Video & fibreoptic laryngoscope

Moderator : Dr. Veena Mathur
Presented by: Dr. Aji Kumar
Department of Anaesthesia , JLN Medical College Ajmer

 Video laryngoscopy is a form of indirect laryngoscopy
in which the clinician does not directly view the
larynx. Instead, visualization of the larynx is
performed with a fiberoptic or digital laryngoscope
inserted transnasally or transorally.[1]
 The images from video laryngoscopy can be displayed
on a monitor for the clinician, patient, and others to
view at the time of the procedure; it can also be
recorded.
 Images are magnified when displayed on the monitor,
allowing for detailed examination of the larynx.

Indications
 Difficult airway situation
 Failed conventional laryngoscopy and intubation
 Diagnostic purposes
 Teaching purposes

 KARL STORZ Video Laryngoscopes
 First Generation - In 2000 KARL STORZ developed,
with the patent of Professor Illias the first video
laryngoscope.

 Second Generation - In 2001 KARL STORZ developed the 2nd model
together with Professor George Berci and Dr. Marshal Kaplan and
included the MVM Technology (Micro Video Module), which allowed
for a smaller camera and more convenient handling.

 Third Generation - In 2003 KARL STORZ developed the V-MAC - in this new
development, the DCI Technology (Direct Coupled Interface) was
incorporated. This enabled multiple devices including Video Laryngoscopes,
Flexible Intubation Scope and Optical Stylets to be connected via a one-chip
camera system to the monitor, improving the video image.

 Fourth Generation - In 2008 KARL STORZ
developed the C-MAC Video Laryngoscope. This latest
generation Video Laryngoscopes is equipped with a
CMOS Chip, LED Light output an Lithium-Ion battery
making the system highly portable and versatile.

 Glidescope
 In 2001, the Glidescope (designed by vascular and general
surgeon John Allen Pacey)
 It incorporates a high resolution digital camera, connected by a
video cable to a high resolution LCD monitor.
 It can be used for tracheal intubation as well as for removal of
foreign bodies from the airway.

 The digital camera is located at the point of angulation
of the blade (rather than at the tip). This placement
allows the operator to more effectively view the field in
front of the camera.
 The video camera is recessed for protection from blood
and secretions which might otherwise obstruct the view.
The steep 60-degree angulation of its blade
improves the view of the glottis by reducing the
requirement for anterior displacement of the
tongue.

 The video camera has a relatively
wide viewing angle of 50 degrees.
 The heated lens innovation helps to prevent fogging of
the lens, which might otherwise obscure the view.
 Tracheal intubation with the GlideScope can be facilitated
by the use of the Verathon Stylet, a rigid stylet that is
curved to follow the 60° angulation of the blade.

McGrath laryngoscope
 The McGrath laryngoscope is a portable
video laryngoscope with a blade length that
can be adjusted to facilitate a child of age 5
years upto an adult .
 The blade can be disconnected from the
handle to facilitate its insertion in morbidly
obese patients in whom the space between
the upper chest and headis reduced.
 The blade is inserted midline, with the
laryngeal structures viewed at a distance to
enhance intubation success.

King vision laryngoscope
 Consists of a reusable LED monitor with handle and
single use blades
 Blade tip has light source and high resolution camera
 2 types of blades 1.) Standard blade
2.) Channeled blade
 Monitor is battery operated and also has port for video
cable

Pentax airway scope
It has a portable battery operated
lcd monitor and a disposable
blade
Blade has a guiding channel for
loading endotracheal tube .
An additional port for suction of
secretions is present in the blade

FLEXIBLE FIBRE OPTIC LARYNGOSCOPE
 The insertion cord contains bundles of optical fibers that transmit the image, a different
group of optical fibers that transmit light to the distal end, and cables from a control
lever in the handpiece that flex and extend the distal section.
 The hollow channel can be used for aspiration of secretions or instillation of local
anesthetic.
 The simplest FFLs have a proximal eyepiece. The image can be displayed on a monitor by
attaching a camera to the eyepiece or by using an FFL with an integral camera.
 The FFL is the most versatile laryngoscope for tracheal intubation and can facilitate
intubation that could not be achieved with any other technique.
 Awake flexiblefiberoptic laryngoscopy is the safest noninvasive means of securing a
critical airway.
The FFL uses flexible optical fibers to transmit
images from a distal lens .

Fiberoscope Components:
Components of a flexible fiberoptic laryngoscope:
a. Body : Tip deflection control lever Eyepiece
Focusing ring Working channel sleeve
b. Insertion cord : Fiberoptic bundles
Optical system
Mechanical system
c. Light transmission cord (Universal cord)

Mechanical System:
• Image bundles
• Illumination bundles
• Working channel
• Angulation control wires
• Flexible distal joint system
All ensheathed in a tough
durable outer covering
Internal components and construction of the insertion
tube of the fiberscope.

Working Channels:
They run the length of the endoscope
Uses:
1. Suctioning can be applied for clearing of secretions.
2. Medications can be instilled into the airway.
3. Biopsy instruments for diagnostic procedures.
4. Instillation port
Angulation control wires:
1. The distal end of the laryngoscope has a two way angulation system.
2. Angulation wire runs the length of the fiberoscope from the control knob
through the metal bands and is fixed at the distal end of the endoscope.
3. Tip deflection is produced by rotating the control knob thus exerting tension
on the angulation wire which inturn flexes the metal band.
4. Flexible section of the distal end has a series of metal bands attached together by flexible
joints

Indications
 Anticipated difficult tracheal intubation
 Anticipated difficult mask ventilation, including sleep apnea
 Anticipated difficult rescue technique
 Confirmation of tracheal tube position
 Diagnosis of malfunction of a supraglottic airway device
 Cervical spine instability (the rigid indirect laryngoscope is an alternative)
 Positioning of a double-lumen tube and bronchial blocker
 Assessment of swelling or trauma after difficulty with airway management
 Intensive care use, including aspiration of secretions and confirmation of the
dilatational tracheotomy site
 Micrognathia
 Mandibular fracture
 Partially obstructing laryngeal lesions such as papilloma
 Trismus
 Craniofacial abnormalities

Versatility of the Flexible FOL
 Flexible and steerable
 Minimal tissue pressure and trauma
 Continuous visualization
 Oral or nasal route possible
 Other intubating devices may facilitate combination
techniques
 Visual confirmation of the depth of intubation on
withdrawal

Advantages of Awake Patient State for FOL
 Spontaneous breathing continues
 Oxygenation and ventilation maintained
 Intubation easier
 Anatomy and muscle tone preserved
 Phonation as a guide
 Safety
 Airway protection preserved
 Options preserved

Flexible FOL Technique
 Anti secretory agent ( glycopyrrolate)
 Effective topical anesthetic, topical vasoconstrictors
 Equipment check: lenses clean and focused, antifog
agent applied
 Tracheal tube mounted on the flexible fiberoptic
laryngoscope for the nasalroute
 Within the oral airway for the oral route
 Patient position: supine, semisitting, or sitting
 Rapport: full explanation of Flexible fiberoptic
laryngoscope technique

Flexible FOL Technique
 Insertion cord kept straight and the scope maneuvered in
three planes
 Tip (flexion-extension, rotation, and advance-withdrawal)
 Secretions aspirated
 Targets (epiglottis, vocal cords, tracheal cartilages, carina)
kept in the center of view as the flexible fiberoptic
laryngoscope is advanced
 Advance to close to the carina Tracheal tube passed over
the flexible fiberoptic laryngoscope
 Tube position confirmed and secured and anesthesia
induced

 Topicalization
 It is the simplest method for anesthetizing the airway.
 Local anesthetic can be sprayed directly onto the desired mucosa.
 Nebulization of lidocaine 2–4% via face mask or oral nebulizer for 15–
30 minutes can achieve highly effective anesthesia of the oral cavity
and trachea for intubation
 Anesthetic-soaked cotton can also be applied
 Vasoconstrictors such as epinephrine (1:200,000) or phenylephrine
(0.05%) can be added to the solution to reduce mucosal bleeding.

 Nerve blocks
 The glossopharyngeal nerve provides sensory innervation to the posterior third of the
tongue, the vallecula, the anterior surface of the epiglottis (lingual branch), the walls
of the pharynx (pharyngeal branch), and the tonsils (tonsillar branch).
 It is most easily blocked where it crosses the palatoglossal arch.
 It can be blocked using one of three methods: topical spray application, direct mucosal
contact of soaked pledgets, or direct infiltration by injection.
 Glossopharyngeal nerve block is not adequate as a solo technique to facilitate
intubation, but in combination with other techniques it is highly effective.

 Nerve blocks
 The superior laryngeal nerve innervates the base of the tongue,
posterior surface of the epiglottis, aryepiglottic fold, and the
arytenoids.
 Direct infiltration is accomplished at the level of the thyrohyoid
membrane inferior to the cornu of the hyoid bone. A reliable block
with a definite endpoint is effected by retracting the needle marginally
after contacting the greater cornu and injecting 2mL of local
anesthetic after negative aspiration.

 Nerve blocks
 Recurrent laryngeal nerve provides sensory innervation to the trachea and vocal folds.
Blockade facilitates comfortable passing of the endotracheal tube into the trachea.
 Translaryngeal block of the recurrent laryngeal nerve is easily accomplished at the level
of the cricothyroid membrane. A 5 or 10-mL syringe with a 22- or 20-gauge needle is
advanced until air is aspirated into the syringe. Four milliliters of local anesthetic are
then injected, inducing coughing that disperses the local anesthetic.
 The recurrent laryngeal nerve can also be blocked by spraying local anesthetic via the
injection port of the fiberoptic bronchoscope.

Issues to take care of
 Neither deep sedation nor general anesthesia should be used
when the airway is compromised.[27]
 Whenthe patient is alert, ventilation, oxygenation, and airway
protection are maintained. Normal pharyngeal tone is preserved,
so there is sufficient space between structures to facilitate vision
several centimeters beyond the distal lens.
 Phonation, which can help identify the larynx, is helpful in
awake patient
 The ideal sedative would have little effect on spontaneous
ventilation and allow patients to protect their airway.
 Dexmedetomidine may provide effective and safe sedation in
apprehensive or combative patients.
 Fentanyl infusions have been used, but careful monitoring is
essential to prevent hypoventilation andhypoxemia.

Problems in fibreoptic Intubation
 High skill level needed for rapid control of the tip of
the laryngoscope
 Secretions, edema, and hemorrhage
 In sedated or drowsy pts Airway less open than when
awake—jaw thrust and/or dedicated oral airway
needed.
 Tracheal tube passage difficult y
 Patient risks: hypoxemia, hypoventilation, and
pulmonary aspiration

Contraindications
 No absolute contraindications
 Uncooperative or unwilling patient .
 Massive airway bleeding , vomitus , airway debris
 Heavily sedated patients and inadequately topicalized
pts.
 Unavailibity of oxygenation and suctioning
(Awake flexible fiberoptic laryngoscopy is safe in a critical airway when expertly used)

Sterilization and Cleaning of the Flexible Fiberoptic Bronchoscope:
Routine Cleansing of the fiberoscope:
Sterilization:
Ethylene oxide gas
Fiberscopes may be sterilized by this method at a temperature of 130F
(54.4C), pressure 20psi and humidity 50% for a period of 4-5 hrs.
Disadvantage: Time consuming
Step 1 Connect suction port to vacuum suction
Step 2 Aspirate approximately 200ml detergent solution through suction
channel
Step 3 Clear suction channel with cleaning brush
Step 4 Wipe shaft and valves with detergent-soaked sponge
Step 5 Aspirate approximately 200ml sterile water through suction channel
Step 6 Wipe shaft and valves with sterile water
Step 7 Proceed with disinfection / sterilization

Routine Cleaning
Immediate cleaning of the fiberoptic bronchoscope and
valves with detergent solution followed by 20 minutes of
disinfection with 2% alkaline glutaraldehyde (cidex) or succine
dialdehyde solution. It is rinsed and the channel is flushed with
70% alcohol. The scope is then allowed to dry.
Storage of Fiberoptic Instruments:
To prevent the fiberoptic bundles from being bent or
broken, the laryngoscope is stored straight in a cylindrical tube
on the portable chart or stored horizontally within the drawer of
a mobile bronchoscopic cart or stored within the soft molded
foam of its carrying case.

Ambu a scope / single use fibrescope
 Single use flexible intubation scope to prevent
reinfection( sterile package)
 Consists of a reusable monitor and single use flexible
introducer with bending section ( 150-130 degree)
 tip of the introducer contains the camera and LED
light source
 Handle of the introducer has connector cable for the
display screen, control lever , suction button, suction
connector, working channel port

Uses of A scope
 For awake intubation in difficult cases- restricted
cervical mobility, cervical spine injuries, limited
mouth opening etc.
 Airway inspection for diagnostic purposes
 Tube position check
 To prevent cross contamination in seropositive cases

Video & fibreoptic laryngoscope

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