Journal of Clinical Anesthesia (2015) xx, xxx–xxx
Correspondence Failed airway management with the GlideScope: it is not the same tool in infants To the Editor: Video laryngoscopy is purported as the new criterion standard for airway management and intubation of trauma patients, and this standard is being adopted by many emergency departments [1]. Video laryngoscopy is recommended as the primary intubating device for adult patients with predicted difficult airways in the emergency department [2]. A recent study of pulmonary critical care fellows showed that video laryngoscopy improved intubation success and decreased complications compared to direct laryngoscopy [3]. Studies such as these are leading pediatric emergency physicians, pediatric intensivists, and neonatal intensivists to use video laryngoscopy more frequently. We report at our institution 4 cases in which infants younger than 1 year were managed with the GlideScope (Bothwell, WA) and suffered airway complications. In 3 of the cases, the airway was easily managed with direct laryngoscopy. A 2-day-old neonate required intubation in the neonatal intensive care unit for respiratory distress. Multiple unsuccessful intubation attempts were made with the GlideScope, and the patient suffered intermittent oxygen desaturation between attempts. The pediatric anesthesia attending physician was called, and the airway was secured easily using conventional direct laryngoscopy. A 4-month-old with microcephaly and epilepsy developed increasing stridor in the pediatric intensive care unit. A single attempt at direct laryngoscopy was unsuccessful by an anesthesia resident. Multiple attempts by the resident to secure the airway with the GlideScope failed. The patient suffered significant oxygen desaturation and bradycardia between attempts requiring epinephrine. An otolaryngology resident was easily able to secure the airway with conventional direct laryngoscopy. A 9-month-old infant suffered near drowning and was brought by emergency medical services to a community hospital. A single attempt at direct laryngoscopy was unsuccessful by the local emergency physician. Our tertiary care transport team arrived, and the emergency medicine physician attempted twice to secure the airway with the GlideScopse. On the first attempt, the wrong size blade was used with an inadequate view. On the second attempt, an adequate view was obtained, but the physician could not pass the endotracheal tube. The patient 0952-8180/© 2015 Elsevier Inc. All rights reserved.
then vomited causing difficult ventilation and oxygen desaturation. A 1.5 classic laryngeal mask airway was placed without improved air movement. A third intubation attempt with the GlideScope was successful. A 3-month-old infant presented to the operating room (OR) for a Nissen fundoplication. First and second attempts at intubation with direct laryngoscopy were unsuccessful by an anesthetist. The third and fourth attempts with direct laryngoscopy were unsuccessful by an attending anesthesiologist. The fifth and sixth attempts at laryngoscopy with the GlideScope failed at which time the mask airway was lost. Oxygen desaturation and bradycardia ensued, and cardiopulmonary resuscitation was initiated. A final seventh attempt at direct laryngoscopy by a second pediatric anesthesiologist was successful. This patient returned to the OR 1 week later, and the airway was easily managed with conventional direct laryngoscopy. The skill of video laryngoscopy is different in pediatric patients compared to adults. This difference appears to be magnified in the infant population younger than 1 year and less than 10 kg. A recent study showed that the use of video laryngoscopy in pediatric patients improved the laryngoscopic view, but the authors do not comment on success of intubation with that view [4]. One of the drawbacks of the pediatric GlideScope is the lack of a preformed stylet. It is challenging to use a standard stylet to shape the endotracheal tube in a position that it will hold its shape and easily pass through the glottis when using video laryngoscopy. For this reason, it is common in pediatric patients to achieve an adequate laryngeal view with the GlideScope but struggle to pass the endotracheal tube. A large study of pediatric patients compared the GlideScope to conventional direct laryngoscopy. The autors found that the time to best view was faster with the GlideScope but the time to intubation was slower, and overall, there was no difference in intubation times comparing video laryngoscopy to direct laryngoscopy [5]. In this study, airway management was performed by experienced pediatric anesthesiologists. Inexperienced providers may also use the wrong size blade. The appropriate size GlideScope blade is larger than the corresponding size straight blade. A Miller 1 blade would correspond to the GlideScope 2 curved blade for a 10-kg infant. Caution should be taken using GlideScope video laryngoscopy for airway management outside the OR in infants. In our experience, failed video laryngoscopy attempts by nonpediatric anesthesia providers can often be managed successfully with conventional direct laryngoscopy.
2 Bridget L. Muldowney MD (Assistant Professor)⁎ Lianne L. Stephenson MD (Assistant Professor) Lana M. Volz MD (Assistant Professor) Guelay Bilen-Rosas MD (Assistant Professor) Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison WI 53792 ⁎ Corresponding author. Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health B6/319, 3272 CSC, 600 Highland Ave, Madison WI 53792 Tel.: +1 608 263 8100; fax: +1 608 263 0575 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2015.03.029
Correspondence
References [1] Michalidou M, O’Keeffe T, Mosier JM, Friese RS, Joseph B, Rhee P, et al. A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients. World J Surg 2015;39(3):782-8. [2] Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Intern Emerg Med 2014;9(1):93-8. [3] Kory P, Guevarra K, Mathew JP, Hedge A, Mayo PH. The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill. Anesth Analg 2013;117(1):144-9. [4] Lee JH, Park YH, Byon HJ, Han WK, Kim HS, Kim CS, et al. A comparative trial of the GlideScope® video laryngoscope to direct laryngoscope in children with difficult direct laryngoscopy and an evaluation of the effect of blade size. Anesth Analg 2013;117(1):176-81. [5] Fiadjoe JE, Gurnaney H, Dalesio N, Sussman BA, Zhao H, Zhang X, et al. A prospective randomized equivalence trial of the GlideScope Cobalt ® video laryngoscope to traditional direct laryngoscopy in neonates and infants. Anesthesiology 2012;116(3):622-8.
Correspondence Failed airway management with the GlideScope: it is not the same tool in infants To the Editor: Video laryngoscopy is purported as the new criterion standard for airway management and intubation of trauma patients, and this standard is being adopted by many emergency departments [1]. Video laryngoscopy is recommended as the primary intubating device for adult patients with predicted difficult airways in the emergency department [2]. A recent study of pulmonary critical care fellows showed that video laryngoscopy improved intubation success and decreased complications compared to direct laryngoscopy [3]. Studies such as these are leading pediatric emergency physicians, pediatric intensivists, and neonatal intensivists to use video laryngoscopy more frequently. We report at our institution 4 cases in which infants younger than 1 year were managed with the GlideScope (Bothwell, WA) and suffered airway complications. In 3 of the cases, the airway was easily managed with direct laryngoscopy. A 2-day-old neonate required intubation in the neonatal intensive care unit for respiratory distress. Multiple unsuccessful intubation attempts were made with the GlideScope, and the patient suffered intermittent oxygen desaturation between attempts. The pediatric anesthesia attending physician was called, and the airway was secured easily using conventional direct laryngoscopy. A 4-month-old with microcephaly and epilepsy developed increasing stridor in the pediatric intensive care unit. A single attempt at direct laryngoscopy was unsuccessful by an anesthesia resident. Multiple attempts by the resident to secure the airway with the GlideScope failed. The patient suffered significant oxygen desaturation and bradycardia between attempts requiring epinephrine. An otolaryngology resident was easily able to secure the airway with conventional direct laryngoscopy. A 9-month-old infant suffered near drowning and was brought by emergency medical services to a community hospital. A single attempt at direct laryngoscopy was unsuccessful by the local emergency physician. Our tertiary care transport team arrived, and the emergency medicine physician attempted twice to secure the airway with the GlideScopse. On the first attempt, the wrong size blade was used with an inadequate view. On the second attempt, an adequate view was obtained, but the physician could not pass the endotracheal tube. The patient 0952-8180/© 2015 Elsevier Inc. All rights reserved.
then vomited causing difficult ventilation and oxygen desaturation. A 1.5 classic laryngeal mask airway was placed without improved air movement. A third intubation attempt with the GlideScope was successful. A 3-month-old infant presented to the operating room (OR) for a Nissen fundoplication. First and second attempts at intubation with direct laryngoscopy were unsuccessful by an anesthetist. The third and fourth attempts with direct laryngoscopy were unsuccessful by an attending anesthesiologist. The fifth and sixth attempts at laryngoscopy with the GlideScope failed at which time the mask airway was lost. Oxygen desaturation and bradycardia ensued, and cardiopulmonary resuscitation was initiated. A final seventh attempt at direct laryngoscopy by a second pediatric anesthesiologist was successful. This patient returned to the OR 1 week later, and the airway was easily managed with conventional direct laryngoscopy. The skill of video laryngoscopy is different in pediatric patients compared to adults. This difference appears to be magnified in the infant population younger than 1 year and less than 10 kg. A recent study showed that the use of video laryngoscopy in pediatric patients improved the laryngoscopic view, but the authors do not comment on success of intubation with that view [4]. One of the drawbacks of the pediatric GlideScope is the lack of a preformed stylet. It is challenging to use a standard stylet to shape the endotracheal tube in a position that it will hold its shape and easily pass through the glottis when using video laryngoscopy. For this reason, it is common in pediatric patients to achieve an adequate laryngeal view with the GlideScope but struggle to pass the endotracheal tube. A large study of pediatric patients compared the GlideScope to conventional direct laryngoscopy. The autors found that the time to best view was faster with the GlideScope but the time to intubation was slower, and overall, there was no difference in intubation times comparing video laryngoscopy to direct laryngoscopy [5]. In this study, airway management was performed by experienced pediatric anesthesiologists. Inexperienced providers may also use the wrong size blade. The appropriate size GlideScope blade is larger than the corresponding size straight blade. A Miller 1 blade would correspond to the GlideScope 2 curved blade for a 10-kg infant. Caution should be taken using GlideScope video laryngoscopy for airway management outside the OR in infants. In our experience, failed video laryngoscopy attempts by nonpediatric anesthesia providers can often be managed successfully with conventional direct laryngoscopy.
2 Bridget L. Muldowney MD (Assistant Professor)⁎ Lianne L. Stephenson MD (Assistant Professor) Lana M. Volz MD (Assistant Professor) Guelay Bilen-Rosas MD (Assistant Professor) Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison WI 53792 ⁎ Corresponding author. Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health B6/319, 3272 CSC, 600 Highland Ave, Madison WI 53792 Tel.: +1 608 263 8100; fax: +1 608 263 0575 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2015.03.029
Correspondence
References [1] Michalidou M, O’Keeffe T, Mosier JM, Friese RS, Joseph B, Rhee P, et al. A comparison of video laryngoscopy to direct laryngoscopy for the emergency intubation of trauma patients. World J Surg 2015;39(3):782-8. [2] Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Intern Emerg Med 2014;9(1):93-8. [3] Kory P, Guevarra K, Mathew JP, Hedge A, Mayo PH. The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill. Anesth Analg 2013;117(1):144-9. [4] Lee JH, Park YH, Byon HJ, Han WK, Kim HS, Kim CS, et al. A comparative trial of the GlideScope® video laryngoscope to direct laryngoscope in children with difficult direct laryngoscopy and an evaluation of the effect of blade size. Anesth Analg 2013;117(1):176-81. [5] Fiadjoe JE, Gurnaney H, Dalesio N, Sussman BA, Zhao H, Zhang X, et al. A prospective randomized equivalence trial of the GlideScope Cobalt ® video laryngoscope to traditional direct laryngoscopy in neonates and infants. Anesthesiology 2012;116(3):622-8.
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