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• W2129129065 abstract "Intubation with a double-lumen endobronchial tube (DLT) can be difficult even in patients with “normal” airways and an adequate direct laryngoscopic view. Thus, it has been proposed that a difficult airway is a relative contraindication for DLT placement. The GlideScope Video Intubation System (Saturn Biomedical System Inc, Burnaby, BC, Canada) is a camera laryngoscope that displays an unobstructed view of the vocal cords on a monitor. It provides a laryngoscopic view equal to or better than that of direct laryngoscopy.1Sun D.A. Warriner C.B. Parsons D.G. et al.The GlideScope Video Laryngoscope: Randomized clinical trial in 200 patients.Br J Anaesth. 2005; 94: 381-384Crossref PubMed Scopus (308) Google Scholar, 2Rai M.R. Dering A. Verghese C. The Glidescope system: A clinical assessment of performance.Anaesthesia. 2005; 60: 60-64Crossref PubMed Scopus (178) Google Scholar, 3Cooper R.M. Pacey J.A. Bishop M.J. et al.Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients.Can J Anaesth. 2005; 52: 191-198Crossref PubMed Scopus (465) Google Scholar This letter describes the use of the GlideScope in managing an unanticipated difficult airway and for replacement of a single-lumen endotracheal tube (SLT) by a DLT over an airway exchange catheter (AEC). A 48-year-old woman (height 162 cm and weight 62 kg) was scheduled for thoracic spine decompression and fusion. General anesthesia and lung separation with a DLT were requested. Her medical problems included non–insulin-dependent diabetes mellitus and chronic hepatitis C. Surgical history was significant for removal of an ovarian tumor under general anesthesia at age 30 at another hospital. She denied knowledge of any prior difficulties with anesthesia. Her preoperative airway examination revealed adequate mouth opening (>4 cm) and intact upper and lower dentition with no evidence of overbite. She was assigned an airway Mallampati score of II and had a full range of active neck flexion and extension. After placement of routine monitoring and preoxygenation, anesthesia was induced with fentanyl, thiamylal, and rocuronium. Facemask ventilation was not difficult. Direct laryngoscopy with a Macintosh size 3 blade revealed a grade III Cormack Lehane view, and the epiglottis could not be lifted. The laryngeal view did not improve despite an enhanced “sniffing” position and the application of external laryngeal manipulation. Laryngoscopy was repeated by using a GlideScope, which showed the arytenoids and the posterior origin of the vocal cords. Advancing the bronchial lumen of a 35F left-sided DLT through the glottis failed after 2 attempts. Intubation with an SLT mounted over a Parker Flex-It Directional stylet (Parker Medical, Englewood, CO) was accomplished successfully on the first attempt. After the GlideScope was withdrawn and the cuff inflated, endotracheal intubation was confirmed by manual ventilation, auscultation, and measurement of exhaled CO2. A 14F AEC (Cook Critical Care, Bloomington, IN) was inserted 25 cm into the SLT, which was then replaced with a DLT. Difficulty was encountered when advancing the bronchial lumen into the trachea. Neither counterclockwise nor clockwise rotation of the DLT helped facilitate tube advancement. The GlideScope was then reinserted and revealed that the tip of the DLT was just above the glottis inlet. Under direct visual control, the bronchial tip and cuff were easily passed through the vocal cords by sliding the DLT over the AEC. The AEC was removed, and the DLT was carefully rotated so that the distal curve was now concave toward the left side and the proximal curve was concave anteriorly to allow endobronchial intubation on the appropriate side. The proper placement of the DLT in the left main bronchus was verified with fiberoptic bronchoscopy. The operation proceeded uneventfully with good lung isolation. Two techniques can be used to achieve lung isolation: (1) placement of a DLT or (2) a bronchial blocker (Fogarty occlusion catheter, Univent tube, or a wire-guided blocker).4Campos J.H. Current techniques for perioperative lung isolation in adults.Anesthesiology. 2002; 97: 1295-1301Crossref PubMed Scopus (100) Google Scholar DLTs and the Univent tube (Vitaid, Williamsville, NY) are relatively difficult to use because they have an increased outside diameter, making them relatively harder to insert, with increased overall rigidity, impairing optimal shaping of the tubes.5Benumof J.L. Difficult tubes and difficult airways.J Cardiothorac Vasc Anesth. 1998; 12: 131-132Abstract Full Text PDF PubMed Scopus (49) Google Scholar, 6Patane P.S. Sell B.A. Mahla M.E. Awake fiberoptic endobronchial intubation.J Cardiothorac Anesth. 1990; 4: 229-231Abstract Full Text PDF PubMed Scopus (25) Google Scholar, 7Ransom E.S. Carter S.L. Mund G.D. Univent tube: A useful device in patients with difficult airways.J Cardiothorac Vasc Anesth. 1995; 9: 725-727Abstract Full Text PDF PubMed Scopus (29) Google Scholar, 8Hagihira S. Takashina M. Mori T. et al.One-lung ventilation in patients with difficult airways.J Cardiothorac Vasc Anesth. 1998; 12: 186-188Abstract Full Text PDF PubMed Scopus (37) Google Scholar The Fogarty occlusion catheter or the wire-guided endobronchial blocker can be passed through an in situ oral or nasal SLT for one-lung ventilation. This patient had an unanticipated difficult airway after routine induction of anesthesia. Because of the authors’ favorable experiences,9Lai H.Y. Chen I.H. Chen A. et al.The use of the GlideScope for tracheal intubation in patients with ankylosing spondylitis.Br J Anaesth. 2006; 97: 419-422Crossref PubMed Scopus (111) Google Scholar the GlideScope has become the first-line alternative technique rather than a straight laryngoscope blade. To help in successfully placing a DLT with the GlideScope, bending the distal portion of the stylet to the same shape as the GlideScope blade is useful.10Jones P.M. Turkstra T.P. Armstrong K.P. et al.Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope.Can J Anaesth. 2007; 54: 21-27Crossref PubMed Scopus (81) Google Scholar, 11Cuchillo J.V. Rodriguez M.A. Considerations aimed at facilitating the use of the new GlideScope videolaryngoscope.Can J Anaesth. 2005; 52 (author reply 661-662): 661Crossref PubMed Google Scholar, 12Doyle D.J. Zura A. Ramachandran M. Videolaryngoscopy in the management of the difficult airway.Can J Anaesth. 2004; 51 (author reply 95-96): 95Crossref PubMed Google Scholar, 13Hernandez A.A. Wong D.H. Using a Glidescope for intubation with a double-lumen endotracheal tube.Can J Anaesth. 2005; 52: 658-659Crossref PubMed Scopus (39) Google Scholar In this patient, even though the laryngeal view improved, the GlideScope did not permit passage of the DLT, and the authors were concerned that further unsuccessful attempts could lead to airway trauma. Therefore, it was decided to secure the airway with an SLT first, and the GlideScope permitted easy SLT intubation with the Parker Flex-It Directional stylet. Although the GlideScope is not mentioned in the guidelines for the management of the unanticipated difficult SLT intubation,14Henderson J.J. Popat M.T. Latto I.P. et al.Difficult Airway Society guidelines for management of the unanticipated difficult intubation.Anaesthesia. 2004; 59: 675-694Crossref PubMed Scopus (844) Google Scholar it can be a powerful alternative technique in this scenario. It should be emphasized that most available AECs are designed for exchange of an SLT. It is, therefore, not ideally suited for a DLT. If there is any question about the outside diameter of an AEC and the internal diameter of the bronchial lumen of a DLT, the fit should be tested in vitro before its use. In addition, excess depth (>26 cm) of AEC insertion increases the risk of tracheobronchial tree perforation.15Benumof J.L. Airway exchange catheters: Simple concept, potentially great danger.Anesthesiology. 1999; 91: 342-344Crossref PubMed Scopus (82) Google Scholar With the aid of the GlideScope, securing the airway with a SLT then replacing the tube over an AEC is a complementary fusion of old and new approaches. The GlideScope is very useful for airway management and tube exchange." @default.
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• W2129129065 title "GlideScope-Assisted Double-Lumen Endobronchial Tube Placement in a Patient With an Unanticipated Difficult Airway" @default.
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