Direct laryngoscopy: Difference between revisions
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==Overview== | ==Overview== | ||
* Used to facilitate intubation | [[File:F4.png|thumb|Oral cavity and oropharynx.]] | ||
* Provides direct line of sight of vocal cords (as opposed to video laryngoscopy) | [[File:F6.png|thumb|Sagittal section through the head and neck showing the subdivisions of the pharynx.]] | ||
[[File:F8.png|thumb|External views of the larynx: (a) anterior aspect; (b) anterolateral aspect with the thyroid gland and cricothyroid ligament removed.]] | |||
[[File:Cartilages and ligaments of the larynx.png|thumb|The cartilages and ligaments of the larynx seen posteriorly.]] | |||
[[File:F5.png|thumb|Larynx as visualized from the hypopharynx.]] | |||
* Used to facilitate [[intubation]]<ref>Peterson K, Ginglen JG, Valenzuela FI, et al. Direct Laryngoscopy. [Updated 2020 Mar 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513224/[Category:Procedures]] | |||
</ref> | |||
* Provides direct line of sight of vocal cords (as opposed to [[video laryngoscopy]]) | |||
* Most often utilizes Mac or Miller Blade | * Most often utilizes Mac or Miller Blade | ||
* Miller blade more popular in pediatric intubation because of floppy epiglottis (most common in those <2 years of age) | * Miller blade more popular in [[Intubation (peds)|pediatric intubation]] because of floppy epiglottis (most common in those <2 years of age) | ||
==Indications== | ==Indications== | ||
*Patients requiring [[Intubation|endotracheal intubation]] | *Patients requiring [[Intubation|endotracheal intubation]] | ||
* | *Foreign body removal (more effective than hyperangulated [[video laryngoscopy]])<ref>Je, S. M., Kim, M. J., Chung, S. P., & Chung, H. S. (2012). Comparison of GlideScope® versus Macintosh laryngoscope for the removal of a hypopharyngeal foreign body: A randomized cross-over cadaver study. Resuscitation, 83(10), 1277–1280.</ref> | ||
*Diagnosis of vocal cord pathology | |||
==Contraindications== | ==Contraindications== | ||
* Absolute: Glottic or supraglottic pathology requiring [[Surgical_airways|surgical airway interventions]] | * Absolute: Glottic or supraglottic pathology requiring [[Surgical_airways|surgical airway interventions]] | ||
* Relative: Anticipated difficult airway that may benefit from [[video laryngoscopy]] or [[awake intubation]] | * Relative: Anticipated difficult airway that may benefit from [[video laryngoscopy]] or [[awake intubation]] with fiberoptics | ||
==Equipment Needed== | ==Equipment Needed== | ||
| Line 18: | Line 25: | ||
* A Macintosh 3 blade or Miller 2 blade are appropriate for most adults | * A Macintosh 3 blade or Miller 2 blade are appropriate for most adults | ||
[[File:Macintosh Blades.jpg|thumb|Macintosh Blades 1-5, from bottom to top]] | [[File:Macintosh Blades.jpg|thumb|Macintosh Blades 1-5, from bottom to top]] | ||
[[File:MAC_MILLER.png|thumb|The Macintosh blade is inserted into the vallecula (left) while the Miller blade is inserted under and lifts the epiglottis (right)]] | |||
==Procedure (Macintosh Blade)== | ==Procedure (Macintosh Blade)== | ||
| Line 37: | Line 45: | ||
''An alternative technique if initially unsuccessful is to purposefully insert the blade into the esophagus and withdrawal until the glottis is visualized'' | |||
==Optimizing Laryngoscopy== | ==Optimizing Laryngoscopy== | ||
| Line 47: | Line 55: | ||
**Use right hand to apply pressure over assistants hand and manipulate trachea until cords are visualized | **Use right hand to apply pressure over assistants hand and manipulate trachea until cords are visualized | ||
**Have assistant maintain position as you deliver tube | **Have assistant maintain position as you deliver tube | ||
*If epiglottis is "floppy" (common in peds), retract blade slightly and lift epiglottis with blade (similar to how Miller blade is used) | *If epiglottis is "floppy" (common in [[Intubation (peds)|peds]]), retract blade slightly and lift epiglottis with blade (similar to how Miller blade is used) | ||
*Can use right hand to lift patients head off bed, when view obtained, have assistant place fist under patient head and use right hand to deliver tube | *Can use right hand to lift patients head off bed, when view obtained, have assistant place fist under patient head and use right hand to deliver tube | ||
==Complications== | ==Complications== | ||
* Dental Trauma (minimize risk while lifting blade upward and away from operator) | * Dental Trauma (minimize risk while lifting blade upward and away from operator) | ||
* Laryngeal Trauma | * Laryngeal Trauma (risk increased with multiple attempts) | ||
* Sympathetic nervous system stimulation leading to tachycardia and hypertension | * Sympathetic nervous system stimulation leading to tachycardia and hypertension | ||
| Line 59: | Line 67: | ||
==External Links== | ==External Links== | ||
*https://litfl.com/direct-laryngoscopy/ | *[https://litfl.com/direct-laryngoscopy/ LITFL: Direct Laryngoscopy] | ||
*https://aneskey.com/direct-laryngoscopy- | *[https://aneskey.com/anatomy-of-direct-laryngoscopy/ Anesthesia Key: Anatomy of Direct Laryngoscopy] | ||
*[https://maricopaemergencymedicine.com/battle-of-the-blades/ COPA STRONG: Battle of the Blades: The Death of DL?] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
Latest revision as of 21:12, 17 April 2024
Overview
- Used to facilitate intubation[1]
- Provides direct line of sight of vocal cords (as opposed to video laryngoscopy)
- Most often utilizes Mac or Miller Blade
- Miller blade more popular in pediatric intubation because of floppy epiglottis (most common in those <2 years of age)
Indications
- Patients requiring endotracheal intubation
- Foreign body removal (more effective than hyperangulated video laryngoscopy)[2]
- Diagnosis of vocal cord pathology
Contraindications
- Absolute: Glottic or supraglottic pathology requiring surgical airway interventions
- Relative: Anticipated difficult airway that may benefit from video laryngoscopy or awake intubation with fiberoptics
Equipment Needed
- Handle with light source
- Macintosh or Miller Blade
- A Macintosh 3 blade or Miller 2 blade are appropriate for most adults
Procedure (Macintosh Blade)
- Place patient into sniffing position
- Use "scissor" technique with right hand to open mouth
- Insert laryngoscope blade into right side of mouth
- Slowly advance blade into mouth while performing "tongue sweep"
- Identify epiglottis
- Advance tip of blade into vallecula
- Lift upward and away from operator to expose glottis
Procedure (Miller Blade)
- Place patient into sniffing position
- Use "scissor" technique with right hand to open mouth
- Insert laryngoscope blade into right side of mouth
- Slowly advance blade into mouth while performing "tongue sweep"
- Identify epiglottis and gently lift with tip of blade
- Lift upward and away from operator to expose glottis
An alternative technique if initially unsuccessful is to purposefully insert the blade into the esophagus and withdrawal until the glottis is visualized
Optimizing Laryngoscopy
- Ensure patient is in sniffing position
- Extension of cervical spine
- Flexion of atlanto-occipital joint
- Bimanual laryngoscopy
- Have assistant place hand over trachea
- Use right hand to apply pressure over assistants hand and manipulate trachea until cords are visualized
- Have assistant maintain position as you deliver tube
- If epiglottis is "floppy" (common in peds), retract blade slightly and lift epiglottis with blade (similar to how Miller blade is used)
- Can use right hand to lift patients head off bed, when view obtained, have assistant place fist under patient head and use right hand to deliver tube
Complications
- Dental Trauma (minimize risk while lifting blade upward and away from operator)
- Laryngeal Trauma (risk increased with multiple attempts)
- Sympathetic nervous system stimulation leading to tachycardia and hypertension
See Also
Airway Pages
- Pre-intubation
- Induction
- Intubation
- Surgical airways
- Post-intubation
External Links
- LITFL: Direct Laryngoscopy
- Anesthesia Key: Anatomy of Direct Laryngoscopy
- COPA STRONG: Battle of the Blades: The Death of DL?
References
- ↑ Peterson K, Ginglen JG, Valenzuela FI, et al. Direct Laryngoscopy. [Updated 2020 Mar 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513224/[Category:Procedures]]
- ↑ Je, S. M., Kim, M. J., Chung, S. P., & Chung, H. S. (2012). Comparison of GlideScope® versus Macintosh laryngoscope for the removal of a hypopharyngeal foreign body: A randomized cross-over cadaver study. Resuscitation, 83(10), 1277–1280.