Some of the more popular posts on this site have been the ones where we vox pop paediatric anaesthetists for their top tips on a topic. The brief is easy: what are the things you most commonly say to people trying to learn this particular skill. Today’s edition – laryngoscopy. So here is a collection of thoughts from Neil Street (NS), Jenny Chien (JC), Jeeves Perera (JP), Justin Skowno (JS), Winnie Fung (WF) and Andrew Weatherall (AW) (who also compiled the tips) all on the topic of what to do with that laryngoscope. It’s not meant to cover the whole world of laryngoscopy and we’ve deliberately avoided chat about videolaryngoscopy as that is it’s own topic, but we do hope it will start a bit of chat.
There aren’t many things that require a single technique. There are some pretty interesting variants on chopstick use. Two karaoke versions of a song are probably going to be fairly unique snowflakes. Even the chicken dance lends itself to variants. They might all be identically annoying 12 minutes in, but they are still different.
The same is true when you pick up the laryngoscope to aid an intubation. If there was one single tip that worked in every patient and in the hands of every anaesthetist, then that’s what everyone would say when you asked for their top tips.
Mostly they don’t though. When I asked around there were certainly a few themes, but there was also plenty of variation. I learnt a thing or two putting them in the one place. Let’s see if anyone else learns a few too.
First up, relax and set up well
JS: Don’t let them scare you. Laryngoscopy in kids is certainly a bit different to adults initially, particularly as they head towards neonates, but it shouldn’t be more difficult. True difficult airway views are more common in adults in fact. A nice calm bag-mask ventilation period while familiarising yourself with your most important task (oxygenation, not intubation) sets you up for a stress free and well pre-oxygenated laryngoscopy.
JP: Positioning is a good start. For the little ones I make sure I start with a neutral neck position.
JC: I find trainees often rush to intubate kids and then attempt laryngoscopy in less than optimal conditions. Perhaps it’s because they often don’t have to wait for the relaxant to work like in most adult cases because they haven’t used relaxant at all. Perhaps they don’t feel confident with bag-mask ventilation. A little more time spent on pre-oxygenation, waiting for drugs to take effect and checking equipment nearly always leads to a smoother attempt at laryngoscopy.
Blade Choice isn’t a Straight Story
JC: For me it’s more about what you are experienced using rather than any particular rule. Personally I like straight blades for under 1’s, mainly because of the slimmer profile in the mouth not because I think they give a far superior view. Above a year old, I don’t have a preference.
AW: There’s really not much evidence out there that laryngoscopy view is better in little kids with straight rather than curved blades, or that intubation success is higher. I think it’s definitely worth being proficient in both and understanding the strengths and weaknesses of each version. If you gave me the choice, I’d pretty much reach for a Macintosh every time, even in neonates. Not just due to familiarity either. Better tongue control (which is such a vital step in kids) and a huge visual space to work in just makes life easier.
NS: If you only had one blade for the rest of your career? The Mac 3.
Stay on the Right Track
NS: The straight blade is a right-sided instrument, not a midline instrument. You have to control that tongue.
WF: Stay at the right side of the mouth. Don’t go midline.
AW: Miller wrote about it. Magill wrote about it. Straight blades are a right-sided instrument. The tongue is a particularly vexatious passenger in paeds airway management. Once it rolls to the right of the straight blade the view is more difficult and it can obstruct the passage of the endotracheal tube. Stay to the right, or go further and make it paraglossal.
Getting the View and Working From the Outside
NS: Use the smallest appropriate straight blade not the largest. Wriggle the tip of the blade side to side gently while withdrawing, or wriggle the larynx from the front of the neck. That way the epiglottis doesn’t fall down all the time before you get a view of the larynx.
WF: Use external laryngeal pressure to get the glottis into view rather than moving the laryngoscope. It makes it less likely the epiglottis will flip out and obscure your view. Also, aim for a grade II laryngoscopic view rather than a grade I. Same reason.
JP: External laryngeal manipulation is better to visualise the vocal cords in neonates than moving the blade back and forth when you see the arytenoids.
AW: The thing is the view. The thing is not picking up the epiglottis. Miller described use of the straight blade in the vallecula and Macintosh described picking up the epiglottis when he wrote about his curved blade. It’s a good thing to be able to use either option, particularly with a straight blade. I don’t tend to go straight down and pull back. I gently look as I go and if I get the view I go with it. If it works better to go past the glottis and gently pull back I do that. It’s the view that matters.
JS: Kids are more flexible than adults in every way, including laryngeal mobility. Getting a good view of the cords is a combination of laryngoscope skills and gentle laryngeal manipulation. You can do this yourself, and then ask your assistant to mimic what you’re doing, or just have a good assistant do it from the start.
AW: Another thing, why do we talk about external laryngeal manipulation like it’s an addition to consider sometimes? Isn’t it really something to do to make it easier pretty much every time?
The Arrival of the Tube
JS: Once you have a view of the cords, do your best not obscure that view with the tube you are so desperate to put in. Introduce the tube from the side of the mouth and visualise it going through the cords. Use the natural curve of the tube to keep your hand from getting in the way. The combination of a great view of the cords, and then a blind placement of the PVC tube leads to frequent frustration, gastric ventilation and burping/swearing.
AW: Maybe it’s because the tube looks like it was curved a bit like a curved blade but a lot of trainees seem to think the tube comes in close to the blade, or in the middle. Let it slip in through the side door. You’ll stay visual with the larynx and the curve can be used to your advantage.
One from Left Field
JP: Every now and then you’ll come across a kid with an acceptable view, but guiding the tube orally just proves difficult. If you have it, a paediatric D-blade used to facilitate a nasal tube just seems to work in these kids sometimes.
Remember the Big Picture
JC: Time spent on laryngoscopy is really important in kids. If you are inexperienced with intubating a child it would be wise to ask your assistant to gently remind you if the saturations are dropping below a certain level or if a certain amount of time has passed. Concentrating on a task you are not familiar with means you forget to look at the rest of the patient.
See? Easy. Don’t rush. Don’t stress about the blade (but know it). Stay right. A little bit of pressure (outside the airway, not on you) is a good thing.
And of course, remember the big picture, not the little view.
There’s a start. Now over to you.
AW has written something elsewhere touching on some of this stuff. That link has some bonus references too.
The image here is up on flickr Creative Commons thanks to Christine und David Schmitt and is unaltered here.
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