My favourite VL view to increase first pass intubation

8 Feb

A debate is ongoing among #FOAMED social media about increasing first passage rate in tracheal intubation and some difficulties when using VL.

At the beginning of my experience with VL I experienced some difficulties, but with a radical change in technical approach I reached a good security on first pass success.

Here are my consideration and I hope will be useful for anyone is starting using VL

 

There are some fundamental differences in VL technique respect to DL, that makes the DL more easy and intuitive to pass the tube trough the cords.

3axys

The 3 axys theory for airway management

“Sniffing position” align the pharyngeal axis with the laryngeal one

Sniffing position

Sniffing position

Perfoming Direct Laryngoscopy with the laryngoscope we align the mouth axis to have a direct view of the cords.

DL view

DL VIEW

 

 

 

 

 

 

 

 

 

 

This view coincide with the route for passing the tube, making this step intuitive and easy.

 

When using a Video Laryngoscope we take our eyes right in front of the larynx, having a perfect “video” view of the vocal cords, but also minimally modifying the axis of the mouth.

Visione in videolaringoscopia

VL VIEW

This difference makes the act of passing the tube not so easy and not so intuitive, cause of the contrast between the perfect video laryngeal view and the not easy passage of the tube trough the cords.

In those cases the stylet, the Bougie/Froban or the external glottic maneuvers, are useful to facilitate the video-intubation.

tubo stylet

Golf stick shape of the tube+stylet

But the first goal is to reach this view on the screen of the videolaryngoscope.

IMG_1278

I want to have the epiglottis right at the center of the screen and this comes prior of a good view of the larynx.

Epiglottoscopy is the key point of my management of the airways in general and when prforming VL in particular.

Having the epiglottis in central position on the screen allow to:

  • lower the glottic plane facilitating intubation
  • decrease  the force to apply on the airways minimizing traumatism and neck movement in case of trauma.
  • fits all the difficult airway situations because a poor view of the cords is what you are looking for!

If you agree, memorize my favorite view and reach for it when using a video device to mange the airways.

All comments are welcome so please let me know your thoughts.

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Una Risposta to “My favourite VL view to increase first pass intubation”

  1. ketaminh 8 febbraio 2015 a 8:17 PM #

    L’ha ribloggato su PHARM.

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