Devices for difficult emergency airway management outside the operating room in adults
- Erik G Laurin, MD, FAAEM
Erik G Laurin, MD, FAAEM
- Professor of Emergency Medicine
- University of California, Davis, Medical Center
- Aaron E Bair, MD, MSc, FAAEM, FACEP
Aaron E Bair, MD, MSc, FAAEM, FACEP
- Professor of Emergency Medicine
- University of California, Davis
- Section Editor
- Ron M Walls, MD, FRCPC, FAAEM
Ron M Walls, MD, FRCPC, FAAEM
- Editor-in-Chief — Adult and Pediatric Emergency Medicine
- Section Editor — Adult Resuscitation
- Neskey Family Professor of Emergency Medicine
- Harvard Medical School
- Brigham and Women's Hospital
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Emergency clinicians commonly encounter difficult airways. Estimates run as high as 20 percent for difficult airways  and approximately 1 percent for failed airways . Difficulty in airway management is variably defined, and includes the need for excess lifting force, poor view of the vocal cords, multiple or prolonged attempts, multiple operators, and the use of multiple intubating devices.
A wide range of devices have been developed to aid in the management of the difficult airway. They incorporate a variety of fiberoptic, video, optical, and mechanical technologies to enable the operator to obtain a better view of the larynx and facilitate passage of an endotracheal tube (ETT) into the trachea. These devices are useful for management of the difficult or failed airway and for routine intubation.
This topic review will discuss the types of devices designed to facilitate management of difficult and failed airways. The overall approach to the management of such airways is reviewed elsewhere. (See "Approach to the difficult airway in adults outside the operating room" and "The failed airway in adults" and "The difficult pediatric airway".)
We define a stylet as a device loaded within the lumen of an endotracheal tube (ETT) in order to assist tracheal placement. A standard malleable metal stylet is inserted into an ETT to lend greater stiffness and thereby improve control. In contrast, specialized stylets facilitate intubation in situations of poor glottic exposure and if adapted with advanced optics, can provide a better view of the glottis than is obtained with direct laryngoscopy.
Endotracheal tube introducers (gum elastic bougie) — The endotracheal tube introducer (ETI) is an effective and inexpensive adjunct to difficult airway management that is easy to use. We recommend that an ETI be readily available in every emergency department. The technique for using these devices and evidence of their effectiveness are reviewed separately. (See "Endotracheal tube introducers (gum elastic bougie) for emergency intubation".)
- Murphy, M, Walls, RM. Identification of the Difficult and Failed Airway. In: Manual of Emergency Airway Management, 3rd, Walls, R, Murphy, MF (Eds), Lippincott, Williams and Wilkins, Philadelphia 2008. p.81.
- Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46:328.
- Soh CR, Kong CF, Kong CS, et al. Tracheal intubation by novice staff: the direct vision laryngoscope or the lighted stylet (Trachlight)? Emerg Med J 2002; 19:292.
- Margolis GS, Menegazzi J, Abdlehak M, Delbridge TR. The efficacy of a standard training program for transillumination-guided endotracheal intubation. Acad Emerg Med 1996; 3:371.
- Wik L, Naess AC, Steen PA. Intubation with laryngoscope versus transillumination performed by paramedic students on manikins and cadavers. Resuscitation 1997; 33:215.
- Hung OR, Pytka S, Morris I, et al. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea. Anesthesiology 1995; 83:509.
- Berns SD, Patel RI, Chamberlain JM. Oral intubation using a lighted stylet vs direct laryngoscopy in older children with cervical immobilization. Acad Emerg Med 1996; 3:34.
- Tsutsui T, Setoyama K. [A clinical evaluation of blind orotracheal intubation using Trachlight in 511 patients]. Masui 2001; 50:854.
- Hung OR, Pytka S, Morris I, et al. Lightwand intubation: II--Clinical trial of a new lightwand for tracheal intubation in patients with difficult airways. Can J Anaesth 1995; 42:826.
- Kanaide M, Fukusaki M, Tamura S, et al. Hemodynamic and catecholamine responses during tracheal intubation using a lightwand device (Trachlight) in elderly patients with hypertension. J Anesth 2003; 17:161.
- Rhee KY, Lee JR, Kim J, et al. A comparison of lighted stylet (Surch-Lite) and direct laryngoscopic intubation in patients with high Mallampati scores. Anesth Analg 2009; 108:1215.
- Amornyotin S, Sanansilp V, Amorntien V, Tirawat P. Effectiveness of lightwand (Trachlight) intubation by 1st year anesthesia residents. J Med Assoc Thai 2002; 85 Suppl 3:S963.
- Konishi A, Kikuchi K, Sasui M. [Cervival spine movement during light-guided orotracheal intubation with lightwand stylet (Trachlight)]. Masui 1998; 47:94.
- Turkstra TP, Pelz DM, Shaikh AA, Craen RA. Cervical spine motion: a fluoroscopic comparison of Shikani Optical Stylet vs Macintosh laryngoscope. Can J Anaesth 2007; 54:441.
- Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical spine motion: a fluoroscopic comparison during intubation with lighted stylet, GlideScope, and Macintosh laryngoscope. Anesth Analg 2005; 101:910.
- Hirabayashi Y, Hiruta M, Kawakami T, et al. Effects of lightwand (Trachlight) compared with direct laryngoscopy on circulatory responses to tracheal intubation. Br J Anaesth 1998; 81:253.
- Kihara S, Brimacombe J, Yaguchi Y, et al. Hemodynamic responses among three tracheal intubation devices in normotensive and hypertensive patients. Anesth Analg 2003; 96:890.
- Favaro R, Tordiglione P, Di Lascio F, et al. Effective nasotracheal intubation using a modified transillumination technique. Can J Anaesth 2002; 49:91.
- Fan KH, Hung OR, Agro F. A comparative study of tracheal intubation using an intubating laryngeal mask (Fastrach) alone or together with a lightwand (Trachlight). J Clin Anesth 2000; 12:581.
- Agrò F, Hung OR, Cataldo R, et al. Lightwand intubation using the Trachlight: a brief review of current knowledge. Can J Anaesth 2001; 48:592.
- Hung OR, Stewart RD. Lightwand intubation: I--a new lightwand device. Can J Anaesth 1995; 42:820.
- Levitan RM, Kush S, Hollander JE. Devices for difficult airway management in academic emergency departments: results of a national survey. Ann Emerg Med 1999; 33:694.
- Birmingham B, Mentzer SJ, Body SC. Laryngeal mask airway for therapeutic fiberoptic bronchoscopic procedures. J Cardiothorac Vasc Anesth 1996; 10:519.
- Benumof JL. A new technique of fiberoptic intubation through a standard LMA. Anesthesiology 2001; 95:1541.
- Ianchulev SA. Through-the-LMA fiberoptic intubation of the trachea in a patient with an unexpected difficult airway. Anesth Analg 2005; 101:1882.
- Jöhr M, Berger TM. Fiberoptic intubation through the laryngeal mask airway (LMA) as a standardized procedure. Paediatr Anaesth 2004; 14:614.
- Hershey MD, Hannenberg AA. Gastric distention and rupture from oxygen insufflation during fiberoptic intubation. Anesthesiology 1996; 85:1479.
- Afilalo M, Guttman A, Stern E, et al. Fiberoptic intubation in the emergency department: a case series. J Emerg Med 1993; 11:387.
- Mlinek EJ Jr, Clinton JE, Plummer D, Ruiz E. Fiberoptic intubation in the emergency department. Ann Emerg Med 1990; 19:359.
- Schafermeyer RW. Fiberoptic laryngoscopy in the emergency department. Am J Emerg Med 1984; 2:160.
- Blanda M, Gallo UE. Emergency airway management. Emerg Med Clin North Am 2003; 21:1.
- Hamilton PH, Kang JJ. Emergency airway management. Mt Sinai J Med 1997; 64:292.
- Sakles JC, Mosier J, Chiu S, et al. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med 2012; 60:739.
- Kory P, Guevarra K, Mathew JP, et al. The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill. Anesth Analg 2013; 117:144.
- Tremblay MH, Williams S, Robitaille A, Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope videolaryngoscope. Anesth Analg 2008; 106:1495.
- Brown CA 3rd, Bair AE, Pallin DJ, et al. Improved glottic exposure with the Video Macintosh Laryngoscope in adult emergency department tracheal intubations. Ann Emerg Med 2010; 56:83.
- Noppens RR, Möbus S, Heid F, et al. Evaluation of the McGrath Series 5 videolaryngoscope after failed direct laryngoscopy. Anaesthesia 2010; 65:716.
- Piepho T, Fortmueller K, Heid FM, et al. Performance of the C-MAC video laryngoscope in patients after a limited glottic view using Macintosh laryngoscopy. Anaesthesia 2011; 66:1101.
- Griesdale DE, Liu D, McKinney J, Choi PT. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth 2012; 59:41.
- Su YC, Chen CC, Lee YK, et al. Comparison of video laryngoscopes with direct laryngoscopy for tracheal intubation: a meta-analysis of randomised trials. Eur J Anaesthesiol 2011; 28:788.
- De Jong A, Molinari N, Conseil M, et al. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Med 2014; 40:629.
- Huang WT, Huang CY, Chung YT. Clinical comparisons between GlideScope video laryngoscope and Trachlight in simulated cervical spine instability. J Clin Anesth 2007; 19:110.
- Robitaille A, Williams SR, Tremblay MH, et al. Cervical spine motion during tracheal intubation with manual in-line stabilization: direct laryngoscopy versus GlideScope videolaryngoscopy. Anesth Analg 2008; 106:935.
- Kill C, Risse J, Wallot P, et al. Videolaryngoscopy with glidescope reduces cervical spine movement in patients with unsecured cervical spine. J Emerg Med 2013; 44:750.
- Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. Crit Care Med 2015; 43:636.
- Sakles JC, Javedani PP, Chase E, et al. The use of a video laryngoscope by emergency medicine residents is associated with a reduction in esophageal intubations in the emergency department. Acad Emerg Med 2015; 22:700.
- Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial. JAMA 2017; 317:483.
- Mosier J, Chiu S, Patanwala AE, Sakles JC. A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department. Ann Emerg Med 2013; 61:414.
- Jones PM, Turkstra TP, Armstrong KP, et al. Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope. Can J Anaesth 2007; 54:21.
- Sakles JC, Kalin L. The effect of stylet choice on the success rate of intubation using the GlideScope video laryngoscope in the emergency department. Acad Emerg Med 2012; 19:235.
- Turkstra TP, Harle CC, Armstrong KP, et al. The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use. Can J Anaesth 2007; 54:891.
- Lieberman, N, Hakim, AR, Lemberg, L, et, al. Trueview® Blade Improves Laryngeal View When Compared to Macintosh Blade. Anesthesiology 2003; 99:A565.
- Khan, Y, Jain, S, Khan, RM, et, al. Use of Macintosh, Trueview, and Airtraq Laryngoscopes for Intubation of Immobilized Manikins Head. Anesthesiology 2007; 107:A588.
- Lu Y, Jiang H, Zhu YS. Airtraq laryngoscope versus conventional Macintosh laryngoscope: a systematic review and meta-analysis. Anaesthesia 2011; 66:1160.
- Maharaj CH, O'Croinin D, Curley G, et al. A comparison of tracheal intubation using the Airtraq or the Macintosh laryngoscope in routine airway management: A randomised, controlled clinical trial. Anaesthesia 2006; 61:1093.
- Maharaj CH, Costello JF, McDonnell JG, et al. The Airtraq as a rescue airway device following failed direct laryngoscopy: a case series. Anaesthesia 2007; 62:598.
- Turkstra TP, Pelz DM, Jones PM. Cervical spine motion: a fluoroscopic comparison of the AirTraq Laryngoscope versus the Macintosh laryngoscope. Anesthesiology 2009; 111:97.
- Hirabayashi Y, Fujita A, Seo N, Sugimoto H. A comparison of cervical spine movement during laryngoscopy using the Airtraq or Macintosh laryngoscopes. Anaesthesia 2008; 63:635.
- Di Marco P, Scattoni L, Spinoglio A, et al. Learning curves of the Airtraq and the Macintosh laryngoscopes for tracheal intubation by novice laryngoscopists: a clinical study. Anesth Analg 2011; 112:122.
- Maharaj CH, Costello JF, Harte BH, Laffey JG. Evaluation of the Airtraq and Macintosh laryngoscopes in patients at increased risk for difficult tracheal intubation. Anaesthesia 2008; 63:182.
- Endotracheal tube introducers (gum elastic bougie)
- Lighted stylets
- Optical stylets
- Flexible endoscope
- EXTRAGLOTTIC DEVICES
- ADVANCED LARYNGOSCOPES
- Video laryngoscopes
- - Evidence and use of video laryngoscopes in emergency settings
- - Types of video laryngoscopes
- Optical laryngoscopes
- SURGICAL AIRWAY DEVICES
- SUMMARY AND RECOMMENDATIONS