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An endotracheal tube with a view

Hi folks

In the past, I have written articles on intubating via SGA(supraglottic airways) either blindly (with the Fastrach ILMA) or with assistance of fibreoptic semirigid optical stylet ( like Levitan FPS).

My good friends at Greater Sydney Area HEMS ( Cliff Reid, Brian Burns, Anthony Lewis, Karel Habig and more) have actually developed a technique to use on their retrieval missions utilising an iGel SGA and the Ambu Ascope. Here are pictures from a poster presentation they gave at Aeromedical Society Australasia cairns 2012 meeting.

IMG_0657

IMG_0658

Essentially they use the disposable Ambu Ascope to intubate the trachea via the IGel, then cut the flexible scope at its connection to the handpiece, then railroad an ETT over the remaining flexible scope part like a bougie technique.

Thats a pretty novel solution to a difficult prehospital and retrieval airway challenge. Traditional flexible fibreoptic airway endoscopes are cumbersome, expensive and easily broken in the prehospital and transport setting. Some services have carried and still carry them but its uncommon. The Disposable Ambu Ascope still costs $200 approx per scope component.

Well the Israeli company ETView Medical LTD, have produced and licensed a disposable ETT with a CMOS camera at its tip, the VivaSight ( previous known as ETView)

Firstly I have no financial disclosures with this company and the products I display during this article were purchased privately for airway research and testing.

The ones I bought cost me 65Euro each. I also bought the RCA adapter to allow connection to my laptop computer via a USB video adapter. This was all up approx 50$ extra.

Here is the ETView disposable tracheoscopic ventilation tube, VivaSight SL ( the company’s description of the device)

igel1

And add a $20 iGel SGA

igel2

then plug the ETView into my laptop

igel3

Note the LED illuminating tip for the CMOS camera. The temperature produced is minimal and well tested for prolonged thoracic procedures, bronchoscopy and lung isolation techniques. The device is FDA licensed.

So with this device, you can perform nasotracheal intubation with video guidance, or you can tube via an iGel like here..note my use of a bougie to facilitate the intubation. In fact in my testing , what worked best was to get a good view of the laryngeal inlet using the Vivasight, then pass a bougie into the trachea under video guidance, then remove the Vivasight, then iGel, leaving the bougie in situ and finally performing a standard bougie assisted ETI but using the Vivasight ETT again for further video guidance. This obviates need for capnography to confirm tracheal position as you can see if you are in the trachea continuosly

Now for prehospital and retrieval medicine, the ETView device has a weakness. The LED light and camera tip need a separate power source. There is a newer model now which I have not tested yet which connects to LCD monitor via miniUSB cable. This might not need a separate power source.

All up its a novel solution to providing cheap disposable, portable flexible airway imaging. And maybe for surgical airway, this ETT with a view can help avoid problems with confirming tracheal position..even in the bloody airway ( it has a flushing channel and port to squirt saline down to clean the camera lense!)..thats the next test..take the ETView to the bloody airway manikin!

 

8 Comments Post a comment
  1. Interesting. I reckon by 2015 we will have some stability in the market of airay options, with a few cheap, robust, reliable devics availabel to all

    Question re the iGel and ambuAdcope technique – I ve used this in mannikins and it is a breeze…but there are two things I wondered

    1/ have NSW HEMS actually used is ‘in anger’ on a real patient?

    And

    2/ why cut the ambu ascipe? You can preload it with an ETT and then just slide it in…

    Cant you?

    December 7, 2012
  2. Hi Tim
    (1) Not yet
    (2) The technique is for use with SGAs that have aperture bars / gates that preclude direct insertion of a tracheal tube, and the aScope is too big to accommodate an airway exchange catheter.
    Cheers!
    Cliff

    December 8, 2012
  3. Ah, so AirQ or FastTrach iLMa would work….or the Ambu proprietary LMA.

    But I suppose iGel is preferred LMA of choice in Ciff’s service.

    Makes sense, thanks for clarifying.

    Will be interesting to see reports of use. Presumably more for secondary retrievals, anticipated or unexpected difficult airways and the like rather than primaries/entrapments…?

    December 10, 2012
    • johannes huitink #

      Tracheal intubation with a camera embedded in the tube tip (Vivasight™)

      J. M. Huitink Staff Anaesthetist1,*,
      E. M. Koopman Specialist Anaesthesia Trainee1,
      R. A. Bouwman Staff Anaesthetist1,
      A. Craenen Specialist Anaesthesia Trainee1,
      M. Verwoert Student2,
      R. Krage Staff Anaesthetist1,
      I. E. Visser Nurse Anaesthetist Trainee1,
      M. Erwteman Staff Anaesthetist1,
      D. van Groeningen Nurse Anaesthetist1,
      R. Tijink Nurse Anaesthetist1,
      A. Schauer Staff Anaesthetist1

      Article first published online: 5 NOV 2012

      DOI: 10.1111/anae.12065

      Anaesthesia © 2012 The Association of Anaesthetists of Great Britain and Ireland

      Issue
      Cover image for Vol. 68 Issue
      Anaesthesia

      Early View (Online Version of Record published before inclusion in an issue)

      Additional Information(Show All)

      How to CiteAuthor InformationPublication History

      You can respond to this article at http://www.anaesthesiacorrespondence.com

      SEARCH
      Search Scope

      Summary

      We studied tracheal intubation in manikins and patients with a camera embedded in the tip of the tracheal tube (Vivasight™). Four people in two teams and two individuals attempted intubation of a manikin through an i-gel™ 10 times each. The tracheas of 12 patients with a Mallampati grade of 1 were intubated with a Vivasight tracheal tube through a Berman airway, passed over a Frova™ introducer. All 60 manikin intubations were successful, taking a mean (SD) time of 1.4 (0.5) s. The fastest intubation was performed in 0.5 s. All 12 participants’ tracheas were successfully intubated in a median (IQR [range]) time of 90 (70–120 [50–210]) s. Seven participants complained of a sore throat, comparable with earlier findings for standard laryngoscopy and intubation: five mild; one moderate; and one severe. Tracheal intubation with the Vivasight through the i-gel or Berman airway is an alternative to existing techniques, against which it should be compared in randomised controlled trials in human participants. It has potential as a fast airway rescue technique.

      December 10, 2012
      • thanks Johannes!

        December 10, 2012
  4. Jimmy D #

    Cliff, et. al.,–Novel way of handling the intubation through the iGel! Used with a bronchoscopic connector, you could ventilate the patient thoroughly up until the point of the iGel removal. Another alternative is to use the Ambu scope to guide a bougie through the glottis alongside the scope, thereby preserving the scope until you are sure you don’t need it anymore (i.e, you have handed off the patient at the receiving hospital). This would take some practice.

    Thanks again!

    December 12, 2012
  5. Thanks – makes sense!

    December 17, 2012

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