Trends in Anaesthesia and Critical Care xxx (2016) 1e6

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Trends in Anaesthesia and Critical Care

journal homepage: www.elsevier.com/locate/tacc

Review

Awake video laryngoscopy e A revolution in the management of the

anticipated difficult airway?
J.A. Lohse, T. Piepho, R.R. Noppens*
Department of Anaesthesiology, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany

a r t i c l e i n f o

Article history:
Received 24 January 2016
Received in revised form
16 February 2016
Accepted 16 February 2016

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Management of anticipated difficult airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Video laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Blade design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Predictors for difficult indirect laryngoscopy/video laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
6. Flexible endoscopic intubation vs video laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7. Comparison of awake use of flexible fiberoptic endoscope and video laryngoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
8. Special indication: awake intubation in the upright position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
9. Airway preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
10. Forces, compression, trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
11. Limitations of awake video laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
12. How we perform awake video laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
The authors technical approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
13. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

1. Introduction Cautious patient preparation is essential in order to reduce the

risk of severe hypoxia or even death when difficulties are antici-
In anaesthesia related complications airway management is a pated during airway management.
major factor in terms of morbidity and mortality. Up to 80% of fatal One of the main reasons for serious adverse events during
causalities in consequence of anaesthesia are associated with in- airway management is the careless handling of patients with an
cidents in the context of airway management [1e3]. On the basis of anticipated difficult airway. This is possibly based on emerging new
an expert evaluation most of these incidents are classified as developments and devices (video laryngoscopy, supraglottic de-
potentially avoidable. vices) which may create an illusion of ease and safety which might
not reflect reality. Several reports indicate that not every difficult
airway situation can be managed using a video laryngoscope.
* Corresponding author. Department of Anaesthesiology, University Medical Therefore, several guidelines suggest to maintain spontaneous
Centre of the Johannes Gutenberg-University, Langenbeckstr 1, 55131 Mainz, breathing in an anticipated difficult airway case until the airway is
Germany.
E-mail address: noppens@uni-mainz.de (R.R. Noppens).
secured [4e8].

http://dx.doi.org/10.1016/j.tacc.2016.02.001
2210-8440/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: J.A. Lohse, et al., Awake video laryngoscopy e A revolution in the management of the anticipated difficult
airway?, Trends in Anaesthesia and Critical Care (2016), http://dx.doi.org/10.1016/j.tacc.2016.02.001
2 J.A. Lohse et al. / Trends in Anaesthesia and Critical Care xxx (2016) 1e6
Table 1
Predictors for difficult airway management [4].
Predictors of difficult mask ventilation

Scars, tumor, inflammation, macroglossia

Pathological anatomie of tongue, neck, larynx, pharynx and trachea

Radiotherapy of mouth and neck

Male gender

Age>55

Snoring, Obstructive sleep - apnoea

Desolate dental chart

Beard

Obesity (BMI >30 kg/m2)

Mallampati III/IV

Negative Upper-Lip-Bite-Test

Thyreomental distance >6 cm
By identifying potential problems and predictors for anticipated
difficult airway management, the first step has already been made
in the right direction to avoid potential life threatening complica-
tions. Predictors of difficult mask ventilation and difficult direct
laryngoscopy may overlap in several respects [Table 1].
The current guideline for airway management of the German
Society of Anaesthesia and Intensive Care Medicine (DGAI)
recommend maintaining spontaneous breathing until the airway is
secured [4,9]. To meet this goal the guideline recommends four
approaches:
1 Flexible intubation endoscope (first choice, gold standard)
2 Indirect laryngoscope (video laryngoscope)
3 Intubation via extraglottic device
4 Translaryngeal or transtracheal oxygenation or surgical airway
The main aim of this review is to give a comprehensive overview
about the most recent developments, new guidelines and in-
vestigations about management of anticipated difficult airway with
special regard to a new, upcoming technique: awake video
laryngoscopy.
2. Management of anticipated difficult airway
Intubation under sedation with preserved spontaneous
breathing is the safest technique to prevent several adverse events
such as hypoxia, brain damage and death. Up to the present, awake
flexible endoscopic intubation under topical anaesthesia and
appropriate sedation remains the first choice in managing the
anticipated difficult airway.
Recently, awake video laryngoscopy comes more and more to
the center of attention as an attractive alternative to awake fiber-
optic intubation [10,11]:
3. Video laryngoscopy
Currently, there is a wide, rapidly expanding spectrum of
different video assisted devices [12]. Video laryngoscopes as a tool
to secure the patient's airway is a very popular technique by reason
of several factors: Compared to other tools, learning how to use a
video laryngoscope appears to be easy. Handling and some tech-
nical aspects are well known from classic direct laryngoscopy.
Several publications indicates that around six video laryngoscope-
guided intubations are necessary to achieve a success rate of >90%
Please cite this article in press as: J.A. Lohse, et al., Awake video laryngoscopy e A revolution in the management of the anticipated difficult
airway?, Trends in Anaesthesia and Critical Care (2016), http://dx.doi.org/10.1016/j.tacc.2016.02.001
Predictors of difficult direct laryngoscopy

Mandibular protusion, malocclusion

Prior difficult intubation

Tracheal stenosis/anatomical variety of trachea

Stridor

Prior Radiotherapy of neck/mouth

Prior surgery of larynx/pharynx

Tumors, abscesses of Head, neck or mediastinum

Goiter

Macroglossia (trisomy 21, mucopolysaccharidosis)

Pregnancy

Mallampati III/IV

Limited mouth-opening

Thyreomental distance >6 cm

Restricted mobility of neck

Dysostosis (mandibulo-/maxillofacial)

Short neck or increased neck circumference

Subglottic stenosis
Tracheal stenosis/anatomical variety of trachea
Fig. 1. Angulated blade tip (e.g. C-MAC D-Blade®) follows anatomical structure of the
upper airway.
in less than three minutes intubation time in simulated settings
[13e15]. However, in a recent publication a significant higher
number of intubations using a GlideScope® have been found
necessary in order to sufficiently visualize, place the tip of the
endotracheal tube at the level of the glottis and introduce the tube
into the trachea [16]. This study indicates that more uses might be
necessary than originally thought in order to master video
laryngoscopy.
Compared to classic, direct laryngoscopy, video-assisted laryn-
goscopy attempts allow a superior view on first trial. The advan-
tages and disadvantages of different types of video laryngoscopes
are well examined and compared in various studies [12,17,18]. Only
in the last couple of years video laryngoscopes have become a
common, widely used tool in clinical routine and emergency
situations.
4. Blade design
Sufficient sedation and topical anaesthesia is mandatory for
visualization of the glottis using a video laryngoscope in the awake
patient. At the same time, soft tissue in the oral cavity and the
pharyngeal area should be as minimal as possible manipulated in
order to avoid discomfort for the patient.
Video laryngoscopes using an angulated blade (e.g. GlideScope®,
C-MAC D-Blade® or McGrath®) open a door to a whole new
 J.A. Lohse et al. / Trends in Anaesthesia and Critical Care xxx (2016) 1e6
Table 2
Predictors for difficult video laryngoscopy [23].
Cormack-Lehane Grade 3 or 4 view at direct laryngoscopy

Abnormal neck anatomy, including radiation changes, neck scar, large neck circumference, neck pathology

limited mandibular protrusion

decreased sternothyroid distance
perspective: The view around the corner without displacing
pharyngeal tissue [12,19].
Because of the angulated blade the camera in the tip follows the
anatomical structure and results in minimal manipulation of
airway tissue [Fig. 1]. A direct view on the glottis is no longer
possible - and necessary. Compared to classic direct laryngoscopy
as well as video laryngoscopy with Macintosh-like blade, the
angulated blade design provides a superior view on the glottis
without using a lot of pressure to surrounding anatomical struc-
tures [20,21].
However, the new perspective involves emerging challenges:
The better visualization of the glottis results not necessarily in a
greater intubation success [22]. According to the angulated tip, the
tube has to pass the way around the corner and than has to be
guided inside the trachea. In that case placement of the tube be-
comes the key step in intubation process instead of just visualiza-
tion of the glottis. These findings are based on experiences with
patients under general anaesthesia, but it is also an issue that has to
be considered in patients with maintained spontaneous breathing.
5. Predictors for difficult indirect laryngoscopy/video
laryngoscopy
The identification of characteristics or test methods to evaluate
predictors for difficult indirect laryngoscopy in the anaesthetized
patient has not yet been sufficiently investigated. Mucosal bleeding
and hypersecretion of the respiratory tract may result in poor
visualization due to obstruction of the camera chip. Very little is
known about predictors for difficult or failed video laryngoscopy.
Today, the only known predictors for impossible indirect laryn-
goscopy seems to be an altered neck anatomy and a significantly
reduced mouth opening, making it impossible to introduce the
device in the oral cavity. So far, only predictors of a difficult intu-
bation using the GlideScope® have been reported in anaesthetized
patients and possibly transfer to other types of video laryngoscopes
[Table 2] [23].
6. Flexible endoscopic intubation vs video laryngoscopy
Video laryngoscopes capture a territory that has been reserved
to glass-fiber optics heretofore: Intubation of awake, spontaneously
breathing patients. The inhibition threshold to perform an awake
fiberoptic/endoscopic intubation seems to be particularly higher
than the awareness of the expected benefits of this method and
possible risks of an intubation under general anesthesia. There are
manifold reasons for this conduct. Fiberoptic intubation is relatively
uncommonly practiced in daily routine. Only approximately 1% of
all intubations are done by a flexible intubating endoscope [24]. As
a challenging approach to learn, fiberoptic intubation is often not as
well trained as it should be. Even experts are in need to practice
regularly to retain their skills [25]. The required equipment and the
technique must be completely mastered. Inexperience in using the
technique is even treated as contraindication for flexible fiberoptic
intubation.
Using a video laryngoscope in anaesthetized patients becomes
more and more familiar and is a frequently used technique with a
high success rate and a steep learning curve. This combination
Please cite this article in press as: J.A. Lohse, et al., Awake video laryngoscopy e A revolution in the management of the anticipated difficult
airway?, Trends in Anaesthesia and Critical Care (2016), http://dx.doi.org/10.1016/j.tacc.2016.02.001
3
makes the device a tempting solution for airway management in
the awake patient.
The use of video laryngoscopy for tracheal intubation under
local anaesthesia has been recently described in multiple publica-
tions: Initial experiences were made in 13 patients with anticipated
difficult airway under local anaesthesia and mild sedation. The
intubations were performed using a combination of GlideScope®
and pre-loaded flexible bronchoscope with 100% success rate, good
acceptance of the patients and a mean intubation time of 68 s [26].
In a study cohort of 50 morbidly obese patients, awake indirect
laryngoscopy turned out as reasonable technique with a success
rate of 96% within the first three attempts and a mean intubation
time of 158 s [27]. In this case, the possible source of errors is
inconsistence in executing sedation and airway anesthesia, which
depended on the personal preferences of the anaesthesiologists.
7. Comparison of awake use of flexible fiberoptic endoscope
and video laryngoscope
With regard to success rate on the first attempt, time to intu-
bate, ease of intubation and patients comfort, awake endoscopic
intubation has been compared to awake video laryngoscopy
(McGrath Series 5®) [28]. Patients with anticipated difficult intu-
bation (n ¼ 92) were given lidocaine 10% metered spray, applied
directly on the mucosa of the pharynx, a transtracheal injection of a
bolus of 100 mg lidocaine and lubrication of oral airway with
lidocaine 2% 1e2 min before attempt of intubation. Remifentanil
infusion was administered to a Ramsay sedation score of 2e4.
Seven patients were excluded, because transtracheal injection
failed. There were 2 patients (video laryngoscopy group) who did
not tolerate the procedure.
There were no differences in time to tracheal intubation be-
tween awake fiberoptic intubation (80 s; IQR 58e117) and awake
video laryngoscopy (62 s; IQR 55e109). Intubation success on the
first attempt was 79% for fiberoptic intubation and 71% for video
laryngoscopy. Both groups were comparable in terms of ease of
intubation and patient comfort.
In a similar study investigating awake fiberoptic vs video lar-
yngoscopic (C-MAC D-Bade®) nasal intubation in 100 patients (50/
group) under topical anaesthesia (noninvasive, following a protocol
that lasts more than ten minutes) and mild sedation (remifentanil,
midazolam) [29]. The median time for intubation was shorter
using the video laryngoscope (38 s; IQR 24e65) compared to
fiberoptic intubation (94 s, IQR 48e323). There were no differences
in the success rate of intubation (96%) and satisfaction of the
anaesthesiologist and patients.
The patients were prepared for awake fiberoptic intubation and
awake video laryngoscopic intubation (C-MAC D-Blade®) in a
similar fashion. Again, no difference in satisfaction between awake
fiberoptic intubation and awake video laryngoscopic intubation,
just like a related study, where no difference in discomfort between
both groups was reported. Both techniques led to a high degree of
patient's acceptance.
A study examining awake fiber optic intubation and awake
video laryngoscopy using GlideScope in 64 morbidly obese patients
presented similar results: No differences concerning patients'
response to intubation, adverse effects or patients' satisfaction
4 J.A. Lohse et al. / Trends in Anaesthesia and Critical Care xxx (2016) 1e6
were found [30]. Both techniques were performed under sedation
(target controlled remifentanil infusion to a Ramsay sedation scale
of 3) and topical anaesthesia.
8. Special indication: awake intubation in the upright
position
Securing the airway of a spontaneously breathing patient in
face-to-face position can be challenging. Awake intubation in up-
right position can reduce a few risks associated with intubation in
traditional position and is often the only way to secure the airway
not just in entrapped emergency patients but also in patients with
severe dyspnea and a constricted airway.
The direct comparison of flexible fiberoptic endoscope and Gli-
deScope® in 23 healthy subjects showed a shorter time (39 s) until
the highest grade view was achieved using the video laryngoscope
[31]. The authors conclude that awake indirect laryngoscopy may be
an alternative to flexible fiberoptic endoscopy in a face to face po-
sition, particularly among providers inexperienced in flexible
fiberoptic intubation However, flexible fiberoptic endoscopy may be
the more reliable tool in reaching high grade views of the larynx.
Based on this study, two different types of video laryngoscopes
were investigated focusing on their usefulness in intubating pa-
tients in the upright position: GlideScope® (angulated blade) and C-
MAC® (Macintosh-Blade) [32]. Topical anaesthesia of 31 healthy
volunteers combined three different approaches: nebulization of
lidocaine through a mouthpiece, lidocaine sprayed into the phar-
ynx using the MADgic® and gargling of lidocaine. 5 volunteers were
excluded on the basis of inadequate topical anaesthesia. Following
topical anaesthesia, participants underwent upright video laryn-
goscopy, twice with GlideScope® and twice with C-MAC® (four
interventions total per participant), using in the inverted “handle
down” (“tomahawak”) e position. The participants' sitting position
could be modified and optimized by the operator. Using Glide-
Scope® resulted in faster initial glottis view (median, IQR: 7,
6.5e8 s), compared to C-MAC® (9.8e13 s). There were no statistical
relevant differences between the two devices with regard to time
until best view was achieved (p ¼ 0.238). However, use of Glide-
Scope® resulted in a better glottic view (POGO%, median (IQR): 61
(47.5e87.5) vs 5 (2.5e20.5); Cormack & Lehane: 1.5 (1e2) vs. 2
(2e3)), compared to C-MAC®. Using GlideScope®, subjects were
able to remain in commonly seating position with only minor
changes. In contrast, using the C-MAC® (Macintosh-blade), a rela-
tively lower sitting position and hyperextended neck improved the
view on the glottis. The authors conclude that a video laryngoscope
with an angulated blade seems to be the better choice to get the
best view in face-to-face-position.
9. Airway preparation
Sufficient topical anaesthesia is the requirement for a successful
performance for awake intubation. Potentially, the quality of local
anesthesia has a greater influence on the patients' acceptance than
Fig. 2. The MADgic® for spraying topical anesthesia.
Please cite this article in press as: J.A. Lohse, et al., Awake video laryngoscopy e A revolution in the management of the anticipated difficult
airway?, Trends in Anaesthesia and Critical Care (2016), http://dx.doi.org/10.1016/j.tacc.2016.02.001
the level of sedation. Several techniques for topical anaesthesia of
the airway have been described. Sometimes several techniques are
combined to achieve an optimal effect for the patient.
Lidocaine in a wide spectrum of concentrations is the most
commonly used anesthetic for topical anesthesia. Local anaes-
thetics should be used cautiously because of their well-known side
effects like arrhythmias and diminishing convulsive threshold. The
maximum dose for topical application is not clear, a range of 4 and
9 mg/kg body weight have been published [11,33].
Lidocaine gel to anaesthetize the nasal mucosa, lidocaine as a
gargle solution, application as a spray and the nebulization using a
face mask are all well established methods for topical anaesthesia.
The anaesthetic results might improve due to a combination of the
different applications.
The effect of chewing lidocaine soaked gauze was unconvincing
in preparation of morbidly obese patients for awake intubation
[34]. This technique had no effect on gagging, compared to a pla-
cebo group.
The MADgic® device with its anatomically shaped tip is an
appropriate tool to apply local anaesthetic onto hypopharynx and
glottis and is used by many clinicians for topical anesthesia [35,36]
[Fig. 2]. However, the number of studies examining the effective-
ness of this device is limited.
Superior laryngeal nerve block and transtracheal injection
through the crico-thyroid membrane using lidocaine has been
shown to achieve a high quality of anaesthesia to the upper airway
[37,38]. Compared to the noninvasive approach, both more invasive
techniques bear potential risks like bleeding, accidental injection to
nearby anatomical structures and failure. Particularly in patients
with distorted anatomy of face or neck (frequently appearing in
maxillofacial and ENT surgery), transcricoidal puncture and supe-
rior laryngeal nerve block may not be suitable methods.
10. Forces, compression, trauma
Dental compression and airway trauma have always been cen-
tral subjects in airway management. Particularly if an awake intu-
bation has to be performed, this matter should move into focus.
Currently only little is known about potential injury of the airway
using awake video laryngoscopy. In a multicenter trial comparing
C-MAC D-Blade® to GlideScope® in anaesthetized patients, airway
injury was rare (lip injury C-MAC®: 3.5% vs. GlideScope®: 2.9%,
Dental injury: 0.2% vs. 0%, tracheal injury 0% vs 0.2% and pharyngeal
injury: 0.7% vs. 1.3%) [39].
Several studies examined forces applied on the front teeth and
anatomical structures of the oral cavity using video laryngoscopes
in patients under general anaesthesia. Four types of laryngoscopes
(Macintosh, GlideScope®, C-MAC®, McGrath®) were compared with
each other with special regard to force on patients maxillary in-
cisors or gums. The study included 25 patients per group; the
procedure was performed under general anesthesia [20]. Compared
to direct laryngoscopy using a Macintosh blade, all video laryngo-
scopes examined were safer for the patient in terms of the forces
applied to the maxillary incisors and number of insertion attempts.
There were no differences measured regarding to the applied forces
between the video laryngoscopes [20,21,40,41].
In another study the forces to the anatomical structures of a
manikin were examined during laryngoscopy using either Glide-
Scope® or direct Macintosh laryngoscope [42]. Three sensors were
attached to the concave surface of the blade. Compared to laryn-
goscopy with Macintosh laryngoscope, the GlideScope® provided
equal or superior visibility of the glottis. It also showed lower
median peak, average and impulse forces applied to the tongue
base. In both laryngoscopes the distal sensor measured the most
force applied to anatomical structures.
 J.A. Lohse et al. / Trends in Anaesthesia and Critical Care xxx (2016) 1e6 5

This finding is in contrast to another study, also comparing

Glidescope® to the traditional Macintosh laryngoscope [41]. The
GlideScope® was found to distribute the forces more homoge-
neously, whereas the forces generated with Macintosh laryngo-
scope were mostly at the area of the blade tip (GlideScope® 8 þ 4 N
vs. Macintosh laryngoscope 40 þ 14 N, p < 0.001).

11. Limitations of awake video laryngoscopy

Awake video laryngoscopy is not suitable for each airway and

each type of patient. In patients with abnormal neck anatomy, in
particular post-radiation and large obstructing tumors, awake
video laryngoscopy might not be an appropriate choice [23]. In
these patients the major limitations are a very small oropharyngeal
space, very rigorous, non elastic tissue which can be hardly moved
and a loss of straight line from the mouth to the glottis. Addition-
ally, a very limited mouth opening may prevent the video laryn-
goscope blade from being placed in the oropharynx. Some patients
present with obstructions below the vocal cords, making it
impossible to advance the tube in the trachea. These patients likely
benefit from flexible fiberoptic intubation.
Sufficient mucosal anaesthesia of oropharynx, glottis and tra- Fig. 4. Topical anesthesia to the larynx.
chea is a mandatory requirement for both, awake video laryngos-
copy and awake fiberoptic intubation. Topical anesthesia can be
applied using the working channel of the endoscope (“spray as you
go”) which allows topicalization throughout the airway. Despite
several very promising publications using various techniques for
applying topical anaesthesia to the airway, currently no adequate,
sufficient and safe method has been identified.
Hypersalivation and mucosal bleeding can make fiberoptic
intubation challenging or even impossible. By using a video
laryngoscope an oropharyngeal space can be created. This gives the
opportunity to achieve an overview and allows suction under
visualization. Anaesthesiologists deciding to perform awake video
laryngoscopy should have a solid background in the practical
handling of video laryngoscopes. Expertise, sufficient exercise and
experience in analog-sedation as well as topical anesthesia are at
least as important as in awake fiberoptic intubation.

Fig. 5. Positioning of the endotracheal tube brought into a “hockstick” shape.

12. How we perform awake video laryngoscopy

Various approaches have been published to achieve this goal,

but the large amount of possibilities may be confusing.

The authors technical approach

Sedation and airway preparation: Most patients receive an oral

Fig. 3. Topical anesthesia of oral cavity and upper pharynx.
pre-medication using a benzodiazepine before they reach the
operating room. After monitoring has been established, the patient
receives 0.1 mg/kg body weight sufentanil intravenously. Lidocaine
10% is sprayed at tongue and upper pharynx twice [Fig. 3].
After giving enough time for i.v. medication and topical anes-
thesia to work, a video laryngoscope with a curved blade (e.g. C-
MAC D-Blade®, GlideScope®, McGrath®) is inserted cautiously. Once
the epiglottis is visualized, 2 ml lidocaine 2% is administered at the
lower pharynx and the epiglottis using the MADgic® device [Fig. 4].
The video laryngoscope is removed afterwards. After a two minute
wait the video laryngoscope is re-inserted and the glottis is visu-
alized. Another spray of topical anesthesia is applied on the glottis
and sub-glottic region and again the video laryngoscope removed.
After another 2 min waiting time the glottis is visualized and the

Please cite this article in press as: J.A. Lohse, et al., Awake video laryngoscopy e A revolution in the management of the anticipated difficult
airway?, Trends in Anaesthesia and Critical Care (2016), http://dx.doi.org/10.1016/j.tacc.2016.02.001
6 J.A. Lohse et al. / Trends in Anaesthesia and Critical Care xxx (2016) 1e6
tube brought into “hockeystick” shape using a malleable stylet is
carefully advanced through the vocal cords [Fig. 5]. After the correct
placement of the tube and confirmation using capnography, gen-
eral anaesthesia is induced.
13. Conclusion
Awake video laryngoscopy might be an appropriate alternative
to flexible endoscopic intubation in many patients with an antici-
pated difficult airway. Compared to flexible fiberoptic intubation,
the technique allows a comparable success rate and an acceptable
length of the procedure. A high level of acceptance (of patients and
users) can be reached with this technique.
Particularly for the group of providers which are inexperienced
and unfamiliar with the handling of a flexible endoscope, awake
video laryngoscopy might be an option in special situations to
maintain spontaneous breathing until the airway is secured.
However, the medical knowledge of how to prepare the airway and
an adequate level of sedation is the prerequisite to be successful. It
has to be emphasized that awake video laryngoscopy should not be
perceived as a replacement for flexible endoscopic intubation. To
learn, train and to maintain the skill to perform awake endoscopic
intubation is important today as ever before.
References
[1] J.H. Schiff, A. Welker, B. Fohr, A. Henn-Beilharz, U. Bothner, H. Van Aken, et al.,
Major incidents and complications in otherwise healthy patients undergoing
elective procedures: results based on 1.37 million anaesthetic procedures, Br.
J. Anaesth. 113 (2014) 109e121.
[2] T.M. Cook, N. Woodall, J. Harper, J. Benger, Major complications of airway
management in the UK: results of the Fourth National Audit Project of the
Royal College of Anaesthetists and the Difficult Airway Society. Part 2:
intensive care and emergency departments, Br. J. Anaesth. 106 (2011)
632e642.
[3] N. Woodall, C. Frerk, T.M. Cook, Can we make airway management (even)
safer?elessons from national audit, Anaesthesia 66 (2011) 27e33.
[4] T. Piepho, E. Cavus, R. Noppens, C. Byhahn, V. Dorges, B. Zwissler, et al., S1
guidelines on airway management : Guideline of the German Society of
Anesthesiology and Intensive Care Medicine, Anaesthesist 64 (2015) 27e40.
[5] G. Schalte, S. Rex, D. Henzler, [Airway management], Anaesthesist 56 (2007)
837e855, 56-7.
[6] J.J. Henderson, M.T. Popat, I.P. Latto, A.C. Pearce, Difficult Airway Society
guidelines for management of the unanticipated difficult intubation, Anaes-
thesia 59 (2004) 675e694.
[7] G. Enterlein, C. Byhahn, [Practice guidelines for management of the difficult
airway: update by the American Society of Anesthesiologists task force],
Anaesthesist 62 (2013) 832e835.
[8] T. Heidegger, H.J. Gerig, C. Keller, Comparison of algorithms for management
of the difficult airway, Anaesthesist 52 (2003) 381e392.
[9] T. Piepho, R.R. Noppens, V. Do € rges, B. Zwissler, A. Timmermann, S1-Leitlinie
Atemwegsmanagement, Anaesth. Intensivmed. 56 (2015) 505e523.
[10] I. Ahmad, C.R. Bailey, Time to abandon awake fibreoptic intubation? Anaes-
thesia 71 (2016) 12e16.
[11] Y. Leung, F.X. Vacanti, Awake without complaints: maximizing comfort during
awake fiberoptic intubation, J. Clin. Anesth. 27 (2015) 517e519.
[12] N. Pirlich, T. Piepho, H. Gervais, R.R. Noppens, Indirect laryngoscopy/video
laryngoscopy. A review of devices used in emergency and intensive care
medicine in Germany, Med. Klin. Intensivmed. Notfmed. 107 (2012) 521e530.
[13] D.C. Ray, C. Billington, P.K. Kearns, R. Kirkbride, K. Mackintosh, C.S. Reeve, et
al., A comparison of McGrath and Macintosh laryngoscopes in novice users: a
manikin study, Anaesthesia 64 (2009) 1207e1210.
[14] G.L. Savodelli, E. Schiffer, C. Abegg, V. Baeriswyl, F. Clergue, J.L. Waeber,
Learning curves of the glidescope, the McGrath and the Airtraq laryngoscopes:
a manikin study, Eur. J. Anaesthesiol. 26 (2009) 554e558.
[15] T. Piepho, K. Weinert, F.M. Heid, C. Werner, R.R. Noppens, Comparison of the
McGrath® Series 5 and GlideScope® Ranger with the Macintosh laryngoscope
by paramedics, Scand. J. Trauma Resusc. Emerg. Med. 19 (2011) 4.
[16] P. Cortellazzi, D. Caldiroli, A. Byrne, A. Sommariva, E.F. Orena, I. Tramacere,
Defining and developing expertise in tracheal intubation using a GlideScope®
for anaesthetists with expertise in Macintosh direct laryngoscopy: an in-vivo
longitudinal study, Anaesthesia 70 (2015) 290e295.
[17] R.R. Noppens, S. Geimer, N. Eisel, M. David, T. Piepho, Endotracheal intubation
using the C-MAC(R) video laryngoscope or the Macintosh laryngoscope: a
Please cite this article in press as: J.A. Lohse, et al., Awake video laryngoscopy e A revolution in the management of the anticipated difficult
airway?, Trends in Anaesthesia and Critical Care (2016), http://dx.doi.org/10.1016/j.tacc.2016.02.001
prospective, comparative study in the ICU, Crit. Care. 16 (2012) R103.
[18] R.R. Noppens, S. Mobus, F. Heid, I. Schmidtmann, C. Werner, T. Piepho, Eval-
uation of the McGrath Series 5 videolaryngoscope after failed direct laryn-
goscopy, Anaesthesia 65 (2010) 716e720.
[19] R.R. Noppens, C. Werner, T. Piepho, [Indirect laryngoscopy : Alternatives to
securing the airway], Anaesthesist 59 (2010) 149e161.
[20] R.A. Lee, A.A. van Zundert, R.L. Maassen, P.A. Wieringa, Forces applied to the
maxillary incisors by video laryngoscopes and the Macintosh laryngoscope,
Acta Anaesthesiol. Scand. 56 (2012) 224e229.
[21] B. Pieters, R. Maassen, E. Van Eig, B. Maathuis, J. Van Den Dobbelsteen, A. Van
Zundert, Indirect videolaryngoscopy using Macintosh blades in patients with
non-anticipated difficult airways results in significantly lower forces exerted
on teeth relative to classic direct laryngoscopy: a randomized crossover trial,
Minerva Anestesiol. 81 (2015) 846e854.
[22] S. Frohlich, L. Borovickova, E. Foley, E. O'Sullivan, A comparison of tracheal
intubation using the McGrath or the Macintosh laryngoscopes in routine
airway management, Eur. J. Anaesthesiol. 28 (2011) 465e467.
[23] M.F. Aziz, D. Healy, S. Kheterpal, R.F. Fu, D. Dillman, A.M. Brambrink, Routine
clinical practice effectiveness of the Glidescope in difficult airway manage-
ment: an analysis of 2004 Glidescope intubations, complications, and failures
from two institutions, Anesthesiology 114 (2011) 34e41.
[24] J.A. Law, I.R. Morris, P.A. Brousseau, S. de la Ronde, A.D. Milne, The incidence,
success rate, and complications of awake tracheal intubation in 1,554 patients
over 12 years: an historical cohort study, Can. J. Anaesth. 62 (2015) 736e744.
[25] E. Fitzgerald, I. Hodzovic, A.F. Smith, 'From darkness into light': time to make
awake intubation with videolaryngoscopy the primary technique for an
anticipated difficult airway? Anaesthesia 70 (2015) 387e392.
[26] F.S. Xue, C.W. Li, G.H. Zhang, X.Y. Li, H.T. Sun, K.P. Liu, et al., GlideScope-
assisted awake fibreoptic intubation: initial experience in 13 patients,
Anaesthesia 61 (2006) 1014e1015.
[27] A.R. Moore, T. Schricker, O. Court, Awake videolaryngoscopy-assisted tracheal
intubation of the morbidly obese, Anaesthesia 67 (2012) 232e235.
[28] C.V. Rosenstock, B. Thogersen, A. Afshari, A.L. Christensen, C. Eriksen,
M.R. Gatke, Awake fiberoptic or awake video laryngoscopic tracheal intuba-
tion in patients with anticipated difficult airway management: a randomized
clinical trial, Anesthesiology 116 (2012) 1210e1216.
[29] A. Kramer, D. Muller, R. Pfortner, C. Mohr, H. Groeben, Fibreoptic vs video-
laryngoscopic (C-MAC((R)) D-BLADE) nasal awake intubation under local
anaesthesia, Anaesthesia 70 (2015) 400e406.
[30] A.A. Abdellatif, M.A. Ali, GlideScope videolaryngoscope versus flexible fiber-
optic bronchoscope for awake intubation of morbidly obese patient with
predicted difficult intubation, Middle East J. Aanaesthesiol 22 (2014)
385e392.
[31] N.A. Silverton, S.T. Youngquist, M.P. Mallin, J.R. Bledsoe, E.D. Barton,
E.D. Schroeder, et al., GlideScope versus flexible fiber optic for awake upright
laryngoscopy, Ann. Emerg. Med. 59 (2012) 159e164.
[32] A.S. Drenguis, J.N. Carlson, GlideScope vs. C-MAC for Awake Upright Laryn-
goscopy, J. Emerg. Med. 49 (2015) 361e368.
[33] P. Maheshwari, Awake nasal intubation and topical anaesthesia: how and
how much? Anaesthesia 70 (2015) 879.
[34] A. Moore, P.O. Hetu, O. Court, W.L. Shan, R. Hatzakorzian, A. El-Bahrawy, et al.,
The effect of chewing lidocaine soaked gauze on intubation conditions during
awake videolaryngoscopy: a randomised controlled trial in the morbidly
obese, Acta Anaesthesiol. Belg 65 (2014) 55e59.
[35] K. Supbornsug, I.P. Osborn, Topicalization of the airway using the glidescope,
Anesth. Analg. 99 (2004) 1263e1264.
[36] F.S. Xue, Q.Y. Yang, X. Liao, J.H. Liu, S.Y. Tong, Topical anesthesia of the airway
using fibreoptic bronchoscope and the MADgic atomizer in patients with
predicted difficult intubation, Can. J. Anaesth. 54 (2007) 951e952.
[37] A.R. Webb, S.S. Fernando, H.R. Dalton, J.E. Arrowsmith, M.A. Woodhead,
A.R. Cummin, Local anaesthesia for fibreoptic bronchoscopy: transcricoid in-
jection or the “spray as you go” technique? Thorax 45 (1990) 474e477.
[38] S. Hamad, M. Al-Alawi, N. Devaney, A. Subramaniam, S. Lane, Evaluation of the
efficacy of transcricoid lignocaine as adjunctive local anaesthesia for fiberoptic
bronchoscopy, Ir. J. Med. Sci. 184 (2015) 273e276.
[39] M.F. Aziz, R.O. Abrons, D. Cattano, E.O. Bayman, D.E. Swanson, C.A. Hagberg, et
al., First-attempt intubation success of video laryngoscopy in patients with
anticipated difficult direct laryngoscopy: a multicenter randomized controlled
trial comparing the C-MAC D-blade versus the glidescope in a mixed provider
and diverse patient population, Anesth. Analg. 122 (2016) 740e750.
[40] T. Russell, S. Khan, J. Elman, R. Katznelson, R.M. Cooper, Measurement of
forces applied during Macintosh direct laryngoscopy compared with Gli-
deScope(R) videolaryngoscopy, Anaesthesia 67 (2012) 626e631.
[41] M. Carassiti, V. Biselli, S. Cecchini, R. Zanzonico, E. Schena, S. Silvestri, et al.,
Force and pressure distribution using Macintosh and GlideScope laryngo-
scopes in normal airway: an in vivo study, Minerva Anestesiol. 79 (2013)
515e524.
[42] T. Russell, C. Lee, M. Firat, R.M. Cooper, A comparison of the forces applied to a
manikin during laryngoscopy with the GlideScope and Macintosh laryngo-
scopes, Anaesth. Intensive Care 39 (2011) 1098e1102.