My favourite VL view to increase first pass intubation

MEDEST

A debate is ongoing among #FOAMED social media about increasing first passage rate in tracheal intubation and some difficulties when using VL.

At the beginning of my experience with VL I experienced some difficulties, but with a radical change in technical approach I reached a good security on first pass success.

Here are my consideration and I hope will be useful for anyone is starting using VL

 

There are some fundamental differences in VL technique respect to DL, that makes the DL more easy and intuitive to pass the tube trough the cords.

3axysThe 3 axys theory for airway management

“Sniffing position” align the pharyngeal axis with the laryngeal one

Sniffing positionSniffing position

Perfoming Direct Laryngoscopy with the laryngoscope we align the mouth axis to have a direct view of the cords.

DL viewDL VIEW

 

 

 

 

 

 

 

 

 

 

This view coincide with the route…

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One thought on “My favourite VL view to increase first pass intubation

  1. Hey Mihn thanks for posting this since it is very important. I’m not sure though why we are still debating this. In my personal experience and humble opinion and one in which Dr. Levitan has eluded to several times in the past and practices with tremendous success, that setting the patient in an ear parallel to sternal notch position(Sniffing Position) aligns your visual axisis much better than any other position. Obviously some PTs may still need more of a head lift or ELM for better visualization, but generally the ear to sternal notch position will do. The other equally important part of this is a midline approach with anatomy identification finding the epiglottis first being most important.

    Personally I have found equally successful that approaching the mouth opening with a midline approach with either VL or DL, then making a slowly progressive approach naming the anatomy to my team as I look for the epiglottis, then finding the epiglottis and manipulating it however appropriate will set you up for the most success. Now with DL you will probably still have enough room to see the path and tip of your ETT if you keep the blade midline depending on how you formed your styletted tube. Straight to cuff is best with its narrow, slim profile with a code like tip formation at the end. Kind of like a bougie… With some VL blades being much larger than DL blades you may have to maneuver the blade left a little to accommodate room for the ETT, but not taking your eye off the prize. I have found that this approach creates the most success for me. I know you guys know all this and probably perform airway management roughly the same way. I just wanted to make sure I did my part in helping make everyone as successful as possible. Thanks for your time!

    Most Success Summary:
    1. Position PT ETSN and Ramp all big bellys or breasts
    2. Maximal Preoxygenation
    3. Airway Assistant holding Styletted ETT straight to cuff, Bougie, Suction
    – VL ETT should have rigid stylet
    4. DL or VL progressive midline approach and epiglotoscopy
    5. Never look away, keep eye on the prize.
    6. May have to perform ELM or added head flexion
    7. May have to move VL blade to left for ETT accommodation

    -Credit needs to be given to Dr. Levitan and the Faculty of the Difficult Airway Course: EMS

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