evaluation of the Endoflex endotracheal tube as an alternative to a rigid styletted tube for GlideScope intubations [letter]. Anaesth Intensive Care. 2009;37(2):326-327. Dupanovic ́ M, Isaacson SA, Borovcanin Z, et al. Clinical comparison of two stylet angles for orotracheal intubation with the GlideScope video laryngoscope. J ClinAnesth. 2010;22(5):352-359. Jones PM, Loh FL, Youssef HN, Turkstra TP. A randomized comparison of the GlideRite Rigid Stylet to a malleable stylet for orotracheal intubation by novices using the GlideScope. Can J Anaesth. 2011;58(3):256-261. Radesic BP, Winkelman C, Einsporn R, Kless J. Ease of intubation with the Parker Flex-Tip or a standard Mallinckrodt endo- tracheal tube using a video laryngoscope (GlideScope). AANA J. 2012;80(5):363-372. Sakles JC, Kalin L. The effect of stylet choice on the success rate of intubation using the GlideScope video laryngoscope in the emergency department. AcadEmerg Med. 2012;19(2):235-238. Jeon WJ, Shim JH, Cho SY, Baek SJ. Stylet- or forceps-guided tube exchanger to facilitate GlideScope intubation in simulated difficult intubations—a randomised controlled trial. Anaesthesia. 2013;68(6):585-590. Doyle DJ. GlideScope-assisted fiberoptic intubation: a new airway teaching method [letter]. Anesthesiology. 2004;101(5):1252. Bader SO, Heitz JW, Audu PB. Tracheal intubation with the Glides- Scope [sic] videolaryngoscope, using a ‘J’ shaped endotracheal tube. Can J Anaesth. 2006;53(6):634-635. Dupanovic ́ M, Diachun CA, Isaacson SA, Layer D. Intubation with the GlideScope videolaryngoscope using the ‘gear stick technique’. Can J Anaesth. 2006;53(2):213-214. Hirabayashi Y. The StyletScope facilitates tracheal intubation with the GlideScope. Can J Anaesth. 2006;53(12):1263-1264. Xue FS, Li CW, Zhang GH, Li XY, Sun HT, Liu KP. GlideScope- assisted awake fibreoptic intubation: initial experience in 13 patients [letter]. Anaesthesia. 2006;61(10):1014-1015. Muallem M, Baraka A. Tracheal intubation using the GlideScope with a combined curved pipe stylet, and endotracheal tube introducer [letter]. Can J Anaesth. 2007;54(1):77-78. Conklin LD, Cox WS, Blank RS. Endotracheal tube introducer-assisted intubation with the GlideScope video laryngoscope. J ClinAnesth. 2010;22(4):303-305. Ciccozzi A, Angeletti C, Guetti C, et al. GlideScope and Frova introducer for difficult airway management. Case Rep Anesthesiol. 2013;2013:717928. Heitz JW, Mastrando D. The use of a gum elastic bougie in combination with a videolaryngoscope. J ClinAnesth. 2005;17(5):408-409. Moore MS, Wong AB. GlideScope intubation assisted by fiberopticscope [letter]. Anesthesiology. 2007;106(4):885. Vitin AA, Erdman JE. A difficult airway case with GlideScope-assisted fiberoptic intubation [letter]. J ClinAnesth. 2007;19(7):564-565. References

  40. Walls RM, Samuels-Kalow M, Perkins A. A new maneuver for endotracheal tube insertion during difficult GlideScope intubation. J Emerg Med. 2010;39(1):86-88. Sharma D, Kim LJ, Ghodke B. Successful airway management with combined use of Glidescope videolaryngoscope and fiberoptic bronchoscope in a patient with Cowden syndrome. Anesthesiology. 2010;113(1):253-255. O’Mahony CJ, Pagano PP. Facilitating GlideScope intubation with the straight end of an endotracheal tube introducer [letter]. J ClinAnesth. 2013;25(7):603-604. Corda DM, Riutort KT, Leone AJ, Qureshi MK, Heckman MG, Brull SJ. Effect of jaw thrust and cricoid pressure maneuvers on glottic visualization during GlideScope videolaryngoscopy. J Anesth. 2012;26(3):362-368. Weissbrod PA, Merati AL. Reducing injury during video-assisted endotracheal intubation: the ‘smart stylet’ concept. Laryngoscope. 2011;121(11):2391-2393. References

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