LARYNGOSCOPES by Dr. Ashok Sharma

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LARYNGOSCOPES

• Presented by - Dr. Ashok Sharma
• Moderator - Dr. Mamta Sharma

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Introduction

• A laryngoscope (larynx scope) is a device that
  is used to visualize the larynx and adjacent
  structures mainly for inserting a tube into
  tracheobronchial tree.

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History

• The first laryngoscope was invented by Manuel
  García in 1854
• Alfred Kirstein developed direct vision
  laryngoscope in1895
• It was popularised by Sir Robert Mackintosh and
  Sir Ivan Magill in early 1940

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Laryngoscopy

• A procedure wherein the larynx is visualized
• Performed for diagnostic, therapeutic
  intubation purposes by various specialists

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View Of Larynx
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CORMACK LEHANE SCORE
Gr II
Gr I
Gr III
Gr IV
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Uses

• Endotracheal Intubation
• Insertion of nasogastric tube and transesophageal
  echocardiac probe
• Foreign body removal
• Upper airway lesion biopsy
• Visualizing and assessing the upper airway (vocal
  cords and larynx)

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Types Of Laryngoscopes

• Direct Rigid laryngoscopes
• Indirect Rigid laryngoscopes which use
  fiberoptics, mirrors, prisms, etc.
• Video laryngoscopes Rigid, Flexible
• Optical stylets
• Flexible fiberoptic endoscopes

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Direct Rigid Laryngoscopes

• Dominant modality since 1940s
• Advantages quick to use, economical,
  rugged, universally available
• Disadvantage alignment of visual, oral
  pharyngeal axis is needed.

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Parts Of Laryngoscope

• Handle
• Blade
• Base
• Heel
• Tongue (Spatula)
• Flange
• Web
• Tip (Beak)
• Light source
• Hook-on (hinged, folding) connection between the
  handle and blade.

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Handle

• Held in the hand during use
• It provides the power for the light
• Accept blades that have a light bulb to have
  metallic contact, which completes an electrical
  circuit when the handle and blade are in the
  working position
• Handles containing batteries or using fiberoptic
  illumination, contain a halogen lamp bulb

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Handle

• Available in several sizes
• Rough surface for grip

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• Short Handles
• Used when
• Chest or breasts contact the handle during use
• Cricoid pressure is being applied.

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Patil-Syracuse Handle

• Can be positioned and locked in four different
  positions

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Blade
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Blade

• Base
• Attaches to the handle
• Slot for engaging the hinge pin of the handle
• End of the base is called the heel
• Tongue (spatula)
• Is the main shaft
• Compress and manipulate the soft tissues
  (especially the tongue) and lower jaw

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Blade

• Flange
• Projects off the side of the tongue and is
  connected to the tongue by the web
• Guide instrumentation and deflect tissues from
  the line of vision
• Determines the cross-sectional shape of the blade
• Tip (Beak)
• Contacts either the epiglottis or the vallecula
  and directly or indirectly elevates the
  epiglottis
• Tip is thickened transversely beaded to
  minimize mucosal damage

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Types of blades

• MACINTOSH (Curved)
• Most popular
• The tongue has gentle curve that extends to the
  tip
• In cross section ,the tongue, web and flange
  form reverse Z
• It is positioned in the vallecula anterior to
  the epiglottis lifting it out of the visual
  pathway
• Size ranges from 1-4, Most adults require size 3

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MACINTOSH (Curved)
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MACINTOSH (Curved)
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Modifications Of MACINTOSH

• Left-handed Macintosch Blade
• English Macintosch
• Polio Blade
• Improved Vision Macintosch Blade
• Oxiport Macintosch(Mac/Port)
• Tull Macintosch
• Fink Blade
• Bizzarri-Giuffrida Blade
• Upscher Low Profile Blade
• Blechman Blade
• Flexible-tip Blade

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MILLER (Straight)

• The tongue is straight with a slight upward curve
  near the tip
• The flange, web, and tongue form a C with the top
  fattened
• It is positioned posterior to the epiglottis,
  trapping it while exposing vocal cords and
  glottis
• Size ranges 0-4

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MILLER (Straight)
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MILLER (Straight)
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Modification Of Miller Blade

• Oxiport Miller Blade
• Tull Miller Blade
• Mathews Blade
• Wisconsin Blade
• Wis-Foregger Blade
• Wis-Hipple Blade
• Schapira Blade
• Alberts Blade
• Michaels Blade

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Contd.

• Soper Blade
• Heine Blade
• Snow Blade
• Flagg Blade
• Guedel Blade
• Bennett Blade
• Evesole Blade
• Seward Blade
• Phillips Blade

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Contd.

• Racz-Allen Blade
• Robertshaw Blade
• Oxford infant Blade
• Bainton Blade
• Doubleangle Blade
• Belscope Blade
• Cranwall Blade
• CW Blade
• Flexible-tip Blade

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Contd.

• FlexiBlade
• Vital View Blade
• Henderson Blade
• Cardiff Blade
• Viewmax Blade
• Dorges Blade
• Truview Blade

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Size of blades for paediatric patients
Childs weight (Kg) Laryngoscope Blade
0 3 Miller 0
3 - 5 Miller 0,1
5 12 Miller 1
12 20 Macintosh 2
20 30 Macintosh 2, Miller 2
gt30 Macintosh 3, Miller 2
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Preparation for Laryngoscopy

• Arrange proper funtioning equipments-
• Suction central, mobile, manual
• Oxygen low and high flows
• Airway equipments laryngoscope, ET tube,
  airway, stylet, reservoir or self inflating bag
• Patient position sniffing
• Monitors pulse oximeter, cardioscope
• Esophageal detection device self evacuating
  bulb, capnograph, CO2 detector device
• Height of operating table at the level of
  laryngoscopists navel
• Never crouch or be too close to the patient

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Techniques Of Laryngoscopy

• Position-
• Optimal Sniffing Position
• 25-35 deg flexion of lower cervical spine and
  85 90 deg head extension at atlanto-occipetal
  joint using pillow of 8-10 cm height under head.
  No head elevation required in children lt8 yr, as
  their large head circumference produces neck
  flexion as the head extended at a-o Joint

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Contd.

• Laryngoscope held in left hand at the junction of
  handle blade
• Optimum opening of mouth with a
  thumb-over-index-finger (scissoring action)
  approach by right hand
• Introduce the blade into the mouth from right
  side without engaging lips and teeth

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Contd.

• As ½ of blade enters the oral cavity sweep the
  tongue to the left
• Advance the blade along the side of tongue
  towards the right tonsillar fossa, when fossa is
  visualized, blade tip is moved to midline
• Advancing blade behind the base of tongue,
  elevating it, epiglottis comes into view
• From here two different techniques for curved and
  straight blades

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For Curved Blade

• Blade is advanced until blade tip fits into the
  vallecula
• Traction applied along the axis of the handle
  moves the base of tongue epiglottis forward and
  glottis comes into view

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For Straight Blade

• Blade is advanced
• Epiglottis identified
• The blade tip is passed posterior to epiglottis
• Blade is lifted anteriorly elevating the
  epiglottis directly and glottis comes into view

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Contd.

• Traction force (upward lifting force) should be
  along the laryngoscope handle approx 25-40
  Newtons
• In difficult laryngoscopy it can be upto 50-70
  Newtons
• Never use the blade as lever and teeth as
  fulcrum, this can lead to damage to maxillary
  teeth

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Contd.

• Infants Neonates have-
• Large head, large tongue, small oral cavity and
  mandibular angle 140 deg
• Epiglottis narrow, floppy, long, U shaped, angled
  backwards at 45 deg to tracheal axis
• Larynx at C3-C4 level, forms acute angle with
  base of tongue, difficult to see

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Contd.

• Straight (Miller) blade designed to pass beyond
  the large floppy epiglottis and elevate it
  directly,
• This is known as Jackson Position

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Maneuvers to improve laryngoscopic view

• Sometimes larynx is not visualized even after
  correct technique, then
• BURP Maneuver - external Backward,
• 
  Upward
• 
  Rightward
• 
  Pressure (BURP)
• on the thyroid cartilage may improve
  visualization of the glottis
• OELM (Optimum External Laryngeal Manipulation)

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Few Specific Blades
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Magills Blade (1926)

• Blade is U shaped in cross section
• Most commonly used in UK

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Oxford Infant Blade

• Straight tongue, curves slight up at tip
• U shaped at proximal end
• Bottom limb of U decreases towards tip
• Used primarily for newborns but can be used upto
  4 yrs, especially in extreme degree of cleft
  palate

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Polio Blade

• Blade is mounted at 135 deg to the handle
• Originally designed to facilitate intubation in
  patients in iron lung ventilators during polio
  epidemic
• Useful in
• Intubation in iron lung
• respirators or body jackets
• Obese
• Breast Hypertrophy
• Short Neck
• Restricted Neck Mobility

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Flexible Tip Blades (Mc-Coy)

• Hinged tip that is controlled by a lever
  attached to the proximal end of the blade
• When the lever is pushed toward the handle, the
  tip of the blade is flexed

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Wisconsin Blade

• Tongue has no curve
• Flange curved to form two thirds of a circle in
  cross section
• Flange depth narrow at proximal and wider in
  distal portion

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Mac Doshi Blade

• Modification of Macintosh
• Height of flange increased by 7 mm (new height 30
  mm) for better mouth opening and retraction of
  tongue
• Useful in
• Edentulous patients
• Double lumen tube placement
• Not useful in patient with buck teeth

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Robertshaw Blade

• Straight tongue with curve near tip
• Lift epiglottis directly
• Used for nasotracheal intubation
• Used in infants and children

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Left-handed Macintosh Blade

• Flange on opposite side
• Used for
• Abnormalities of right of face or oropharynx,
  left handed intubators, intubating in right
  lateral position, positioning tracheal tube
  directly on the left side of mouth

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English Macintosh

• Flange is curved and lower at the handle end
• Modified English macintosh
• Reduced flange to
• decrease pressure on
• maxillary incisors

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Alberts and Michaels Blades

• Cut away flange increase visibility
• Has a recess to facilitate ET tube insertion
• Albert 67 deg angle
• Michaels -93 deg angle with the handle
• Used for paeditric patient

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Oxiport Blades

• Modified Macintosh and Miller blade with a
  tube to deliver oxygen

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Tull (Suction) Blades

• Modified Macintosh and Miller blade with suction
  port near tip
• suction channel up to handle and has a
  finger-controlled valve to control the suction

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Fink Blade

• Wider tongue with sharper curve at distal end
• Height of flange reduced
• Light bulb more towards the distal end

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Bizzarri-Giuffrida Blade

• Flange is removed, except for a small part that
  encases light bulb
• Less chance to damage upper teeth
• Useful for patients with
• limited mouth opening
• prominent incisors
• receding mandible
• short, thick neck
• anterior larynx

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Upsher Low Profile Blade

• Low flange
• Fairly straight proximal section that leads to a
  tip with a significant curve
• Designed for insertion into a small mouth

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Mathews Blade

• Straight with a wide and flattened petalloid
  configuration at the tip
• Designed for difficult nasotracheal intubation

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Wis-Foregger Blade

• Tongue and flange straight
• Distal portion of blade is wider and formed
  slightly to right

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Wis-Hippel Blade

• Tongue straight
• Flange large and circular and runs parallel to
  tongue
• Tip wider
• Designed for use in infants

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Schapira Blade

• Straight blade with a tip that curves upward
• The vertical component is minimal

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Soper Blade

• Has a slot into the tip which prevent the
  epiglottis from slipping off the blade

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Heine Blade

• Straight
• Slight upward curve at tip
• Flat flange
• Useful in children with large tongue

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Snow Blade

• Hybrid blade with Miller tongue and Wis-Foregger
  flange
• Curved 1 inch from tip

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Flagg Blade

• Straight tongue
• C shaped flange that gradually decrease in size
  towards distal end

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Guedel Blade

• Straight blade with tongue at 72 deg with handle
• Flange U shaped
• Light is near the tip with an uptilt of 10 deg

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Bennett Blade

• Upper part of flange is omitted

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Eversol Blade

• Straight
• Flange, web and tongue form C near proximal end
• Upper flange tapers from midway to the tip

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Seward Blade

• Straight tongue with a curve near the tip
• Small reverse Z shaped flange
• Used in children lt 5 years
• Used for nasotracheal intubation

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Phillips Blade

• Straight, low flange, curved tip.
• Light bulb on left side

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Bainton Blade

• Straight tongue with distal 7 cm tubular
• Protects from obstruction by blood, secretion,
  intra oral mass
• Intraluminal light source
• For patients with right sided or circumferential
  pharyngeal lesions

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Double-angle (Choi) Blade

• Spatula has two angulations, 20 and 30 deg
• Spatula and tip form wide flat surface
• Flange eliminated so more room for tracheal tube
  insertion
• Bulb between two curvature.
• Used for patient with anterior larynx

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Blechman Blade

• Modification of macintosh blade
• Sharply angled tip to elevate the epiglottis
• Flange removed near the handle end of the blade

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Cranwall and Whitehead Blades

• Curved tip, reduced flange to decrease the
  potential for damage to upper teeth
• Useful for anaesthesia provider with limited use
  of left arm

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CW Blade

• Designed to be inserted and removed with
  horizontal flange almost parallel to teeth

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Viewmax Blade

• Optic side port on standard Macintosh blade that
  refracts image approx 20 deg
• Allows more anterior view from a position 1 cm
  behind left tip, while same time allowing
  standard direct view

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Belscope Blade

• Straight blade bent forward 45 deg near mid point
• A prism of transparent acrylic can be attached to
  blade proximal to angle
• Improved view of laynx can be obtained and less
  damage to teeth

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Prisms

• Attached to blade by using a clip
• A refraction is provided in the line of sight
• Huffman Prism

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Indirect Rigid Fiberoptic Laryngoscopes
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BULLARD LARYNGOSCOPE

• Rigid, metal, shaped to follow the contour of
  oropharynx and epiglottis

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Bullard Laryngoscope in use
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Bullard Laryngoscope

• Working channel extends from the scope body to
  the point where the light bundles end at the tip
• can be used for suction, oxygen insufflation,
  administration of local anesthetics or saline, or
  passage of an airway exchange or jet ventilation
  catheter
• Three sizes are available pediatric, pediatric
  long, and adult

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Contd

• Introducing (Intubating) Stylet
• To facilitate passage of the tracheal tube into
  the laryngeal inlet
• Multifunctional stylet
• Hollow core can serve as a guide for a flexible
  fiberscope, tracheal tube exchanger,
  intratracheal catheter or small catheter
• Used to instill local anesthetic into the trachea

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Advantages

• Difficult, life-threatening conditions such as
• Cervical spine fracture
• Upper body burns
• Trauma
• Patients with TMJ immobility
• Congenital airway problems such Pierre Robins
  syndrome
• Rapidity of intubation
• Low risk of failed intubation or trauma to lips
  and teeth
• Less discomfort

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Disadvantages

• Requires experience and maintenance of skills
• Tracheal tube larger than 7.5 mm may cause the
  introducing stylet to be displaced posteriorly,
  which may make intubation more difficult.
• Intubation may take slightly longer time .

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WUSCOPE

• Combines rigid, tubular blade and flexible
  fiberscope.

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Blade Portion

• Three detachable metal parts handle, main blade,
  and bivalve element
• Main blade and bivalve element are anatomically
  shaped. When positioned together, they form two
  passage ways -
• a)a larger one for a suction
• catheter or tracheal tube
• B)a smaller one for the fiberscope
• An oxygen channel is alongside the slot for the
  fiberscope.

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Advantages

• Place both tracheal and double-lumen bronchial
  tubes in difficult-to-intubate patients.
• Tubular structure protects the fiberoptic lens
  from blood, secretions, and redundant soft tissue
  so useful in the patient with airway obstruction
• Handle-to-blade angle facilitates entry in obese
  patients and in those with barrel chests, short
  necks, or large breasts.

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UPSHER SCOPE

• Consists of a C-shaped metal blade, shaped to
  approximate the curve of the oropharynx

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UPSHER SCOPE

• Advantages
• To intubate patients with difficult airways
• Can be used with all sizes of adult tracheal
  tubes
• Disadvantage
• Not suitable for nasotracheal intubation
• Secretions can obscure the view
• Longer time needed to perform intubation

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Indirect Rigid Fiberscopy
Indications Contraindications
Predicted difficult intubation Blood and secretions in upper airway
Failed routine intubation Distorted upper airway anatomy
Unstable cervical spine, requiring minimal cervical movement Upper airway obstruction due to foreign body
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Indirect Rigid Fiberscopy
Advantages Disadvantages
In comparison to flexible fiberscopes these are sturdier Better control of soft tissue Allow for improved management of secretions More portable and lesser cost Can not be used in presence of blood and secretions Being made of non-malleable metal (Except Airtraq), can damage teeth or soft tissue
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Video Laryngoscopes

• New generation method of laryngoscopy and
  tracheal intubation
• Images from distal end of laryngoscope blade
  carried on to screen either
• Attached to handle (McGrath)
• Carried to it by optical cable (Glidescope,
  C-Mac, Trueview)

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Advantages of Video Laryngoscopes

• Provide superior visualization and magnified view
  of glottic structures
• Lesser mouth opening and neck extension needed
• Helpful in intubation of patients with difficult
  airway
• The operator and assistant can see the same view
  and coordinate better.
• Easy to learn and enhance laryngoscopy teaching
  to beginners

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Video Laryngoscopes

• Glidescope Video Laryngoscopes
• Mcgrath Video Laryngoscope
• Trueview PCD Laryngoscope
• Pentax Airway Scope
• Airtraq Optical Laryngoscope With Video
• C-Mac Video Laryngoscope
• Video Macintosh
• Angulated Video Intubation Laryngoscope
• Berci-Kaplan DCI video Laryngoscope system and
  TelePack endoscope

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GLIDE SCOPE

• It incorporates a high resolution digital
  camera, connected by a video cable to a high
  resolution LCD monitor.

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GLIDE SCOPE

• Steep 60-degree angulation, reduced overall
  thickness of 14 mm of its blade improves the view
  of the glottis
• Embedded anti-fogging mechanism
• Used for tracheal intubation to provide
  controlled mechanical ventilation
• For removal of foreign bodies from the airway
• Both anesthetized and awake patients with
  difficult airways
• Latest version Cobalt uses disposable blade

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McGrath Videolaryngoscope

• Videoscope with built in screen
• Blade design similar to Glidescope
• Plastic sheath for blade
• Blade adjustable

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McGrath Video Laryngoscope

• Only laryngoscope with a feature of variable
  length blade
• Optical polymer-made single use blade is mounted
  as a sleeve over the CameraStick
• This blade can be adjusted to give variable
  length for use from children gt5yrs to large
  adults
• Depth of blade 13mm easy for patients with
  limited mouth opening
• Low cost, single use blade less cross
  infection, reduced sterilization time and cost

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TRUEVIEW PCD LARYNGOSCOPE
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TRUEVIEW PCD LARYNGOSCOPE

• Functions both as optical and video laryngoscope
• Can be attached to any other monitor with a CCD
  camera head
• Provide a clear enlarged view that enhance ease
  of tracheal intubation
• Oxygen flow via a side channel on handle provides
  continuous oxygenation delays desaturation and
  prevents fogging of lens and clear secretions in
  its path
• 5 blade sizes from neonate to large adults
• For patients with collar in place, limited mouth
  opening, micrognathia

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PENTAX AIRWAY SCOPE

• Consists of disposable transparent blade, 12 cm
  cable with a charged coupled device (CCD) and 2.4
  inch LCD
• Blade has channel for suction/oxygenation, cable
• Blade is anatomically shaped and tube is
  premounted on it and CCD camera is 3 cm proximal
  from tip of blade
• Provide good view of glottis and adjacent
  structures

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PENTAX AIRWAY SCOPE
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AIRTRAQ Video Laryngoscope
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AIRTRAQ Optical Laryngoscope

• Consists a curved blade with 2 channels
• One channel anatomically shaped and appropriate
  size tube can be pre mounted on it
• Other channel contains series of lenses, prisms
  and mirrors that transfer image from illuminated
  tip to a proximal viewfinder
• Good quality view of glottis, adjacent structures
  and tip of ET tube without need of aligning 3
  airway axes (Oral, Pharyngeal, Tracheal)
• Do not obstruct view of vocal cords during act of
  laryngoscopy
• Can be used for routine and difficult airways
  both

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C-Mac Video Laryngoscope

• Clear image, without fogging
• Record still images video sequences on SD
  memory card
• Blade flattened round edges so useful in case
  of reduced oral aperture and less damage to teeth
  soft tissue
• No need of stylet

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Angulated Video-intubation Laryngoscope

• Plastic blade with a 25 deg angulated tip
• Vertical flange is flattened
• A channel leads from handle to blade tip for
  fiberscope insertion
• Useful in children requiring manual in-line neck
  stabilization

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VIDEO MACINTOSH

• A Macintosh blade attached to the handle and the
  image-light bundle threaded through a small metal
  guide in the blade and advanced two thirds of the
  length of the blade

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Berci-Kaplan DCI video Laryngoscope System
TelePack Endoscope

• MAC 34, Miller 0-4, and Dorges laryngoscope
  blades, handle with integrated, interchangeable
  video camera and control unit with LCD screen,
  and xenon light source
• Excellent visualization and video documentation
• No requirement of sniffing position of head
• Useful for anterior airways and patients with
  limited neck extension
• Can be used for nasal intubation and change of ET
  tubes

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Flexible Fiberoptic Endoscope

• Light source-
• Handle with batteries
• Separate light source
• Handle-
• Houses batteries
• Eyepiece, focusing ring,
• Working channel port,
• Tip control lever
• Insertion cord-
• Image-conducting Bundle
• Light-conducting Bundle
• Working channel
• Tip Flexion Cables

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Flexible Fiberoptic Endoscope

• Used to-
• Place and evaluate placement of tracheal,
  double-lumen, tracheostomy, and gastric tubes and
  bronchial blockers
• Check tube patency, evaluate airway,
• Locate and remove secretions

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Advantages

• Laryngoscopic intubation can be done via nasal
  route also
• Neck extension and mouth opening not necessary
• Anatomical variations can be overcome
• Topical / regional anaesthesia is adequate in the
  awake patient
• Good view of the glottis, larynx, trachea and
  bronchi

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Disadvantages

• Delicate instrument and needs extra care
• High cost
• Takes a little time and practice to learn
• Tissue oedema and blood can obscure vision
• Cleaning / sterilization takes time

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Cleaning Of Rigid Laryngoscope

• Remove batteries, clean the handle with water and
  detergent then with alcohol
• Handle can be sterilized by using steam, plasma
  or gas (ETO)
• Rinse blade with water and enzymatic detergent
  using a soft brush
• Blade can be sterilized by ETO, steam, plasma or
  liquid chemical
• Disposable covers for handle and blades available
• Disposable handles and blades also available

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Cleaning Of Flexible Endoscope

• Best to decontaminate in an endoscopic unit
• Exterior should be wiped with a disinfectant
• All channels should be flushed with water and
  enzymatic detergent
• After leak testing, fiberscope immersed in
  enzymatic detergent solution (2-5 minutes)
• Special cleaning device inserted into channels to
  clean them
• Rinse fiberscope and all channels with water and
  lastly with alcohol
• Hang the endoscope to allow any remaining fluid
  to drain out of insertion tube

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Complications

• Common General
• Dental injury
• Minor bleeding
• Lip, gum, or tongue trauma
• Common Cardiovascular Consequences
• Tachycardia
• Hypertension

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Complications

• Uncommon General
• Eye trauma/Corneal abrasion
• Major bleeding
• Airway edema
• Temporomandibular joint dislocation
• Vocal cord paralysis
• Laryngospasm
• Bronchospasm
• Hypoxemia
• Esophageal intubation (if undetected)
• Endobronchial intubation

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Complications

• Uncommon Cardiovascular Consequences
• Bradycardia (particularly in children)
• Myocardial ischemia
• Rare
• Esophageal perforation from malpositioned ET tube
• Arytenoid dislocation
• Aspiration
• Cervical spine injury
• Tracheal perforation
• Elevated intracranial pressurre

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Referances -

• Understanding Anesthesia Equipments by Dorsch and
  Dorsch Fifth Edition
• Airway Management by Rashid M Khan
• Fourth Edition
• www.frca.co.uk (Anaesthesia UK)

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