| 1. Use the device for most easy / routine cases until you are very comfortable with its use. That way, when you need it for a particularly difficult airway case you will already be quite familiar with the mechanics of the device. In one study [140], primary intubation with the device was successful in 98 percent of 1,755 cases and rescued failed direct laryngoscopy in 94 percent of 239 cases. |
| 2. When placing the GlideScope, insert it slightly to the left of the midline to ensure adequate room to the right of the device to get the tube into the mouth. This is particularly important when large diameter tubes are inserted, such as the double lumen tubes used for thoracic surgery or the wide-diameter tubes with embedded electrodes used in many thyroid surgery cases. |
| 3. When placing the endotracheal tube, start by placing it gently under direct vision and then switch to the monitor view once it is has been gently placed deep into the oropharynx. This two-phase approach is recommended to reduce the chance of causing harm or injury to one of the tonsillar pillars or to the soft palate. |
| 4. The angulation of the tip of the endotracheal tube is very important. Too little a bend, and the endotracheal tube tip points to the esophagus and not the glottic aperture; too much of a bend and the endotracheal tube tip tends to get caught on the anterior tracheal wall. A reusable rigid stylet that matches the angulation of the blade is available; it has been shown to be equal in efficacy to a disposable malleable stylet. |
| 5. It is not uncommon that videolaryngoscopy users achieve an excellent view of the glottis but experience difficulty advancing the endotracheal tube into the glottic aperture because of the tube abutting against the anterior tracheal wall. If this happens, withdrawing the stylet by 3 to 5 cm tends to straighten the tip of the tube and propel it in the right direction. Other techniques, such as the “gear stick” technique [30], the “reverse loading” technique [31] or the “J-shape” technique [29] also can be helpful. |
| 6. Paradoxically, maximizing the size of the glottic view with full and complete advancement of the GlideScope into the oropharynx may adversely impact on the ease of intubation. With more limited advancing of the laryngoscope, the “approach angle” of the endotracheal tube is often more amenable to easy passage of the tube into the glottis. That is, the position that provides the best glottic view is generally not the position that makes intubation the easiest, where a “good enough” view is usually the most favorable [141]. Where a suboptimal view is obtained, use of an airway introducer can sometimes be helpful. These include the Eschmann guide [142, 143] the Frova introducer [144] as well as other products. |
| 7. Nasal intubations are surprisingly easy. No stylet is used. Manipulate (flex or extend) the head to ensure easy passage of the tube. Forceps are rarely needed. However, use of regular Magill forceps is difficult in this setting; rather, use a pair of curved intubating forceps should the need arise. |
| 8. Using the GlideScope for awake intubation can be valuable when fiberoptic scopes are unavailable. It is accomplished after the patient's airway has first been well anesthetized with lidocaine or other drug. |
| 9. Remember that the GlideScope can be useful in swapping out endotracheal tubes [145]. |
| 10. Finally, remember that there are situations where the video laryngoscope will fail you, and that these are often unexpected. Always have a backup plan for this eventuality. For me, this usually involves asleep fiberoptic intubation, asleep fiberoptic intubation in conjunction with the GlideScope (as described above), insertion of a supraglottic airway followed by use of a 4 mm fiberscope jacketed by an Aintree catheter, or simply waking up the patient. |