Keywords

Indications

  • Difficult/impossible direct laryngoscopy [1, 2]

    • Congenital abnormalities of airway

    • High Mallampati grade [3]

    • Dental appliances

  • Failed direct laryngoscopy

Contraindications

  • Absolute

    • Morbid obesity

    • Airway foreign body

    • Expanding neck mass

  • Relative

    • Abnormal airway anatomy

    • Airway lesions (e.g., abscess, mass, epiglottitis) that change oropharyngeal anatomy

    • Acute care where concomitant resuscitation requires a well-lit room

    • Lack of familiarity or experience with procedure

    • “Can’t oxygenate, can’t ventilate” situation

Materials and Medications

  • Intravenous (IV) access, O2, monitor

  • Ambu bag with supplemental oxygen

  • Suction (Yankauer and tubing)

  • Lighted stylet (LS)

  • Endotracheal tube (ETT) 2.5-mm larger than LS with 10-cc syringe

  • Surgilube

  • Intubation medications (this procedure may be performed as an awake or a rapid sequence intubation)

Methods

  1. 1.

    Preoxygenate.

  2. 2.

    Positioning:

    1. (a)

      Sniffing position, pinna at the level of the sternal notch (Fig. 15.1).

    2. (b)

      Skip sniffing position if cervical spine injury is suspected.

  3. 3.

    LS-ETT unit preparation:

    1. (a)

      Insert the wire stylet into the device.

    2. (b)

      Check the LS light.

    3. (c)

      Lubricate the LS with K-Y Jelly.

    4. (d)

      Position the LS just distal to the Murphy eye.

    5. (e)

      Curve the LS to user preference at the line labeled “bend here.”

  4. 4.

    Administer intubation medications.

  5. 5.

    Have an assistant apply cricoid pressure.

  6. 6.

    Grasp and elevate the patient’s jaw near the corner of the mouth with the operator’s thumb, index, and middle fingers, elevating the tongue and epiglottis along with it.

  7. 7.

    Using the free hand, insert the LS-ETT unit into the oropharynx and advance (Fig. 15.2).

  8. 8.

    Use the midline glow in the neck to guide insertion of the LS-ETT (Fig. 15.3).

  9. 9.

    Bright light below the thyroid prominence indicates correct placement of the ETT tip.

  10. 10.

    Dim or blurred light or light at the thyroid prominence suggests incorrect positioning (Fig. 15.4).

  11. 11.

    If the transilluminated light is dim, off center, or not seen, esophageal positioning must be considered:

    1. (a)

      Withdraw the LS-ETT unit approximately 2–5 cm.

    2. (b)

      Reposition the patient’s head and neck.

    3. (c)

      Reattempt according to steps 5–8.

  12. 12.

    Placement of the ETT (Fig. 15.5):

    1. (a)

      Hold the LS-ETT unit steady with one hand.

    2. (b)

      Check the depth of the ETT and adjust accordingly.

    3. (c)

      Release the LS latch that holds the ETT to the LS.

    4. (d)

      While holding the ETT in position, gently slide the LS out from the ETT.

    5. (e)

      Inflate the ETT balloon.

  13. 13.

    Confirm ETT placement (continuous end-tidal CO2 [EtCO2], colorimetric capnometry).

  14. 14.

    Secure the ETT.

Fig. 15.1
figure 1

Sniffing position, pinna at the level of the sternal notch

Full size image
Fig. 15.2
figure 2

Grasp and elevate the patient’s jaw near the corner of the mouth with the operator’s thumb, index, and middle fingers, elevating the tongue and epiglottis along with it. Using the free hand, insert the LS-ETT unit into the oropharynx and advance

Full size image
Fig. 15.3
figure 3

(a–c) Use the midline glow in the neck to guide insertion of the LS-ETT. (d) Bright light below the thyroid prominence indicates correct placement of the ETT tip

Full size image
Fig. 15.4
figure 4

Dim or blurred light or light at the Laryngeal prominence suggests incorrect positioning

Full size image
Fig. 15.5
figure 5

(a) Hold the LS-ETT unit steady with one hand. (b) Check the depth of the ETT and adjust accordingly. (c) Release the LS latch that holds the ETT to the LS. (d) While holding the ETT in position, gently slide the LS out from the ETT

Full size image

Pearls and Pitfalls

  • Pearls

    • LS-ETT complex: Typically the classic “hockey-stick” shape with the 90° curve just proximal to the cuff is recommended [2].

    • Dimming the room lights will enhance transillumination.

    • Pulling the wire stylet out from the LS-ETT unit will make it more pliable and may facilitate its placement in the trachea and removal of the LS.

    • Some LS devices may start to blink after 30 seconds to prevent bulb overheating.

    • The LS may be used with nasotracheal intubation, intubation through a laryngeal mask airway (LMA), or conventional laryngoscopy to enhance success.

  • Pitfalls

    • LS intubation should not be used as an emergency airway alternative by a proceduralist unfamiliar with the technique:

      • It is technically complicated and more challenging than many other airway adjuncts in the standard difficult airway algorithm.

      • One study compared the use of four rescue airway devices in the difficult airway algorithm. A success rate of only 20% was achieved with the Trachlight™ lighted stylet on the first attempt when in the hands of the novice physician when used as a rescue device in their difficult airway algorithm [4].

    • In very thin patients, transillumination may be visualized quite well even when the LS-ETT unit is in the esophagus:

      • When the unit is in the esophagus, typically the light will be more diffused.

      • When the unit is in the trachea, the transilluminated area will be well circumscribed.

    • In obese patients or patients with significant neck tissue, the transilluminated light from the LS-ETT unit may be dim despite correct positioning in the trachea.