types of VL and its uses

1. VIDEOLARYNGOSCOPES FOR
TRACHEAL INTUBATION
ZIKRULLAH

2. Introduction
Advantages & Disadvantages
Videolaryngoscopy over Direct laryngoscopy
Characterstics of ideal Videolaryngoscopes
VL aided tracheal intubation
Classification and Description of
videolaryngoscopes
Summary
CONTENTS

3. Endotracheal intubation is a medical
procedure in which a tube is placed into the
trachea through mouth or nose.
Endotracheal intubation remains a
specialized learned skill and difficult
endotracheal intubation remains an
important adverse event.
INTRODUCTION

4. Enhanced visualization of the airway has
been accomplished with the adaptation of
fiberoptic bronchoscopes for this purpose.
But, the skill of fiberoptic intubation is
difficult to learn, and the scopes are
expensive to maintain.
INTRODUCTION

5. Recently, the development of less expensive,
smaller, and more reliable video cameras has
revolutionized the design of laryngoscopes and
the process of endotracheal intubation.

6. What is a Videolaryngoscope (VL)
It is an Indirect laryngoscope
consist of a handle and laryngoscope
blade
micro video-chip camera embedded into the
end of the blade.
An external monitor; liquid crystal display
(LCD) through a video system.

9. ADVANTAGES:
Eye and airway need not line up.
Better view when mouth opening or neck
mobility is limited.
Others can see and help.
Permits sharing of medical information among
the team.
Generally higher success rate, especially in
difficult situations.

10. DISADVANTAGES:
Variable learning curves; may take longer
to intubate.
Passage of tube may be difficult despite
great view; stylet often necessary
Fogging and secretions may obscure view

11. Loss of depth perception.
More complicated.
Expensive; to possess and to mantain

12. VL Over DL:
Patient related factors: such as
-limited mouth opening
-limited neck mobility
-obesity
-craniofacial
-chest wall abnormalities
can prevent
visualization

13. VL Over DL:
Patient’s position:
-within a traction device
-within radiologic equipment
-entrapped within a vehicle
prevents
adequate
visualization

14. Teaching purpose: Video laryngoscopy
provides a shared view for the teacher
and student.
Video output can be streamed through a
video conferencing or Internet link. This
makes distance learning and consultation
possible.
VL Over DL:

15. The better laryngoscopic view generally provided
by video techniques may improve the likelihood
of success for inexperienced operators.
By using a video technique, information
concerning the patient’s anatomy and any
difficulty that the operator is experiencing may be
easily evident → Assistant may help.

16. CONCLUSION:
• Overall success rate in unselected cases
between 94 – 100 %
• Improvement in grading CL
• VL as first choice in patients with higher
risks of Difficult DL (CL ≥ 3)
• VL as a rescue device in patients following
failed intubation with DL

17. CHARACTERSTIC OF IDEAL VL’s:
Should be intuitive to the operator and easy to
learn and teach.
The device should be adaptable for different
types of endotracheal intubations-
-oral or nasal
-both adults and children
-should permit the use of special-purpose
tubes such as double-lumen tubes.

18. The laryngoscope should be inexpensive.
The laryngoscope should be lightweight,
handy, and easy to maneuver.
Should have success in unusual locations in
the field, during transport, and on hospital
floors.

19. Anti-fog capability: Even the greatest camera
may be rendered useless if condensation is
present on the lens.
A long-lasting rechargeable battery with an
alternative alternating-current (AC) power
source is important.
Image storage capacity: can be used for
review, quality assurance and teaching.

20. Advantage over fiberoptic bronchoscopy
(FB)
Railroading of the endotracheal tube over
the fiberscope remains a “blind technique”
and may result in injury to laryngeal
structures due to impingement of tube

21. Limitations of VL over FB
Cannot be introduced through nose or tracheostomy
Cannot be used in patients with complete trismus or
wired jaw.
Not helpful in confirming the placement of a double
lumen tube, bronchial blocker or performing
pulmonary toilet.

22. VIDEO LARYNGOSCOPE
AIDED TRACHEAL
INTUBATION: THE 4 STEPS

23. Look Into The Pt’s Mouth→
insert the layrngoscope into
the mouth and gently advance
towards the root of tongue
STEP 1

24. Look at the Screen→
Optimise the position
of the layrngoscope to
get the best glottic
view
STEP 2

25. Back To Looking In Mouth→ETT
is inserted gently upto the tip of
laryngoscoe avoiding injury to
tonsils or soft palate
STEP 3

26. Sight back to the Screen→
ETT directed toward the
glottis and between the
vocal cords(gently rotate or
redirect)
STEP 4

29. CLASSIFICATION OF
VIDEOLARYNGOSCOPES

31. GLIDESCOPE
(Verathon, Bothell, Washington)

32. Blade: 13 mm thick & curved to a
60° angle to match anatomical
alignment.
CMOS camera, an LED light source,
anti-fogging mechanism and a
separate view screen.
Size ranging from 2,3,4,5 from
paediatric to adult and morbidly
obese.

33.  Stroumpoulis and colleagues performed direct
laryngoscopy followed by laryngoscopy with the
GlideScope in 112 patients with predicted difficult
intubation. The percentage of Cormack grade 1 and 2
views increased from 63% to 90% with the GlideScope,
and intubation was successful in 98% of cases.
 Nakstad and Sandberg examined the use of the
GlideScope Ranger during intubations of a simulated
entrapped patient.
 In this study, 8 anesthesiologists intubated a manikin with
access only to the caudal end of the head. While only half
could successfully accomplish the intubation with a
Macintosh, all could secure the airway within 60 seconds
using the GlideScope.

34. McGRATH

35. Portabile, easy to setup, lack
of wires and cables.
An 1.7” LCD screen is mounted
atop the handle of the
laryngoscope to display the
image. Screen angle is
adjustable
An adjustable Camera Stick

36. A low cost single-use, 13mm
thick, polycarbonate blade cover
can be placed over the
CameraStick
 Powered by a single rechargible
1.5V AA battery(2hr) or a
standard alkaline battery in
handle(1hr)

37. O’Leary and co-workers reported successful
endotracheal intubation with the McGrath in 30
instances in which traditional laryngoscopy had
failed
In inexperienced hands, however, Walker and
colleagues concluded that the McGrath offered no
advantage to traditional laryngoscopy, and they
found the intubation time longer than with direct
laryngoscopy (median 47 s vs 30 s).

38. TRUVIEW

39. Truview comes with 5 blade sizes: neonate to
large adult
Side channel for oxygen: prevents fogging and
provides apneic oxygenation.

40. Distal lens on optical view
tube is a prism
Permits visualization of
structures 47⁰
anterior(useful for
anterior larynx)
Can be used as optical
laryngoscope or as
videolaryngoscope

41. PENTAX AWS

42. Portable, 2AA Battery operated, Waterproof
2.4-inch color LCD view screen and CCD camera
Clear plastic disposable guide channel blade(135⁰
angle) that snaps onto the device

43. A target symbol on the monitor shows the
intended path of the ETT

45. AIRTRAQ
(Prodol Meditec S.A, Vizcaya, Spain)

46. The Airtraq is a single-use optical device with a 60
min battery life.
Different sizes are available for various ETT sizes,
pediatric, nasotracheal, and double-lumen
endobronchial intubations.
A 30–45-second warm-up time is necessary to
reduce fogging.
A video camera can attach to the optical lens to
permit viewing on an external monitor or
recording.

48. Tuna Erturk et al (2015) concluded that in cases with
seemingly difficult intubations, the Airtraq laryngoscope
has an advantage over the Macintosh laryngoscope, owing
to its better view of the oropharyngeal and glottic areas &
is helpful in facilitating intubation in patients with limited
head extension.
Gómez-Ríos MÁ et al (2016) evaluated the advantages of
the Airtraq device with accessory technology innovation-
“Airtraq video laryngoscope” by four experienced
anesthesiologists and were asked to state their
preference. The anesthesiologist showed their
preference for AVL and they found that this innovation
offers several benefits in contrast to direct vision via the
eyepiece.

49. KING VISION

50. Portable, Durable and Reusable
video display.
Powered by Standard AAA size batteries that
lasts for ̴90 min.
The LED light and CMOS camera( resolution=
640 x 480 VGA)
Monitor: 6.1cm / 2.4" diagonal; anti-
reflective coating on display window

51. Blades: Disposable,
Affordable,
Size #3, non channeled /
standard (13mm) &
channeled(18mm);
The LED light and CMOS
camera are mounted on the
disposable blades.

52. Murphy LD et al (2014) concluded that there was a
lower Cormack-Lehane grade and higher
percentage of glottic opening with the KVL
compared to MAC.
Akihisa Y et al in 2014 concluded that the KVC but
not the KVNC, could be used as an alternative
device for intubation by novice personnel.

53. C-MAC

54. The C-Mac laryngoscope has a dedicated 7-
inch portable external monitor to display a
high-resolution image (800*480) with an 80°
angle of view
The camera’s electronics are incorporated
into the handle of the laryngoscope, with the
image acquired by a CMOS chip incorporated
into the blade along with an LED light source.

55. Sizes 2, 3, and 4 reusable Macintosh blades are
available. Sterile processing of the reusable
blade is required after use.
Angulated blade is available only in size 4
which is called C-Mac “D” Blade.
Powered by a rechargeable battery that
permits ̴2 hours of continuous operation. The
system can be used while recharging on AC.
Images can be recorded in JPEG or MPEG4
format.

56.  Images of c-mac

57. Turkey 2014
Comparison of glottic view
Conclusion:
C-Mac VL is efficient and safe as a primary rescue device in
unexpected failed intubations

58. STORZ BERCI-KAPLAN DCI

59. The Berci-Kaplan DCI (V-MAC) is compatible with
other Storz endoscopic video imaging systems.
 Miller and Macintosh blades in pediatric and
adult sizes are available.
Sterile processing of the blade is necessary after
use.
The camera’s electronics are incorporated into the
handle of the laryngoscope. The angle of view is
60°. A high resolution (15,000 pixel) image is
viewed on an external monitor, which simplifies
shared viewing and teaching

60. In pediatric patients, Vlatten and colleagues
compared the use of the DCI laryngoscope to
standard laryngoscopy using a Miller 1 or
Macintosh 2 blade in children <4 years old.
Video laryngoscopy provided a better view of
the glottis, but intubation time was
longer.Macnair and colleagues published
similar results.

61. COOPDECH C-SCOPE

62. Resembles a traditional battery-powered
laryngoscope with an attached 3.5-inch view
screen on its handle.
The view screen has an external videoout
port.
Contains the LED light source and CCD
camera unit that attaches to a reusable
blade.

63.  Only video laryngoscope with Miller,
Macintosh, Bullard and J-shaped blades.
Sizes 2, 3, and 4 Macintosh and sizes 0 and 1
Miller blades are available.
Powered by rechargeable lithium-ion
battery, ̴60 min. The unit can also be run on
AC power via a dedicated charger.

64. VIDEOSTYLET

65. Stylets are rigid or semi-rigid
rods that carry both light and
video bundles.
Lightweight, cost effective and
highly portable video-assisted
intubation stylet.
Video stylet has two detachable
parts:
-Display module: 2.4 inches color
TFT LCD
-Stylet module: with a light
source

66. Advantageous for oral endotracheal
intubation when mouth opening is
limited.
Require a substantial learning curve
and the optics may be subject to
secretions and fogging

67. OTHERS
The Bonfils
Intubating Stylet
The Clarus Video
Stylet
The Video RIFL (Rigid And
Flexing Laryngoscope

68. DIFFICULT
VIDEOLARYNGOSCOPY:
CRITERIA

69. All predictors present till date are for
conventional rigid laryngoscopy.
Those pertaining to videolaryngoscopy may
include:
-Altered neck anatomy
-Presence of surgical scar
-Radiation changes,
-Oropharyngeal or neck mass
-Mouth opening <1.5cm
-Reduced thyromental distance.

70. COMPLICATIONS OF VL

71. ƒ“Time to intubation” is significantly longer with VL.
May cause prolonged apnea time
Prolonged apnea with a VL may cause hypoxia in
patients with reduced oxygen store, such as obese
patients, obstetric women
Difficulty during insertion of the tracheal tube may
result in injuries to the soft palate, oropharynx, and
tonsils
There is possibility of endotracheal tube impingement
at the vocal cords or luminal surface of the anterior
tracheal wall. This can often be overcome by rotating
the tube at 180° after withdrawing the stylet.

72. SUMMARY

73. Video techniques are quickly replacing direct
laryngoscopy in many practices, especially
when teaching novices or when difficult
intubation is anticipated.
Each model of video laryngoscope has its own
unique strengths, weaknesses, and best
applications.
No one model appears uniformly superior to
another, and none is 100% successful.

74. Those instruments that appear familiar and
intuitive to the experienced user, may be
more easily accepted into clinical practice.
Video techniques are continuously evolving
and is likely that it will continue to evolve.