JB Brodsky-Core Topics in Anesthesia and Perioperative care 2018 -VL

New Book : Comments about VL combined with Cricoid Pressure

Professor JB Brodsky is a Stanford based Anesthesiologist focused on advanced airway applications to Obesity Surgery and Thoracic Anesthesia with an interesting observation about use of Video laryngoscopy and Rapid Sequence intubation.

Professor Brodsky notes that the controversial item of cricoid pressure application may be a problem with video laryngoscopy application.

Highly Angled Video Laryngoscopy Blades (eg. GlideScope and Mcgrath)

• The physical lifting of the tip of the laryngoscope blade is often not appreciated by the casual user. Those familiar with classic DL blades increase lifting effort when ever they have a problem with the view. Usually backing off the tip of the blade by 1/2 -1 cm is the correct response . increased force of lifting of the tip can produce such angulation of the airway with a peak at the cricoid position that even though the view seems to be excellent there is no way to pass the ETT into the descending trachea. Brodsky points out that pressure on the cricoid actually increases this airway distortion and makes intubation even more difficult.

• Bottom line is that the skilled user must ask the question: what are my efforts doing to deform the airway?  The usual answer is that a very light lift of the tongue with minimal lift of the tip of the blade will allow you to see and easily pass the ETT into the trachea which normally lies just anterior to the esophagus and should remain there.

• The use of the directive stylet is essential to have a high degree of control of the endotracheal tube and this device should be used with a gentle touch under visual control to avoid unnecessary injury to the palate or tonsils.

Direct Viewing Video Laryngoscope Blades ( typical Storz Blade and Glidescope Direct)

• There is less problem with these blades because they do less distortion of the airway.

• The direct blade is just that and it will be unable to handle more challenging airway anatomy because it is fundamentally a direct laryngoscope albeit a more effective one.

• The direct blade is easier to use for new users of video laryngoscopy and is excellent for training and development of airway skills.

Conclusion:

Professor Brodsky's point may be a bit subtle but one must understand this to be a truly skilled video airway expert.


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