laryngoscope class by Dr Sandeep Singh Jadon ppt.pptx

Laryngoscope full details class for Anaethesia notes

1. LARYNGOCOPE Dr Sandeep Singh Jadon MBBS MD Anaesthesiology Gajraraja Medical College Gwalior

2. INTRODUCTION A device used to visualise the larynx and adjacent structures – mainly for inserting a tube into the tracheobronchial tree

3. HISTORY The first laryngoscope was invented by Manuel Garcia in 1854 Alfred Kirsten developed direct vision laryngoscope in 1895 Later popularised by Sir Robert Macintosh and Sir Ivan Magill in early 1940

4. LARYNGOSCOPY A procedure in which the larynx is visualized Useful for diagnostic , therapeutic and intubation purposed by various specialists

5. View of larynx

6. USES Endotracheal intubation Insertion of Nasogastric tube and trans oesophageal echo cardiac probe Foreign body removal Upper airway lesion biopsy visualising and assessing upper airway ( vocal cords and larynx)

7. TYPES OF LARYNGOSCOPES Direct Rigid Laryngoscopes Indirect Rigid Laryngoscopes which uses Fiber optic, prisms, mirrors etc. Video laryngoscopes– rigid and flexible Flexible Fiber optic Endoscopes

8. DIRECT RIGID LARYNGOSCOPE Dominant modality since 1940s Advantage: quick to use, economical, rugged, universally available Disadvantage: alignment of visual, oral and pharyngeal axis is needed

9. PARTS OF LAYNGOSCOPE Handle Blade - Hook on( hinged,folding ) connection between handle and blade Base Heel Tongue(Spatula) Flange Web Tip(beak) Light source bulb

10. HANDLE Held in hand during use Provides the power for light Accepts blade that have a light bulb to have a metallic contact, which completes the circuit when the handle and blade are in working position Handles containing batteries or using fiber optic illumination, contain a halogen lamp bulb Available in several sizes , and have a rough surface for grip

11. SHORT HANDLE: Used when: Chest or breast tissue contact the hand during use Cricoid pressure is being applied

12. Patil –Syracuse Handle Can be positioned and locked in four different positioned

13. Blade

14. Blade Base: Attaches to handle Slot for engaging the hinge pin of the handle End of the base is called the heel Tongue: is the main shaft Compress and manipulate the soft tissues ( esp the tongue) and lower jaw

15. Blade Flange: Projects off the side of the tongue and is connected to the tongue by web Guide instrumentation and deflect tissues from the line of vision Determines the cross-sectional shape of the blade Tip: Contacts either the epiglottis or the vallecula and directly or indirectly elevates the epiglottis Tip is thickened &transversely beaded to minimise mucosal damage

16. 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 ant. To the epiglottis lifting it out of the visual pathway Sizes ranges from 1-4, The no.4 blade may be more useful than no.3 in normal and large sized adults

17. MACINTOSH(CURVED)

18. MACINTOSH(CURVED)

19. MODIFICATIONS OF MACINTOSH Left handed Macintosh Blade English Macintosh Polio Blade Improved Vision Macintosh Blade Oxiport Macintosh(Mac/Port) Tull Macintosh Fink Blade Bizzari-Giuffrida Blade Upscher Low Profile Blade Blechman Blade Flexible-tip Blade

20. MILLER(STRAIGHT) The tongue is straight with a slight upward curve near the tip The flange , web, and tongue form C with the top flattened It is positioned posterior to the epiglottis, trapping it while exposing the vocal cords and glottis Size ranges from 0-4

21. MILLER BLADE

22. Modification of MILLER Blade Oxiport Miller Blade Tull Miller Blade Mathews Blade Winconsin Blade Wis-Hipple Blade Schapira Blade Alberts Blade Michaels Blade Soper Blade Heine Blade Snow Blade Flagg Blade Guedel Blade Robertshaw Blade Oxford infant Blade Bianton Blade Double- angle Blade Belscope Blade Cranwall Blade CW Blade Flexible –tip Blade Racz -Allen Blade

23. SIZES OF BLADES FOR PEDIATRIC PATIENTS CHILD’S WEIGHT(KG) LARYNGOSCOPE BLADE 0-3 Miller 3-5 Miller 0,1 5-12 Miller 1 12-20 Macintosh 2, 20-30 Macintosh 2, Miller 2 >30 Macintosh 2, Miller 2

24. Preparation for Laryngoscopy Arrange proper functioning equipment- Suction –central, mobile, manual Oxygen- low and high flows Airway equipments - Laryngoscope, ET tube, airway, stylet , reservoir or self inflating bag Patient position- sniffing Monitor –pulse oximeter , Ecg Esophageal detection device- capnograph , CO2 detector device Height of operating table at the level of laryngoscopist’s navel Never crouch or be too close to the patient

25. Techniques of Laryngoscopy Position : Optimal sniffing position 25-35 degree flexion of lower cervical spine and 85-90 degree head extension at atlanto - occipital joint using pillow of 8-10cm height under head. No head elevation required in children in children <8yrs, as the their large head circumference produces neck flexion as the head extended at a-o Joint

26. continued… 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 As half of blade enters the oral cavity sweeps 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

27. 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

28. For Straight Blade Blade is advanced Epiglottis identified The blade tip is passed post. to epiglottis Blade is lifted ant. e levating the epiglottis directly and glottis comes into view

29. Continued… Traction force (upward lifting force) should be along the laryngoscope handle & approx 25-40 Newtons In difficult laryngoscopy it can be upto 50-70 N Never use the blade as lever and teeth as fulcrum, this can lead to damage to maxillary teeth Infants and neonates: have large head ,tongue , small oral cavity; epiglottis narrow, floppy ,long, Ushaped , angled backwards at 45degree to tracheal axis; Larynx at C3-C4 level, forms acute angle with base of tongue, difficult to see. Therefore Straight( Miller) blade designed to pass beyond the large floppy epiglottis and elevate it directly, known as JACKSON Position

30. Manoeuvres to improve Laryngoscopic View Sometimes larynx is not visulaised even after correct technique, then BURP Manoeuver- external Backward, Upward, Rightward Pressure on thyroid cartilage may improve visualisation of glottis OLEM (Optimum External Laryngeal Manipulation)

31. Mc –Coy (flexible tip blades) 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 blade is flexed Some points : Tilting tip for elevation of epiglottis Increased view of larynx Less force required to intubate Unique design Less risk of trauma Ideal for difficult intubations

32. VIDEO LARYNGOSCOPES A new generation method of laryngoscopy and tracheal intubation. In this the images from distal end of the laryngoscope blade are carried on to the screen, which is either attached to the handle or carried to it by optical cable. There is superior visualisation of the glottic structures, A id in tracheal intubations with difficult airway Opertaor and assistant can see the same view and coordinate better A lso enhance laryngoscopy teaching to beginners. These are: Mc Grath video laryngoscope Truview PCD laryngoscope Glideoscope laryngoscope video system C-Mac video laryngoscope Pentax –AWS video laryngoscope King Vision video laryngoscope Berci –Kaplan DCI video laryngoscope system

33. Steps during video laryngoscopy

34. Glide scope It incorporates a high resolution digital camera, connected by a video cable to high resolution LCD monitor Embedded anti fogging mechanism used for difficult airway intubations, for removal of foreign bodies from airways Comes in three models: standard; paediatric ; neonatal version to suit all ages Has a steep 60 degree angulation, reduced overall thickness of 14mm of its blade improves the view of glottis Latest version COBALT uses disposable blade

35. MC GRATH VIDEOLARYNGOSCPE Videoscope with built in screen Blade similar to Glidescope Plastic sheath for blade Blade adjustable , only laryngoscope with a feature if variable blade length Depth of blade 13mm easy for patients with limited mouth opening Low cost, single use blade, reduced sterilisation time

36. TRUEVIEW PCD LARYNGOSCOPE Functions both as optical and videolaryngoscope Can be attached to any other monitor with a CCD camera head Provide clear enlarged view that enhance ease of tracheal intubation Oxygen flow via side channel on handle provides continous oxygenation- dealys desaturation and prevents fogging of lens and clear sectetions in its path 5 blade sizes- from neonates to adults Best suited for patients with limited mouth opening, micrognathia , collar in place

37. PENTAX AIRWAY SCOPE Consist of disposable transparent blade, 12cm cable with charged coupled device(CCD) and 2.4inch LCD Blade has channel for suction/oxygenation; cable Blade is anatomically shaped and tube is premounted on it and CCD cameras is 3cm proximal from tip of blade Provide good view of glottis and adjacent structures

38. C-MAC VIDEOLARYNGOSCOPE 4 th gen video laryngoscope by Karl Storez Clear image without fogging Record still images and video sequences on SD memory card Blade flattened and round edges so useful in case of reduced oral aperature and less damage to teeth and soft tissues Available in 4 sizes(1-4) D-blade ( Dorges ) for difficult airway , with angulation of >60 degree, comes in only one adult size

39. King vision A durable , fully portable digital video laryngoscope Device has high quality reusable display and disposable blades Comes in 2 versions: Channeled - allows Ets 6.0-8.0 Non Channeled Has antifogging coat on lens preventing blurring of view

40. FLEXIBLE FIBER OPTIC ENDOSCOPE Dr Peter Murphy was the first to use flexible fiberscope to perform tracheal intubation in 1967 Device description: Light source Handle Eyepiece Focussing ring Working channel ports Tip control lever Insertion cord Universal cord for light transmission

41. Fiber optic intubation It can be performed awake or in anaesthetised patient. Indications : Where there is known or suspected difficulty with mask ventilation or tracheal intubation

42. Contraindications “critical airway” = a patient with stridor has an airway that become obstructed with minimal provocation

43. Approach Oral or nasal approach: Nasal is preferred, - due to- easier line of access to larynx, better tolerated Oral approach- though mouth has greater volume, but easier to stray away from midline, so a split oral airway i.e., Berman or Ovassapian is used

44. Preparation: Equipment An Anaesthetic machine Suction Emergency drugs Monitors- Ecg , NIBP, Pulse oximeter , capnograph (EtCo2) Nasopharyngeal airways Fiberoscope : Operator to set the scope and monitor. Following steps are followed:

45. Preparation of patient Explain the procedure to the patient Full monitoring to be applied before starting the procedure. Antisailogogues : Inj Glycopyrrolate 4-8mcg/kg given I.M (more effective im as compared to iv in anaesthic room) an hour before intubation, dries mucus membranes, which both increases the efficacy of topical anesthesia, and improves intubating conditions by decreasing secretions Patient and operator position:

46. Oxygen delivery: Important as sedation is given to the patient. Devices such as single nasal prongs, a nasal sponge or Hudson mask (non rebreathable mask) cut appropriately to allow access to nostril of patient Sedation: Conscious sedation is desirable. Along with good local analgesia. The goal is to provide good analgesia and amnesia in a calm and cooperative patient , following verbal commands, while maintaining patent airway, adequate oxygenation and ventilation

47. Local anaesthesia of the airway: Vasoconstrictors : Its addition ( e.g. epinephrine 0.1%, phenylephrine0.5%-1%, xylometazoline 0.05%) 1-2 drops in each nostril, decreases local blood flow, slows the rate of absorption of LA and prolongs its effect Its recommended that the conc. Of epinephrine should not be more than 1:200 000 A combination of vasoconstrictor plus local anaesthetic can be used e.g.(Co- Phenylcaine (50mg/ml lidocaine , 5mg,ml phenylephrine) Maximum topical safe dose of lidocaine to be used upto 9mg/kg for airway mucosa Anaesthetising the nasopharynx : The trigeminal nerve provides the sensory fiberes to nasal mucosa, which also innervates the superior segment of tonsils, uvula, pharynx

48. Different techniques available to anaesthetise the nose. Best is Co- Phenylcaine f/b Instillagel (2% lignocaone and chlorhexidine ) to the nares Others- 4% cocaine soaked cotton swabs Nebulised 4% lidocaine (4-6)ml ‘ Moffets ’ solution which is 1ml 1:1000 epinephrine , 2ml 1% sodium bicarbonate and 2ml 10% cocaine Anaesthetising the oropharynx: Pharynx and post. Third of tongue is innervated by glossopharyngeal nerve Mucosal atomiser devices(MAD) useful to assist in depositing The local anaesthetic as fine droplets .

49. A benzocaine lozenge may be used to start the process Instillagel can be gargled orally to anaesthetise the pharynx, f/b 1% and 4% lidocaine spray Anaesthetising the larynx: Vagus supplies sensory branches both above and below vocal cords via two main branches. The sup. Laryngeal nerve- supplies arytenoids, epiglottis, sensation above vocal cords; Recurrent Laryngeal nerve- below vocal cords The commenest method to anaesthetise larynx is to spray lignocaine directly down the fiberscope side port (Spray-as-you-go technique) 2ml of 4% lox with air is injected via sideport forcefully on- epiglottis, above the cords, below the cords, the trachea; Whenever it is given cough reflex occurs, therefore to wait until the view clears.

50. Other techniques:

51. Bronchoscopy and intubation: Operator passes the scope thru nose under direct vision Scope should be held taught and straight Small movements od the tip of scope tend to allow the most successful manoeuvring through the airway As epiglottis and cords are visualised the spray-as-you-go technique is instigated Ask pt to take deep breath facilitates entery of scope through cords Through the cords advance the tip of scope till a reasonable distance ETTube is railroaded in a twisting motion after applying lubrication on nares with lignocaine jelly and to the cuff of the tube. If resistance is met, it is likely that tube tip has caught on the arytenoids A 360 degrees continual rotation shouls overcome this

52. Advance the ETT into the trachea over the scope until tip of tube is correctly positioned above the carina. Withdraw fiberscope and attach the circuit to ETT, fix and check to b/l equal air entry Capnography will confirm the correct placement and general anaesthesia can be induced (iv/inhalational)

53. Complications

54. Continued 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 Advantages: Laryngoscopic intubation can be done via nasal route also In restricted neck movements and mouth opening To overcome Anatomical variations Good view of glottis, larynx, trachea

55. Disadvantages Delicate instrument and needs extra care High cost Learning curve , needs practice Tissue oedema and blood can obscure vision Cleaning/ sterlization takes time

56. Thank you.