LARYNGOSCOPES(1).pptx 2.pptx its about history of laryngoscope

laryngoscope

1. LARYNGOSCOPES

2. INTRODUCTION Laryngoscope is an instrument used to visualize the larynx and surrounding structures . The main purpose of a laryngoscope is to aid the intubation. Laryngoscopes, by bringing the esophagus and larynx under view, are helpful in passing the nasogastric tube, oral suctioning, throat packing and removing oral foreign body.

3. HISTORY I n 1880s t racheal intubation with metal tubes was practiced by physicians William Macewen, Joseph O’Dwyer using fingers as a guide to treat subglottic edema due to diphtheria . Larynx was first visualized by Manuel Garcia, a singer, who used an indirect mirror to visualize the cord movement during singing. A rigid laryngoscope design that is still popular among the ear, nose, and throat (ENT) surgeons for direct laryngoscopy was described by Caveliar Jackson around 1907. Jackson laryngoscope has a “U” shaped handle with a straight blade and “O” shaped flange

4. In 1913, Janeway designed the “L” laryngoscope with straight blade and batteries within the handle. I n 1941 Miller’s modification of straight blade introduced . I n 1943 Sir Robert Macintosh introduced his curved blade the Macintosh blade, and described the indirect method of epiglottis lift to expose the larynx. The era of indirect laryngoscopy in anesthesia started with the Siker mirror laryngoscope and then by prisms introduced by Huffman.

5. PARTS OF LARYNGOSCOPE A laryngoscope consists of a detachable blade and a handle. The blade is attached to the handle by a “hinge” type of joint. Handle Blade Base Heel Tongue (Spatula) Flange Web Tip (Beak) Light source Hook-on (hinged, folding) connection between the handle and blade.

6. BLADE Blade is that portion of the laryngoscope that is introduced in the mouth. It has a tongue, flange, base, web, light source and a tip . The tongue or spatula is that portion of the blade which is used to swipe the tongue aside and depresses lower jaw for visualization of the larynx. Depending on the shape of the tongue or spatula, the blades are classified as straight or curved. Parts of curved blade

7. Parts of straight blad

8. The flange accommodates the tongue and keeps it away from the line of vision. The portion of the blade that connects the tongue and the f lange is called the web or the vertical part . Tip is the most distal part of the blade that is used to lift the epiglottis either directly or indirectly by upward traction or “hooking the vallecula” . The part of the blade that contacts the handle is called the base ,t he slot on the base helps in hinging the handle . The lowermost part of the base is the heel. Heel contains small metal ball that provides the contact for the handle . The light source is either an incandescent bulb or a fiberoptic channel with a halogen or xenon bulb in the handle .

9. SIZES OF BLADES

10. HANDLE Held in the hand during use and has rough surface to improve the grip 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 .

11. Stubby handles are used in obese patients or parturient to avoid the large breast. Pencil handles are used in pediatric patients. Fiberoptic handles have a green ban d .

12. TYPES OF LARYNGOSCOPES

13. Patil Syracuse handle It is an adjustable handle where in the blade can be locked in four positions making different angles with the handle (180 ° , 135 ° , 90 ° , and 45 ° )

14. 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

15. 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 Belchman Blade Flexible-tip Blade

16. 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

17. 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

18. Size of blades for paediatric patients

19. Guedel blade The flange of the Guedel blade is a complete “U” turned to the right side.

20. Flagg blade The Flagg blade is straight with a very slight curve at the distal tip, the C-shaped cross- section tapering gradually from its proximal to distal end.

21. Wisconsin blade One of the popular straight blades of 1930s was the Wisconsin type it is a straight blade with a flange that widens distally and curves to the right. Wisconsin blade is available in sizes 2, 3 and 4 with newer versions having fiberoptic lights

22. Whitehead modification of Wisconsin blade The whitehead modification of Wisconsin blade has a reduced flange and is open proximally and distally .

23. Miller blade In 1941 Sir Robert A Miller modified the then existing straight blade to form the Miller’s blade which was meant for both adult and pediatric patients. Disadvantage of Miller blade is that the light source would disappear under the tongue8 and the tongue tends to bulge in front of the blade. Original Miller blade

24. Present Miller’s blade has undergone the following modifications . In 1946 Miller described the pediatric modification of his adult blade. The tongue is straighter The channel formed by the tongue and the flange is no longer meant for introducing the ETT. Miller blades with fiberoptic light source are available. Some of these blades have the bulb protected by the flange

25. Miller’s blade: Bulb protected by flange Miller’s blade still forms the prototype of straight blade in the present era as it is inseparable from infant and difficult pediatric intubation. Curved tip of the straight blade is ideal for elevation of the f l oppy infant epiglottis.

26. Snow Blade In 1962, Dr John Snow introduced a slimmer and smaller version of the Miller blade

27. Phillips blade The Phillips blade designed by Dr Otto C Phillips in 1972 combines the features of Jackson and Miller blade. The shaft of the Jackson blade was maintained for easy ETT insertion. The curved tip of miller blade helps lifting the epiglottis. The light bulb is in the left.

28. Schapira Blade Dr Max Schapira introduced a blade in 1973 with a minimal web and no flange. This blade also had a deeper curve distally to cradle the tongue and sweep it to the left . Schapira M. A modified straight laryngoscope blade designed to facilitate endotracheal intubation.

29. Seward Blade T he Seward blade has a straight tongue which curves upwards distally. F orms a reverse “Z” shape in cross-section with the web and tongue. The Seward blade was designed to be used in neonatal resuscitation. It is suitable for children up to 5 years of age and for nasal intubation.

30. Robertshaw Blade One of the few blades used in infants and children is the Robertshaw blade. The distinguishing feature of this blade is that the step is deviated to the left and it has a minimal flange curving to the right. Robertshaw blade provides binocular vision

31. Cranwall Blade The Cranwall blade has a curved tip like a Miller blade. There is a reduced flange to decrease the potential for damage to the upper teeth

32. Oxford Blade or Bryce-Smith 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

33. Laryngoscopes with Curved Blade

34. Macintosh Curved Blade Sir Robert Reynolds Macintosh in 1943 during a tonsillectomy surgery . Macintosh blade has a curved spatula, the vertical height is raised and the flange is turned to the left. The tongue, web and the flange form a reverse “Z” in cross-section. Macintosh blade was patented in two countries. Thus we have two models of Macintosh, the “English” Macintosh or the E-Mac and the “American” MacIntosh or the A-Mac.

35. English Macintosh: I n 1958 shifted from brass Macintosh blade to stainless steel model . T he straight portion of the flange was reduced to a smooth curve right up to the tip. The height of the flange is reduced so the blade is longer than the original Macintosh blade to improve vision in anterior laryn x.

36. American Macintosh: C ompared to A-Mac, E-Mac has better laryngoscopic . S traight proximally to provide more space. The curved flange ends proximal to the tip .

37. Reduced flange Macintosh: It is a modification of Macintosh blade, where the proximal flange is reduced to avoid dental Improved vision Macintosh: Improved vision Macintosh has a concave tongue in the midportion to allow better vision

38. 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

39. Bizzarri-Giuffrida Blade (flangeless Macintosh ) 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

40. Choi Double-Angle Laryngoscope 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

41. McCoy Blade The McCoy blade [Corazzelli-London-McCoy (CLM) blade] is a flexible tip blade that has a hinged tip controlled by the lever. When the lever is pressed towards the handle, 2.5 cm of the distil tip is flexed by 70 ° . When the lever is activated the tip flexes and elevates the epiglottis furthermore, thus improving the Cormack and Lahane laryngoscopic grade. McCoy blade forms a part of the difficult intubation trolley. . Due to minimal cervical manipulation, the blade has been preferred in the unstable cervical spine.

42. 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

43. Cormack-Lehane (CL) Classification: Grade I: Full view of the glottis (vocal cords). Grade II: Partial view of the glottis, or only the arytenoid cartilages visible. Grade III: Only the epiglottis is visible. Grade IV: Neither the glottis nor epiglottis is visible.

44. Laryngoscopes with Features of both Straight and Curved Blade

45. Cardiff Blade Cardiff blade has features of both straight and curved blade in order to have a universal blade for children of enabling its use by direct or indirect elevation of the epiglottis.

46. Soper Blade Has a slot into the tip which prevent the epiglottis from slipping off the blade

47. Blades with Special Functions

48. Oxiport Blades Modified Macintosh and Miller blade with a tube to deliver oxygen

49. Tull (Suction) Laryngoscope 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

50. 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

51. Indirect Rigid Fiberscopy

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

53. Siker laryngoscope: A mirror laryngoscope . H as a stainless steel mirror attached to the blade in a copper jacket. This blade was invented for difficult laryngoscopy in patients with buck teeth, anterior larynx and macroglossia .

54. Belscope Blade Straight blade bent forward 45 deg near mid point A prism of transparent acrylic can be attached to blade proximal to angle I mproved view of larynx can be obtained and less damage to teeth

55. Indirect Rigid Fiberoptic Laryngoscopes

56. F iberoptic bundles could be used to visualize the glottis. As the larynx is not under direct vision, these laryngoscopes are called “indirect”. The basic structures of an indirect rigid fiberoptic laryngoscope are— Three channels, two fiberoptic channels for light and image . Anatomically curved thin blade . An eye piece with diopter adjustment for image viewing either directly or by a camera source on the monitor.

57. The rigid fiberoptic indirect laryngoscopes are— Bullard laryngoscope UpsherScope laryngoscope ’ Augustine ScopeTM WuScope.

58. BULLARD LARYNGOSCOPE Working channel extends from the scope body to the point where the light bundles end at the tip . C an 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 .

59. WUSCOPE Combines rigid, tubular blade and flexible fiberscope . 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.

60. UPSHER SCOPE Consists of a C -shaped metal blade, shaped to approximate the curve of the oropharynx 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

61. Indirect Rigid Fiberscopy

62. I ndirect Rigid Fiberscopy

63. 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 )

64. 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

65. 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 and TelePack endoscope

66. GLIDE SCOPE 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

67. McGrath Videolaryngoscope Only laryngoscope with a feature of variable length blade This blade can be adjusted to give variable length for use from children >5yrs to large adults

68. TRUEVIEW PCD LARYNGOSCOPE Provide a clear enlarged view that enhance ease of tracheal intubation Oxygen flow via a side channel on handle provides continuous oxygenation – delays desaturation For patients with collar in place, limited mouth opening, micrognathia

69. PENTAX AIRWAY SCOPE Consists of disposable transparent blade

70. AIRTRAQ Video Laryngoscope Good quality view of glottis, adjacent structures and tip of ET tube without need of aligning 3 airway axes (Oral, Pharyngeal, Tracheal

71. 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

72. Angulated Video-intubation Laryngoscope Useful in children requiring manual in-line neck stabilization

73. 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

74. Flexible Fiberoptic Endoscope

75. 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

76. 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

77. 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

78. Disposable laryngoscopes SINGLE USEDISPOSABE LARYN GOS COPES

79. Laryngoscopy A procedure wherein the larynx is visualized Performed for diagnostic, therapeutic & intubation purposes by various specialists

80. COMPLICATIONS OF LARYNGOSCOPY Common Complications: Pain, Swelling, and Bleeding Hoarseness Gagging or Vomiting Infection

81. Less Common but Serious Complications: Vocal Cord Damage Arytenoid Cartilage Dislocation Airway Trauma Dental Injuries Laryngeal Reflexes

82. 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 Complications