Difficult tracheal intubation: modern methods for solving
Difficult tracheal intubation is defined as “the inability to visualize by an experienced anesthesiologist any portion of the glottis after repeated attempts at direct laryngoscopy”. The incidence of difficult laryngoscopy reaches 8 % (Crosby et al., 1998). The incidence of difficult intubation in general is 1 : 100 intubations, failed intubation — 1 : 2,000 (Barnard O. et al., 2000). In the structure of anesthetic mortality, mortality associated with difficult intubation reaches 30 % (Miller R.D., 2007), and the incidence of “impossibility of any intubation or ventilation” ranges from 0.01 to 2 cases per 10,000 intubations (Bellhouse S.P. et al., 1996; Linkins K. et al., 2003). In the United States, there are annually registered up to 1 million of tracheal intubation conditions in emergency situations, both in and outside the hospital. About 95 % of intubations are successfully performed by anesthesiologists and emergency physicians, while the paramedics carry out a successful tracheal intubation only in 45 % of cases, indicating different levels of skills. According to Wang et al. (2011), Hubble et al. (2010), the number of successful tracheal intubation depends on the clinical experience, and is being improved with it. The authors found that in order to achieve successful intubation skills, it is necessary to perform not less than 20 difficult intubations. It is also necessary to improve the material and technical base in order to conduct difficult intubation manipulation by both young professionals, and experienced anesthesiologists and physicians of other specialties. The most common cause of a failed intubation is the inability to visualize the vocal cords. Videolaryngoscopy is a method that helps to improve the quality of understanding and perception and, consequently, to increase the “respiratory education” of doctors. Distinctive feature of videolaryngoscopy is that the visualization of anatomical structures takes place through the screen, like broncho- and endoscopes. According to Griesdale (2012), videolaryngoscopy by 80 % improves the view of the larynx as compared to direct laryngoscopy. Videolaryngoscopy have a large screen that allows you to visualize the structure of the respiratory system in real time more easily and quickly. This feature also allows the teacher to monitor and demonstrate the correctness of the tracheal intubation. Videolaryngoscopy allows you to visualize anatomical structures: the vocal cords, glottis in situations when by means of direct laryngoscopy it is impossible or difficult that reduces the risk of failed tracheal intubation. At the same time, data on the use of videolaryngoscopy in clinical practice are insufficient. Despite the published reviews and accumulated experience, techniques and indications for the use of these devices are covered incompletely. Our experience of using videolaryngoscopy is more than 6 years, both in the everyday practice of anesthesiologist, and the training of doctors — interns and students, and it allowed to identify the characteristic features of tracheal intubation. First of all, it concerns the technique of laryngoscopy during intubation. Unlike conventional laryngoscopy, when laryngoscopic blade is inserted into the right corner of the mouth and is held up to right palatine arches, blade of videolaryngoscope is put from the midline. The mistake is too deep introduction of the blade and the associated difficulty in visualizing the glottis. For a correct and quick visualization of the glottis and epiglottis, the introduction of the blade should be careful and step by step, at an average language line, repeating its anatomical shape with a constant image control. Glottis from the entrance of the esophagus should be differentiated, focusing on the following topographical landmarks: the epiglottis, vocal cords, corniculate and cuneiform tubercles. In this regard, according to recent recommendations and studies, tracheal intubation involves 4 steps (30 seconds for all stages): stage 1 — zero time — the blade is introduced into the oral cavity; stage 2 — visualization of the epiglottis and vocal cords; stage 3 — the best visualization of the entrance into the trachea; stage 4 — the introduction of the endotracheal tube into the trachea. Thus, the use of videolaryngoscopy provides valuable information not only at the time of intubation attempts, but also when training doctor interns, anesthetists, emergency physicians, enables to identify errors in the technique of tracheal intubation. As a result, it allows us to work and secure — to teach the technique of tracheal intubation, and to improve existing skills during a difficult intubation. Introduction of videolaryngoscopy in anesthetic practice is a real help for the standard fibreoptic laryngoscopy and in orotracheal intubation, including complex tracheal intubation. Mastering videolaryngoscopy is easier, as videolaryngoscope structure allows the best visualization of the laryngeal structures, and understanding intubation technique by interns reduces the risk of a failed intubation. Teaching emergency physicians the technique of tracheal intubation, both by direct laryngoscopy and videolaryngoscopy method, can improve the quality of emergency medical care for patients in critical situations and transport stages, providing clear airway, oxygenation and ventilation.
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