Systematic videolaryngoscopy use: remain aware of the risks

doi:10.21203/rs.3.rs-3401257/v1

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Case Report

Systematic videolaryngoscopy use: remain aware of the risks

https://doi.org/10.21203/rs.3.rs-3401257/v1

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Background:Videolaryngoscopy is a life-saving technique recommended in difficult intubation algorithms in both the operating room and critical care settings. It has demonstrated numerous advantages in terms of increasing the success rate of first-attempt intubations.

However, it is not without risks, notably in terms of injuries to the ENT area. These injuries and their incidence are very rarely described in the large trials promoting the routine use of videolaryngoscopy. This case-control study aims to highlight this risk in order to discuss the promotion of routine videolaryngoscopy use.

Case report: A 52-year-old woman undergoes an inguinal hernia repair under coelioscopy. After two failed attempts of direct laryngoscopy, intubation using videolaryngoscopy is successfully performed on the first attempt. However, in the postoperative period, a lesion resembling a perforation of the anterior pillar of the right tonsillar fossa is discovered. The injury heals well after 10 days of monitoring.

Discussion:Injuries to the ENT area following videolaryngoscopy are not uncommon and are even more frequent than after direct laryngoscopy. This can be explained by a false sense of security induced by a perfect view of the glottis on the screen, a pursuit of this perfect view even when it is not suitable for intubation with a glide scope, and the use of a too rigid stylet.

Conclusion:It is advisable to exercise caution regarding the routine use of videolaryngoscopy until more substantial studies assessing this specific risk are conducted.

Videolaryngoscopy

case report

adverse effect

traumatic lesion

In the midst of discussions about the primary use of videolaryngoscopy in numerous situations, we aim to describe a case of pharyngeal trauma and discuss the risks associated with this technique.

The videolaryngoscope (VL) is a device equipped with an integrated camera on a blade similar to a standard laryngoscope. The role of VL in airway management during intubation with conventional tube in critical care, as well as in the operating room for difficult intubation, has been extensively studied. Various articles demonstrate that VL usage enhances the first-attempt intubation success rate¹ ² ³ ⁴ ⁵ ⁶.

The Glidescope® VL (Fa. Verathon Inc.) is a widely employed videolaryngoscope in operating rooms and critical care units. It is a reliable and user-friendly device, extensively studied for conventional orotracheal intubation⁷. Presently, the literature does not distinguish significant differences between various VL devices⁸.

The anticipated benefits include improved vocal cord visualization, reduced tube-induced injuries to the vocal cords, pharynx, and trachea, along with potentially shorter intubation times and associated desaturation⁹. However, the technique might also lead to mechanical complications, notably laryngeal trauma ¹⁰ ¹¹ ¹².

Recent publications advocate for routine use in critical care and operating rooms, especially in obese patients ¹³ ⁴ ⁵. Nevertheless, this approach remains debatable ³ ¹⁴ ¹⁵.
In this context, we intend to discuss this approach through a clinical case that transpired in our medical facility.

We present a case of a 52-year-old female patient admitted for inguinal hernia repair under coelioscopy. Preoperative assessment revealed a Mallampati score of III, a thyromental distance of over 65mm, and a mouth opening of more than 35mm.

Following two unsuccessful direct laryngoscopy attempts, videolaryngoscopy using GlideScope®-Titanium (Verathon Inc.) with a disposable size 4 laryngoscope blade (2.7mm thickness) was performed. On the screen, vocal cords were entirely visualized, indicating Cormack Lehane grade 1. Intubation with a 7.5mm diameter tube and rigid stylet was accomplished after encountering some resistance during advancement.

The patient was successfully intubated. Post-surgery extubation proceeded smoothly, with minor blood traces during oropharyngeal suctioning.

The on-call anesthetist was alerted for odynophagia. The examination revealed the following findings (Picture 01):

An Ear, Nose, and Throat (ENT) specialist described the injury as a traumatic wound with transfixing injury to the anterior pillar at the upper pole of the right tonsillar fossa, accompanied by hematomas on the right soft palate and right intermaxillary commissure. Suturing was not recommended, and local care with an expected 10-day healing period was advised.

Numerous articles show that VL reduces intubation failure ^{1 2 3 4 5 6} and associated complications, including hypoxemia ^{2 9}, in general surgery as well as in situations of intubation with double-lumen tubes¹⁶.

The use of VL in critical care units has also demonstrated its advantages in terms of first-attempt intubation success^{5 17}, even in situations that are more prone to difficult intubtion¹⁷, particularly in obese subjects¹³. The literature on this topic evolves rapidly, with some advocating for first-line VL use even in routine surgical cases ⁴, some have even adopted this approach¹⁸. However, both French and American medical societies currently recommend VL as a second-line option and highlight specific contraindications : mouth opening < 2.5cm, fixed flexion of the spine, aerodigestive tract tumor ^{19 20} .

Despite its benefits, VL can lead to injuries in the airway in about 1% of cases ¹⁴. These traumas, although often minor, can sometimes be major in 0.3% of cases¹⁴. It has also been shown that VL causes more oropharyngeal injuries compared to direct laryngoscopy, up to 15 times more¹¹. These injuries have generally favorable outcomes¹².

These side effects are scarcely described by major articles highlighting the benefits of VL or recommending it for first-line use, even though they are not insignificant.

Factors contributing to these injuries include

A false sense of security from perfect Cormack 1 views, which might lead to blind advancement of the tube, potentially causing injuries, sometimes, it can even paradoxically complicate intubation by causing the tube to encounter unvisualized oropharyngeal and hypopharyngeal structures, leading to difficulties. The Cormack 1 view mentioned earlier exacerbates the issue as it may encourage excessive force on the tube to bring it into view on the screen, thereby increasing the risk of injury. The literature refers to the "blind spot" of VL²¹.
The search for the Cormack 1 view on the screen, as done in direct laryngoscopy, is common when using a VL device. This is known as the Kovac sign: visualization of the entire glottis and the cricoid cartilage in the subglottic area. However, this view is not suitable for the proper descent of the tube into the subglottic space with this device, which features a hyperangulated blade. With this screen view, the risk is higher for causing injury to the right arytenoid or the anterior tracheal wall ²².
The rigid and hyperangulated metal stylet used with VL can also contribute to injuries, particularly if incorrectly inserted ²².

Management approach to limit the risk

Use a strict algorithm when undergoing a VL intubation²³:

Insert the VL blade into the midline of the mouth and visually control its descent to avoid patient injury with the blade.

Look at the screen, search for the Kovac sign, and inspect the glottis.

Look at the patient's mouth and advance the tube under direct visual control. Once the distal end of the tube is out of sight, shift attention back to the screen.

Look at the screen and seek a view equivalent to Cormack 2, with the distal end of the tube visible. Advance the tube to the entrance of the glottis. Remove the 5 cm stylet. Advance the tube below the glottis, then remove the stylet completely. Inflate the cuff under VL control.

Use a more flexible endotracheal tube introducer, with atraumatic distal end.

If, despite these precautions, a lesion is still caused ¹²:

Seek consultation with an Ear, Nose, and Throat (ENT) specialist.
Treatment is usually conservative with local care and monitoring.
Surgical sutures may be required if there is perforation or the presence of a large mucosal flap.
Antibiotic therapy may be necessary if the laceration is greater than 2 cm.

While VL is an invaluable tool in airway management algorithms, it is essential to acknowledge its higher likelihood of causing upper airway injuries compared to direct laryngoscopy. Until more comprehensive patient studies assess the incidence of these complications, caution might be warranted before recommending routine first-line VL use.

Acknowledgement:

special thanks to Mr. Stéphane Fouquet (State-certified anesthesia nurse) for his precious and active contribution to this work.

• Ethics approval: non applicable

• Consent to participate: acquired
• Consent for publication: Informed consent was obtained from the patient for the publication of the case report.

• Availability of data and materials: the datasets generated and/or analyzed during the current study are available in the supplementary file repository.
• Competing interests: none
• Funding: none
• Authors' contributions: F.D and G.D wrote the main manuscript, P.B described the case, M.R officered and promoted the case, R.Z described the lesions.

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No competing interests reported.

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Systematic videolaryngoscopy use: remain aware of the risks

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Abstract

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Implication Statement

Introduction

Clinical Case

Discussion

Factors contributing to these injuries include

Management approach to limit the risk

Conclusion

Declarations

Acknowledgement:

References

Additional Declarations

Supplementary Files

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