The GlideScope for tracheal intubation in patients with grade IV modified Cormack and Lehane

The GlideScope video laryngoscope (GSVL; Verathon Medical, British Colombia, Canada) is a new intubating device. It was designed to provide a better view of the glottis without the need for alignment of the oral, pharyngeal and tracheal axes. We used it for intubating an 11-year-old child with pneumonia, skeletal deformities and facial dysmorphic features which made endotracheal intubation difficult. The patient required semi-urgent intubation, which was not possible by Macintosh laryngoscope (Penlon, Abingdon, UK), and the GlideScope was used for successful intubation. The 11-year-old male patient had mental retardation, cerebral palsy and skeletal deformities (kyphoscoliosis and bilateral foot deformity), contracted upper limbs and dysmorphic features of the face. He was bed-ridden and had nasogastric tube feeding with repeated admission for aspiration pneumonia as his family refused percutaneous gastrostomy or jejunostomy, but there was no previous admission to ICU or intubation. The patient was admitted this time again for aspiration pneumonia. He was treated with antibiotics on the ward and was kept on intravenous crystalloids with oxygen supplementation for 1 day, but his oxygen saturation dropped below 90% with borderline arterial blood gas (ABG) on 15 l/min with a nonrebreathing mask and he became more tachypnoeic, his chest was full of secretions and he had a weak cough. His chest radiograph worsened but he was maintaining his blood pressure. Neurologically, there was no change in the sensorium. A decision was made to move the patient to ICU and start noninvasive ventilation. Unfortunately, this lasted for only a short time as no mask would fit him because his facial dysmorphic features caused a large leak without improvement in oxygen saturation and ABG. So, we planned for endotracheal intubation and mechanical ventilation. After discussion with the primary team and re-assessment of his airway we decided to involve an otolaryngologist for possible tracheostomy which would also help with his ventilation in ICU and long-term toilet of the chest with protection of his airway and reduce the possibility of aspiration while using the nasogastric feed. His intubation was anticipated to be difficult as he had long prominent incisors, with an inter-incisor gap of 2 cm, a high arch palate and receding chin. He had a stiff neck and the atlanto-occipital extension was completely limited (perhaps because of his contracture). Mallampati assessment could not be done as the patient was not cooperative. The family consented and the patient was moved quickly to theatre with oxygen. On the operating table it was difficult to lie him straight as he had severe kyphoscoliosis so we used rolled towels on the side to support him. It was difficult to perform a tracheostomy under local anaesthesia as he was mentally retarded (not cooperative) and he would not have tolerated any sedation. The nasogastric tube was removed after suctioning (feeding had already stopped more than 24 h earlier). All facilities for difficult intubation were prepared as per our hospital protocol including a GlideScope, fibre-optic scope and cricithyrotomy set. With 100% oxygen, saturation was maintained at around 88%. It was difficult to fix the mask on his face. So inhalational induction was started with sevoflurane and 100% oxygen. When the patient was induced, laryngoscopy was carried out with a size 3 Macintosh blade. The laryngeal view was grade IV modified Cormack and Lehane (MCLS) and the glottic opening was not viewed. Then, without wasting time in further attempts, we attempted to use the GlideScope. As the cervical spine was totally immobile with a small inter-incisor gap, using the GlideScope was difficult and we could hardly place it in the patient's mouth. Although we could not obtain a clear laryngoscopic view, we could at least see part of the glottis. A size 6 cuffed endotracheal tube on a stylet was negotiated through the glottis and bilateral air entry ensued. Tracheostomy was carried out uneventfully by an otolaryngologist. The patient was on mechanical ventilation in ICU for 1 week without any problems and was then moved to the ward with the tracheostomy and a Swedish nose. The use of the GlideScope in this case prevented the patient from having any further desaturation, as it helped us to intubate the patient on the very first attempt the GlideScope was introduced. Since its commercial introduction in 2002, numerous studies have indicated that the GSVL can provide laryngeal visualization during orotracheal intubation that is similar or superior to the Macintosh direct laryngoscope (MDL), and that it is an effective device for difficult airway management. The GlideScope has improved the laryngeal view and provided better glottic exposure in patients with expected difficult airway and also in patients requiring general anaesthesia for elective surgery without difficult airway.1–4 The GlideScope has an exaggerated blade curvature due to addition of a camera at the inflection point of the blade, which allows for 60° blade angulation with enhanced optics that give a view of the glottis without the need to align the oral and tracheal axis and that makes intubation easier. In contrast, a poor laryngeal view was frequently noticed as the cause of failed intubations with the Macintosh laryngoscope.5,6 Not only does it gives a good option when it is used for those with difficulty in mobilizing the neck and modified Cormack and Lehane (MCLS) grade III or IV by direct laryngoscopy, but also it can be used for assessing the airway after induction and intubating those patients with dysmorphic features.1,3,4

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