1Staff Anesthetist and Intensive Care Physician, Department of Anesthesia and Intensive Care, Empress Elisabeth Hospital of the City of Vienna, Vienna, Austria.
Address correspondence and comments to Klaus Krasser.
Received from the
Department of Anesthesia
and Intensive Care, Empress Elisabeth Hospital
of the City of Vienna, Vienna, Austria.
Received from the Department of Anesthesia and Intensive Care, Empress Elisabeth Hospital of the City of Vienna, Vienna, Austria.
Published: June 25, 2007.
The correct citation of this correspondence is:
Krasser K. Injuries associated with GlideScope video laryngoscopy-assisted
tracheal intubation. Internet Journal of Airway Management
Date accessed: month day, year.
Last updated: December 8, 2008.
We introduced the GlideScope Video Laryngoscope (GVL; manufactured by Verathon Medical, Bothell, Washington, United States) into clinical practice at our institution in May 2005. Because of expected difficulties in manipulating the tracheal tube (TT) through the oropharynx and the laryngeal aperture into a midtracheal position, all novice users of the GVL first received formal hands-on training on a suitable airway model and instruction during the early series of performance on patients by an experienced user of the GVL (8).
Within a short period of time, we became familiar and confident with the use of the GVL (using the device now in over 1000 patients) and published our experiences (with various GVL blade models and systems) for laryngoscopy and orotracheal intubation in altogether 884 adult patients (with variable degrees of airway difficulties and a wide range of conventional laryngoscopic view grading) without observing any severe injury associated with airway management (7-9). In all these clinical evaluations, we used the Schroeder directional tracheal tube stylet (DS; the Parker Flex-It Stylet, manufactured by Parker Medical, Colorado, United States) for advancing and passage of the TT through the laryngeal aperture; the oropharyngeal passage of the styletted TT was performed with special caution, because this maneuver is usually blind (by diverting the visual attention of the operator from the patient to the monitor) until the tip of the TT comes into view on the monitor.
Pharyngeal injuries may be the result of uncontrolled TT advancement. Cooper (3) was the first who reported two cases of pharyngeal injuries associated with GVL-assisted orotracheal intubation (both performed using conventional malleable TT stylets) in patients with expected difficult airways (DAs); in both instances, the TT had passed through the right palatopharyngeal arch. In the first patient, there were difficulties in advancing the TT through the oropharynx and the laryngeal aperture into a midtracheal position, requiring multiple attempts and two operators; in the second patient, a novice user of the GVL performed orotracheal intubation, requiring two attempts to bring the TT into view on the monitor.
Within a few months, seven further cases of pharyngeal injuries involving the GVL for orotracheal intubation (performed using conventional malleable TT stylets) have been reported. Choo and co-workers (2) and Hsu and co-workers (6) observed a similar complication as first described by Cooper (3) after routine orotracheal intubation using the GVL. Malik and Frolik (11) also encountered a penetrating injury of the soft palate associated with GVL-assisted orotracheal intubation in a patient with a previously experienced DA. Chin and co-workers (1), Cross and co-workers (4), and Hirabayashi (5) recently added three further reports on palatal injuries associated with GVL-assisted orotracheal intubation.
We are also aware of a case with laceration of the soft palate experienced by a novice user of the GVL (a staff anesthetist of our institution, without prior formal instruction in the technique) in a patient with unanticipated difficult conventional laryngoscopy (8). Multiple attempts to insert the TT into the oropharynx were required; probably, the DS used in this patient protuded beyond the distal end of the TT. Because of bleeding, the surgical procedure planned (elective thyroid surgery) had to be postponed; fortunately, the defect closed spontaneously after a few days following the injury and thereafter, the patient received a GVL-assisted tracheal intubation (successful after the first attempt, performed by an experienced operator) and the operation was completed without further complications.
We therefore stress again, that the styletted TT (especially with a conventional malleable stylet or the rigid stylet provided by the manufacturer of the GVL in place) should be introduced and advanced through the oral cavity with special caution. Strategies to minimize pharyngeal injuries associated with GVL-assisted orotracheal intubation, particularly in patients with limited mouth opening and/or restricted pharyngeal space, should involve early passage of the styletted TT during oropharyngeal insertion of the GVL blade or under direct visual control, preferably midline along the flange of the blade. Although rarely used in clinical practice, the DS may offer less potential to injure pharyngeal structures. When there is any resistance encountered during oropharyngeal (and/or laryngeal) passage of the TT, we now use the GVL as airway for reliable and atraumatic flexible bronchoscopy-assisted orotracheal intubation. Early withdrawal of any stylet (used for easier tracheal intubation) after advancing the tip of the TT through the laryngeal aperture should also become the recommended practice in order to prevent tracheal injuries.
Several months after the publication of this correspondence, Vincent and co-workers (12) communicated a further case of palatal injury associated with GVL-assisted orotracheal intubation (using the GVL rigid stylet) in a patient with a DA (with a large mass involving the right supralaryngeal area); after tracheal intubation, they noted that the soft palate had been perforated by the styletted TT; fortunately, the defect closed spontaneously within nine days following the injury. Meantime, an additional case of palatopharyngeal wall perforation (again with the use of GVL rigid stylet) in a patient with apparently normal airways was reported (10); in this case, there were no sequelae other than minor bleeding and mild sore throat, and no surgical intervention was necessary.
Cooper RM. Complications associated with the use of the GlideScopeR videolaryngoscope. Can J Anesth 54:54-57, 2007.
Cross P, Cytryn J, Cheng KK. Perforation of the soft palate using the GlideScopeR videolaryngoscope (correspondence). Can J Anesth 54:588-589, 2007.
Hirabayashi Y. Pharngeal injury related to GlideScope videolaryngoscope (correspondence). Otolaryngol Head Neck Surg 137:175-176, 2007.
Hsu WT, Hsu SC, Lee YL, Huang JS, Chen CL. Penetrating injury of the soft palate during GlideScopeR intubation (correspondence). Anesth Analg 104:1609-1610, 2007.
Krasser K, Missaghi SM, Moser A, Lackner-Ausserhofer H, Zadrobilek E. Evaluation of the GlideScope Ranger Video Laryngoscope in clinical practice. Internet Journal of Airway Management 4:2006-2007. Date accessed: December 8, 2008.
Krasser K, Missaghi SM, Moser A, Zadrobilek E. Evaluation of the Standard Adult GlideScope Video Laryngoscope: orotracheal intubation by novice users after formal instruction.
Krasser K, Moser A, Missaghi SM, Lackner-Ausserhofer H, Zadrobilek E. Experiences with the Lo Pro Adult GlideScope Video Laryngoscope for orotracheal intubation. Internet Journal of Airway Management 4, 2006-2007. Date accessed: December 8, 2008.
Leong WL, Lim Y, Sia ATH. Palatopharyngeal wall perforation during GlideScopeR intubation. Anaesth Intensive Care 36:870-874, 2008.
Malik AM, Frogel JK. Anterior tonsillar pillar perforation during GlidescopeR video laryngoscopy. Anesth Analg 104:1610-1611, 2007.
Vincent RD, Wimberly MO, Brockwell RC, Magnuson JS. Soft palate perforation during orotracheal intubation facilitated by the GlideScope videolaryngoscope. J Clin Anesth 19:619-621, 2007.
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