Correspondence

Use of the GlideScope for

double-lumen
endobronchial intubation
Dr Russell et al. recently published
the results of a randomised
controlled trial comparing the
GlideScope with the Macintosh
laryngoscope for double-lumen endobronchial intubation [1]. We
would like to thank our colleagues
from Toronto for performing this
study, which provides useful information on the use of GlideScope
for this purpose, but wish to comment on some aspects of this study
compared with a preliminary observational study published in 2012
[2].
Firstly, the operators were similar in both centres with regard to
training with the GlideScope and
also with the concomitant use of
the GlideScope with double-lumen
endobronchial intubation. The ratio
of operators to cases was comparable, with 30 operators/80 cases
(38%) in Toronto and 17/50 (34%)
at our institution.
Secondly, the authors reported
a 17% failure for rst attempt at
intubation with the GlideScope,
compared with 9% with the Macintosh, stating that these results are
similar to those in our study. We
indeed reported a failure rate of
26% on the rst attempt with the
GlideScope in our study, but the
time allowed to succeed was 60 s,
as opposed to 120 s in Toronto. In
Quebec City, our failure rate was
4% at 120 s (unpublished data).
Thirdly, Russell et al. reported
that three out of 40 cases had cuff
rupture with the GlideScope, but
none in the Macintosh group.

Anaesthesia 2014, 69, 180194

Unfortunately, they did not mention how many subjects had upper
teeth. In our study, we had 17/50
(34%) subjects with upper teeth and
we had no tracheal cuff ruptures.
This occurs frequently in the presence of upper teeth when using a
double-lumen endobronchial tube.
We described in 1999 a technique
to help minimise this problem, simply by inserting the tube in the
mouth before the laryngoscope, and
we use it successfully with the
GlideScope as well [3].
Fourthly, the main difference
between these two studies is that we
used the GlideRite Double-Lumen
Tube Stylet (GR-DLT-S) we
designed in 2009, in collaboration
with Verathon Medical Inc. (Bothell, Washington, USA). This semirigid stylet is a safe and effective
way to ease the insertion of the
double-lumen endobronchial tube
with minimal trauma. In Toronto,
the original malleable stylet supplied with the double-lumen endobronchial tube was used. The
operator shaped it to replicate the
curve of the GlideScope or the
Macintosh blades curvature as
needed. In our experience, this original aluminium stylet is too malleable and does not maintain its
curvature when facing any obstruction in the upper airway. We postulate that the difference in the rate
of success at 120 s (96% in our
study vs 83% in the Toronto study)
might be explained by the use of
different stylets, knowing that operators had similar expertise with the
GlideScope.
We agree with the authors that
the GlideScope is not an easy device
to use for double-lumen endobron-

2014 The Association of Anaesthetists of Great Britain and Ireland

chial intubation, particularly with

novices. Our conclusion is that
using GlideScope in combination
with a double-lumen endobronchial
tube requires training. The presence
of upper teeth and small mouth
opening might add some degree of
difculty but the use of special
techniques and facilitating tools,
such as the GR-DLT-S, can greatly
improve the success rate of intubation. In our teaching institution, we
encourage the use of the GlideScope/DLT/GR-DLT-S combination
for every case in order to develop
our expertise with these devices and
to enable us to be more efcient
when facing a difcult intubation.
J. S. Bussi
eres
J. Somma
A. Rousseau
Institut universitaire de cardiologie
et de pneumologie de Qu
ebec
Qu
ebec, Canada
Email: jbuss@criucpq.ulaval.ca
L. Harvey
Laval University
Qu
ebec, Canada
JSB is the designer of the GlideRite
Double-Lumen Tube Stylet distributed by Verathon Medical Inc.,
Burnaby, Vancouver, Canada. No
other external funding or no
competing interests declared. Previously posted on the Anaesthesia
correspondence
website:
www.
anaesthesiacorrespondence.com.

References
1. Russell T, Slinger P, Roscoe A, McRae K,
Van Rensburg A. A randomised controlled trial comparing the GlideScope
and the Macintosh laryngoscope for
double-lumen endobronchial intubation.
Anaesthesia 2013; 68: 12538.
2. Bussieres JS, Martel F, Somma J, Morin S,
Gagne N. A customized stylet for Glide-

181

Anaesthesia 2014, 69, 180194

Scope(R) insertion of double lumen
tubes. Canadian Journal of Anesthesia
2012; 59: 4245.
3. Fortier G, St-Onge S, Bussieres J. Two
other simple methods to protect the tracheal cuff of a double-lumen tube.
Anesthesia and Analgesia 1999; 89:
1064.
doi:10.1111/anae.12581

Retrograde tracheal
intubation for bleeding
and fragmenting airway
tumours
Vieira and colleagues report emergency awake retrograde tracheal
intubation for a patient with critical
airway obstruction from a friable,
haemorrhagic periglottic tumour,
claiming it may be the safest
option [1]. We agree that retrograde techniques may have particular utility in airways compromised
by bleeding or secretions, which
render approaches relying on visualisation difcult or impossible.
We have concerns, however,
that, for the patient they describe,
this approach may not be the safest
airway plan.
The authors describe use of a
guidewire for their retrograde intubation. Whilst guidewires are stiffer
and can predictably traverse a narrowed airway with less risk of
impingement or coiling than alternatives (such as epidural catheters),
they have a drawback: they may
cause more trauma. This would be
of major importance for their
patient with critical obstruction.
Trauma is possible either during

182

Correspondence

initial passage of the wire across the

tumour or during the subsequent
pulling of the wire xed to the
Murphys eye of the tracheal tube.
For the latter, tension on the guidewire may result in impingement of
the wire or afxed tube into the
anterior structures of the airway,
especially the tumour. This may
result in severe bleeding or tumour
fragmentation. In Dharas review of
retrograde techniques he calls this a
cheese wire effect and tumour in
the path of access to the larynx is a
contra-indication to a retrograde
approach [2]. Since the patient had
already received superior laryngeal
nerve blocks, there are added risks of
aspiration in a patient with an unprotected upper airway. This would have
turned a drama into a crisis.
We agree that a proactive,
awake front-of-neck technique is a
good rst choice: we conclude that
insertion of a cuffed tube via a cricothyroidotomy or tracheostomy
under local anaesthesia is arguably
safer in this complex, risky, uncertain and dynamic scenario [3].
D. R. Ball
M. Stallard
Dumfries and Galloway Royal
Inrmary
Dumfries,UK
Email: michael.stallard@nhs.net
DRB has received equipment for
evaluation, teaching and use from
Aircraft Medical, Cook Medical,
Dolphys, Freelance Surgical, Smiths
Medical, Storz Medical and Trucorp. No other external funding or
competing interests declared. Previously posted on the Anaesthesia

correspondence website: www.anaes

thesiacorrespondence.com.

References
1. Vieira D, Lages N, Dias J, Maria L, Correia
C. Ultrasound-guided retrograde intubation. Anaesthesia 2013; 68: 10766.
2. Dhara SS. Retrograde tracheal intubation. Anaesthesia 2009; 64: 10941104.
3. Watson SJ, Ball DR. Letter 3. British Journal of Anaesthesia 2012; 109: 4601.
doi:10.1111/anae.12571

A reply
We thank Drs Ball and Stallard for
their letter related to our article [1]
in which we describe a new application of ultrasound in airway management. We used a guidewire
because, in our department, we
have had better results compared
with epidural catheters, which occasionally become kinked or coiled.
We use the soft tip of the guidewire
and continuously observe the
tumour and the possibility of guidewire tension by direct laryngoscopy.
If we feel resistance and too much
tension on the guidewire, leading to
the possibility of a cheese wire
effect [2], we stop and revert to
Plan B, which could be a front of
neck technique. We did not choose
cricothyrotomy or tracheostomy as
a Plan A because they are more
invasive and take longer to perform
compared with retrograde intubation. Our main objective using
ultrasound was to make retrograde
intubation safer and more predictable. In conclusion, retrograde
ultrasound-guided intubation is

2014 The Association of Anaesthetists of Great Britain and Ireland

Copyright of Anaesthesia is the property of Wiley-Blackwell and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.