Chapter 18

Laryngoscopes
P. 521


Laryngoscopes are used t o vi ew the l arynx and adj acent st ructures, most commonl y
f or the purpose of insert i ng a tube i nto the tracheobronchial tree. Ot her purposes
i ncl ude pl acing a gastri c tube or transesophageal echocardi ac probe, f orei gn body
removal , and vi sual i zi ng and assessi ng t he upper ai rway. They range f rom si mpl e
ri gi d scopes wi th a l i ght bul b to compl ex f i beropt i c video devices. The wi de range of
avai l able devices at tests t o the diverse dif fi cul t ies encountered i n thei r use.
Rigid Laryngoscopes
Description
Ri gi d l aryngoscopes are manuf actured ei ther as a si ngl e-piece or a separate
detachabl e bl ade and handl e. In the l at ter case, t he l i ght source i s ei t her a l amp
at tached t o the blade or a lamp i n the handl e wi t h a l i ght gui de i n the bl ade. For a
detachabl e handle and blade, the l ight source i s energi zed when the blade and
handl e are l ocked i n the operat ing posi ti on. A hook-on (hinged, fol di ng) connect ion
bet ween t he handl e and bl ade i s most commonl y used. The handl e i s f i t ted wi t h a
hi nge pi n that f i ts into a sl ot on t he base of the blade. This al l ows the blade to be
quickly and easi l y att ached or detached. A single-pi ece l aryngoscope has a swi tch
on the handl e that cont rol s power to t he l amp. Standards coveri ng ri gi d
l aryngoscopes i ncl ude the Ameri can Soci ety f or Testi ng and Materi als (ASTM) F-
965 and F-1195 and t he Internat i onal Standards Organi zat i on (ISO) 7376 (1, 2,3).
Handle
The handl e is t he part hel d i n the hand during use. I t provi des the power f or the
l i ght. Most of ten, di sposable batteri es are the power source. Handl es wi th
rechargeabl e bat teri es are avai l able (4). Fiberoptic-i l l umi nated l aryngoscopes may
use a remot e elect ri cal l y operated l i ght source. Most handl es are desi gned t o
accept ei ther f i beropt ic-i l lumi nated or l amp-i n-bulb blades, but some can accept
ei ther one.
Handles desi gned to accept blades that have a l i ght bul b have a met all i c cont act,
whi ch completes an el ectri cal ci rcui t when the handl e and bl ade are in the working
posi t i on. Handl es contai ni ng batteri es and usi ng f i beropti c i l l uminati on contai n a
hal ogen lamp bul b. When the handle and blade are l ocked in t he working posi t ion,
an activator swi t ch i s depressed. This provi des a connecti on between the bul b and
t he bat teri es. A halogen lamp bulb has a l onger l if e than other l i ght bul bs. Studi es
have shown t hat the i l l umi nat i on is bett er wi th l amp-i n-bl ade than f iberopti c
systems (5,6, 7,8).
Handles are avai l able i n several si zes (Fi g. 18.1). The surf ace i s usual l y rough for
i mproved grip. Short handl es may be advant ageous for pat ients i n whom the chest
and/or breasts contact the handl e during use, when cricoid pressure i s bei ng
appli ed, or when t he pat i ent i s in a body cast (9). Another techni que f or handl i ng
t his si tuat i on is t o i nsert the bl ade l at eral l y i nto t he mout h,
P. 522

t hen to advance and rotate i t unt il i t i s i n a mi dl ine posi ti on (10,11).The blade can
be detached f rom the handl e bef ore i t i s inserted i nto the mouth and t hen can be
at tached t o the handl e af ter i t i s pl aced (12).

View Figure

Figure 18.1 Laryngoscope handles. (Courtesy of Rusch,
Inc.)

Al though most bl ades f orm a ri ght angl e wi th the handle when ready f or use, the
angle may al so be acute or obtuse. An adapter may be f i t ted between the handl e
and the bl ade to al l ow t he angl e to be al tered (13,14, 15) (Fi g. 18.1). The Pati l -
Syracuse handl e (Fi g. 18.2) can be posi ti oned and l ocked i n f our dif ferent posi t i ons
(16).
Some handl es al low t he bul b and battery port i on to be removed as a uni t . This
al l ows the outer part of the handl e to be cl eaned and di si nfect ed or steri l i zed.
Blade
The bl ade i s the component that is i nsert ed i nto t he mout h. When a bl ade i s
avai l able i n more than one si ze, the blades are numbered, wi t h the number
i ncreasi ng wi t h si ze. Table 18.1 shows the appropriat e si ze marki ngs according t o
t he ISO standard (3). Disposabl e bl ades are avai labl e (Fi g. 18.3).
The bl ade i s composed of several parts, incl udi ng the base, heel , tongue, f lange,
web, ti p, and l i ght source (Fig. 18.4).

View Figure

Figure 18.2 Patil-Syracuse handle. With this handle, the
blade can be adjusted and locked in four different positions
(45, 90,135, or 180). (Courtesy of Mercury Medical.)

The base i s the part t hat att aches to t he handl e. It has a sl ot f or engagi ng the
hi nge pi n of the handl e. The end of the base i s cal l ed the heel .
The t ongue (spatula) is t he mai n shaf t. It serv es to compress and manipul ate t he
sof t t i ssues (especi al l y the t ongue) and l ower j aw. The long axi s of the tongue may
be st raight or curved in part or al l of i ts l ength. Blades are commonl y referred to as
curved or st rai ght, depending on t he predominant shape of the tongue. In general ,
P. 523


P. 524

st rai ght bl ades provide better l aryngeal visual izati on, whi l e curved blades make
i ntubat ion easi er (17). When a sat i sfactory vi ew i s obtained but i nt ubati on is
di ff i cul t, the use of a bougie or a stylet (Chapter 19) may be hel pful (18).
TABLE 18.1 Size Markings for Laryngoscopes
Marking I ntended Use
000 Small premature infant
00 Premature infant
0 Neonate
1 Small child
2 Child
3 Adult
4 Large adult
5 Extra-large adult
From International Standards Organization. Anaesthetic and respiratory equipment-
laryngoscopes for tracheal intubation (ISO 7376). Geneva, Switzerland: Author, 2003.


View Figure

Figure 18.3 A: Reusable handle with curved
(Macintosh) and straight (Miller) disposable blades. B:
Disposable handle and blade. (Courtesy of Rusch, Inc.
and Vital Signs.)


View Figure

Figure 18.4 The parts of the Macintosh (top) and the Miller
(bottom) blades are illustrated. The tip is the distal end of
the blade intended for insertion into the patient. The
proximal end is the part closest to the handle. (Redrawn
from a drawing in Committee, American National Standards
Institute. Draft standard, laryngoscopes for tracheal
intubation (Z-79). Philadelphia: ASTM.)


View Figure

Figure 18.5 Left-handed Macintosh blade. (Courtesy of
Penlon Ltd.)

The f lange proj ects off the si de of the t ongue and i s connected to i t by t he web. I t
serves to gui de i nst rumentati on and def l ect ti ssues f rom the l i ne of vi si on. The
f lange determi nes the cross-secti onal shape of the bl ade. The vert i cal height of the
cross-sect ional shape of a blade i s someti mes referred to as the step (19).
The t ip (beak) contacts ei ther t he epi gl ot ti s or t he val l ecul a and di rect l y or
i ndi rectl y el evates the epi gl ot ti s. I t i s usuall y bl unt and thi ckened to decrease
t rauma.
The bl ade may have a l amp (bulb) (Fi g. 18.5) or a f i beropti c bundl e that t ransmi ts
l i ght f rom a source i n t he handl e (Fi g. 18.6). The l amp screws i nt o a socket t hat
has a metal l i c contact. On most bl ades, the socket i s located near the t i p. When t he
bl ade i s i n the worki ng posi t ion, el ect ri cal contact wi th t he power source i n the
handl e i s made. The socket is subj ect to soi l i ng by f luids t hat can af fect t he
el ect rical contacts, causi ng the l i ght t o fai l .
A f i beropti c-i l lumi nated bl ade has an encased f i beropt ic bundl e that transmi ts li ght
f rom a source i n the handl e or t he base of the bl ade. Because there is no bulb or
el ect rical contact i n t he bl ade, cl eaning and steri l i zati on are easi er. The ISO
standard (3) requi res f i beropti c-i l lumi nated bl ades to have a green mark on the
heel .

View Figure

Figure 18.6 English Macintosh blade. (Courtesy of Welch
Allyn, Inc.)

I n most cases, usi ng a laryngoscope presents l i tt l e or no dif f icul t y to t he
experienced operator, and ski ll i s of more import ance than t he t ype of bl ade
empl oyed. There are, however, si tuat i ons i n which a cert ai n bl ade may be
part icularl y advantageous (20). These si t uat i ons have l ed t o the devel opment of a
number of dif ferent bl ades. The bl ades di scussed here are al l avai l abl e
commerci al l y i n the Uni ted Stat es at t he ti me of thi s wri ti ng. A number of other
bl ades have been descri bed i n the l i terature.
Macintosh Bl ade
The Macintosh (Fi gs. 18. 3, 18.4, 18.14, 18.15) is one of t he most popul ar bl ades
(21,22,23). The t ongue has a gent l e curve that extends to the t i p. I n cross secti on,
t he tongue, web, and f l ange f orm a reverse Z. Numerous modi f i cat i ons have been
suggested (24,25, 26,27,28, 29,30,31,32,33,34,35,36,37). The no. 4 blade may be
more usef ul t han t he no. 3 i n normal and l arge-si zed adul ts (38).
Cervi cal spi ne movement i s greater wi t h the Maci ntosh bl ade compared wi t h the
Mi l l er bl ade, a l i ght wand, or t he Gl i deScope (39, 40,41,42).
Left-handed Macintosh Bl ade
The l ef t-handed (reversed) Maci nt osh blade (Fi g. 18.5) has the fl ange on t he
opposi te side f rom the usual Maci ntosh blade (43). This bl ade may be usef ul f or
abnormal i ti es of the right si de of the f ace or oropharynx, l ef t -handed i nt ubat ors,
i ndi vi dual s wi th l imi ted use of the l ef t arm, i nt ubat i ng i n the ri ght l ateral posi ti on, or
posi t i oni ng a tracheal t ube di rect l y on the lef t side of the mouth (44, 45,46,47, 48).
Engli sh Maci ntosh
The Engl ish Macintosh (Fi g. 18.6) is simi lar to t he convent i onal Maci ntosh except
t he f l ange i s curved and l ower at t he handl e end. Two studies have f ound t hat t hi s
bl ade provi ded bet ter resul ts than other commonl y used bl ades (49,50).
A modi f i cat i on is shown i n Figure 18.7. I t has a reduced f l ange to decrease
pressure on the maxi l lary i nci sors.

View Figure

Figure 18.7 English Macintosh blade with reduced flange.

P. 525



View Figure

Figure 18.8 The polio blade. (Courtesy of Sun Med.)

Polio Blade
The poli o bl ade (Fi g. 18.8) i s al so a modi fi cat ion of the Maci ntosh. The bl ade i s
of fset f rom the handle at an obtuse angle t o al l ow i ntubati on i n i ron l ung respi rators
or body j ackets; af ter t he anesthesi a screen i s i n place; and of pat i ents wi t h
obesi ty, breast hypert rophy, kyphosi s wi t h severe barrel chest deformi ty, a short
neck, or restricted neck mobi l i t y (51,52). Disadvantages of t hi s bl ade are t hat l i tt l e
f orce can be appl i ed, and control i s mini mal (12).

View Figure

Figure 18.9 A: The improved vision (IV) Macintosh blade
(left) and the conventional Macintosh blade (right). Note
the improved vision when the blade is viewed from the
proximal end. B: Conventional Macintosh blade (top) and
the IV Macintosh blade (bottom). On the IV Macintosh, the
midportion of the spatula is concave. (Courtesy of Gabor B.
Racz, M.D.)


View Figure

Figure 18.10 The oxiport Macintosh blade. (Courtesy of
Mercury Medical.)

Improved Vi sion Macintosh Blade
The i mproved vi si on (IV) Maci ntosh bl ade (Fi g. 18. 9) i s simi l ar t o the st andard
versi on except that the mi dport i on of the tongue i s concave (36,53).
Oxiport Macintosh (Mac/ Port)
The Oxiport Maci ntosh bl ade (Fig. 18. 10) i s a Maci ntosh bl ade wi th a tube added to
del i ver oxygen.
Tull Macintosh
The Tul l (sucti on) bl ade (Fig. 18. 11) i s a modi f i ed Maci nt osh that has a sucti on port
near the t i p. The suct ion channel extends next to the handl e and has a f i nger-
control led val ve so that sucti on can be control l ed by the l aryngoscopi st .
Fink Bl ade
The Fi nk bl ade (Fi g. 18.12) is another modif i cat ion of the Macintosh. The t ongue is
wi der and has a sharper curve at the di st al end. The height of the f lange is
reduced, especial l y at t he proxi mal end. The l ight bul b i s placed f art her f orward
t han on the convent ional Macintosh bl ade.

View Figure

Figure 18.11 Tull (suction) Macintosh and Miller blades.
The finger-controlled valve allows suction to be regulated
by the laryngoscopist. (Courtesy of Mercury Medical.)

P. 526



View Figure

Figure 18.12 The Fink blade. Note that the tongue is more
curved at the tip, and the flange is reduced at the proximal
end compared with the Macintosh blade. The light bulb is
placed nearer the distal end. (Courtesy of Puritan-Bennett
Corp.)

Bizzarri-Giuffrida Bl ade
The Bi zzarri -Gi uf f rida bl ade (f l angel ess Macintosh) (Fi g. 18.13) i s a modi f i ed
Maci nt osh on which t he f lange is removed, except for a smal l part that encases the
l i ght bul b (20,36,54). Thi s modi f i cat i on was made t o l i mi t damage t o the upper
t eeth. The blade i s desi gned f or pat i ents wi t h a l i mi t ed mouth openi ng, promi nent
i nci sors, recedi ng mandi bl e, short and thick neck, or anteri or l arynx.
Upsher Low Profile
The Upsher l ow prof i l e (ULP) blade (Fi g. 18. 14) i s a modi f i ed Maci ntosh wi th a l ow
f lange and a fai rl y strai ght proxi mal sect i on that l eads t o a t i p wi t h a signif i cant
curve. It i s designed f or i nserti on i nt o a smal l mouth.
Upsher ULX Macintosh Bl ade
The ULX bl ade (Fi g. 18.15) has a l i t tl e more curve than the standard Macintosh
bl ade.
Mill er Blade
The Mi l l er (Fi gs. 18. 3, 18.4, 18.16) i s one of t he most popul ar bl ades (55). The
t ongue i s st raight wi th a sl ight upward curve near t he ti p. In cross secti on, the
f lange, web, and t ongue f orm a C wi th t he top f at tened. Some versi ons of the bl ade
have the l amp socket on the tongue, whi l e others have i t on the web. The l amp may
be on ei t her t he ri ght or l ef t side of the blade. I f the bul b is on t he lef t side, the
bul b i s easi er t o change but can be covered by the t ongue. Pl aci ng t he bul b on the
ri ght si de al lows i t t o be protected by the f lange (56). Several modi f i cat i ons have
been descri bed (57,58, 59, 60,61).

View Figure

Figure 18.13 The Bizzarri-Giuffrida blade. (Courtesy of
Puritan-Bennett Corp.)


View Figure

Figure 18.14 Upsher low profile blade. Top: A standard
Macintosh blade. Bottom: A ULP blade.

I n compari ng the Maci ntosh and Mi l l er bl ades, i t was f ound t hat f orce, head
extensi on, and cervi cal spine movement were l ess wi t h the Mi l l er (39,40, 41).
Oxiport Miller Blade
The Oxiport Mi l l er (Mi l l er/port , oxyscope) bl ade (Fi g. 18.17) has a bui l t-i n tube that
al l ows del ivery of oxygen duri ng i ntubati on (62,63,64). I t may al so be used f or
sucti oning. When usi ng t hi s bl ade, oxygen i nsuff l ati on duri ng i ntubat i on has been
f ound t o lessen oxygen desaturati on i n spontaneousl y breathi ng anesthet ized
pati ents (65,66).
Tull Miller Blade
The Tul l (sucti on) Mi l l er bl ade i s a standard Mi l l er bl ade wi th a sucti on tube whose
port ends near the bl ade t i p (Fi g. 18.11). Near t he handle i s a f i nger-cont rol l ed port
t hat al l ows sucti on to be cont rol l ed.
Mathews Blade
The Mathews blade (Fi g. 18.18) i s strai ght wi t h a wi de and f l att ened pet al l oi d
confi gurati on at the ti p. I t i s desi gned f or di f f i cul t nasot racheal i ntubat ions.
Wisconsin Blade
Unl i ke the Mi l ler blade, t he Wisconsin bl ade' s t ongue has no curve (Fi g. 18.19).
The f lange i s curved t o f orm t wo thi rds of a ci rcle i n cross secti on
P. 527

(20). The f l ange depth is narrow at t he proxi mal end and is wi der i n the distal
port ion.

View Figure

Figure 18.15 ULX blade. The ULX blade is at the top. A
standard Macintosh blade is at the bottom. (Picture courtesy
of Mercury Medical.)

The Whi tehead modif i cat ion of the Wi sconsi n bl ade (Figs. 18. 20, 18.40) has a
reduced f l ange and is open proxi mal l y and distal l y.
Wis-Foregger Blade
The Wi s-Foregger blade (Fi g. 18.21) i s a modif i cat ion of the Wi sconsi n bl ade, wi t h
a st rai ght tongue and a f l ange that expands sl i ghtl y toward t he di st al end (67). The
di stal port ion of the blade is wi der and formed sl i ght l y t o the ri ght.

View Figure

Figure 18.16 Miller blades. (Courtesy of Sun Med.)

Wis-Hippl e Blade
The Wi s-Hipple bl ade (Fi g. 18.22) is a modi f ied Wi sconsi n bl ade. The tongue i s
st rai ght, and
P. 528

t he f l ange i s l arge and ci rcul ar. Compared wi t h the Wi sconsi n blade, t he fl ange is
st rai ghter and runs paral lel to t he tongue and the t i p i s wi der. It i s designed
pri mari l y f or use i n i nfants.

View Figure

Figure 18.17 Oxiport Miller blades. (Courtesy of Rusch,
Inc.)


View Figure

Figure 18.18 The Mathews blade. (Courtesy of Mercury
Medical.)

Schapira Blade
The Schapi ra blade (Fi g. 18.23) i s a strai ght bl ade wi t h a t ip t hat curves upward
(68). The vert ical component is mi ni mal .
Alberts Blade
The Al berts bl ade (Fi g. 18.24) combines characteri sti cs of the Mi l l er and Wis-Hi ppl e
bl ades wi t h a cut -away f l ange to increase vi si bi l i t y. There i s a recess to f aci l i tate
t racheal tube i nsert i on. The blade forms a 67-degree angl e wi th t he handle. It is
used for pedi at ri c pat i ents.
Michaels Blade
The Mi chael s blade (Fi g. 18.24) di ff ers f rom t he Al berts bl ade onl y i n that i t forms a
93-degree angl e wi t h the handl e.
Soper Bl ade
The Soper bl ade (Fi g. 18.25) combi nes t he Z shape on the f l ange of the Macintosh
bl ade wi th a st rai ght bl ade (20, 69). It has a sl ot bui l t i nto the ti p, whi ch is i ntended
t o prevent t he epi gl ot ti s f rom sl ipping off t he bl ade.
Heine Bl ade
The Heine bl ade (Fi g. 18.26) is strai ght wi t h a sl i ght upward curve at t he ti p. The
f lat f l ange i s curved away f rom the bl ade. I t i s usef ul f or chi l dren wi t h l arge
t ongues.

View Figure

Figure 18.19 The Wisconsin blade. (Courtesy of Ohio
Medical Products, a division of Airco, Inc.)


View Figure

Figure 18.20 Whitehead modification of Wisconsin blade.
(Courtesy of Sun Med.)

Snow Bl ade
The Snow bl ade (Fi g. 18.27) i s a hybri d bl ade consi sti ng of a Mi l l er t ongue and a
Wis-Foregger f l ange (70). It i s curved 1 i nch f rom the ti p.
Flagg Blade
The Fl agg blade (Fi g. 18.28) has a st raight t ongue. The f lange has a C shape that
graduall y decreases i n si ze as i t approaches the di stal end.
Guedel Blade
The Guedel bl ade (Fi g. 18.29) i s a strai ght bl ade on whi ch t he t ongue i s set at a
72 angl e to t he handle. The f lange has the shape of a U on i ts si de. The l i ght i s
cl ose to the t i p, whi ch has an upti l t of 10.
Bennett Blade
The Bennet t bl ade (Fi g. 18.30) is a modi f icati on of the Guedel bl ade. I t al so f orms
an acute angl e wi t h the handl e. The upper part of the fl ange has been omi t ted.
Eversole Blade
The Eversol e bl ade (Fi g. 18.31) has a st raight tongue. The f lange f orms a C wi t h
t he tongue and web near t he proxi mal end. Mi dway t o t he t i p, the upper f l ange
t apers.
Seward Blade
The Seward bl ade (Fi g. 18.32) has a st raight tongue wi th a curve near t he ti p (71).
I t has a smal l reverse Z-shaped f l ange. The blade is usef ul f or nasot racheal
i ntubat ion because i ts shape al lows a Magi l l f orceps to be introduced wi t h minimum
l oss of view. It i s i ntended f or use in chil dren younger t han 5 years ol d.

View Figure

Figure 18.21 The Wis-Foregger blade. (Courtesy of
Puritan-Bennett Corp.)

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View Figure

Figure 18.22 The Wis-Hipple blade. (Courtesy of Puritan-
Bennett Corp.)


View Figure

Figure 18.23 The Schapira blade. (Courtesy of Puritan-
Bennett Corp.)


View Figure

Figure 18.24 The Alberts (top) and Michaels (bottom)
blades. The Alberts blade offers a sharp 67 angle, whereas
the Michaels blade has a slight 93 angle. (Courtesy of
North American Drager.)


View Figure

Figure 18.25 The Soper blade. (Courtesy of Penlon Ltd.)


View Figure

Figure 18.26 Heine blades. (Courtesy of Heine Ototechnic
Manufacturing Co., Inc.)


View Figure

Figure 18.27 The Snow blade. (Courtesy of Air Products
and Chemicals, Inc.)


View Figure

Figure 18.28 The Flagg blade. (Courtesy of Ohio Medical
Products, a division of Airco, Inc.)


View Figure

Figure 18.29 The Guedel blade. (Courtesy of Penlon Ltd.)


View Figure

Figure 18.30 The Bennett blade. (Courtesy of Puritan-
Bennett Corp.)

P. 530



View Figure

Figure 18.31 The Eversole blade. (Courtesy Puritan-
Bennett Corp.)

Philli ps Blade
The Phi l l i ps blade (Fi g. 18.33) is strai ght wi th a l ow f l ange and a curved ti p si mi l ar
t o a Mi ll er blade (72). The l i ght bulb i s on the l ef t si de of the bl ade.
Racz-All en Blade
The Racz-Al l en bl ade i s st rai ght wi t h a curved ti p (73). The proxi mal port i on of t he
bl ade f lexes to rel i eve pressure on the teeth. The vertical port ion i s hi nged and
hel d i n posi ti on by a spri ng. The spri ng al l ows l at eral def lect ion of the vert i cal
port ion wi t hout occl udi ng t he vi ew. Exposure i s i mproved by t i l t i ng the l aryngoscope
handl e t o the l ef t. The hi nged port i on is concave al ong i ts length. The t ongue
surf ace i s rough and unpol ished to reduce sl i ppage.
Robertshaw Blade
The Robertshaw bl ade (Fi g. 18. 34) has a strai ght t ongue wi t h a gent le curve near
t he ti p (74). I t i s desi gned to l if t the epi gl otti s i ndi rect l y. The f lange i s ext ended to
t he l ef t . The bl ade was desi gned f or i nf ants and chi l dren. I t may be usef ul f or
nasot racheal intubati on, because i t al l ows a Magil l f orceps t o be i ntroduced wi t h a
mi nimum l oss of vi ew.
Oxford Infant Blade
The Oxf ord infant bl ade (Fig. 18. 35) has a strai ght t ongue that curves up sli ghtl y at
t he ti p. I t has a U shape at t he proxi mal end, wi th t he bot tom l imb of t he U
decreasi ng toward t he ti p so that the di stal part i s open. It tapers f rom a maxi mum
wi dt h at the proximal end t o the ti p. Al though intended pri mari l y f or newborns, i t
can be used f or chil dren up to 4 years of age.

View Figure

Figure 18.32 The Seward blade. (Courtesy of Penlon Ltd.)


View Figure

Figure 18.33 Phillips blades. (Courtesy of Mercury
Medical.)

Bainton Blade
The Bai nton bl ade (Fi g. 18.36) has a st raight tongue (20, 75). The di stal 7-cm
secti on i s tubul ar so that i t i s protected f rom obstructi on by edematous ti ssue,
bl ood, secret i ons, int raoral masses, and scar ti ssue and has an i nt ralumi nal l i ght
source. The ti p i s beveled at a 60 angl e t o create an oval opening at the distal end
of t he t ube. A t racheal tube of 8 mm or l ess can be i nsert ed through the tubul ar
l umen wi thout si gni f icant l y obst ructi ng vi si on.
The Bai nton bl ade i s designed for pat ients wi t h ri ght -si ded or ci rcumferenti al
pharyngeal lesi ons. The tubul ar port ion can di spl ace t issues ci rcumf erent ial l y and
t hus overcome thi s probl em.
A modi f i ed t wo-pi ece tubul ar pharyngol aryngoscope is al so avai lable. The two part s
of t he bl ade are hel d together by a screw duri ng intubat ion. A tracheal t ube i s
pl aced i nt ral uminal l y into the gl ott i s and then the t wo pi eces are di smantl ed and
removed f rom around t he t ube.
Double-angle Blade
The spatul a of the doubl e-angl e (Choi ) bl ade (Fi g. 18. 37) has two angul ati ons, 20
and 30 degrees, to i mprove l i f t i ng of the epi gl ot ti s. The spatul a and ti p form a wi de,
f lat surface. The bul b i s l ocat ed on the l ef t edge of the bl ade bet ween the t wo
curvatures. The f l ange has been el i mi nat ed. The bl ade may be
P. 531

especi al l y usef ul f or t he pat ient wi th an anteri or l arynx. The absence of t he f lange
l eaves more room to pass the t racheal tube than wi t h a strai ght bl ade.

View Figure

Figure 18.34 The Robertshaw blade. (Courtesy of Penlon
Ltd.)


View Figure

Figure 18.35 The Oxford infant blade. (Courtesy of Penlon
Ltd.)

Blechman Blade
The Bl echman bl ade (Fi g. 18.38) i s a modi fi cat i on of the Maci nt osh bl ade, wi th the
t i p angled sharpl y to el evate t he epi gl ott i s. The f l ange has been removed near t he
handl e end of the bl ade.
Belscope Bl ade
The Belscope bl ade (Fi g. 18.39) is a st raight bl ade bent f orward 45 degrees near
i ts mi dpoi nt (78). The t i p i s beaded on t he undersi de, and the handl e i s off set . The
bl ade i s designed to be used li ke a st rai ght bl ade, wi t h the t i p l i f t ing the epigl ot t is.
I t i s avai lable i n several lengths.
When a sat i sf actory view of the l arynx cannot be obtained, a pri sm of transparent
acryl i c can be at tached t o the bl ade j ust proxi mal to t he angle (Fi g. 18. 39B).
Moi st ure condensat i on on the pri sm can be prevented by appl yi ng an ant i f og
preparat i on to the pri sm and/or warmi ng i t bef ore use. Another measure t o prevent
f oggi ng i s to di rect a conti nuous f l ow of oxygen over the prism through a sucti on
catheter taped to the bl ade (79). Because the i mage of the l arynx i s rotat ed, t he
user' s head must be moved hi gher and fart her f orward t han when t he prism i s
omi tt ed.

View Figure

Figure 18.36 The Bainton blade. Note the distal tubular
section. (Courtesy of Mercury Medical.)

Several studi es have shown t hat an improved view of the l arynx can of ten be
obtai ned wi t h t he Bel scope compared wi t h other bl ades (80, 81,82,83). The
Bel scope provi des a greater di stance bet ween the posteri or end of the bl ade and
t he upper teeth, maki ng i t l ess l i kely t o contri bute to dental damage than other
bl ades (82). This bl ade f eel s di f f erent f rom ot her blades, so practice i s necessary
t o acqui re prof i ci ency (77,84). I ntubat ion may t ake l onger and be l ess successful
when t he prism i s used (85).
Cranwall Blade
The Cranwal l bl ade (Fi g. 18.40, top) has a curved ti p l i ke a Mi l l er bl ade. There i s a
reduced f l ange to decrease the potenti al for damage to the upper t eeth. I t may be
useful for an anesthesi a provi der who has li mi ted use of the l ef t arm (48).

View Figure

Figure 18.37 The double-angle blade. (Courtesy of Jay J.
Choi, M.D.)

P. 532



View Figure

Figure 18.38 Blechman blade. (Courtesy of Mercury
Medical.)

CW Blade
The CW bl ade i s shown i n Figure 18.41. It i s designed t o be i nserted and removed
wi th t he hori zontal f lange al most parall el t o the teet h.
Flexi ble-tip Bl ades
There are a number of fl exibl e ti p bl ades t hat have a hi nged t i p that is cont rol l ed by
a lever att ached to t he proxi mal end of the blade (86,87) (Fi g. 18.42). When the
l ever is pushed toward the handl e, the ti p of t he bl ade i s fl exed (Fi g. 18.42B).
Fl exi bl e-ti p bl ades are avai l abl e under vari ous names, i ncl udi ng McCoy, Fl ipper,
Fl ex Ti p, l everi ng laryngoscope bl ade, and art icul ati ng l aryngoscope blade. Vari ous
bl ades havi ng a f l exi bl e ti p are avai l abl e, i ncl udi ng pediatric bl ades, and Mi l l er
(Fi g. 18.43) and Maci ntosh (Fig. 18. 42) blades are avai l abl e. The t i p i s less
rounded than on t he usual Maci ntosh bl ade (88). It may be hel pful to use a narrow
handl e wi t h these bl ades (89).

View Figure

Figure 18.39 The Belscope blade. A: Blade without prism.
B: Blade with prism attached. (Courtesy of Dr. Paul
Bellhouse.)


View Figure

Figure 18.40 Cranwall (top) and Whitehead (bottom)
blades. (Courtesy of Bay Medical, Inc.)

The f lexi bl e t i p bl ade may be hel pf ul when a di f fi cul t i nt ubat i on is encountered
(88,90,91, 92, 93,94,95, 96,97,98,99). Even if the bl ade does not improve the vi ew of
t he l arynx, i t may i mprove the l ikel ihood of successf ul i ntubat i on by el evati ng the
epi gl ot ti s (100,101,102). I t may be especi al l y usef ul i n pat i ents wi t h mi ni mal neck
movement (97,103,104,105,106). External laryngeal pressure may f urther i mprove
t he vi ew but al so may worsen i t (96,105,107,108, 109). I n some pat ients i n whom
t he vi ew i s sati sf actory wi t h t he Maci ntosh blade, using t he l everi ng bl ade may
make the vi ew worse (49,88,110, 111).
St udi es have shown t hat usi ng the f l exi bl e ti p blade resul ts i n si gni fi cantl y less
f orce bei ng appl i ed and a reducti on in the st ress response compared wi th t he
Maci nt osh blade (112,113).
Probl ems have been reported wi t h t he f lexible t ip bl ades (114,115). In one case,
t he connecti on of the lever mechani sm was broken, so the ti p of t he bl ade woul d
not f l ex. The hi nged t i p f rom the bl ade has become detached (116). Arytenoi d
di sl ocati on has been reported wi th i ts use (117).
P. 533



View Figure

Figure 18.41 CW blade.

Flexi blade
The Fl exibl ade i s a st ai nl ess st eel blade wi t h si x sl ots and seven wi ndows on the
f lange (118, 119). The bl ade consists of a rigid rear port ion, a f l exi bl e intermedi ate
port ion, and a ri gi d f ront porti on. A l ever (control t ri gger) i s at tached at the
proxi mal end of t he bl ade. Squeezing the t ri gger causes the i ntermedi ate port i on to
become more curved. The blade is i nsert ed wi th the cont rol tri gger rel eased.
The Fl exibl ade can be used for both routi ne and di ff i cul t intubat ions (49). I n most
cases, the view i mproves when t he bl ade i s f l exed (120,121,122,123,124).
The Fl exibl ade has been reported to have broken af ter onl y f i ve uses (120). It i s
i mportant that the blade is not manual l y f lexed and that i t i s di sengaged f rom the
bl ade by rotati ng i n the hori zontal and not the vert i cal di recti on (125). Another
probl em involved i ncorrect assembl y (126). The l ight bundl e was on the wrong side
of t he bl ade and poi nti ng away f rom the l arynx.
There have been reports of damage to the teeth and gums (127,128). A t ongue
l acerat ion was noted af ter an attempt at i ntubat ion wi t h an i ncorrect l y assembl ed
bl ade (125).
Vital Vi ew Blade
The Vi t al Vi ew l aryngoscope bl ade i s a disposabl e plasti c bl ade t hat contai ns a
f iber l i ght. One study showed no si gni fi cant di ff erence i n the view of t he gl ot ti s or
t he success rat e of tracheal i ntubati on wi th the Vi tal Vi ew compared wi t h a reusabl e
metal bl ade (129).
Henderson Blade
The Henderson bl ade i s a large, st rai ght bl ade wi t h a st rai ght ti p that ext ends wel l
beyond t he mai n part of the bl ade (130). In cross sect ion, the bl ade is semi t ubular.
I t can accommodate an 8-mm t racheal tube (131). When used wi t h the paraglossal
t echni que, a bet ter vi ew i s obtai ned by opt imi zi ng control of the sof t t i ssues and
i mprovi ng the l i ne of si ght .
Cardiff Bl ade
The Cardi f f bl ade is desi gned f or use in chi l dren f rom bi rth to adol escence
(132, 133). Several si zes are avai lable (133). The di st al part is curved at an angl e
of 85 degrees. Proximal l y, the bl ade has a Z-shape. The
P. 534

web and f l ange are at tenuated di stall y so t hat t he termi nal part cont i nues as a
curved spatul a, narrowi ng at t he ti p. I t termi nates wi th a thickened, t ransverse
bead.

View Figure

Figure 18.42 Curved flexible tip blades. A: Unflexed. B:
Pushing the lever toward the blade causes the tip to be
flexed. (Courtesy of Heine USA Ltd.)


View Figure

Figure 18.43 Straight blades with flexible tips.

Viewmax Blade
The Vi ewmax l aryngoscope (Fi g. 18.44) has an opt ic si de port on a standard
Maci nt osh blade that ref racts the i mage approxi matel y 20 degrees f rom the
hori zont al . Thi s modi f icati on al l ows for a more anteri or vi ew f rom a posi ti on 1 cm
behind t he l ef t ti p of the bl ade whi le at the same ti me al l owi ng t he standard di rect
vi ew.
Dorges Blade
The Dorges l aryngoscope bl ade combi nes features of both t he Mi l l er and Maci ntosh
bl ades (133). Compared wi t h the Maci ntosh, t he f lange has a l ower height, and the
curve of the bl ade i s l ess. It i s avail abl e in onl y one si ze and can be used i n
pati ents >10 kg. It has 10- and 20-kg markings on the blade. St udi es have found
t hat the Dorges di d not perf orm any bet ter t han the standard Macintosh blade i n
easy or di ff i cul t i ntubat ion scenari os (111,133).

View Figure

Figure 18.44 Viewmax blade. (Courtesy of Rusch, Inc.)

Truvi ew Bl ade
The Truvi ew bl ade i s a standard Maci ntosh bl ade that i ncorporates an unmagnif ied
opti c si de (pri sm). Adul t and pediatric sizes are avai labl e. The prism causes a 20-
degree angl e of ref ract ion. I t can be used as a st rai ght or curved blade.
Prisms
Prisms t hat can be at tached and detached from t he l aryngoscope blade are
avai l able i n various si zes (Fig. 18.45). They are at tached to a l aryngoscope bl ade
by using a cli p. A ref racti on is provi ded i n the l i ne of si ght, t hereby bri ngi ng i nto
vi ew st ructures wi t hi n a f ew mi l li meters of the ti p of the blade. The i mage i s ri ght
si de up. It i s i mportant to warm t he prism bef ore use t o prevent condensati on.
The Huff man pri sm (134,135,136) is a bl ock of Pl exi gl as shaped to f i t on the
proxi mal end of a no. 3 Maci ntosh blade (Fi g. 18.46). The Huf fman pri sm
l aryngoscope blade has t he pri sm bui l t into t he blade. An addi ti onal 20 ref racti on
f rom ri ght to l ef t is added because t he prism i s to the lef t of the mi dl ine. The pri sm
l aryngoscope blade all ows ei ther conventi onal di rect l aryngeal exposure or i ndi rect
vi ewi ng through the pri sm.
Techniques of Use
The opti mal posi ti on f or l aryngoscopy f or most adul t pati ents i s approxi matel y 35-
degree f l exi on of the l ower
P. 535

cervi cal spi ne and an 85-degree to 90-degree head extensi on at t he atl anto-
occi pi tal l evel , the so-cal led snif f ing posi ti on (137). El evat i on beyond the sni ff ing
posi t i on may improve the vi ew i n cases of di ff icul t l aryngoscopy (138). The l ower
cervi cal spi ne port i on can be mai ntained in a fl exed posi t ion by usi ng a pil l ow under
t he head. Atl anto-occipi t al j oi nt extensi on is achi eved by pressure on the top of the
head and/ or upward t ract ion on t he upper t eet h or gums. In obese pat i ents,
consi derabl e shoulders and head el evati on may be necessary so that an i magi nary
hori zont al l i ne connects the pati ent' s st ernal notch wi t h t he external audi t ory
meatus (139). A cushion desi gned to provi de the best possibl e posi t i on has been
devel oped (Fi g. 18.47). I n chi ldren, i t may be unnecessary to fl ex the lower cervi cal
vertebrae. I n neonates, i t may be necessary t o el evate the shoul ders because the
head is rel ati vel y l arge.

View Figure

Figure 18.45 Prisms for attachment to laryngoscope blades.
(Courtesy of Anesthesia Asssociates, Inc. San Marcos, CA.)

Ambi ent l i ght should not be overl y bri ght (140). The operat ing l i ght shoul d not shi ne
on the face.

View Figure

Figure 18.46 The Huffman prism. (Courtesy of Penlon
Ltd.)

The l aryngoscope handle i s hel d i n the gl oved l ef t hand. Moi steni ng or l ubricati ng
t he bl ade wi l l f aci l i tate i nserti on if the mouth i s dry. In some si tuat i ons, the chest
wi l l i mpi nge on t he handl e, maki ng i t di ff i cul t t o i nsert t he bl ade. In these cases, a
short handl e may be used, t he bl ade may be i nsert ed si deways (10), or the bl ade
may be i nsert ed and then at tached t o the handl e (12,141).
The f ingers of the ri ght hand are used to open the mout h and spread t he l i ps. In
pati ents wi t h denti ti on, the opti mum openi ng of the mouth i s of t en achieved wi th a
t humb-over-index-f i nger approach, wi th t he i ndex
P. 536

f inger on the maxi ll ary teeth and t he thumb pl aced on the l ower t eet h.

View Figure

Figure 18.47 Troop elevation pillow. A standard pillow
should be used with this. The elevation pillow helps to
achieve a better position for ventilation and laryngoscopy in
large-framed and obese patients. The head and neck are
elevated above the level of the chest and abdomen. The
upper airway is more isolated, and the weight of the
abdomen is moved away from the diaphragm. This pillow is
easier and quicker to use and more stable than a stack of
blankets. (Courtesy of Mercury Medical.)


View Figure

Figure 18.48 A: Intubation with a straight laryngoscope
blade. The tip of the blade picks up the epiglottis. B:
Intubation with the curved laryngoscope blade. The
epiglottis is below the tip of the blade. A small pillow under
the head allows better visualization of the larynx. (Courtesy
of Vance Robideaux, M.D.)

The bl ade i s i nserted at the ri ght side of the mouth. Thi s reduces the l ikeli hood that
t he i ncisor t eeth wi l l be damaged and hel ps to push the t ongue to t he lef t . The
bl ade i s advanced along the si de of the t ongue toward t he ri ght tonsi l l ar f ossa so
t hat the tongue l ies on the l ef t si de of t he bl ade. The ri ght hand keeps t he li ps f rom
get ti ng caught bet ween t he teeth or gums and the bl ade. If the tongue i s sl ippery,
pl aci ng t ape on t he li ngual bl ade surf ace may be hel pful (142). When the ri ght
t onsi l lar fossa i s visual i zed, t he bl ade t ip i s moved t oward the mi dl ine. The blade i s
t hen advanced behi nd the base of the tongue, el evati ng i t, unt il t he epigl ot ti s
comes i nto vi ew.
There are two met hods f or elevating the epi gl ot ti s, depending on whether a st raight
or curved bl ade i s bei ng used.
Strai ght Blade Technique
The strai ght bl ade i s shown in posi ti on for i nt ubati on i n Figure 18.48A. The bl ade i s
made t o scoop under the epi gl ot tis and l i f t i t anteri orl y. The vocal cords shoul d be
i denti f i ed. If t he bl ade i s advanced too far, i t wi l l elevat e the l arynx as a whole
rather than expose t he vocal cords. Occasional l y, t he blade wi l l expose t he
esophagus. I t shoul d then be wi t hdrawn sl owl y. I f i t i s wi t hdrawn too f ar, the t i p of
t he epi gl ott i s wi l l be rel eased and f l i p over the gl ot ti s.
A st rai ght bl ade can al so be i nsert ed into the val l ecul a (t he angle made by t he
epi gl ot ti s wi th t he base of the tongue) and used i n the same manner as a curved
bl ade (see below).
Another techni que usi ng a strai ght blade has been reported to succeed af ter f ai l ure
wi th a Maci ntosh bl ade (143). The blade is passed f rom t he ri ght corner of the
mouth into the groove between the t ongue and the t onsil , di spl aci ng the t ongue to
t he l ef t . The bl ade i s advanced, t he epi gl otti s i denti f ied, and t he bl ade t ip passed
posteri or t o t he epi gl ot ti s. Next , the bl ade is l i f t ed anteri orl y, el evati ng the
epi gl ot ti s di rectl y so that the gl ot ti s is exposed. The blade is then moved toward t he
mi dl i ne, pushing t he t ongue to the l ef t . Wi th t hi s approach, an assi stant may be
needed to ret ract t he corner of the mouth so t hat t he t racheal tube can be
mani pulat ed i nto pl ace. The use of a bougi e or st yl et i n the t racheal tube may be
hel pf ul (144). Al ternatel y, the l aryngoscope handle may be swi t ched f rom l ef t to
ri ght and the tracheal t ube i nt roduced f rom t he l ef t side of the mouth (145).
Curved Blade Technique
Fi gure 18. 48B shows the curved bl ade i n posi ti on. Af t er t he epi gl ot ti s is visual i zed,
t he
P. 537

bl ade i s advanced unti l t he ti p f i ts into the val lecul a. Tracti on is then appl i ed al ong
t he handle at ri ght angl es to the bl ade t o move the base of t he tongue and the
epi gl ot ti s f orward. The gl ott i s should come i nt o view. I t i s i mportant that t he end of
t he handle opposi te t he bl ade i s not pull ed backward. Thi s wi l l cause the ti p to
push the l arynx upward and out of si ght and coul d cause damage t o the t eet h or
gums (146,147).
A curved bl ade can al so be used as a strai ght bl ade, l if ti ng t he epi gl ot ti s di rectl y, i f
i t is l ong enough (148).
I n cases of di ff icul t laryngoscopy, a lef t -mol ar or ri ght -mol ar approach of ten
i mproves t he laryngeal view (149). The l ef t-mol ar approach i s may be especi al l y
hel pf ul and may spare the incisor t eet h (150,151).
Other Maneuvers
Even wi t h correct techni que, t he larynx wi l l not al ways be vi suali zed. Di spl aci ng t he
l arynx by external backward, upward, and ri ght ward pressure (BURP) on the t hyroi d
cart i l age may i mprove vi suali zati on of t he gl ott i s (149,152, 153, 154,155,156,157).
Mandibular advancement may al so i mprove the view (158). I nf lati ng a Fogart y
catheter att ached to the back of the t ongue bl ade port i on may i mprove vi sual i zati on
i n some cases (99,159, 160, 161,162, 163,164,165).

View Figure

Figure 18.49 Disposable laryngoscope covers. A: The
cover ensheaths both the blade and the handle. B: Only the
blade is covered. (Courtesy of Blue Ridge Products.)

Cleaning
The cleani ng of l aryngoscopes has been a subj ect of debat e f or several years.
Si nce bl ades are i nsert ed i nto t he mouth and of ten cause bl eeding, t here i s
potenti al f or cross i nf ect i on among pati ents. The handl e, whi le not in di rect cont act
wi th t he pat ient, may be contami nated wi th bl ood or secreti ons f rom the anesthesia
provi der' s hands.
Recommended cleani ng procedures, i ncl udi ng washi ng the blade and l i qui d
chemical st eril i zat ion, are di scussed i n detai l in Chapter 34. Some blades can be
steam autocl aved. Steam aut oclaving may reduce the lumi nance of f i beropt ic
bl ades over t i me (166,167).
Di sposabl e laryngoscope bl ades and handl es are avai lable Fi g. 18.3). When the
enti re bl ade and handle are disposabl e, t he bat tery and/or l i ght source are usual l y
reusable. Whi l e some studies show that some si ngle-use plast ic bl ades perform
l ess sati sf actori l y than reusabl e bl ades (168,169, 170, 171), some si ngl e-use bl ades
were rat ed hi ghl y by anesthesi a provi ders (169,172,173). Di sposabl e met al bl ades
may break more easi l y than reusabl e ones (174). Pl asti c laryngoscopes have l ess
potenti al f or dental f racture than metal bl ades (175). Di sposabl e covers are
avai l able f or the blade or t he ent i re bl ade and handl e (Fi g. 18.49). However, t hey
reduce i l lumi nati on (176, 177).
P. 538


Flexible Fiberoptic Endoscopes
The f lexi bl e f i beropt ic endoscope (f i berscope) i s used t o pl ace and eval uate
pl acement of tracheal , doubl e-l umen, tracheostomy, and gastric tubes and
bronchial bl ockers; check tube patency; eval uat e the ai rway; and l ocate and remove
secreti ons (178, 179,180, 181, 182,183). The f l exible f iberopti c endoscope can be
used wi t h a video camera and screen.
Description
The f iberscope (Fi g. 18.50) is composed of several part s, whi ch i ncl ude t he l i ght
source, handl e, and f l exi bl e i nsert i on porti on (184,185,186).
Light Source
Handle with Batteries
A handle wi th batteri es that uses a halogen l i ght bul b is compact , convenient, and
i nexpensive. However, the i l lumi nat i on wi l l usual l y be weaker than that f rom a
separate source.
Separate Light Source
The l i ght source is contained i n a separate box, uses mai ns power, and i s
connected t o the scope by a universal (l i ght transmi ssion) cord. A bri ght l ight
wi thout much heat i s produced. Ul t raviol et l i ght i s fi l tered i n the f iberscope but not
i n the l i ght source or transmission cord. When the cord is at tached to an act i ve
l i ght source and the open end can focus the l i ght onto a f lammable materi al , a f i re
can resul t . Fi res are di scussed in detai l i n Chapt er 32.
Handle
The handl e (cont rol body, body) (Fi g. 18. 51) i s the part hel d i n the hand duri ng use.
I t houses the bat teri es, i f t hey are used as t he power source, or t here may be a
connector for a separate l i ght source. Ot her parts of the handl e i ncl ude t he
eyepi ece, focusi ng ring, worki ng channel port , and the ti p control l ever or knob. By
t urning t he f ocusi ng (adj ust i ng) ri ng, the i mage can be brought into f ocus. A camera
can be att ached to t he eyepi ece for remote vi ewi ng.

View Figure

Figure 18.50 Flexible fiberoptic laryngoscope. Light is
supplied from a separate source. The lever on the handle
controls deflection of the tip in two directions. Two ports
attach to the working channel. One is for insufflation or
injection, and one is for suctioning. (Courtesy of Olympus
Corp.)

The t ip (bending, angul ati on) cont rol l ever or knob may be on the side of the body
or a t humb-control led l ever system on t he back of the handl e. By turni ng this l ever,
t he i nserti on cord ti p can be f lexed or extended i n one pl ane. A f ul l range of moti on
can be achi eved by rotat i ng the enti re i nst rument . Many f i berscopes have a t ip-
l ocki ng l ever that l ocks t he t ip i n a desi red posi ti on.

View Figure

Figure 18.51 Handle of flexible fiberscope. The syringe is
attached to the working channel. At the bottom is the lever
for controlling the tip. Above it to the left is the connection
for the light source. At the top is the connection for suction
tubing and the suction control. The eyepiece, to which a
camera may be attached, is to the right.

P. 539


Insertion Cord
The i nsert i on cord (shaf t , t ube) i s the port i on of the fi berscope that i s i nserted i nto
t he pat ient and over whi ch the tracheal tube can be passed. I t contains an image-
t ransmi t t ing bundl e, one or t wo l i ght -conducti ng bundl es, t wo angul ati on wi res, and
someti mes a worki ng channel . These are surrounded by a protect ive wi re mesh and
vi nyl coveri ng. Ci rcul ar depth marks are usual l y present. Thi s porti on is f ul l y
submersible, whi ch f aci l i tates cleani ng.
The outside diameter of the insert i on cord det ermi nes the smal l est si ze tracheal
t ube that the cord can pass through. The i nside di ameter of the t racheal tube
shoul d be at l east 1 mm l arger than the i nsert i on cord outsi de diameter. The
connecti on of the handl e to the i nsert i on porti on is usual l y tapered to hol d the
t racheal tube.
The i nsert i on cord l ength vari es. For t racheal intubati on i n adul ts, a 50-cm insert i on
cord i s usual l y suf f i ci ent . Doubl e-l umen bronchi al and nasot racheal t ube inserti on
may requi re a l ength of 55 t o 60 cm.
Image-conducting Bundle
The i mage-conducti ng (opt ic f iber, i mage t ransmi ssi on, i mage gui de) bundl e
t ransmi ts the image f rom t he di stal l ens t o the eyepi ece. The f ibers are arranged so
t hat the relat i onship of one fi ber to the other i s the same at each end of the bundl e.
Such a bundl e is cal l ed coherent and al lows a clear image to be t ransmi t ted. A l ens
at t he user' s end al l ows the i mage t ransmi tted by the fi bers to be f ocused. Except
at t he ends where the f ibers are fused f or strengt h, the bundle i s fl exi bl e but
del i cate. When broken, a f iber wi l l no longer pass i ts i mage, and the viewer wi l l see
a bl ack dot in t hat f i ber's l ocati on.
Light-conducting Fiber Bundle
The l i ght -conducti ng f iber (l i ght guide, l i ght transmissi on, i ll umi nat i on) bundl e
t ransmi ts l ight f rom a powerful source wi thout produci ng dangerous heati ng. Unli ke
t he i mage-conduct ing bundl e, the f i bers are not arranged i n a preci se manner. This
i s known as an i ncoherent bundl e.
Working Channel
Most scopes have a worki ng (instrument) channel that extends the l ength of the
scope. Thi s can be used f or suct ioni ng, i nj ect i ng sal ine or medi cat i ons, insuf f l at ing
gases, or passi ng instruments (such as f orceps, brush, gui dewi re, or st yl et ).
Tip Flexion Cables
Two t i p f lexi on cabl es (angulat i on wi res, cont rol wi res, ti p-bendi ng cont rol wi res)
connecti ng the ti p to the bendi ng knob on the handle are placed al ong t he si des of
t he i nserti on cord.
Endoscopi c Accessori es
Accessory devi ces to protect the f i berscope f rom t he t eeth, keep i t i n the mi dl i ne,
and di rect i t t o the vi ci ni t y of the l arynx are of ten used. These are di scussed i n
Chapter 16. A ni ppl e f rom a baby bott le may be used i n an awake i nf ant (187).
Endoscopy usi ng a supral aryngeal ai r way device i s di scussed i n Chapter 17.
Another useful i t em is a device t o support the j aw (188,189).
I t i s usef ul t o have a cart f or f iberopti c endoscopes (Fi g. 18. 52). Thi s cart wi l l
contai n the vi deo camera and accessories such as a video recorder, l i ght source,
and a di splay screen. A cabinet t o store t he f i beroptic scope i n such a way t hat i t
wi l l not be damaged i s al so an important part.
Techniques of Use
Intubation
When using a f lexi ble f iberopt ic scope f or i ntubat ion, the choi ce of t racheal t ube i s
i mportant (182, 190, 191,192, 193, 194). The t racheal t ube wi l l be more l ikel y t o
advance i nt o the t rachea i f the largest scope that f i ts easi l y insi de the t racheal tube
i s used (195,196). A tube wi th a ti p designed to mi ni mi ze t he di stance between the
f iberscope and t he t ube' s l eadi ng edge may pass more easi l y than a standard tube
(197, 198,199,200, 201, 202,203, 204). A spi ral embedded t ube may pass more easi l y
t han a tube wi t h a pref ormed curve (205,206,207,208). Warmi ng a standard
t racheal tube may faci l i tate passage. A sl eeve may be pl aced on the f i berscope t o
i ncrease i ts diameter (209,210).
An ai rway exchange catheter that f i ts over the endoscope may be used (211,212).
A f i berscope can be i nsert ed ei ther nasal ly or oral l y in awake or anest het i zed
pati ents who are ei t her breathi ng spontaneousl y or being vent i l ated (213). Al though
f iberopti c intubat ion can be performed i n unconsci ous i ndi vi duals, most authors
recommend that when possi bl e i t be perf ormed in t he awake pati ent usi ng sedati on
and topi cal anesthesi a. Loss of consciousness is associ ated wi t h a l oss of tone in
t he submandi bul ar muscl es that di rectl y support the tongue and i ndi rect l y support
t he epi gl ott i s.
Because thi s instrument is expensive and del i cate, great care must be t aken t o
prevent damage. A mi nor bl ow can break glass f i bers. As wel l , care must be taken
t o avoi d forceful bending al ong the cord. The inserti on port i on shoul d not be
wi thdrawn or advanced wi t h t he t i p angul ated.
Bef ore use, t he l ight shoul d be tested. The t i p shoul d be treated wi th ant i foggi ng
solut i on or be pl aced in warm water (not sal i ne) f or several mi nut es bef ore use.
Al ternati vel y, the t ip can be bri ef ly held agai nst the buccal mucosa t o warm t he
l ens. Hot ai r f rom a convect i ve warmi ng devi ce (Chapter 31) may be di rected over
t he ti p. The f ocusi ng ri ng shoul d be adj usted by vi ewi ng smal l pri nt at a distance of
2 to 3 cm. The f l exi bl e porti on shoul d be coat ed wi th a l ubricati ng gel , but the
l ubricant shoul d not contact t he l ens. Tubi ng f or sucti on or oxygen i nsuf f l at ion
shoul d be attached to t he appropri ate port .
P. 540

Oxygen suppl ied t hrough t he worki ng channel wi l l support pat i ent oxygenati on,
cl ear secret i ons, and def og the opti cs. Control l ever f uncti on shoul d be assessed.
The t racheal tube should be advanced up t he scope and anchored f i rml y on t he
wi der port i on of the inserti on cord.

View Figure

Figure 18.52 Cart for endoscopic equipment. A: Front
view. The monitor can be used to view the image at the end
of the fiberscope. The light source is placed on the shelf.
The cabinet at the right is used to store flexible endoscopes.
B: Side view showing cabinet.

The proximal cont rol secti on i s hel d i n one hand wi th the i ndex f i nger on the
sucti on/i nsuff l ati on port and t he t humb on the l ever t hat cont rol s angulati on of t he
di stal t ip. The other hand hol ds the shaf t of the scope and gui des i ts advance.
Opt imal posi ti oni ng f or f i beropt ic l aryngoscopy incl udes extendi ng the cervical
spine rat her t han f l exi on as recommended for di rect l aryngoscopy (214, 215).
Because the cables are not st rong enough t o l i f t or di sl odge ti ssues, i t i s import ant
t o have an ai r space at t he end of the t i p. In t he anesthet i zed pat ient, visual i zat ion
i s of ten di ff i cul t or i mpossi ble unless some means to expand the pharynx is used.
Thi s may be accompl i shed by havi ng a second person pull the t ongue ant eri orl y or
el evate the j aw (216,217,218,219,220). Occasi onal l y, i t may be necessary to l if t t he
l arynx by grasping i t external l y. Al ternatel y, a t ongue ret ractor or a ri gi d
l aryngoscope can be used to push the tongue f orward
(101, 151,218,219, 221, 222,223, 224, 225,226). The awake pat ient can be asked t o
st i ck out his or her t ongue, whi ch i s then hel d gent l y between gauze by an
assi stant. Special ai rways have been developed to aid f iberopti c intubat ion. These
are discussed i n Chapter 16.
Di sori entati on i n the ai rway i s best resol ved by slowl y wi t hdrawi ng the ti p and
exami ni ng t he area wi t h gentl e up and down t i p def l ecti on, by rot at ing t he scope as
a uni t , or by al ternately advancing the t i p and wi t hdrawi ng i t sli ghtl y. If the view i s
consi stent l y f oggy or hazy, i rri gati on wi th sal i ne and suct ion wi l l usual l y resol ve
t his problem. Adherent secret ions may requi re t he instrument to be wi thdrawn and
t he ti p mechani cal l y cleaned wi th a moi st gauze. If suct ion i s bei ng appl i ed, i t may
draw ti ssue over the scope t ip.
I f bl ood or secreti ons are present, the gl ot ti c openi ng may be l ocated by usi ng
capnography (227,228) or by pl aci ng a gui de wi re passed retrograde through t he
worki ng channel (229,230). Ret rograde i nt ubati on i s discussed in Chapt er 21.
Passi ng the t racheal tube over the f i berscope f requentl y meets resistance. Rotati ng
t he tracheal t ube 90 countercl ockwi se may be hel pf ul (231,232,233,234,235,236).
Ot her helpful maneuvers i nclude appl yi ng a j aw t hrust , applyi ng external pressure
on the larynx, and elevati ng the epi gl ot ti s by using a rigi d l aryngoscope or the
f ingers (102,237,238, 239). Another method t o overcome resi stance i s to i nsert a
smal l er t racheal tube beyond the t racheal tube ti p
P. 541

(240, 241). St i ll anot her t echni que is to pass an ai rway exchange cathet er via t he
t racheal tube besi de t he f l exi bl e scope unt i l the t ip of the catheter is visual i zed
near the cari na (242).
I f the t i p of the f i berscope protrudes through t he tracheal t ube's Murphy eye, i t may
not be possi bl e to sli p the tube off t he endoscope or t o wi t hdraw the f i berscope
f rom the t racheal tube (243,244). The f i berscope and tracheal t ube may need to be
wi thdrawn as a uni t . To avoi d t hi s probl em, t he tracheal t ube shoul d be threaded
onto the f i berscope bef ore endoscopy, or t he fi berscope shoul d be advanced
t hrough the tube under di rect vi sion, i dent i fyi ng both t he si de and di stal openi ngs
and taki ng care t o pass t he f i berscope through the distal one. The endoscope ti p
shoul d be in t he neut ral posi t i on as the t racheal tube i s advanced and the
f iberscope i s wi t hdrawn.
A variety of t echni ques are avai l abl e. The f i rst i s t o thread a t racheal or doubl e-
l umen tube wi t h the l umen l ubri cat ed over the cord unti l i t abuts the handl e,
advance t he f lexible port i on unti l the t ip enters the t rachea or bronchus, then
t hread the tube over the endoscope. Wi th the second techni que, the tracheal tube
i s fi rst advanced i nt o the pharynx so t hat i t acts as a gui de to bri ng t he ti p of the
scope cl ose to the entrance of the l arynx. The f i berscope i s passed through the
t ube and i nto t he t rachea, then t he tube i s threaded over i t . A thi rd techni que i s to
use t he f iberscope to pl ace a gui de wi re or st yl et i nto the t rachea
(245, 246,247,248). The f iberscope i s wi t hdrawn, and a tracheal tube i s passed over
t he gui de and i nto t he t rachea. Thi s may be especi al l y usef ul in small pat ients. A
st yl et may be i nsert ed al ongside the f i berscope i n the t racheal t ube, but t hi s wi l l
mean t hat t he shape of the t racheal tube cannot be al tered.
Oral Intubation
Oral i ntubati on i s consi dered more di f f i cul t than nasal i nt ubati on. The ti p enters the
l arynx at an acut e angl e to the gl ott i s whereas vi a the nasal route, i t i s at an
obl i que angl e. Intubat ion may be easi er i f used wi t h an accessory t hat wi l l protect
t he i nstrument f rom the pati ent ' s t eeth, gui de i t i nt o the mi dl i ne, and keep the
t ongue f rom f al li ng backward. These met hods are di scussed i n Chapter 16. The
i nsert i on cord i s pl aced i n the mi dl ine and advanced under di rect vision, curvi ng
downward at the posteri or pharyngeal wal l , seeki ng the epi glott is. It is i mportant
t hat the ti p be kept i n t he mi dl i ne as i t i s advanced. When the epi gl otti s has been
l ocated, the f iberscope t i p i s rotated downward so that i t passes beneat h the
epi gl ot ti s and i s then turned upward unti l t he vocal cords are seen. The t i p i s then
passed between the cords and advanced several cent i meters i nto the trachea. For
bronchial i ntubat ion, the ti p is advanced i nto t he desi red mainstem bronchus.
Wi th the f i berscope ti p in pl ace, the lubri cated tube i s advanced over the scope,
whi ch f unct i ons as a st yl et . The bevel shoul d face posteriorl y (249). The f i berscope
shoul d be used t o verif y that the tube t i p i s correct l y posi ti oned and then
wi thdrawn, l eavi ng t he tube in pl ace.
Nasal Intubation
Fi beropt i c nasot racheal i ntubat ion i s usual ly easi er t han orotracheal i nt ubati on
because mi dl i ne posi ti oning i s easier to mai nt ai n, the pat ient cannot bi te the scope,
and the nasopharyngeal anat omy natural l y di rects the t ube i nt o the t rachea. It i s
associ ated wi th l ess cervi cal spi ne mot i on than di rect l aryngoscopy or other
methods of ai rway management (250). A nasopharyngeal ai rway may be used to
l ubricate and di l ate the nasal passages, then removed. The f i berscope shoul d be
advanced through the t racheal tube bef ore i nsert i on, because i t may not be
possi bl e t o i nsert a tube loaded over a fi berscope through a narrowed nasal
passage af ter successf ul i nsert ion of the f i berscope int o the t rachea (251).
Tracheal Tube Exchange
To exchange a t racheal t ube, the new t ube i s threaded over the f i berscope. In one
t echni que, t he inserti on port i on of the f iberscope i s advanced into the t ube t o be
repl aced (252). As the ol d tube i s pul l ed out, i t i s cut and removed f rom around the
f iberscope. The new t ube i s then advanced i nto pl ace over the f iberscope.
I n an al t ernative techni que, the existi ng tube i s visual i zed i n the pharynx by usi ng
t he f i berscope and i s fol l owed down t o the l evel of the vocal cords (253). It may be
advisabl e to i nsert an ai rway exchange cat het er t hrough the ol d t racheal tube
before removi ng i t t o al low f or venti l ati on or rei ntubat i on over i t i f t he new tracheal
t ube cannot be passed into the t rachea (252). The cuf f on the exi st ing t ube i s then
defl ated, and the f iberscope i s advanced through t he space around the tube past
t he cords. The ol d t ube i s removed, and the new one i s advanced over t he
f iberscope i nt o posi ti on.
Extubati on
The f iberscope can be used to eval uate a di ff i cul t extubati on (254), especi al l y i n a
pati ent who woul d be dif f icul t t o reintubate. The f iberscope i s inserted through the
t ube and the tube wi t hdrawn f rom the l arynx. The worki ng channel can be used to
i nsuf f lat e oxygen. If necessary, t he tube can be rei nserted over t he f iberscope.
Advantages
Fl exi bl e fi beropt i c endoscopy i s a very rel i abl e approach to di ff i cul t ai rway
management. I t can be used oral l y or nasal l y and when access to the ai rway i s
l i mi ted. I t can be used i n pati ents of any age and i n any posi ti on.
The f lexi bl e f i berscope can be used to i ntubat e pat ients who are di ff icul t or
i mpossible t o i ntubate wi th a ri gi d laryngoscope
(178, 246,255,256, 257, 258,259, 260, 261). I t i s especi all y useful for pati ents wi t h
unstabl e cervical spines and f or those at high ri sk for dental damage (262,263,264).
I t can be
P. 542

used i n cases where the pat i ent cannot be placed i n the supine posi ti on (265). I t
can be used by an anesthesia provi der who has l imi ted use of the l ef t arm (48).
I nsuf f l ati ng oxygen or j et venti l at ion through t he sucti on channel may provi de
addi ti onal ti me when di ff i cul ty i n passing t he t racheal tube i nto the t rachea i s
encountered.
Disadvantages
The f lexi bl e f i beropt ic endoscope i s more expensive, f ragi l e, and dif f icul t to use
and cl ean than a rigid l aryngoscope (266). Fi beropti c i ntubati on requi res more t i me
t han i ntubat ion wi t h a ri gid l aryngoscope, so i t i s of l i mi ted use in emergency
si tuat ions or duri ng a rapi d sequence inducti on. I t requi res consi derable experience
and ski l l maint enance. It does not al low di rect manipul ati on of ai r way st ructures.
I ntubat ion wi t h t he f lexi ble f iberopti c scope may be di f f i cul t or i mpossi bl e wi t h
cert ai n pati ents (267, 268). A maj or i mpedi ment to i ts successf ul use i s the
presence of signif i cant amounts of bl ood and/ or secreti ons. If al uminum hydroxi de
or magnesium tri si l i catebased antaci ds are used, t here may be a whi ti sh f i l m on
t he end of t he scope that i mpedes vision (269).
Gastric di st ensi on and rupture, t ension pneumo-t horax, and subcutaneous
emphysema have al l occurred af ter oxygen i nsuf f lat i on through the worki ng channel
(270, 271,272,273).
Laryngeal t rauma may occur wi th f iberopti c i ntubat ion (274). This i s f requent ly
associ ated wi th di ff i cul ty i n passi ng the t racheal tube i nto t he trachea over the
f iberscope.
Cleaning
Cl eani ng procedures wi l l vary wi t h t he part i cular scope bei ng used. I t is i mportant
t o read the i nst ructi on manual caref ul l y, because i mproper care can cause
extensi ve and expensive damage t o the scope. Cleani ng methods are di scussed i n
more det ai l in Chapter 34.
Indirect Rigid Fiberoptic Laryngoscopes
Bullard Laryngoscope
Description
The Bul l ard l aryngoscope (Fig. 18.53) has a ri gi d met al bl ade speci al l y shaped to
f ol l ow t he contour of the
P. 543

oropharynx and rest beneath the epi gl otti s. Fi beropt ic bundl es f or i l l umi nat ion and
operator viewi ng are housed i n a sheat h on the post erior aspect of the bl ade. A
vi ewi ng arm wi th eyepi ece extends at a 45-degree angl e f rom the handl e. A snap-
on di opt er f or users wi t h uncorrected vi si on i s avai l able. Later versions have an
eyepi ece that can be focused. A vi deo camera can be attached to t he eyepiece f or
remot e viewi ng.

View Figure

Figure 18.53 A: Bullard laryngoscope with a battery handle
and a introducing stylet. Between the handle and the stylet
is a port for attaching a syringe or inserting a wire. B:
Patient end. At left is the light channel. In the middle is the
working channel. The image-transmitting bundle is at the
right. If an extender is used, it is slipped over the tip.

The power source may be bat teri es and a hal ogen bul b in the handle or an adaptor
f or a fl exi bl e f i beropt i c cabl e that i s connected to a hi gh-i ntensi ty l i ght source.
A working channel extends f rom the scope body to t he poi nt where the l ight bundl es
end at the t i p. I t can be used for suct i on, oxygen i nsuff l ati on, admi ni st rat i on of l ocal
anesthet ics or sal i ne, or passage of an ai rway exchange or j et venti l at ion catheter
(275, 276). The end nearest the handl e has a Luer l ock connector f or at tachi ng a
medi cati on syri nge.
Three si zes are avai l able: pedi at ri c, pedi at ri c l ong, and adul t (Fig. 18.54). The
pediatric version i s used f or babi es. The pedi at ri c l ong versi on i s used f or pat i ents
up to 8 t o 10 years of age. The adul t versi on i s intended for adul ts and chi l dren
over 8 to 10 years but may be useful i n younger pat i ents (277,278). A plast ic bl ade
extender i s avail abl e and may be especi al l y usef ul i n tal l er pati ents (279). The
extender i s al so usef ul when i ntubat ing male pat i ents but i s of ten not hel pf ul or
even a hindrance when i ntubat i ng females. The pedi at ri c handl e may be used wi t h
t he adul t bl ade t o decrease the wei ght.

View Figure

Figure 18.54 Bullard laryngoscopes. The handle contains
batteries that power a halogen light bulb. Note that the
curve of the adult blade differs from the other two.
(Courtesy of Circon ACMI, a division of Circon Corp.)


View Figure

Figure 18.55 Introducing stylets for Bullard laryngoscope.
The adult version is on the left and the pediatric version on
the right. (Courtesy of Circon ACMI, a division of Circon
Corp.)

Two st yl ets are avai l able. They are designed to f ol low t he contour of t he
l aryngoscope blade and at tach to t he body of the l aryngoscope.
Introducing (Intubating) Stylet
The i nt roduci ng st yl et (Fig. 18.55) has a curve of approxi mately 20 degrees to the
l ef t near t he t i p to bri ng the end of the st yl et i nt o the f i el d of vision and to f aci l i tate
passage of the t racheal tube i nto t he laryngeal inlet . I t at taches near t he base of
t he vi ewi ng arm wi th a spri ng-l oaded, l ocki ng mechanism.
Multifunctional Stylet
The mul t if uncti onal st yl et (Fi g. 18. 56) consi sts of a l ong, hol l ow t ube t hat i s curved
at t he t ip t o di rect the t ube i nto t he f i el d of visi on. It may att ach to the viewi ng arm
by using a screw clamp. Its hol l ow core can serve as a gui de f or a f l exi bl e
f iberscope, tracheal tube exchanger, or smal l catheter. It can al so be used t o i nsti l l
l ocal anestheti c into t he trachea.
Techniques of Use
Bul l ard l aryngoscopy can be perf ormed i n the awake pati ent wi t h topical anesthesi a
or i n an anesthet i zed
P. 544

pati ent who i s ei ther paral yzed or breathi ng spontaneousl y (280,281). For pat i ents
who are breathing spont aneousl y, oxygen can be i nsuff l ated t hrough t he worki ng
channel (282, 283, 284). This wi l l hel p to bl ow secret i ons away f rom t he vi si on
bundl es and prevent f oggi ng (285). Jet venti l ati on can be administered by usi ng the
worki ng channel (286,287,288). Sucti on can also be appl ied to the channel , but t hi s
may pul l ti ssue agai nst the end of the f i beropt ic bundl e and impede vi si on.

View Figure

Figure 18.56 Multifunctional stylets with screw clamps.
The adult version is at the top. The pediatric version is at the
bottom. Note the end of the lumen through which a wire can
be inserted. (Courtesy of Circon ACMI, a division of Circon
Corp.)

Bef ore use, t he i mage bundl e wi ndow at the distal end of t he sheath shoul d be
wi ped cl ean. Intubat ion can be accompl ished wi th a st yl eted t racheal t ube, a
t racheal tube wi t h a di rect i onal ti p, or one of t he Bul lard st yl ets. A Parker or spi ral -
embedded t ube i s a good choice (279). If t he pediat ric i ntroduci ng st yl et or t he
mul ti f uncti onal stylet is used, t he t racheal tube connector must be removed before
i t is backl oaded over the styl et .
Bef ore the t racheal tube is pl aced on the styl et , a smal l amount of l ubri cant shoul d
be appl i ed t o the st yl et and the t ube. Warmi ng the tube may make passage i nt o the
t rachea easier. The tracheal t ube i s t hreaded over the l ubricated stylet so that t he
t i p of the st yl et prot rudes through the Murphy eye. The pedi at ri c and mul ti purpose
st yl ets should be posi ti oned near t he tracheal tube t ip but not prot rudi ng through
t he end.
The styl ett racheal tube combi nat i on is f astened to the l aryngoscope. Thi s bri ngs
t he verti cal part of the st yl et behi nd and to the ri ght of t he laryngoscope i n the
groove f ormed by the blade ant eri orl y and the l ens housi ng i n the mi ddl e. When
properl y l oaded, the t ip of the i nt roduci ng styl et shoul d be vi si bl e at the f our o'clock
posi t i on. The mul t i purpose st yl et t i p may not be vi si bl e.
I f the pati ent is l arge, i t may be helpful to add the pl asti c t i p extender to the ti p of
t he scope. An at tempt shoul d be made to remove the bl ade extender af ter i t cl icks
i nto pl ace (289). I t may come off i n the mout h i f i ncorrectl y at tached (290).
Ant i f og soluti on shoul d be added t o the t i p of the f i beropt ic bundl e (279). An
al ternati ve i s to pl ace the laryngoscope at the end of the tubi ng f rom a convecti ve
warmi ng devi ce (Chapt er 31) for a f ew mi nut es pri or t o intubati on (291). Thi s wi l l
warm t he bl ade and prevent f ogging.
The user i s posi t ioned at pati ent ' s head and t he scope hel d i n t he l ef t hand wi th t he
handl e hori zontal . The pati ent' s head is kept i n t he neutral posi ti on.
Oral Intubation
Ei ther by manual l y openi ng the mouth or wi t h the ai d of a t ongue blade, t he Bul l ard
bl ade i s i nserted i n the mi dl ine of the oral cavi t y, wi t h t he handl e hori zontal . The
handl e somet imes i mpi nges upon t he chest duri ng inserti on, especiall y in obese
pati ents. In these cases, i t can be removed pri or to i nserti on and then reconnected
or a short handl e used (279,292).
When using the i ntroduci ng st yl et, i t can be posi t ioned to the ri ght of the bl ade as i t
i s i nsert ed i nto t he mout h. The f i ngers of the l ef t hand that holds the scope can
maneuver the st yl et behi nd the blade once i t i s in the mouth. One mi stake that
many users make is t ryi ng t o l ook through the eyepi ece as the bl ade i s bei ng
i nsert ed. When doing thi s, the scope of ten gets turned t o one si de or t he other, and
t he cl ini ci an i s unable to i denti f y where the t i p i s placed. It i s recommended that the
bl ade be i nsert ed wi thout l ooki ng through the eyepiece but watching t hat the scope
remai ns in t he mi dl i ne duri ng inserti on. As the bl ade i s advanced, the handl e i s
rotated to the vert i cal posi ti on so t hat t he bl ade sl i des over the tongue. Once the
bl ade has been rotated around the t ongue and i t feels that i t has seated i n the
pharynx, upward movement al ong the axi s of the handle i s exerted t o vi suali ze t he
l arynx. This i s the fi rst ti me that the cli ni ci an shoul d l ook t hrough t he eyepi ece. If
properl y placed, ei ther the epiglot t is or t he gl ot ti s shoul d come i nto vi ew through
t he eyepiece. The blade can be used to l if t t he epi gl ot ti s di rectl y or i ndi rectl y.
Occasi onal l y, i t may be necessary to di spl ace t he bl ade sl i ghtl y posteri orl y and
t hen l i f t vert ical l y to opti mize vi sual i zat ion.
P. 545


Once t he l arynx is visual i zed, t he st yl et t ip i s mani pul at ed wi t h the l ef t hand unti l i t
poi nts bet ween the cords. Under visual i zat ion, the tube i s advanced off the styl et
unti l the cuf f passes the vocal cords. The l aryngoscope and st yl et are then
removed. If the t ube does not enter the t rachea, the tube and st yl et must be
wi thdrawn and the stylet pl aced t hrough the Murphy eye bef ore another attempt at
i ntubat ion i s made. In some cases, t he ti p of t he tracheal t ube wi l l i mpact on t he
ri ght arytenoi d or aryepi gl ot ti c fold (293). I f this occurs, the scope and st yl et shoul d
be reposi ti oned t o t he l ef t . I f this does not work, anot her maneuver i s to rotate the
t ube 180 degrees, posi ti oning the end of the bevel near t he bl ade and havi ng the
t i p of the st yl et prot rude through the t racheal tube. If the tube passes through the
vocal cords but cannot be advanced past the l evel of the cri coi d cart i l age, the
l aryngoscope shoul d be angled f orward sli ght l y.
I f the mul t if uncti onal scope is used, the t ip may not be vi si bl e when the scope i s
properl y placed. An int ubati on catheter can be advanced sl i ghtl y unt i l i t i s
vi suali zed. The catheter i s then pl aced through the vocal cords and t he tracheal
t ube advanced over t he catheter. The mul t if uncti onal st yl et does not have t he
maneuverabi l i t y that the introduci ng stylet aff ords.
Nasotracheal Intubation
A st yl et i s not used for nasotracheal i nt ubat i on. A di recti onal t ip t racheal tube may
be useful i n t hi s si tuati on (294, 295,296). The larynx is vi sual i zed by usi ng the
Bul l ard l aryngoscope i nserted t hrough t he mouth, and t he pat i ent ' s head posi t i on
and thyroi d carti l age are manipul ated t o al low t he tracheal t ube t o be advanced
bet ween t he vocal cords under di rect vi si on.
Another method used f or nasal intubati on was described for an inf ant wi th Treacher
Col l ins syndrome (297). The pati ent was f i rst intubated orall y. A smal l t ube
changi ng catheter was pl aced though the nose and under di rect vision mani pulated
al ongsi de the orot racheal tube. The oral tube was removed, and a nasal t ube was
passed over the catheter i nto the l arynx.
Advantages
The Bul l ard l aryngoscope is usef ul i n pat ients who are di ff i cul t t o i ntubate,
i ncl udi ng t hose i n whom head and neck movement is l i mi ted or undesi rable; those
wi th l i mi ted mouth openi ng, poor dent i t i on, pharyngeal or l aryngeal pathol ogy, or
f aci al f ractures; and the morbidl y obese
(276, 282,285,298, 299, 300,301, 302, 303,304, 305,306,307,308,309). I t has proved
useful i n chi l dren wi th Treacher Col l ins and Pierre-Robi n syndromes (297,310,311).
I t causes l ess cervi cal spi ne movement than conventi onal l aryngoscopy (41,312).
Compared wi t h f l exi bl e f i beropt ic i ntubat i on, t he Bul l ard l aryngoscope provides
quicker i ntubat ions (281, 313).
Ot her advant ages include rapi di t y of i ntubati on, l ow ri sk of f ai l ed i ntubati on or
t rauma to l i ps and teeth, and less di scomf ort i n t he awake pat ient t han di rect
l aryngoscopy (287). I t i s more resi st ant to probl ems wi t h secret ions and more
rugged than a f l exible f i berscope. Whi l e there i s a learni ng curve, t his l aryngoscope
can soon be used qui ckl y and eff icientl y. A ski l l ed assistant is not needed to
perf orm a jaw t hrust or t o hol d an ai rway i n pl ace. It requi res a mouth openi ng of
onl y 7 mm. Lat er versi ons are f ul l y i mmersible f or cl eani ng.
Disadvantages
Use of the Bul l ard scope requi res experi ence and mai ntenance of ski l l s. The
equipment i s somewhat expensive. Cl eani ng i s somewhat i nvolved. I ntubat ion may
t ake sl i ght l y l onger than wi t h a ri gi d l aryngoscope (314). It cannot be used by an
anesthesi a provi der who has l i mi ted use of t he l ef t arm (48).
Usi ng a tracheal t ube l arger t han 7.5 mm may cause the i ntroducing stylet to be
di spl aced posteri orl y, which may make intubati on more di ff icul t (315). Cert ai n
t racheal tubes (e.g. , the metal l i c l aser t ube) (Chapter 19) wi l l not f i t over the st yl et .
Double-l umen tubes wi l l not f i t the stylets. In these cases, anot her tube can be
i nsert ed by usi ng the Bul lard, and a t ube exchanger can be used to i nsert t he
desi red t ube.
There are report ed cases where the blade extender was acci dental l y di sl odged
because i t was not securel y attached (290,316,317).
WuScope
Description
The WuScope (Fig. 18.57) combi nes a ri gi d, t ubular blade and a f l exible f iberscope.
I t can be batt ery powered or used wi t h a fi beropt i c l i ght source (318).
Flexible Fiberscope Portion
The f iberscope has short l ight - and i mage-transmi t ti ng f iberopti c bundles and ti p
defl ecti on cont rol . The upper segment of t he i nsert i on cord has the same
confi gurati on as the cone-shaped WuScope handle.
Blade Portion
The bl ade port i on has t hree detachabl e metal parts: handl e, main bl ade, and
bi val ve el ement. The bi valve el ement can be at tached or rel eased f rom the handl e
and the di stal mai n bl ade by separate i nterl ocki ng mechani sms.
The handl e is a cone-shaped tube that recei ves the fi berscope at t he t op and
connects to t he mai n bl ade at t he base. The handl e-to-bl ade angl e i s 110 degrees.
An extender adjusts the l engt h of t he f i berscope i nserti on port i on f or t he adul t
bl ade.
The mai n bl ade and bivalve element are anatomi cal l y shaped. When posi ti oned
t ogether, t hey f orm two passageways: a l arger one f or a sucti on catheter or
t racheal tube and a smal ler one f or the f i berscope (Fi g. 18.58). An oxygen channel
i s alongsi de the sl ot f or t he f i berscope.
P. 546



View Figure

Figure 18.57 WuScope. Shown from left to right are the
fiberscope, the large-adult bivalve element, the large-adult
main blade, the adult bivalve element, the adult main blade,
the extender, and the handle. (Picture courtesy of ACHI
Corporation.)


View Figure

Figure 18.58 Three channels of the WuBlade for the
suction catheter and tracheal tube, fiberscope, and oxygen.

Di ff erent sizes of bl ades and bi valve el ements can be used wi th t he handle. The
adul t blade can accommodate a t racheal tube of up to 8.5 mm, whi l e the l arge-adul t
bl ade can contai n a 9.0-mm tube.
Techniques of Use
The WuScope can be used to f aci l i tate intubati on i n the awake or anestheti zed
pati ent . The pati ent ' s head shoul d be i n the neut ral posi t i on.
The components are assembl ed (Figs. 18.59, 18.60). If the adul t bl ade i s used, the
extender shoul d be at tached to t he handl e. The t racheal tube should be l ubri cated
and i nsert ed unt i l the Murphy eye i s j ust beyond the
P. 547

di stal edge of the bi val ve el ement. Use of the t racheal tube that i s desi gned for use
wi th t he Fast rach i ntubat ing l aryngeal mask may facil i tate passage through t he
gl ot ti s (204). The sucti on or ai rway exchange cathet er shoul d al so be lubri cated.
Oxygen t ubi ng should be connected to the oxygen channel . Ant i foggi ng sol ut ion
shoul d be appl i ed to the l ens.

View Figure

Figure 18.59 WuScope, partially assembled, showing
fiberscope and assembled handle, blade, and bivalve
element.


View Figure

Figure 18.60 Fully assembled WuScope with a tracheal
tube in the tracheal tube passage, a suction catheter in the
tracheal tube lumen, and oxygen tubing connected to the
oxygen port.

Orotracheal Intubation
Hol di ng the metal porti on of the handl e, the scope is i nsert ed i nto the pati ent' s
mouth in t he mi dl i ne much l i ke an oropharyngeal ai rway. The handl e i s gradual l y
rotated toward the operator as the blade advances over t he tongue. The operator
l ooks through t he eyepi ece and i denti f i es t he posteri or pharyngeal wal l and
epi gl ot ti s as the scope is advanced. If t he epi gl ot ti s bl ocks the vi ew, t he device
may be wi thdrawn sl i ghtl y and readvanced to l i f t i t up. A sucti on catheter i n t he
t racheal tube passageway can be used to remove excessive blood or secreti ons.
When t he larynx comes i nt o view, the distal mai n blade i s adj usted, i f necessary, to
al i gn the t racheal tube wi t h the glott ic openi ng. Once the t racheal t ube i s properl y
posi t i oned, i t is advanced into the trachea. Al ternati vel y, a suct ion catheter or
ai rway exchange catheter may be advanced through t he t racheal tube i nto the
t rachea. An i nt ubati on gui de that can be maneuvered may be useful (319). Thi s
t hen serves to di rect the t racheal t ube t hrough the gl ott is. The bi val ve el ement i s
removed f i rst . The handl e, mai n bl ade, and f iberscope are then removed as a uni t,
l eavi ng t he tracheal tube i n pl ace.
Nasotracheal Intubation
For nasotracheal i ntubati on, t he bi val ve el ement is not at tached t o the scope. Af t er
a tracheal tube i s passed i nto the oropharynx through t he nostri l , the scope i s
posi t i oned i nsi de t he mouth in a manner si mi l ar t o oral intubat ion. The concave
undersurf ace of the distal mai n blade is di rect ed to st raddl e the t racheal tube and
t o gui de i t t oward the gl ottis. The t racheal tube i s advanced into t he trachea, and
t he devi ce i s removed f rom the mouth.
Tracheal Tube Exchange
The WuScope can be used to exchange a t racheal tube (320). A new t racheal tube
mounted i n the WuScope i s advanced i nt o the oropharynx and posi ti oned anteri or
t o t he existi ng tube. A catheter i s passed t hrough the tracheal tube and i nto the
l arynx beside t he ol d tube. The exi sti ng tube i s wi t hdrawn, and the new tube i s
advanced into the trachea over t he catheter.
Advantages
The WuScope has been used successful l y to pl ace both t racheal and doubl e-l umen
bronchial tubes i n dif f icul t -t o-intubat e pati ents (318,321,322,323,324,325,326). Its
t ubul ar struct ure protects the fi beropt ic l ens f rom bl ood, secreti ons, and redundant
sof t t i ssue. Thi s may make i t especi al ly usef ul i n t he pati ent wi t h ai rway obstructi on
resul ti ng f rom hematoma or edema. No f orceps or st yl et i s needed, so t he ri sk of
ai rway i nj ury is l ow. Suct ioni ng and oxygen admi ni st rat i on can be perf ormed
si mul taneousl y. Unl i ke f l exi bl e f i beropt i c endoscopy, one can vi ew the t racheal tube
as i t advances through the gl ot ti c openi ng into the trachea.
The handl e-to-bl ade angl e f aci l i tat es ent ry i n obese pat ients and in t hose wi t h
barrel chests, short necks, or l arge breasts. There i s no need for head extensi on or
t ongue l i f t ing. Mi ni mal j aw openi ng i s necessary.
P. 548



View Figure

Figure 18.61 UpsherScope. The larger photograph shows
the delivery slot for the tracheal tube. The blade is attached
to a conventional Upsher handle. The inset shows the
opposite site of the blade with the eyepiece. A fiberoptic
cable from the light source is attached to the handle.
(Courtesy of Mercury Medical.)

Disadvantages
Li mi tat i ons i ncl ude a hi gh ini t ial cost, the need for new cl eani ng and disi nf ecti ng
rout ines, t he need t o learn and master new ski l l s, and the ti me requi red t o
assembl e and di sassembl e the devi ce. The f lexible f iberscope may be damaged. It
may not be useful i n a pat i ent wi th a severel y l i mi ted mouth opening. Appl i cat i on of
cricoi d pressure decreases the ease of i ntubati on when usi ng thi s device (327).
UpsherScope
Description
The UpsherScope (Fi g. 18.61) consi sts of a C-shaped met al bl ade, shaped to
approxi mate t he curve of t he oropharynx (328). The open part of the C t o the ri ght
ends about 1 i nch f rom t he end of the blade. The distal part of t he bl ade has an
upward curve. To the lef t are two t ubes that carry f iberopti c bundles. Both bundl es
end where the semi ci rcul ar channel ends. Proxi mall y, the vi ewi ng bundl e terminates
i n an eyepiece wi t h a f ocusi ng ri ng whi l e the l ight bundl e makes contact wi th t he
f iberopti c l i ght source at the handl e. An Upsher handl e must be used. A remot e
l i ght source can be used. A camera can be at t ached f or remot e vi ewi ng. I t is
presentl y avai l abl e onl y i n an adul t si ze. A pedi atri c versi on is sai d to be in
devel opment.
Techniques of Use
Pri or to i ntubati on, t he vi ewi ng f i beropt ic bundl e should be t reated wi t h an
anti f oggi ng sol ut ion. The t racheal tube shoul d be l ubri cat ed and pl aced i n the
del i very sl ot wi th t he ti p not qui te protrudi ng f rom the di stal end of the channel (Fig.
18.62). I nsert ing a bougi e through the t racheal tube si gni f i cantl y improves the
chances of successf ul i ntubat ion (329). The blade is cl i pped to the handl e and t he
vi ewi ng l ens f ocused. Head and neck f l exi on wi l l i ncrease the probabi l i t y of
success.
The scope shoul d be introduced central l y i nt o t he mout h. A j aw l i f t is usual l y
hel pf ul . Occasi onall y, chest i mpedance may make i t necessary to i nt roduce t he
scope si deways, t hen rot ate i t to a cent ral posi t ion. It is t hen advanced al ong the
oropharyngeal curve. When the l arynx comes into vi ew, t he scope ti p i s posi ti oned
under t he epi gl ot ti s, and the scope i s elevated to al i gn
P. 549

t he l ower part of the bl ade wi t h t he arytenoi d carti l ages. The t racheal tube, bougi e,
or ai rway exchange cathet er i s then advanced under di rect visi on between the vocal
cords. The scope i s then removed f rom the t ube and rotated out of t he mouth.

View Figure

Figure 18.62 UpsherScope with tracheal tube loaded onto
it.


View Figure

Figure 18.63 Shikani optical stylet. Both the adult and
pediatric stylets can be attached to the same handle. Note
the tube stop and the connection for oxygen tubing.

I f the t ube i s di ff icul t to advance, t hi s can of ten be corrected by rotati ng t he
t racheal tube 90, further f lexion of the head on the neck, modi f icati on of the vector
of l i f t , rotati ng the t i p of the scope to the l ef t or ri ght , or passi ng a gui de wi th
subsequent passage of t he t racheal tube over i t (328, 329). The bl ade somet i mes
rol l s of f the tongue to the si de. When thi s occurs, a paramedi an approach shoul d
be at tempted.
Advantages
The UpsherScope is usef ul t o i ntubate pat i ents wi t h di ff icul t ai rways wi t hi n a
reasonabl e ti me (328). It can be used wi t h al l si zes of adul t tracheal tubes. I t can
be cl eaned by usi ng t he St eri s system.
Disadvantages
I n routi ne intubati on, the UpsherScope has demonst rated no advantages over
conventi onal laryngoscopy. The t ime needed t o perf orm i nt ubat i on and the number
of attempts have been si gni f i cantl y l onger and hi gher wi t h the UpsherScope (330).
The UpsherScope is not sui t abl e f or nasot racheal i ntubati on. Secret i ons can
obscure the view (328,329).
Optical Intubating Stylets
A number of devi ces that combi ne f i beroptic i magi ng wi th an i nt ubat i on st yl et have
been descri bed (331,332,333,334,335,336,337,338,339,340, 341, 342,343, 344).
These are ref erred to as opt ical i ntubati ng styl ets, optical st yl ets, i nt ubat ing
f iberopti c st yl ets, st yl et l aryngoscopes, or vi sual scopes. Some have a mechani sm
t o al t er t he shape of the styl et duri ng use. Most can be att ached to a vi deo
t ransmissi on system so that i ntubati on can be observed on a moni t or. Some have a
port f or oxygen i nsuf f l ati on, drug admi nistrati on, or sucti on. Some are batt ery
operated. Others requi re a separate l i ght source, and some can be used ei ther way.
Some can be used wi th a f iberopti c handl e f or a ri gi d bl ade.
Description
Shikani Optical Styl et
The Shikani opti cal st yl et (Seei ng Optical St yl et, SOS) (Fi g. 18.63) i s a stai nl ess
steel mall eable styl et (336,337,345,346,347). It comes i n a pref ormed J-shape but
can be bent at the t i p. It has a handle, eyepi ece, adj ustabl e tube stop, and i nt egral
port f or i nsuf f l ati ng oxygen through the t racheal tube. The eyepiece has a f ixed
f ocus on t he area around t he ti p of the f i beropti c bundle. It can be used wi t h
several l ight sources.
There i s bot h an adul t and a pediatri c si ze. The adul t si ze wi l l f i t a t racheal t ube of
5. 5 mm or l arger. The pedi atric si ze wi l l f i t a t ube of 3 mm or l arger.
Bonfils Retromolar I ntubation Fiberscope
The Bonf i l s int ubati on f iberscope (Fi g. 18. 64) i s a nonmal l eabl e st yl et l aryngoscope
wi th a 40 distal curve (348). It has a 5-mm outsi de di ameter and a l ength of 40 cm.
A 6.0 mm or l arger t racheal tube can be i nserted over i t . It has a movable eyepi ece
as wel l as a sli de adapter f or stabi l i zi ng the tracheal t ube. The adaptor has a
connector to admi ni ster oxygen duri ng i ntubat ion. It can be used wi t h bat teri es or a
separate f iberopti c l ight source.
Techniques of Use
Pri or to i ntubati on, ant i foggi ng agent is placed on the lens or the styl et is warmed
i n water or sali ne. I t shoul d
P. 550

be i nsert ed into the tracheal tube wi thout i ts t ip prot ruding past t he t ip and t hen
f ixed to the tube. Wi th a pedi at ri c tracheal tube, i t may be necessary t o remove the
connector.

View Figure

Figure 18.64 Bonfils intubating fiberscope.

The pati ent is pl aced in the neut ral posi t i on or wi th a pi ll ow under t he head. If
secreti ons are present, they shoul d be removed bef ore proceeding f urther. A ri gid
l aryngoscope or j aw t hrust shoul d be used to l i f t the epi glott is (336,344,347,349). I t
may al so be helpful to grasp the tongue and draw i t out of the mouth. The handl e i s
hel d i n the ri ght hand and the styl et inserted i nt o the mouth in t he midl i ne and
advanced into the hypopharynx j ust beyond the t i p of the epi gl ott is. The st yl et i s
t hen advanced under di rect vi si on through the vocal cords. For some pati ents, i t
may be necessary t o appl y external pressure on the larynx. I f secreti ons are a
probl em, i nsuff lati ng oxygen may i mprove the view. If ori entat ion i s l ost , the scope
shoul d be wi t hdrawn unti l orientati on is re-establ ished.
When an i nt rat racheal posi t i on is achi eved, the tube shoul d be advanced i nto the
t rachea. The st yl et i s removed by rol l i ng the handl e toward t he pat i ent ' s chest ,
f ol l owi ng the curve. I t shoul d not be pul led strai ght out.
A ret romol ar approach is somet imes used (350). The scope i s i nsert ed between the
cheek and t he mol ars on t he pati ent 's ri ght si de wi th t he end of the scope point i ng
t oward t he mi dl ine.
An opt i cal styl et can be used vi a a Fast rach I nt ubati ng Laryngeal Mask Ai rway
(ILMA) (351). I t can also be used as a l ightwand. I t can be used to check t racheal
t ube posi t i on. I t may be used to pl ace a doubl e-l umen endobronchi al t ube (352) or
t o di rect a sucti on cat heter i nto a mai nst em bronchus.
Advantages
Opt ical styl ets are rel ativel y easy to use for routi ne and di f fi cul t i nt ubat i ons,
al though practi ce wi l l be requi red t o achi eve and maintai n profi ci ency
(307, 332,334,335, 336, 337,340, 343, 344,346, 347,353,354). Intubati on wi th t hi s
device may be successful af ter f ai l ed di rect l aryngoscopy (350). Si nce the trachea
can be visual i zed, esophageal i ntubat ion shoul d not occur. The i nci dence of sore
t hroat and the i ncrease i n heart rate are l ess than wi t h conventi onal laryngoscopy
(332, 340,355,356). The risks of dental trauma and sof t ti ssue damage wi l l be
reduced if a conventi onal l aryngoscope i s not used i n conj uncti on wi th t he opt ical
st yl et . The use of an opti cal stylet may resul t i n l ess cervical spine movement t han
when convent ional l aryngoscopy is used (357).
The opti cal styl et i s more port abl e, rigi d, and rugged and costs less than a
f iberscope. However, bendi ng may damage t he f i beropt i c f i bers. I t may be a usef ul
al ternati ve when a f iberopti c endoscope i s not avai l able.
Disadvantages
I ntubat ion t i me may be l onger t han wi th conventi onal laryngoscopy (335).
I ntubat ion i s faster t han wi th the int ubati ng LMA-Fastrach, but t he ti me to
venti l ati on i s short er wi th t he ILMA-Fastrach (342). The i ni ti al cost of the moni tor,
l i ght source, and associated equi pment i s hi gh. Secreti ons on the l ens may cause
i ntubat ion f ai l ure (334,340). The major l i mi tat i on is t hat i t cannot be ori ented i n a
preci se di rection. Nasal i ntubati on cannot be performed wi th some of these
devices.
Video Laryngoscopes
A vi deo l aryngoscope can be created by at tachi ng a video system to a f lexi bl e
f iberscope or an optical st yl et . Several l aryngoscopes t hat are speci al l y desi gned t o
work wi t h a vi deo system are commerci al l y avai lable (Fi g. 18. 65).
Vi deo l aryngoscopy has many advantages. The displ ayed anatomy is magnif i ed,
and a l arger vi ewi ng angl e i s provi ded. The operator and assi st ant can coordi nate
t hei r movements because each sees t he same i mage on t he moni tor (358). The
abi l i t y to proj ect the i mage seen through the l aryngoscope makes i t a good t eachi ng
t ool ,
P. 551

al l owi ng the supervi sor t o moni tor the i ntubat i on process more ef fecti vely
(359, 360,361). Posi ti oni ng the moni tor over the pati ent ' s chest al l ows the i ntubator
t o work and observe i n one axi s (359).

View Figure

Figure 18.65 Video laryngoscope stand. The whole unit is
portable. (Courtesy of Saturn Biomedical.)

Usi ng a vi deo l aryngoscope may resul t in l ess neck movement than when usi ng a
conventi onal laryngoscope, dependi ng on the parti cul ar l aryngoscope (362). It
al l ows the anesthesia provider to mai nt ai n a di st ance f rom t he pati ent duri ng
i ntubat ion, and t hi s coul d make i t usef ul in pati ents who have infecti ous diseases
(363). In one case, the recorded int ubati on was usef ul i n demonstrat ing t o the
pati ent t hat the i ntubat i on had been perf ormed properl y and was not responsibl e f or
t he di sl ocati on of the arytenoi d cart i lage (364).
I n addi ti on t o al l owi ng l aryngoscopy and intubati on t o be vi sual i zed, i t can be used
t o observe bougi e placement (365,366), movement of the vocal cords af ter t hyroi d
surgery (367,368,369,370), verif y tracheal t ube posi ti on, and ai d in t racheal tube
exchange.
A l i mi tat i on of these devi ces i s the need for a video-endoscopy moni tori ng system,
so i t may not be sui tabl e f or use outsi de a heal th care f aci l i t y. However, most
operati ng sui tes are equi pped wi th vi deo-endoscopy moni t oring syst ems to whi ch
t hese devi ces can be connected.

View Figure

Figure 18.66 GlideScope. Note the 60-degree angulation of
the blade. (Courtesy of Saturn Biomedical.)

GlideScope
Description
The Gl i deScope (Fi g. 18. 66) has a mi ni ature di gi tal camera on the undersi de of a
pl ast i c blade. A l i ght-emi tt ing devi ce (LED) mounted besi de the camera provides
i l l umi nat ion. The blade has an embedded anti foggi ng mechani sm and a 60 bend at
t he midpoi nt. As a resul t , t he vi ew f rom the camera i s dif ferent f rom the one seen
when l ooki ng i nto the mouth. The i mage i s transmi tt ed vi a a cabl e to a moni t or
screen. A portable Gl ideScope that can operate on battery power and one suppl yi ng
a col or i mage are avai l abl e (371). The Gl ideScope i s avai l abl e i n adul t and
pediatric sizes (neonate, i nf ant , and chi l d).
Use
I mmersi ng the bl ade i n l ukewarm water f or a f ew mi nutes before usi ng i t may
i mprove vi si on (372). It can be used as a curv ed or st rai ght bl ade.
The use of a st yl et i n the t racheal or doubl e-l umen t ube i s recommended. The angl e
on the st yl et shoul d be at l east 50 to 60 degrees (373,374,375,376,377). A
mal leabl e st yl et whose shape can be changed duri ng use may be helpful (378).
Wi th the head i n a neut ral posi ti on, the Gl i deScope i s i nsert ed i n t he mi dl ine. In
pati ents wi t h l i mi ted mouth openi ng or l i mi ted head/neck movement, i t may be
hel pf ul to insert the l aryngoscope upside down and then rotat e i t countercl ockwi se
(372). I t i s hel pful to i dent i f y the uvul a and ensure that i t is centered on the moni t or
before advanci ng the scope around the t ongue (379). The bl ade shoul d be
advanced anteri or t o the epi glott i s. Af ter the t ip i s in t he val l ecul a, t he scope i s
gentl y el evated.
I ntubat ion occasional l y f ai l s despi te an excel l ent laryngeal view (378,379,380). Thi s
may be overcome by i nserti ng t he tracheal tube upsi de down, rot at i ng i t whi l e i t i s
P. 552

i nsert ed, usi ng a t racheal tube wi t h a blunt t i p, changi ng the styl et ' s curve, sl i ght
wi thdrawal of the l aryngoscope, wi thdrawi ng t he st yl et, rel axing t he l aryngoscope
el evati on, appl yi ng external l aryngeal pressure, i nsert i ng a tube nasal l y, or
i nsert i ng a bougi e f ol l owed by rail roadi ng the tracheal tube over i t
(363, 369,372,379, 382).

View Figure

Figure 18.67 Video Macintosh. The fiberoptic bundle is
inserted into the blade. The blade can be removed for
cleaning.

I f the Gl i deScope is l ef t i nsi de a pat ient f or an extended peri od of t i me, there is a
t heoret ical risk of damage to the ti ssues, as t he gl ass wi ndow wi l l be hot ter t han
41C (106F). Theref ore, t he Gl i deScope must be removed af t er i ntubat ion i s
compl ete.
Evaluation
St udi es show t hat the Gl ideScope yi el ds a comparabl e or superi or gl ott i c view
compared wi t h di rect laryngoscopy (363,371,377, 379, 383,384,385, 386,387). It has
been used successf ul ly i n both anestheti zed and awake pati ents wi th di f f i cul t
ai rways, i ncluding f ol l owi ng fai l ed f i beropt i c i ntubati on (383,388,389,390,391). I t
causes l ess cervical spine movement than the Macint osh blade (42). The l earni ng
curve appears to be rapi d (379, 385, 392). However, i t may not be sui table f or use
wi th neonat es (393). In some cases, i t may be di ff i cul t or i mpossi bl e to pass the
t racheal tube despi te a good vi ew of the gl ott i s (61,382).
Video Macintosh Intubating Laryngoscope
The Vi deo Maci ntosh int ubati ng l aryngoscope (Fi g. 18.67) has a Maci nt osh blade
at tached t o the handl e and the image-l i ght bundl e threaded through a smal l metal
gui de i n the blade and advanced t wo thi rds of t he l ength of the bl ade (359). Ant if og
solut i on should be placed on the t i p of the image-l i ght bundl e. I t may provi de a
bet ter vi ew than a t radi ti onal Maci nt osh l aryngoscope (394).
Angulated Video-intubation Laryngoscope
The angl ed vi deo i ntubat ion l aryngoscope (AVI L) has a plast ic bl ade whose t ip i s
angul ated at approximat el y 25 degrees (344). The verti cal fl ange i s f lat t ened. A thi n
channel leads f rom the handl e to t he bl ade t i p and permi ts f l exi bl e f i berscope
i nsert i on. It has proven usef ul i n chi ldren requi ri ng manual i n-l i ne neck st abi l i zati on
(362, 395).
Tooth Protectors
A tooth protector (mout h guard, mouth protect or, dent guard) (Fi g. 18.68) is pl aced
over the upper teeth to prot ect them f rom t he laryngoscope bl ade. It may also
prevent the bl ade f rom get ti ng caught i n a gap bet ween the teet h. Use of a
protect or does not guarantee saf et y f rom dent al t rauma (396,397). Al t hough i t wi l l
prevent di rect t rauma t o the surf ace of the t eeth, i t cannot prevent transmi ssi on of
pressure to the roots.
Tooth protectors are avai l able i n dif ferent designs (Fi g. 18.57) and are fashi oned
f rom a variety of materi als. A custom tooth protect or, professi onall y made f rom an
i mpressi on of the pat i ent ' s teet h, can provi de si gni f i cant protect ion (398). A tooth
protect ion devi ce may be at tached to the l aryngoscope bl ade (399,400,401).
These devices may make i t harder t o vi sual i ze the larynx and may make t racheal
t ube i nserti on more dif f icul t because of l ack of space (396). They sl i ght l y i ncrease
t he i ntubati on t ime (402). Cut ti ng of f part of the right si de of t he prot ector or usi ng
a transparent prot ector may decrease these problems. I t may be necessary t o
remove the protector bef ore i ntubati on can be accompl i shed.
P. 553



View Figure

Figure 18.68 Tooth protectors. (Courtesy of Sun Med.)

Complications of Laryngoscopy
Dental Injury
Damage to teet h, gums, or dental prostheses is the most f requent anesthesi a-
rel ated i nsurance cl ai m (403, 404,405, 406, 407). I n addi t ion to cosmeti c
di sf igurement and discomf ort, t here may be pul monary compli cat i ons i f the
di sl odged tooth or f ragment is aspi rated. Prof use bl eedi ng may resul t (408).
A tooth or prostheti c device may be chi pped, broken, l oosened, or avulsed. The
t eeth most l ikel y to be damaged are those that have been restored or weakened
t hrough peri odontal disease, but sound teeth may al so be af f ected (409). The upper
i nci sors are most f requent l y i nvolved (405, 410). Thi s i s most of ten caused by usi ng
t he teeth as a f ulcrum point for t he l aryngoscope whi l e el evati ng the epi glott is.
The condi ti on of each pati ent ' s teeth shoul d be carefull y assessed preoperat ivel y t o
i denti f y possi bl e problems. I nqui ry shoul d be made concerni ng vul nerable dental
repai r work or l oose or cari ous teeth. Anat omi cal condi t ions i n the mout h and
pharynx that can cause di f fi cul t y should be noted. The pat i ent shoul d be advised
beforehand if there is l i kel y to be a probl em. A suture may be placed around a
l oose t oot h to prevent i t f rom enteri ng the ai rway i n the event i t becomes disl odged.
I n pati ents 4 to 11 years old, the deci duous teeth may be easi l y di sl odged. I f such
t eeth are l oose, removal bef ore or duri ng anesthesia may be i ndi cat ed.
When t here are gaps bet ween the upper f ront t eeth, a port i on of a tracheal tube or
ot her devi ce may be used to bridge the gap, or a t oot h protector may be used.
Keepi ng a part i al upper denture i n place may prevent the l aryngoscope f rom
sl i ppi ng into gaps bet ween t eet h.
I f a tooth, f ragment, or dent al appl iance i s di slodged, forei gn body aspi rati on
shoul d be a major concern. An immediate search shoul d be conducted, st art i ng wi t h
an examinati on of the oral cavi ty and the area surrounding t he pati ent 's head.
Chest and neck radi ographs must be t aken i f the f ragment is not recovered.
Di ff erent t ypes of tooth damage may occur (403). These requi re di f f erent
t reatments. A qual if ied dent i st or oral surgeon shoul d be consul ted. If a tooth is
avulsed, i mmedi ate replacement i n i ts ori ginal posi ti on and stabi l i zati on wi l l
i ncrease t he chances of successful reimpl antati on (411).
Tooth protectors may prevent dent al damage. Pl acing adhesive tape or other
materi al s on the fl ange of the blade has al so been report ed to be eff ect ive
(401, 412). I nsert ing t he l aryngoscope blade f rom t he l ef t corner of the mouth may
spare t he inci sor t eeth (150).
Cervical Spinal Cord Injury
Aggressi ve head posi ti oni ng duri ng i ntubat ion, especi al ly head or neck ext ensi on,
has the potenti al t o cause damage i n the pati ent wi t h an unstable cervi cal spi ne
(413). An unstabl e cervical spi ne can be associ ated wi t h a congeni tal weakness,
mal f ormat i on, f racture, or di sl ocati on of a cervi cal vertebra or other condi ti ons such
as osteoporosi s, connect ive t i ssue di sease, or t umor (312, 414,415). Case reports
t hat descri be neurol ogi c det eri orat ion af ter i nt ubat i on exi st (416,417,418), al though
t he cont ri buti on of l aryngoscopy to these i nj uri es remai ns debat abl e and the overal l
ri sk appears to be l ow (418,419,420,421). It may be advi sable to invol ve the
neurosurgeon t o wi t ness the i nt ubat i on so that a maneuver t hat coul d cause harm
can be avoi ded.
There are no data to suggest that any mode of ai rway i ntervent i on is superior i n
decreasi ng secondary i nj ury or i mprovi ng outcome (312,422). Manual i n-l ine
i mmobi l i zat i on reduces spi nal movement and the l i kel i hood of secondary injury
(39,312,422,423,424,425,426,427,428,429). A cervical col l ar shoul d be not be
rel i ed on f or t hi s purpose.
Damage to Other Structures
Report ed i nj uri es to t he upper ai rway i nclude abrasi on; hemat oma; and l i ps,
t ongue, pal at e, pharynx, hypopharynx, l arynx, and esophagus l acerati ons. A
common occurrence i s rol l ing the upper or l ower l i p bet ween the teeth and the
l aryngoscope blade as the blade is i nsert ed. Osteomyel i ti s of the mandi bl e has
been report ed (430). The l ingual and/or hypogl ossal nerve may be injured
(431, 432,433,434, 435). Aryt enoi d subluxat ion may occur (436). Anteri or
t emporomani di bul ar j oi nt (TMJ) disl ocati on may occur (437,438). Pat ients wi th TMJ
derangements
P. 554

of ten state that thei r probl em began f ol lowi ng general anest hesi a (439).
There i s a signif i cant increase i n t he rate of ai rway-rel ated compl icati ons as the
number of l aryngoscopi c attempts increases (440). The Ameri can Soci ety of
Anesthesi ol ogi sts (ASA) Task Force on t he Management of t he Dif f icul t Ai rway has
recommended l imi ti ng t o three at tempts (441, 442).
Shock or Burn
I f a l aryngoscope l ight that i s lef t ON contacts the pat ient, a burn may resul t
(443, 444). A short ci rcui t can resul t in the handle and blade rapidly heati ng
(445, 446). The t i p of a fi berscope appli ed di rectl y t o the skin may produce a burn
(447).
Swallowing or Aspirating a Foreign Body
Cases have been reported i n whi ch the bul b or ot her part of a l aryngoscope was
aspi rated or swal l owed (448,449, 450, 451,452,453). It is i mportant to make every
ef fort t o f i nd t hese f orei gn bodi es. If t hey cannot be found in t he oral cavi ty or
around the pat i ent 's head, x-rays of the chest and neck shoul d be taken. Part of a
t umor may be di sl odged into t he ai rway and may become i mpl anted (454).
Laryngoscope Malfunction
The most common l aryngoscope mal functi on i s li ght f ai l ure. Thi s may be the resul t
of a defecti ve power source, l amp, or socket ; i ncorrect assembl y; or poor cont act
bet ween t he bl ade and handle. Fiberopti c l aryngoscopes are more rel i abl e because
t he hal ogen l amp' s useful l i f e i s l onger than an ordinary l ight bul b, and the l amp i s
usual l y i n the handl e rather than i n t he blade. Vari ous part s of t he bl ade and handl e
may break (452, 455,456, 457, 458,459, 460, 461,462,463,464, 465,466, 467, 468).
Mi sassembl y may resul t in f ai lure (469).
A preuse check wi l l det ect most mal funct ions. An extra handle and blade should
al ways be i mmedi at el y avai l abl e. Neglecti ng t o observe t hese precaut ions could
spel l di saster, especi al l y when a rapi d sequence i nduct ion is t o be perf ormed
(470, 471).
Circulatory Changes
Laryngoscopy may resul t i n si gni f i cant i ncreases i n bl ood pressure and heart rate,
al though t hese changes are l ess than those associ ated wi t h tracheal i ntubat i on
(219, 472,473,474, 475, 476).
Disease Transmission
The risk of i nfect ion t ransmi ssi on, parti cul arl y Creut zf el dt-Jakob di sease, via
l aryngoscopes, i s unknown but is a mat ter of concern to anesthesi a provi ders
(177, 477,478). The use of a disposabl e bl ade cover or di sposabl e l aryngoscope
bl ade has been encouraged (172,176,479).
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P. 560


Questions
For the f ol lowing quest ions, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
1. The best positi on for i ntubating an adult pati ent when usi ng a rigi d
l aryngoscope is
A. Shoul ders el evated
B. Fl exi on of the l ower cervi cal spi ne and extensi on of t he head
C. Fl at on t he bed
D. Pressure exerted on the top of the head
Vi ew Answer2. Techniques for i nserti ng a tracheal tube with a flexible
fiberoptic endoscope include
A. Vi sual i zi ng the larynx wi t h the f iberopt ic endoscope, placi ng the endoscope i nto
t he l arynx, and sl i di ng the t racheal t ube over the endoscope
B. Pl acing a bougi e in t he trachea under di rect vi si on by usi ng the fi beropt i c
endoscope and then i nsert ing the tube over the bougi e
C. Pl aci ng the tracheal t ube i nt o the pharynx as a gui de f or pl acement of the
f iberopti c endoscope and then advanci ng t he endoscope and t hen the tube i nto the
l arynx
D. Pl aci ng the tracheal t ube i nt o the l arynx wi th a bl ind t echni que and checking i ts
posi t i on wi t h the f i berscope
Vi ew Answer3. If the tracheal tube cannot be advanced over a fl exible
endoscope into the trachea, which of the fol l owing maneuvers may be hel pful ?
A. Wi thdrawi ng the tube and rotati ng i t 90 degrees
B. El evati ng the mandi bl e
C. Appl ying external pressure on t he l arynx
D. Using a rigi d l aryngoscope t o el evat e the epi gl ott is
Vi ew Answer4. Reported compli cations associated wi th laryngoscopy
i ncl ude
A. Tooth damage
B. The f i beropt ic scope prot rudi ng t hrough the Murphy eye
C. Damage to t he cervi cal spi nal cord
D. Damage to t he recurrent laryngeal nerve
Vi ew Answer5. Which maneuvers are useful for nasal i ntubation wi th a
fiberoptic scope?
A. Usi ng a nasopharyngeal ai rway to di late t he nose
B. I nt roduci ng the tube t hrough a speci al l y desi gned mask
C. Using a sl i t nasopharyngeal ai rway t o i ntroduce t he t ube
D. I nt roduci ng the f i berscope oral l y and using i t t o gui de the tube f rom t he nose
Vi ew Answer6. In whi ch situations woul d it be advantageous to use a
short rigi d laryngoscope handl e?
A. When cri coi d pressure i s bei ng appl i ed
B. When t he pat i ent i s in a body cast
C. When the pat i ent has large breasts
D. When the neck is f rozen in t he f l exed posi ti on
Vi ew Answer7. Techniques that may be hel pful to intubate a patient when
i t is di fficult to pl ace a conventi onal laryngoscope blade i n the mouth because
of an anatomic abnormal ity include
A. I nsert ing the bl ade i nto the mouth wi thout t he handle at tached and then
at tachi ng the handle
B. I nsert ing the bl ade i nto the mouth l ateral l y and movi ng i t to the i ntubati ng
posi t i on
C. I nsert i ng t he bl ade wi th a 90-degree t urn and then turni ng i t to t he intubati ng
posi t i on
D. I nsert i ng t he bl ade 180 degrees f rom normal and rot ati ng i t to the normal
i ntubat ing posi ti on as i t i s bei ng i nserted
Vi ew Answer8. When intubating chil dren,
A. Cervi cal f l exion i s f requent l y not necessary
B. The head shoul d be extended 70 t o 85
C. The shoul ders f requentl y need t o be elevat ed
D. I t wi l l of t en be necessary t o ext end t he head over the end of t he bed
Vi ew Answer9. Which of the statements below are advantages of
fiberoptic i ntubation?
A. I t i s easi er t han ri gid l aryngoscope i ntubati on
B. There i s less cervi cal spi ne movement
C. I nst ruments used are robust
D. I t i s usef ul f or di f fi cul t i nt ubat i ons
Vi ew Answer10. Problems associated with fl exi ble fiberoptic i ntubation
i ncl ude
A. Cardi ac dysrhyt hmias
B. Great er l ength of t i me t o perf orm
C. Hypertensi on
D. The presence of bl ood and secreti ons
Vi ew Answer11. Compl icati ons associated wi th i nsuffl ating oxygen
through the working channel include
A. Gastri c rupture
B. Tensi on pneumothorax
C. Subcutaneous emphysema
D. Ai r embol i sm
Vi ew Answer12. Situations in which the Bul l ard laryngoscope woul d be
hel pful i ncl ude
A. Li mi ted mouth openi ng
B. Treacher Coll i ns syndrome
C. Morbi d obesi t y
D. Cervi cal spi ne f ractures
Vi ew Answer