VIDEO & FIBREOPTIC LARYNGOSCOPY

VIDEO & FIBREOPTIC LARYNGOSCOPEModerator : Dr. Veena Mathur Presented by: Dr. Aji KumarDepartment of Anaesthesia , JLN Medical College Ajmer

Video laryngoscopy is a form of indirect laryngoscopy in which the clinician does not directly view the larynx. Instead, visualization of the larynx is performed with a fiberoptic or digital laryngoscope inserted transnasally or transorally.[1]

The images from video laryngoscopy can be displayed on a monitor for the clinician, patient, and others to view at the time of the procedure; it can also be recorded.

Images are magnified when displayed on the monitor, allowing for detailed examination of the larynx.

IndicationsDifficult airway situation

Failed conventional laryngoscopy and intubation

Diagnostic purposes

Teaching purposes

KARL STORZ Video LaryngoscopesFirst Generation - In 2000 KARL STORZ developed, with the patent of Professor Illias the first video laryngoscope.

KARL STORZ Video LaryngoscopesSecond Generation - In 2001 KARL STORZ developed the 2nd model together with Professor George Berci and Dr. Marshal Kaplan and included the MVM Technology (Micro Video Module), which allowed for a smaller camera and more convenient handling.

KARL STORZ Video LaryngoscopesThird Generation - In 2003 KARL STORZ developed the V-MAC - in this new development, the DCI Technology (Direct Coupled Interface) was incorporated. This enabled multiple devices including Video Laryngoscopes, Flexible Intubation Scope and Optical Stylets to be connected via a one-chip camera system to the monitor, improving the video image.

KARL STORZ Video LaryngoscopesFourth Generation - In 2008 KARL STORZ developed the C-MAC Video Laryngoscope. This latest generation Video Laryngoscopes is equipped with a CMOS Chip, LED Light output an Lithium-Ion battery making the system highly portable and versatile.

GlidescopeIn 2001, the Glidescope (designed by vascular and general surgeon John Allen Pacey) It incorporates a high resolution digital camera, connected by a video cable to a high resolution LCD monitor. It can be used for tracheal intubation as well as for removal of foreign bodies from the airway.

The digital camera is located at the point of angulation of the blade (rather than at the tip). This placement allows the operator to more effectively view the field in front of the camera.

The video camera is recessed for protection from blood and secretions which might otherwise obstruct the view.

The steep 60-degree angulation of its blade improves the view of the glottis by reducing the requirement for anterior displacement of the tongue.

The video camera has a relatively wide viewing angle of 50 degrees.

The heated lens innovation helps to prevent fogging of the lens, which might otherwise obscure the view.

Tracheal intubation with the GlideScope can be facilitated by the use of the Verathon Stylet, a rigid stylet that is curved to follow the 60 angulation of the blade.

McGrath laryngoscopeThe McGrath laryngoscope is a portable video laryngoscope with a blade length that can be adjusted to facilitate a child of age 5 years upto an adult .

The blade can be disconnected from the handle to facilitate its insertion in morbidly obese patients in whom the space between the upper chest and headis reduced.

The blade is inserted midline, with the laryngeal structures viewed at a distance to enhance intubation success.

King vision laryngoscope

Consists of a reusable LED monitor with handle and single use bladesBlade tip has light source and high resolution camera2 types of blades 1.) Standard blade 2.) Channeled bladeMonitor is battery operated and also has port for video cable

Pentax airway scope

It has a portable battery operated lcd monitor and a disposable blade

Blade has a guiding channel for loading endotracheal tube .

An additional port for suction of secretions is present in the blade

FLEXIBLE FIBRE OPTIC LARYNGOSCOPE

The insertion cord contains bundles of optical fibers that transmit the image, a different group of optical fibers that transmit light to the distal end, and cables from a control lever in the handpiece that flex and extend the distal section.

The hollow channel can be used for aspiration of secretions or instillation of local anesthetic.

The simplest FFLs have a proximal eyepiece. The image can be displayed on a monitor by attaching a camera to the eyepiece or by using an FFL with an integral camera.

The FFL is the most versatile laryngoscope for tracheal intubation and can facilitate intubation that could not be achieved with any other technique.

Awake flexiblefiberoptic laryngoscopy is the safest noninvasive means of securing a critical airway.

The FFL uses flexible optical fibers to transmit images from a distal lens .

Fiberoscope Components:Components of a flexible fiberoptic laryngoscope:Body :Tip deflection control leverEyepieceFocusing ringWorking channel sleeveb. Insertion cord :Fiberoptic bundlesOptical systemMechanical systemc. Light transmission cord (Universal cord)

Mechanical System:Image bundles Illumination bundlesWorking channelAngulation control wiresFlexible distal joint systemAll ensheathed in a tough durable outer covering

Internal components and construction of the insertion tube of the fiberscope.

Working Channels:They run the length of the endoscopeUses:Suctioning can be applied for clearing of secretions.Medications can be instilled into the airway.Biopsy instruments for diagnostic procedures.Instillation port Angulation control wires:The distal end of the laryngoscope has a two way angulation system.Angulation wire runs the length of the fiberoscope from the control knob through the metal bands and is fixed at the distal end of the endoscope.Tip deflection is produced by rotating the control knob thus exerting tension on the angulation wire which inturn flexes the metal band.Flexible section of the distal end has a series of metal bands attached together by flexible joints

Indications

Anticipated difficult tracheal intubationAnticipated difficult mask ventilation, including sleep apneaAnticipated difficult rescue techniqueConfirmation of tracheal tube positionDiagnosis of malfunction of a supraglottic airway deviceCervical spine instability (the rigid indirect laryngoscope is an alternative)Positioning of a double-lumen tube and bronchial blockerAssessment of swelling or trauma after difficulty with airway managementIntensive care use, including aspiration of secretions and confirmation of the dilatational tracheotomy siteMicrognathia Mandibular fracturePartially obstructing laryngeal lesions such as papilloma Trismus Craniofacial abnormalities

Versatility of the Flexible FOL

Flexible and steerableMinimal tissue pressure and traumaContinuous visualizationOral or nasal route possibleOther intubating devices may facilitate combination techniquesVisual confirmation of the depth of intubation on withdrawal

Advantages of Awake Patient State for FOL

Spontaneous breathing continuesOxygenation and ventilation maintainedIntubation easierAnatomy and muscle tone preservedPhonation as a guideSafetyAirway protection preservedOptions preserved

Flexible FOL Technique

Anti secretory agent ( glycopyrrolate)Effective topical anesthetic, topical vasoconstrictorsEquipment check: lenses clean and focused, antifog agent appliedTracheal tube mounted on the flexible fiberoptic laryngoscope for the nasalrouteWithin the oral airway for the oral routePatient position: supine, semisitting, or sittingRapport: full explanation of Flexible fiberoptic laryngoscope technique

Flexible FOL TechniqueInsertion cord kept straight and the scope maneuvered in three planesTip (flexion-extension, rotation, and advance-withdrawal)Secretions aspiratedTargets (epiglottis, vocal cords, tracheal cartilages, carina) kept in the center of view as the flexible fiberoptic laryngoscope is advancedAdvance to close to the carina Tracheal tube passed over the flexible fiberoptic laryngoscopeTube position confirmed and secured and anesthesia induced

TopicalizationIt is the simplest method for anesthetizing the airway.Local anesthetic can be sprayed directly onto the desired mucosa.Nebulization of lidocaine 24% via face mask or oral nebulizer for 1530 minutes can achieve highly effective anesthesia of the oral cavity and trachea for intubationAnesthetic-soaked cotton can also be applied Vasoconstrictors such as epinephrine (1:200,000) or phenylephrine (0.05%) can be added to the solution to reduce mucosal bleeding.

Nerve blocksThe glossopharyngeal nerve provides sensory innervation to the posterior third of the tongue, the vallecula, the anterior surface of the epiglottis (lingual branch), the walls of the pharynx (pharyngeal branch), and the tonsils (tonsillar branch).It is most easily blocked where it crosses the palatoglossal arch.It can be blocked using one of three methods: topical spray application, direct mucosal contact of soaked pledgets, or direct infiltration by injection.Glossopharyngeal nerve block is not adequate as a solo technique to facilitate intubation, but in combination with other techniques it is highly effective.

Nerve blocksThe superior laryngeal nerve innervates the base of the tongue, posterior surface of the epiglottis, aryepiglottic fold, and the arytenoids.Direct infiltration is accomplished at the level of the thyrohyoid membrane inferior to the cornu of the hyoid bone. A reliable block with a definite endpoint is effected by retracting the needle marginally after contacting the greater cornu and injecting 2mL of local anesthetic after negative aspiration.

Nerve blocks Recurrent laryngeal nerve provides sensory innervation to the trachea and vocal folds. Blockade facilitates comfortable passing of the endotracheal tube into the trachea.Translaryngeal block of the recurrent laryngeal nerve is easily accomplished at the level of the cricothyroid membrane. A 5 or10-mL syringe with a 22- or 20-gauge needle is advanced until air is aspirated into the syringe. Four milliliters of local anesthetic are then injected, inducing coughing that disperses the local anesthetic.The recurrent laryngeal nerve can also be blocked by spraying local anesthetic via the injection port of the fiberoptic bronchoscope.

Issues to take care ofNeither deep sedation nor general anesthesia should be used when the airway is compromised.[27] Whenthe patient is alert, ventilation, oxygenation, and airway protection are maintained. Normal pharyngeal tone is preserved, so there is sufficient space between structures to facilitate vision several centimeters beyond the distal lens. Phonation, which can help identify the larynx, is helpful in awake patient The ideal sedative would have little effect on spontaneous ventilation and allow patients to protect their airway.Dexmedetomidine may provide effective and safe sedation in apprehensive or combative patients.Fentanyl infusions have been used, but careful monitoring is essential to prevent hypoventilation andhypoxemia.

Problems in fibreoptic Intubation

High skill level needed for rapid control of the tip of the laryngoscopeSecretions, edema, and hemorrhageIn sedated or drowsy pts Airway less open than when awakejaw thrust and/or dedicated oral airway needed.Tracheal tube passage difficult yPatient risks: hypoxemia, hypoventilation, and pulmonary aspiration

Contraindications No absolute contraindications Uncooperative or unwilling patient .Massive airway bleeding , vomitus , airway debrisHeavily sedated patients and inadequately topicalized pts.Unavailibity of oxygenation and suctioning (Awake flexible fiberoptic laryngoscopy is safe in a critical airway when expertly used)

Sterilization and Cleaning of the Flexible Fiberoptic Bronchoscope:Routine Cleansing of the fiberoscope:Sterilization:Ethylene oxide gasFiberscopes may be sterilized by this method at a temperature of 130F (54.4C), pressure 20psi and humidity 50% for a period of 4-5 hrs.Disadvantage: Time consumingStep 1Connect suction port to vacuum suctionStep 2Aspirate approximately 200ml detergent solution through suction channel Step 3Clear suction channel with cleaning brushStep 4Wipe shaft and valves with detergent-soaked spongeStep 5Aspirate approximately 200ml sterile water through suction channelStep 6Wipe shaft and valves with sterile waterStep 7Proceed with disinfection / sterilization

Routine CleaningImmediate cleaning of the fiberoptic bronchoscope and valves with detergent solution followed by 20 minutes of disinfection with 2% alkaline glutaraldehyde (cidex) or succine dialdehyde solution. It is rinsed and the channel is flushed with 70% alcohol. The scope is then allowed to dry. Storage of Fiberoptic Instruments:To prevent the fiberoptic bundles from being bent or broken, the laryngoscope is stored straight in a cylindrical tube on the portable chart or stored horizontally within the drawer of a mobile bronchoscopic cart or stored within the soft molded foam of its carrying case.

Ambu a scope / single use fibrescope

Single use flexible intubation scope to prevent reinfection( sterile package)Consists of a reusable monitor and single use flexible introducer with bending section ( 150-130 degree) tip of the introducer contains the camera and LED light sourceHandle of the introducer has connector cable for the display screen, control lever , suction button, suction connector, working channel port

Uses of A scopeFor awake intubation in difficult cases- restricted cervical mobility, cervical spine injuries, limited mouth opening etc.Airway inspection for diagnostic purposesTube position checkTo prevent cross contamination in seropositive cases

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