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Understanding Anesthetic

Equipment & Procedures


A Practical Approach

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DVD Contents

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DVD-1 DVD-2
1. Peripheral Intravenous (IV) Cannulation 10. Peripheral Nerve Block Using Peripheral Nerve

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Dwarkadas K Baheti, Anil Agarwal, Sujeet KS Gautam Stimulator (PNS)
Devangi A Parikh, Aparna A Nerurkar
2. General Anesthesia Steps and Technique
Naina P Dalvi 11. Ultrasound-guided Peripheral Nerve Block
2.1 Induction of Anesthesia Manoj R Shahane
2.2 Mask Ventilation
2.3 Endotracheal Intubation
2.4 Laryngeal Mask Airway (LMA) Insertion

o 12. Central Venous Cannulation


Lipika A Baliarsing, Anjana D Sahu
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3. Video Laryngoscopy 13. Radial Artery Cannulation
Manoj R Shahane Lipika A Baliarsing, Anjana D Sahu
4. Proseal Laryngeal Mask Airway (LMA) 14. Pulmonary Artery Catheterization
Insertion Sarita Fernandes
Sheila N Myatra, Jeson R Doctor
4.1 Introducer Tool Guided Insertion 15. Somatosensory-evoked Potential (SSEP)
4.2 Digital Insertion Technique Rajashree U Gandhe, Chinmaya Bhave,
4.3 Bougie Guided Insertion
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Neeta V Karmarkar, Amruta A Ajgaonkar


4.4 Rotation Technique
4.5 LMA Position Confirmation
5. Fiberoptic Intubation
Anil Parakh, Ameya Panchwagh

6. Lung Isolation Techniques


Vijaya P Patil
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6.1 Orientation of Bronchoscopic View


6.2 Double Lumen Tube Insertion
6.3 Arndt Blocker Insertion
6.4 Coopdech Blocker Insertion

7. Neuromuscular Block Monitoring


Falguni R Shah, Preeti A Padwal
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8. Spinal and Combined Spinal–Epidural


Anesthesia
Manjari S Muzoomdar, Preeti G More

9. Caudal Block
Anila D Malde
9.1 Caudal Landmarks
9.2 Caudal Drugs
9.3 Caudal Procedure

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Understanding Anesthetic
Equipment & Procedures

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A Practical Approach

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Editors

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Dwarkadas K Baheti MD
Consultant Anesthesiologist and Pain Physician
Bombay, Lilavati, Shushrusha, and Raheja Hospitals

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Mumbai, Maharashtra, India
Former Professor and Head
Department of Anesthesia and Pain Management
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Bombay Hospital Institute of Medical Sciences
Mumbai, Maharashtra, India

Vandana V Laheri DA MD
Former Professor and Head
Department of Anesthesia
ESI PGIMSR and Mahatma Gandhi Memorial Hospital
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Mumbai, Maharashtra, India


Former Professor
Department of Anesthesia
Lokmanya Tilak Municipal Medical College and General Hospital
Mumbai, Maharashtra, India
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Foreword
Dipankar Dasgupta
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The Health Sciences Publishers


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Understanding Anesthetic Equipment & Procedures: A Practical Approach

First Edition: 2015


ISBN 978-93-5152-124-2
Printed at

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Dedicated to

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Technicians, Engineers, Scientist, and Doctors
Who made Anesthesiology
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What it is today!!!
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Contents

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Contributors xi

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Foreword xv
Preface xvii

Section 1: Historical Perspective


1. Evolution of Anesthesia Practice
Vandana V Laheri, Preeti G More

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2. Anesthesia Equipment in India—A Historical Perspective 18
Vasumathi M Divekar

Section 2: Role of Physical Principles


3. Utility of Physical Principles in Anesthetic Practice 25
Aparna S Budhakar, Shashank A Budhakar
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Sectioin 3: Medical Gases and Distribution System


4. Medical Gas Supply, Storage, and Safety 33
Vandana V Laheri, Amit K Sarkar
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Section 4: Anesthesia Machine and its Components


5. The Anesthesia Machine 61
M Ravishankar

6. Pressure-reducing Valves (Pressure Regulators) 73


Vandana V Laheri
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7. Flowmeters 78
Preeti G More

8. Vaporizers 88
Anjali A Pingle, Mandar V Galande

9. Anesthetic Breathing Systems 113


M Ravishankar

10. Anesthesia Ventilators 124


Anila D Malde

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Understanding Anesthetic Equipment & Procedures: A Practical Approach

Section 5: Airway Equipment


11. Face Masks 137
Naina P Dalvi, Nazmeen I Sayed

12. Laryngoscopes 143

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Naina P Dalvi, Nazmeen I Sayed

13. Tracheal Tubes 161


Naina P Dalvi

14. Double Lumen Tubes and Bronchial Blockers 181

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Vijaya P Patil, Bhakti D Trivedi, Madhavi D Desai

15. Cricothyrotomy: Emergency Surgical Airway of Choice 191

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Vijaya P Patil

16. Supraglottic Airway Devices 197


Sheila N Myatra, Jeson R Doctor

17. Non-rebreathing Valves 212


Prerana N Shah

18. Airways
Prerana N Shah
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19. Ventilating Systems—Manual Resuscitators 223
Prerana N Shah

20. Accessories, Connectors, Bite Block, Magill’s Forceps, Stylet, and Laryngeal Sprays 226
Prerana N Shah

21. Oxygen Therapy Devices and Humidification Systems 233


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Raghbirsingh P Gehdoo, Sohan L Solanki

22. Video Laryngoscopy 239


Manoj R Shahane

23. Fiberoptic Airway Management 242


Anil Parakh, Ameya Panchwagh
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Section 6: Monitoring Equipment


24. Electrocardiogram Monitoring and Defibrillators 263
Samhita Kulkarni, Amit M Vora

25. Pulse Oximeters 268


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Anila D Malde

26. Noninvasive and Invasive Blood Pressure Monitoring 283


Nandini M Dave, Amit Padvi

27. Capnography 288


Dinesh K Jagannathan, Bhavani S Kodali

28. Respiratory Gas Monitoring and Minimum Alveolar Concentration 295


viii Sheila N Myatra, Sohan L Solanki

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Contents

29. Bispectral Index 304


Ajit CS Pillai

30. Temperature Regulation and Patient Warming Devices 311


Satish K Kulkarni

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31. Neuromuscular Blocks and Their Monitoring with Peripheral Nerve Stimulator 315
Falguni R Shah, Preeti A Padwal

32. Pulmonary Function Tests 326


Charulata M Deshpande, Sarika Ingle

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33. Peripheral Venous Cannulation 339
Anil Agarwal, Sujeet KS Gautam, Dwarkadas K Baheti

34. Central Venous and Arterial Cannulation 345

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Lipika A Baliarsing, Anjana D Sahu

35. Pulmonary Artery Catheterization 363


Sarita Fernandes

36. Cardiac Output Monitors


Vasundhra R Atre, Naina P Dalvi

37. Entropy
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380
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Naina P Dalvi, Nazmeen I Sayed

38. Somatosensory-evoked Potentials 385


Rajashree U Gandhe, Chinmaya P Bhave, Neeta V Karmarkar, Amruta A Ajgaonkar

39. Point-of-care Monitoring Equipment 391


Indrani HK Chincholi
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Section 7: Equipment for Central Neuraxial and Regional Blocks


40. Spinal, Epidural, and Combined Spinal–Epidural Anesthesia 413
Manjari S Muzoomdar, Preeti G More

41. Peripheral Nerve Stimulators/Locators, Needles, and Catheters 437


Aparna A Nerurkar, Devangi A Parikh
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42. Ultrasound-guided Blocks 457


Manoj R Shahane

43. Infusion and Syringe Pumps 462


Smita D Sharma
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Section 8: Miscellaneous
44. How to Interpret X-rays, CT Scan, and MRI in Clinical Anesthesia Practice 471
Abhijit A Raut, Prashant S Naphade

45. Equipment for Anesthesia in Remote Locations 487


Aparna A Nerurkar, Devangi A Parikh

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Understanding Anesthetic Equipment & Procedures: A Practical Approach

46. Role of Anesthetist in Preventing Nosocomial Infections 496


Vaibhavi Baxi, Dwarkadas K Baheti

47. Simulators in Anesthesia 504


Nandini M Dave

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Section 9: Maintenance, Safety, and Hazards
48. Cleaning and Sterilization of Anesthetic Equipment 509
Nandini M Dave

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49. Anesthesia: Safety and Prevention of Hazards and Accidents 515
Pradnya C Kulkarni

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Appendices
Appendix 1: Safety Check of Anesthesia Machine 537
M Ravishankar

Appendix 2: Protocol for Checking Anesthetic Equipment 538


M Ravishankar

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Index 541
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Contributors

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Editors

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Dwarkadas K Baheti MD Vandana V Laheri DA MD
Consultant Anesthesiologist and Pain Physician Former Professor and Head
Bombay, Lilavati, Shushrusha, and Raheja Hospitals Department of Anesthesia
Mumbai, Maharashtra, India ESI PGIMSR and Mahatma Gandhi Memorial Hospital
Former Professor and Head
Department of Anesthesia and Pain Management
Bombay Hospital Institute of Medical Sciences
o Mumbai, Maharashtra, India
Former Professor
Department of Anesthesia
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Mumbai, Maharashtra, India Lokmanya Tilak Municipal Medical College and
General Hospital
Mumbai, Maharashtra, India

Contributing Authors
Anil Agarwal MD MNAMS Vaibhavi Baxi DA FCPS DNB
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Professor Consultant Anesthetist


Department of Anesthesia Department of Anesthesia
Sanjay Gandhi Postgraduate Institute of Medical Sciences Lilavati Hospital and Research Centre
Lucknow, Uttar Pradesh, India Mumbai, Maharashtra, India

Amruta A Ajgaonkar MBBS DNB Post-doctoral Fellowship (ISNACC) Chinmaya P Bhave MBBS DNB PDF
in Neuroanesthesia Consultant Anesthesiologist
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Department of Neuroanesthesia Kokilaben Dhirubhai Ambani Hospital and


Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute
Medical Research Institute Mumbai, Maharashtra, India
Mumbai, Maharashtra, India
Shashank A Budhakar MD FRCA
Vasundhra R Atre MD DHA MPhil BA
Consultant
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Senior Consultant
Department of Anesthesia
HPB and Transplant Anesthesiologist
Global Hospitals Lilavati Hospital
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

Lipika A Baliarsing MD Aparna S Budhakar MD FRCA


Professor Consultant
Department of Anesthesia Department of Anesthesia
Topiwala National Medical College and BYL Nair Hospital Jaslok Hospital
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

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Understanding Anesthetic Equipment & Procedures: A Practical Approach

Indrani HK Chincholi MBBS DA MD DNB Rajashree U Gandhe MD


Professor Consultant Neuroanesthesiologist
Department of Anesthesia Kokilaben Dhirubhai Ambani Hospital and Medical
Topiwala National Medical College and BYL Nair Hospital Research Institute
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

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Naina P Dalvi MD DNB MNAMS FCPS DA Sujeet KS Gautam MD FIPP
Additional Professor Assistant Professor
Department of Anesthesia Department of Anesthesia
Lokmanya Tilak Municipal Medical College and Sanjay Gandhi Postgraduate Institute of Medical Sciences

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General Hospital Lucknow, Uttar Pradesh, India
Mumbai, Maharashtra, India
Raghbirsingh P Gehdoo MD DA
Nandini M Dave MD DNB MNAMS PGDHHM PGDMLS Professor

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Additional Professor Department of Anesthesia
Department of Anesthesia Tata Memorial Hospital
Seth GS Medical College and KEM Hospital Mumbai, Maharashtra, India
Mumbai, Maharashtra, India
Sarika Ingle MD
Madhavi D Desai DA DNB
Associate Professor

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Department of Anesthesia, Critical Care, and Pain
Associate Professor
Department of Anesthesia
Topiwala National Medical College and BYL Nair Hospital
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Tata Memorial Centre Mumbai, Maharashtra, India
Mumbai, Maharashtra, India
Dinesh K Jagannathan MBBS DA Diplomate American Board of
Charulata M Deshpande MD DA Anesthesiology Fellowship in Obstetric Anesthesiology
Professor Consultant Anesthesiologist
Department of Anesthesia Department of Anesthesiology
Topiwala National Medical College and BYL Nair Hospital Fortis Malar Hospital
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Mumbai, Maharashtra, India Chennai, Tamil Nadu, India

Vasumathi M Divekar BSc DA MD MNAMS Neeta V Karmarkar MBBS DA DNB Post-doctoral Fellowship
Emeritus Professor (ISNACC) in Neuroanesthesiology
Department of Anesthesia, PDY Patil Medical College Department of Anesthesia
Mumbai, Maharashtra, India Kokilaben Dhirubhai Ambani Hospital and Medical
Research Institute
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Jeson R Doctor MD DNB Mumbai, Maharashtra, India


Assistant Professor
Department of Anesthesia, Critical Care, and Pain Bhavani S Kodali MD
Tata Memorial Hospital Vice Chairman (Clinical Affairs)
Mumbai, Maharashtra, India Department of Anesthesiology
Brigham and Women’s Hospital
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Sarita Fernandes MD Boston, Massachusetts, USA


Additional Professor Associate Professor
Department of Anesthesia Harvard Medical School
Topiwala National Medical College and BYL Nair Hospital Westwood, Massachusetts, USA
Mumbai, Maharashtra, India
Pradnya C Kulkarni MD DA DAFRCA
Mandar V Galande MD Professor and Head
Clinical Assistant Department of Anesthesia
xii Fellow in Cardiac Anesthesia, Narayana Health Care Bomaby Hospital and Medical Research Centre
Bengaluru, Karnataka, India Mumbai, Maharashtra, India

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Contributors

Satish K Kulkarni MD FRCA Preeti A Padwal DNB


Consultant Clinical Associate
Department of Anesthesia Department of Anesthesia
Lilavati Hospital and Research Centre Lilavati Hospital and Research Centre
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

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Samhita Kulkarni DNB Ameya Panchwagh MD
Doctor, Department of Cardiology Junior Consultant
Kikabhai Hospital Department of Anesthesia
Mumbai, Maharashtra, India Global Hospital, Dr ED Borges Road

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Mumbai, Maharashtra, India
Anila D Malde MD DA
Professor Anil Parakh MD
Department of Anesthesia Consultant Anesthesiologist

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Lokmanya Tilak Municipal Medical College and Department of Anesthesia
General Hospital Global Hospital, Dr ED Borges Road
Mumbai, Maharashtra, India Mumbai, Maharashtra, India
Preeti G More MD FPCI Devangi A Parikh MD DNB
Associate Professor
Department of Anesthesia
ESI PGIMSR and Mahatma Gandhi Memorial Hospital

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Department of Anesthesia
Lokmanya Tilak Municipal Medical College and
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Mumbai, Maharashtra, India
General Hospital
Manjari S Muzoomdar MD Mumbai, Maharashtra, India
Consultant Anesthesiologist
Vijaya P Patil MD Diploma in Hospital Administration
Department of Anesthesia
Professor
Breach Candy, Saifee, and Dalvi Hospitals
Department of Anesthesia, Critical Care, and Pain
Mumbai, Maharashtra, India
Tata Memorial Hospital
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Sheila N Myatra MD FICCM Mumbai, Maharashtra, India


Professor
Department of Anesthesia, Critical Care, and Pain Ajit CS Pillai MD
Tata Memorial Hospital Consultant Anesthesiologist
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

Prashant S Naphade MD DNB Anjali A Pingle MBBS DA DNB FRCA


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Radiologist Consultant Anesthesiologist


Department of Radiology, ESIS Hospital Department of Anesthesia
Mumbai, Maharashtra, India PD Hinduja Hospital and Research Centre
Mumbai, Maharashtra, India
Aparna A Nerurkar MD DNB
Additional Professor Abhijit A Raut MD
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Department of Anesthesia Consultant


Lokmanya Tilak Municipal Medical College and Department of Radiology
General Hospital Kokilaben Dhirubhai Ambani Hospital
Mumbai, Maharashtra, India Mumbai, Maharashtra, India

Amit Padvi MD Fellowship in Pediatric Anesthesia (MUHS) M Ravishankar MD DA FRCP


Assistant Professor Professor and Head
Department of Anesthesia Department of Anesthesia and Critical Care
Seth GS Medical College and KEM Hospital Mahatma Gandhi Medical College and Research Institute xiii
Mumbai, Maharashtra, India Puducherry, India

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Understanding Anesthetic Equipment & Procedures: A Practical Approach

Anjana D Sahu MD Manoj R Shahane MD


Assistant Professor Clinical Director, Department of Anesthesia
Department of Anesthesia Overlook Hospital
Topiwala National Medical College and BYL Nair Hospital Summit, New Jersey, USA
Mumbai, Maharashtra, India Director, Ambulatory Surgery Center of Edison

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New Jersey and Metropolitan Surgical Institute
Amit K Sarkar BE PGDIM South Amboy, New Jersey, USA
Deputy General Manager–MES Sales
Department of Health Care Smita D Sharma DNB
Linde India Limited Consultant Anesthetist

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Kolkata, West Bengal, India Department of Anesthesia
Bombay Hospital and Medical Research Centre
Nazmeen I Sayed MBBS DNB PDCC Mumbai, Maharashtra, India
Assistant Professor

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Department of Anesthesia Sohan L Solanki MD PDCC
Lokmanya Tilak Municipal Medical College and Assistant Professor
General Hospital Department of Anesthesia, Critical Care, and Pain
Mumbai, Maharashtra, India Tata Memorial Hospital

Prerana N Shah MD
Additional Professor
Department of Anesthesia
o Mumbai, Maharashtra, India

Bhakti D Trivedi MD
Assistant Professor
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Seth GS Medical College and KEM Hospital Department of Anesthesia, Critical Care, and Pain
Mumbai, Maharashtra, India Tata Memorial Centre
Mumbai, Maharashtra, India
Falguni R Shah MD DNB FCPS MNAMS
Consultant Anesthesiologist Amit M Vora MD DM DNB
Department of Anesthesia Consultant Cardiologist
Lilavati Hospital and Research Centre Kikabhai, Lilavati, and Breach Candy Hospitals
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Mumbai, Maharashtra, India Mumbai, Maharashtra, India


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Foreword

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The editors have come out with the much needed textbook “Understanding Anesthetic Equipment & Procedures:
A Practical Approach.”

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I am exceptionally happy and privileged to write a foreword as most of these contributors are closely acquainted with
me for years. To introduce an editor with his team of authors is one of the most difficult tasks. Hope I am able to do total
justice to them.
The editors have done a fine job in selecting an accomplished group of contributors who are well known in each of

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their respective academic inclination, capability, and dedication. Authorship helps dedicate one’s efforts in nurturing the
best outcome to be appreciated across the globe. This experienced group has done a wonderful literature search and
documented them in their novel way in front of the world of anesthesiology.
Dr Baheti himself is a respected dolorologist with a prolonged and profound experience as a senior consultant
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anesthesiologist. He is a rare combination of practising both his specialties (Anesthesiologist and Pain Physician) with
success. In addition, he reared up a parallel urge towards academy. This classical production under our scrutiny is a proof of
his dedication and efforts.
Dr Laheri is a passionate teacher and is exceptionally vibrant with the knowledge of basic physics as well as the
mechanism involved in the appliances of anesthesia and critical care.
Man has to live his life with a long-standing determination, and for a doctor, it has to be added with proper intervention
of disease and disability. For anesthetists like us, the motto is to combat critical illness and alleviate pain. There is
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anthropological evidence that medicine evolved from man’s earliest attempt to get spirituality in his grasps and attain his
position in the cosmos.
While practicing the essence of ignorance to be corrected by ultra-modern textual knowledge, the book will provide us
with deep insight, inward understanding, and deeper observation. I quote from the “Principles and Art of Plastic Surgery”
by Dr Ralph Millard JR— “There is little that can be called original since a sharp flint opened an abscess and some horse hair
threaded through the fine thorn needle sewed up a wound. Yet, it all goes on bit by bit and the wheel of progress turns just
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a little in a man’s life. “


Under the editorial guidance of Dr Baheti and Dr Laheri, the contributors have compiled a comprehensive textbook
that will tremendously help the national and international students. During our clinical functioning, we constantly search
for literatures on anesthetic equipment. I have been lucky to observe their academic performances through different
meetings and publications.
I conclude with hearty congratulations to the editors and the contributors for taking up this academic challenge. As I
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always say, full effort is full attainment. Well done champs! Until you spread your wings, you have no idea how far you can fly!
Wish the book awards Dr Baheti and Dr Laheri the much desired academic glory along with all their associates and will
reach to the international fraternity of learners.

Dipankar Dasgupta MD DA FAMS


Director of Anesthesiology, Jaslok Hospital and Research Centre
Mumbai, Maharashtra, India
Former Professor, Seth GS Medical College and KEM Hospital
Former Professor, TN Medical College and BYL Nair Hospital
Former Professor, and Hod, Anesthesia, Critical Care and Pain, Tata Memorial Hospital
Mumbai, Maharashtra, India

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Preface

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Anesthesiology as specialty over the decades is witnessing the revolution in the understanding of the technological
advances in medicine. The highly sophisticated equipment built on high engineering and physical standards

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(e.g., flow‑meters, valves, vaporizers, breathing circuits, ventilators, monitoring equipment, use of nerve stimulator, USG
and fluoroscopy) has provided an edge and expertise to anesthesiologists.
Many undergraduates, postgraduates, and practising anesthesiologists are enthusiastic to understand basics of the
equipment and learn the procedure techniques while administering anesthesia. These anesthesiologists do not have
access for a comprehensive reference book.

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We, the practising anesthesiologist, have recognized the problem and realized the need for such a book on anesthesia
equipment and procedures with DVDs. It is our sincere attempt to come out with a book on anesthesia equipment to fill
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the vacuum.
We express our heartfelt gratitude to all the contributors; without their help, this Herculean task was impossible. We
have taken utmost care to bring out the book of an international quality at an affordable price.
We sincerely hope that our efforts to bring out with the book will benefit the undergraduates, postgraduates, and
practising anesthesiologists, who will ultimately provide better patient care and improve surgical outcome.

Dwarkadas K Baheti
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Vandana V Laheri
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C hapter

12 Laryngoscopes

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Naina P Dalvi, Nazmeen I Sayed

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Abstract
Laryngoscope, an instrument used to visualize the larynx, is to the anesthetist what the oxygen is to a living being. This essential topic is
covered in detail in this chapter. Beginning from a brief history this chapter describes the basic structure of laryngoscope and then goes
ahead to describe its essential modifications till date. “Video laryngoscopes” the latest invention requiring equal attention is covered in
another chapter.

INTRODUCTION

o The laryngoscope had a battery based external light source. In


1913, Janeway designed the “L” laryngoscope with straight blade
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Laryngoscope is an instrument used to visualize the larynx and and batteries within the handle. Enumerable modifications
surrounding structures either by displacing the soft tissue away of the straight blade were then introduced, but the design that
from the line of vision or by optical aids. The main purpose of a persists is the Miller’s modification of straight blade introduced
laryngoscope is to aid the intubation. Laryngoscopes, by bringing in 1941. Laryngoscopy in this era was performed by lifting the
the esophagus and larynx under view, are helpful in passing the epiglottis. This type of laryngoscopy is a struggle in adults and
nasogastric tube, oral suctioning, throat packing and removing so no design of straight blade was satisfactory. Relief came when
oral foreign body. Sir Robert Macintosh introduced his curved blade in 1943 the
Tracheal intubation with metal tubes was practiced in 1880s Macintosh blade, and described the indirect method of epiglottis
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by physicians William Macewen, Joseph O’Dwyer using fingers lift to expose the larynx. Macintosh blade has no substitute for
as a guide to treat subglottic edema due to diphtheria1 (Fig. 1). laryngoscopy in normal patients and has undergone negligible
Larynx was first visualized by Manuel Garcia, a singer, who changes since first introduced. Macintosh blade was not the
used an indirect mirror to visualize the cord movement during answer for anterior larynx or difficult intubation. The era of
singing.2 Many mirror based instruments were invented by
otolaryngologists to visualize the larynx. But a rigid laryngoscope
design that is still popular among the ear, nose, and throat (ENT)
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surgeons for direct laryngoscopy was described by Caveliar


Jackson around 1907. Jackson laryngoscope has a “U” shaped
handle with a straight blade and “O” shaped flange (Fig. 2).
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Fig. 1  Blind tactile intubation with metal tube by Joseph O’Dwyer Fig. 2  Caveliar Jackson laryngoscope

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Section 5: Airway Equipment

indirect laryngoscopy in anesthesia started with the Siker mirror • The flange accommodates the tongue and keeps it away from
laryngoscope and then by prisms introduced by Huffman. the line of vision. The flange, web and tongue decide the
cross sectional shape of the blade
VARIOUS PARTS OF LARYNGOSCOPE • The portion of the blade that connects the tongue and the
flange is called the web or the vertical part
A laryngoscope consists of a detachable blade and a handle. The • Tip is the most distal part of the blade that is used to lift the

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blade is attached to the handle by a “hinge” type of joint. epiglottis either directly or indirectly by upward traction or
“hooking the vallecula”
Blade • The part of the blade that contacts the handle is called the
Blade is that portion of the laryngoscope that is introduced in the base. The slot on the base helps in hinging the handle
mouth. It has a tongue, flange, base, web, light source and a tip • The lowermost part of the base is the heel. Heel contains

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(Figs 3 and 4). small metal ball that provides the contact for the handle
• The tongue or spatula is that portion of the blade which is • The light source is either an incandescent bulb or a fiberoptic
used to swipe the tongue aside and depresses lower jaw for channel with a halogen or xenon bulb in the handle (Fig. 5).
Light can be measured at a number of points:3

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visualization of the larynx. Depending on the shape of the
tongue or spatula, the blades are classified as straight or – At its source: Luminous flux, measured in lumens.
curved – At the surface receiving the light that is being illuminated:
Illuminance measured in lux. A minimum illumination
of 700 lux at a distance of 20 mm has been suggested in a
draft standard for laryngoscopes from the International

o Organization for Standardization (ISO). The proposed


standard of 700 lux may possibly be too bright. Factors
such as light distribution and laryngoscope design
also need to be considered and maintained as they
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may have considerable effect on light requirements. A
laryngoscope with an adjustable light output may be
the answer to provide every anesthetist’s illumination
needs4
– By looking at the amount of light re-emitted from a surface
in a given direction: Luminance measured in candela
per square meter (cd/m2). During direct laryngoscopy,
perception of the surface brightness of the larynx
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depends on light transmitted back to the laryngoscopist’s


eyes from the surface of the larynx; this is the luminance.
The luminance of the larynx is dependent, in turn, on
Fig. 3  Parts of curved blade both the illuminance and the light reflected from the
tissues. The minimum required luminance for effective
laryngoscopy is 100 cd/m2.
The sizes of blades to be used in patients given by ISO
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standards (Table 1).5

Handle
The part of the laryngoscope that is held in the hand is called
the handle. Handles are striated to give a firm grip and harbor
the batteries. Contact area on the handle comes in contact with
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the metal ball on the heel of the blade when the blade is hinged
to the handle, thus completing the electrical circuit that powers
the bulb. They also harbor the halogen bulb in laryngoscopes
with fiberoptic illumination. Stubby handles are used in obese
patients or parturient to avoid the large breast. Pencil handles
are used in pediatric patients. Fiberoptic handles have a green
band (Fig. 6).
Patil Syracuse handle is an adjustable handle where in the
blade can be locked in four positions making different angles
144 Fig. 4  Parts of straight blade with the handle (180°, 135°, 90°, and 45°) (Fig. 7).6

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Chapter 12: Laryngoscopes

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Fig. 5  Fiberoptic light source

Table 1  The sizes of blade and their use


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Size Patient type


000 Small premature infant
00 Small premature infant
0 Neonate
1 Small child
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2 Child
3 Adult
4 Large adult
5 Extra-large adult
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Using a Howland lock on any conventional laryngoscope can


reduce the blade angle to 45° (Fig. 8).

TYPES OF LARYNGOSCOPES (TABLE 2)

Laryngoscopes with Straight Blades Fig. 6  Types of handle

Laryngoscopy before introduction of Macintosh laryngoscope


was by the blade being introduced from the center of the mouth history laryngoscope blades were straight blades as they gave
and lifting the epiglottis directly. Thus in the initial years of more room for intubation. 145

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Section 5: Airway Equipment

Table 2  Types of laryngoscopes

Rigid
•  Direct-classified on the bases of the blade type
– Laryngoscopes with straight Guedel, Wisconsin, Miller, etc.
blade

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– Laryngoscopes with curved blade Macintosh, Bizzarri-Giuffrida, etc.
– Laryngoscopes with features of Cardiff, Dorges
both blades
– Laryngoscopes for special Flexitip, Polio, Oxiport, Tull, etc.
purpose

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•  Indirect
– Prisms Belscope, Trueview, Huffman prism
– Optical Bullards, Usheroscope, Augustine
Scope

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– Optical stylet type Bonfil’s retro molar, Shikani’s
intubating stylet
– Video laryngoscopes Berci DCI, C-Mac, Glidescope, etc.
Flexible

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Fiberoptic bronchoscope
Fig. 7  Patil Syracuse handle
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Fig. 9  Guedel blade

progressively reduced and the flange was then designed only to


Fig. 8  Howland lock keep the tongue from falling in the line of vision.

The basic design of the straight blade consists of a straight Guedel Blade
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tongue, a flange that curves to the right and a curved tip to lift the The flange of the Guedel blade is a complete “U” turned to the
epiglottis. The tongue, web and flange together formed a channel right side. The tongue is placed at an angle of 72° to the handle
that was used for unobstructed vision directly up to the larynx. to allow lifting the epiglottis without using the teeth as a fulcrum.
This channel was used to pass the endotracheal tube (ETT). The distal tip has a 10° curve. Guedel blade is available in sizes 1,
“The larger the curve the better the insertion of tube” was 2, 3 and 4 (Fig. 9).
the opinion held in the 1930s and 1940s. But later it was realized
that broad bases at the proximal end caused dental damage,7
Flagg Blade
so the height of blades were successively reduced. As the ETT
is introduced through such channels the larynx is out of sight The Flagg blade is straight with a very slight curve at the distal tip, a
146 causing difficulty in intubation. So the large right sided curve was light source placed quite distally and the C-shaped cross- section

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Chapter 12: Laryngoscopes

tapering gradually from its proximal to distal end. It is available in Wis-Foregger is a modification of the Wisconsin blade with a
sizes 0, 1, 2, 3 and 4 (Fig. 10). flange that expands towards the distil end. The distil part is wider
with slight right curve (Fig. 13).
Wisconsin Blade Wis-Hipple blade is a modification of Wisconsin blade meant
mainly for infants. The semicircular channel is present but the
One of the popular straight blades of 1930s was the Wisconsin flange is more parallel to the spatula and is less curved. It is

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type. The Wisconsin blade, designed by University of Wisconsin available in sizes 00, 0, 1 and 1.5 (Fig. 14).
Anesthesiologists at the Wisconsin General Hospital in Madison,
is a straight blade with a flange that widens distally and curves to
Miller Blade
the right. This curve forms two-thirds of circle in cross-section.
The tip is widened to help lift the epiglottis. Wisconsin blade is In 1941 Sir Robert A Miller modified the then existing straight
available in sizes 2, 3 and 4 with newer versions having fiberoptic blade to form the Miller’s blade which was meant for both

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lights (Fig. 11). adult and pediatric patients.7 This blade was longer than the old
The whitehead modification of Wisconsin blade has a straight blades and only one size was available for all patients
reduced flange and is open proximally and distally (Fig. 12). except infants. It was shallow at the base and narrower at the tip.

o th
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Fig. 10  Flagg blade Fig. 12  Whitehead modification of Wisconsin blade
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Fig. 11  Wisconsin blade Fig. 13  Wis-Foregger blade 147

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Section 5: Airway Equipment

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Fig. 14  Wis-Hipple blade Fig. 16  Present day Miller’s blade

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Fig. 15  Original Miller blade Fig. 17  Miller’s blade: Bulb protected by flange
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The distal 2 inch of the blade was curved upwards to allow lift • The tongue is straighter
of epiglottis. For better light the bulb was placed distally close to • The channel formed by the tongue and the flange is no longer
the tip. Flange was “C” shaped. Like in other straight blades, the meant for introducing the ETT. The tube is inserted from the
tongue, web and the flange were to form a channel for visualizing angle of the mouth
the larynx and passing the tube (Fig. 15). • Miller blades with fiberoptic light source are available.
Disadvantage of Miller blade is that the light source would Some of these blades have the bulb protected by the flange
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disappear under the tongue8 and the tongue tends to bulge in (Fig. 17).
front of the blade. Miller’s blade still forms the prototype of straight blade in the
Present Miller’s blade has undergone the following modifications present era as it is inseparable from infant and difficult pediatric
(Fig. 16): intubation. It forms a part of the armamentarium of pediatric
• In 1946 Miller described the pediatric modification of difficult airway algorithm of American Pediatric Association.10
his adult blade.9 This blade could be inserted anterior or Advantage being—
posterior to the epiglottis. Miller sizes available now are 00, • Curved tip of the straight blade is ideal for elevation of the
0, 1, 2, 3 and 4 floppy infant epiglottis. Attempts to lift the epiglottis directly
• Flange height has been reduced and the flange is less curved with the smooth rounded tip of the Macintosh blade causes
148 and forms a compressed “D” when seen longitudinally the epiglottis to slip out

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Chapter 12: Laryngoscopes

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Fig. 18  Snow blade Fig. 19  Phillips blade

o
Better vision with a straight blade when compared to curved
blades in anterior larynx (e.g. infant larynx, micrognatia)11,12
Narrow based straight blade occupy less space than the
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curved blades.

Snow Blade
In 1962, Dr John Snow introduced a slimmer and smaller version
of the Miller blade which was 15 mm in width and height and
162 mm in length. The distal one inch is curved upwards and has
a rounded peak at the tip to lift the epiglottis (Fig. 18).13
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Phillips Blade
The Phillips blade designed by Dr Otto C Phillips in 1972
combines the features of Jackson and Miller blade. The shaft of
the Jackson blade was maintained for easy ETT insertion. Thus
the blade has a large “C” shaped large channel for tube insertion Fig. 20  Schapira blade
and a small curved tip to lift epiglottis efficiently. The curved tip Source: Schapira M. A modified straight laryngoscope blade designed to
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of miller blade helps lifting the epiglottis. The light bulb is in the facilitate endotracheal intubation. Anesth Analg. 1973;52(4):553-4
left (Fig. 19).12
age and for nasal intubation. It has an adult sized light bulb for a
Schapira Blade brighter vision (Fig. 21).9

Dr Max Schapira introduced a blade in 1973 with a minimal


Robertshaw Blade
web and no flange. This blade also had a deeper curve distally to
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cradle the tongue and sweep it to the left (Fig. 20).14 One of the few blades used in infants and children is the
Robertshaw blade. The distinguishing feature of this blade is that
Seward Blade the step is deviated to the left and it has a minimal flange curving
to the right. These flange tappers smoothly to the tip. Thus the
The Seward blade has a straight tongue which curves upwards channel of the straight blades is lost in this model. The vertical
distally. The flange proximally curves to the left and forms a height is also reduced so the lateral wall is obliterated. Thus
reverse “Z” shape in cross-section with the web and tongue. Robertshaw blade provides binocular vision.9 The light source
Towards the rounded tip, the flange curves slightly to the right is well protected from the tongue inside the vertical step. The
protecting the bulb. The Seward blade was designed to be used in straight tongue has a gentle curve near the tip and this blade is
neonatal resuscitation. It is suitable for children up to 5 years of used to lift the epiglottis indirectly (Fig. 22). 149

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Section 5: Airway Equipment

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Fig. 21  Seward blade Fig. 23  Cranwall blade

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Fig. 22  Robertshaw blade Fig. 24  Oxford blade


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Cranwall Blade Laryngoscopes with Curved Blade


The Cranwall blade has a curved tip like a Miller blade. There is a Macintosh Curved Blade
reduced flange to decrease the potential for damage to the upper
teeth (Fig. 23). Sir Robert Reynolds Macintosh in 1943 during a tonsillectomy
surgery noticed how easily the Boyle Davis mouth gag lay
open the larynx. The same day he got the mouth gag soldered
Oxford Blade
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to a handle. Thus the Macintosh curved blade was invented.


The Oxford or Bryce-Smith blade is a straight blade in which Macintosh blade was shorter than the existing blades so that
the flange and the web form a U-shape and the flange gradually the tip finished just before the epiglottis. Initially this blade had
tapers distally with the distal 2–5 cm being open. Though meant various types of curves as Macintosh was of the opinion that the
for neonates, it can be used for children up to 3 years. The broad curve did not matter but the length had to be short enough just to
proximal flange helps prevent the upper lip from obscuring the reach the epiglottis. Later, the curve of the Macintosh blade was
view and also potentially helps in difficult cleft-palate situations. settled to match the anatomical curve of the Magill’s ETT.15
The light is well protected in the web to the right of the flange. Macintosh blade has a curved spatula, the vertical height is
Green line version is available (Fig. 24). raised and the flange is turned to the left. The tongue, web and
150

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Chapter 12: Laryngoscopes

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Fig. 25  Original Macintosh blade Fig. 27  American Macintosh

o
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Fig. 26  English Macintosh blade Fig. 28  Reduced flange Macintosh blade
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the flange form a reverse “Z” in cross-section. The tip is smooth straight proximally to provide more space. The curved flange
and rounded (Fig. 25). Versions with fiberoptic light source are ends proximal to the tip (Fig. 27).
also available. But compared to A-Mac, E-Mac has better laryngoscopic
Macintosh blade was patented in two countries. Thus we view.16
have two models of Macintosh, the “English” Macintosh or the Reduced flange Macintosh: It is a modification of Macintosh
E-Mac and the “American” MacIntosh or the A-Mac. blade, where the proximal flange is reduced to avoid dental
English Macintosh: Longworth Scientific Instrument injuries (Fig. 28).
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Company (now Penlon) in 1958 shifted from brass Macintosh Improved vision Macintosh: Improved vision Macintosh
blade to stainless steel model. The less malleable stainless steel has a concave tongue in the midportion to allow better vision
resulted in changes in the standard Macintosh blade giving rise (Fig. 29).
to the “E-Mac” or English Macintosh.15 Thus the straight portion Left handed Macintosh: Mirror-image version of the
of the flange was reduced to a smooth curve right up to the tip. Macintosh blade exists for use with the right hand in which
The height of the flange is reduced so the blade is longer than the flange is on the opposite side. Potential uses include
the original Macintosh blade to improve vision in anterior larynx. laryngoscopy of patients in the right lateral decubitus position,
Size 0, 1, 2, 3, 4 and 5 are available (Fig. 26). or with right-sided facial or oropharyngeal abnormalities, and
American Macintosh: A-Mac still retains the original shape procedures in which the ETT should be located on the left side
of standard Macintosh. The flange is higher than E-Mac and is of the mouth. 151

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Section 5: Airway Equipment

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Fig. 29  Improved vision Macintosh blade Fig. 31  Choi double-angle laryngoscope
Source: Choi JJ. A new double-angled blade for direct laryngoscopy.
Anesthesiology. 1990;72:576

o wide and flat so that tongue or epiglottis can be lifted easily. The
light source lies along the left edge of the blade between the two
angles and is protected by the minimal flange. The double-angled
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blade can be used to lift the epiglottis directly or indirectly. It is
commercially available in one adult and one pediatric size.

McCoy Blade
The McCoy blade [Corazzelli-London-McCoy (CLM) blade] is
a flexible tip blade that has a hinged tip controlled by the lever.
When the lever is pressed towards the handle, 2.5 cm of the distil
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tip is flexed by 70°.3 This blade is called by various names such


as Flipper, Flex-tip, levering laryngoscope blade and articulating
laryngoscope blade. McCoy blade is a modification of Macintosh
blade available in sizes 1, 2, 3 and 4. Greenline version of McCoy
laryngoscopes are available. This blade is inserted and used
Fig. 30  Bizzarri-Giuffrida blade as the normal curved blade with the tip lying in the vallecula.
When the lever is activated the tip flexes and elevates the
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Bizzarri-Giuffrida Blade epiglottis furthermore, thus improving the Cormack and Lahane
laryngoscopic grade. McCoy blade forms a part of the difficult
The Bizzarri-Giuffrida blade (flangeless Macintosh) is named intubation trolley. McCoy blade with bougie has been used to
after its two inventors Dr Joseph G Giuffrida and Dr Dente V successfully intubate Cormack and Lahane grade IV patients. Due
Bizzari.17 The vertical part of Macintosh blade is removed and to minimal cervical manipulation, the blade has been preferred
only a small part of the flange protecting the bulb is left. This in the unstable cervical spine.19,20 The head extension required
blade was designed to be used in patients with limited mouth for laryngoscopy and the stress response to laryngoscopy are less
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opening, buck teeth and anterior larynx. The slimness of the with the McCoy blade than with the Macintosh blade (Fig. 32).21,22
blade allows easy insertion and manipulation of the blade in Flexi-tip is available with the Seward straight blade in size
such difficult intubation (Fig. 30). no. 1 for pediatric use (Fig. 33).11

Choi Double-Angle Laryngoscope Laryngoscopes with Features of


Choi in 1990s described a double-angled blade (Fig. 31). Choi
18 both Straight and Curved Blade
intended to design a blade eliminating the drawbacks of both
Cardiff Blade
Macintosh and Miller blade. Thus the flange of Macintosh blade
is removed and the straight tongue is given two incremental Cardiff blade was designed with features of both straight and
152 angles—proximal 20° and distal 30°. The spatula and tip are curved blade in order to have a universal blade for children of

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Chapter 12: Laryngoscopes

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Fig. 32  McCoy blade Fig. 34  Cardiff blade

enabling its use by direct or indirect elevation of the epiglottis. It

o tapers gradually from the heel to 11 mm at its tip, corresponding


to the width of a Macintosh 2 blade tip. The working length of
125 mm, however, is between those of Macintosh 3 and 4 blades.
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Similarly, the lower profile 15 mm reverse Z-shaped vertical step
and flange may facilitate the blade’s insertion in limited mouth
opening situations. Two (10 kg and 20 kg weight) markings on
the front and rear of the blade serve as a rough guide for insertion
depth when using the blade in the pediatric patient more than
10 kg.3

Soper Blade
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Originally described as a modification of Macintosh, but is


essentially a straight blade with a slight distal curve. Like in the
Macintosh, the step and the flange form a reverse Z in cross-
section. A transverse slot in the distal tip is provided to help lift
Fig. 33  Flexi-tip with Seward straight blade the epiglottis (Fig. 35).
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all age groups. This blade is meant to lift the epiglottis indirectly
as most anesthetists are comfortable with this method of
laryngoscopy. The proximal 6 cm of the tongue and flange are
straight and form a reverse “Z” in cross-section. The web and
flange are attenuated distally so that the terminal part continues
as a curved spatula, narrowing at the tip. It terminates with a
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thickened, transverse bead. The blade when opened makes


an angle of 85° with the handle. A miniature halogen bulb is
embedded in the web. The proximal straight part provides more
space and ensures laryngeal view when the ETT is introduced.
The 85° angle allows gentle indirect lift of the epiglottis instead of
forceful leverage (Fig. 34).9

Dorges Blade
Similar effort to have a universal blade in adults and children
resulted in the introduction of the Dorges universal laryngoscope. 153
The blade is mainly straight with a slightly curved distal end, Fig. 35  Soper blade

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Section 5: Airway Equipment

Blades with Special Functions


Oxiport Blade
A channel for oxygen insufflation is present in the Oxiport blade
which comes in the Miller or Macintosh profile (Fig. 36).

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Tull (Suction) Laryngoscope
Laryngoscope with a suction port that extends down to the handle
and has a finger controlled valve to operate. This laryngoscope
also comes in both Miller and Macintosh profile (Fig. 37).

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Polio Blade
A modification of Macintosh curved blade described by

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Dr  Foregger in 1954 is a special blade meant for intubation of
patients in “iron-lung” ventilators. The blade makes an obtuse
Fig. 38  Polio blade

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angle with the handle and thus does not impinge on the chest
plate of the respirator during intubation.23
The use of this blade has also been described in obese
patients with large breast, in kyphoscoliosis with barrel chest, in
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patients with restricted neck movements due to cervical collar
(Fig. 38).24

Rigid Indirect Laryngoscopes


Prisms Type
Prisms refract light to bring the laryngeal view in the line of vision.
Thus prisms are a form of indirect laryngoscope. Mirror prism
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was used by Siker in his laryngoscope in 1965. Huffman designed


a prism made of Plexiglass® in 1968. Belscope is a laryngoscope
based on prisms mechanics.
Fig. 36  Oxiport blade Siker laryngoscope: A mirror laryngoscope described by
Ephraim S Siker has a stainless steel mirror attached to the
blade in a copper jacket. The distal portion is three inches
long and at an angle of 135° to the 2½ inch proximal portion
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of the blade. The mirror gives an inverted image of the larynx.


The copper jacket conducts the patient’s endogenous heat
minimizing fogging. Because of the curve of the blade, a
styleted ETT is required. This blade was invented for difficult
laryngoscopy in patients with buck teeth, anterior larynx and
macroglossia (Fig. 39).25
Huffman’s prisms: John P Huffman, a research nurse
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anesthetist replaced the mirror prism by Plexiglass® (acrylic


glass). The prism was cut, sanded, and polished to an angle of 30°
and was clipped to a Macintosh blade.26 The refraction provided
by the prism brought the larynx and tip of a tracheal tube into the
line of vision.
Prisms are available in different sizes and can be attached to
the blades by metal clips (Fig. 40). The image is right side up.
The PrismviewTM blades are available in Macintosh A or E
profile. The optically polished prism provides a refraction of 30°
154 Fig. 37  Tull (suction) laryngoscope without inversion (Fig. 41).

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Chapter 12: Laryngoscopes

Belscope: CP Bellhouse designed the Belscope. This is a


straight blade with a 45° bend at the midpoint. A lamp is placed
2 cm from the tip. The blade has a horizontal shallow step and
a pair of tapering steel lungs that accommodates a prism just
before the bend. The acrylic prism is cut at 62° angle at the front
face and the rare surface is used to view the image. The prism is

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detachable. The blade comes in three sizes from tip to the angle:
(1) 6.7 cm, (2) 8 cm and (3) 9.3 cm. The angulated Belscope can
be used for direct laryngoscopy or for indirect laryngoscopy with
the prism in case of difficult intubation (Fig. 42).27
Viewmax®: Viewmax® blade has a detachable metal channel,

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attached to the Macintosh blade, with an optical lens at the tip
and an eye piece distally. The lens refracts the image 20 degrees
anteriorly for better viewing in anterior larynx. The blade comes
in adult and pediatric sizes (Fig. 43).

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Fig. 39  Siker laryngoscope

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Fig. 42  Belscope laryngoscope

Fig. 40  Prisms


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Fig. 41  PrismviewTM laryngoscope Fig. 43  Viewmax® blade 155

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Section 5: Airway Equipment

Rigid Indirect Fiberoptic Laryngoscopes (Optical) adult blade respectively. The blade curves up to 90°. A disposable
plastic blade tip extender can be used to extend the length of the
After introduction of science of fiberoptic in medical field in Bullard laryngoscope blade tip. Designed to aid in picking up the
1930s, an array of fiberoptic laryngoscopes were designed, first epiglottis in larger patients, this device clicks firmly to the metal
rigid then flexible. Now fiberoptic bundles could be used to blade tip. The extender may remain in the mouth after removal
visualize the glottis. As the larynx is not under direct vision, these of the blade; hence it is necessary to inspect the blade and the

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laryngoscopes are called “indirect”. The basic structures of an extender after withdrawal.
indirect rigid fiberoptic laryngoscope are— The working channel splits proximally to into two parts:
• Three channels, two fiberoptic channels for light and image
(1) a part with a luer-lock and (2) another for the stylet. In the
bundles and a working channel
pediatric version the second part accepts the Bullard intubating
• Anatomically curved thin blade
mechanism (Fig. 46).
• An eye piece with diopter adjustment for image viewing

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either directly or by a camera source on the monitor. This
eyepiece is an extension of the fiberoptic viewing channel
• Handle.

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The rigid fiberoptic indirect laryngoscopes are—
• Bullard laryngoscope
• UpsherScope laryngoscope
• Augustine ScopeTM
• WuScope.

Bullard Intubating Laryngoscope

o
The Bullard laryngoscope, designed by Dr Roger Bullard is the
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prototype of rigid indirect laryngoscopes (Fig. 44). Bullard
laryngoscope comes in three sizes:28
1. Pediatric (newborn to 2 years)
2. Pediatric long (2–10 years)
3. Adult.
Bullard laryngoscope has an anatomical curved blade posterior
to which run the above mentioned three channels (Fig. 45). The
thickness of the blade is 0.64 cm. The pediatric blade has a width
of 1.3 cm while the adult blade has a width of 2.5 cm. The internal
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radius of curvature is 0.74 inch and 1.32 inch in pediatric and Fig. 45  Parts of Bullard laryngoscope
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156 Fig. 44  Different sizes of Bullard laryngoscope Fig. 46  Bullard laryngoscope: pediatric version

12.indd 156 8/19/2014 12:47:27 PM


Chapter 12: Laryngoscopes

The Bullard intubating mechanism is a thumb-lever activated Two reasons might account for the limited usefulness of
forceps that allows the operator both to advance the intubating the Upsherscope. First, the blade shape does not match airway
forceps (and attached ETT) into the larynx and to release the ETT anatomy in all patients. The angle of the blade curvature, and
when properly positioned.29 especially that of tube channel, is 60° often resulting in a restricted
The luer-lock part can accept a syringe for local anesthetic view of the larynx. Second, as the fiberoptic bundles end 1 inch
instillation or attachment of oxygen tubings. from the tip, the blade tip is not seen entirely during intubation

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A working channel extends to the tip. It can be used for causing difficulty in lifting the epiglottis.
suction, oxygen insufflation, administration of local anesthetics
or saline, passage of epidural catheter or passage of an airway Augustine ScopeTM
exchange or jet ventilation catheter.30
Like the UpsherScope, the Augustine Scope has a tube channel
The channel for illumination has a conventional battery
and fiberoptic image and light channels and does not have a

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harboring handle attachment. An adopter and handle for high
working channel, but the tube channel is lateral to the blade
illumination light source is optionally provided. The handle and
tip and the tip has modifications for easy lift of epiglottis. Two
the eyepiece are at 45° angle.
bulbous protrusions are present on either side of a middle
The light bundle begins 2 mm from the tip. Proximally they

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indentation of the tip. When the leading edge is placed in the
end at the eyepiece. The eyepiece has diopter adjustment and vallecula, the middle indentation straddles the hypoepiglottic
can be connected to a camera source. fold in the vallecula and the protrusions lie in the recesses of the
vallecula. Traction brings the cords in view. A metallic epiglottis
UpsherScope Laryngoscope flap is also present that lifts the epiglottis as the tube is advanced.
The Augustine has an inbuilt light source with battery pack and

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It differs from the Bullard laryngoscope in having a J-rather than
L-shaped blade, which is narrower and more rounded in profile.
The blade has a “C” shaped tube guiding channel open towards
the right on the posterior aspect. Located along with the tube
an eyepiece.32 This scope is not commercially available (Fig. 48).

WuScope
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channel are two fiberoptic channels, one for operator viewing The WuScope designed by Dr Tzu-Lan Wu, is a combination
and one for illumination. The blade is curved 60°. The C-shaped of rigid laryngoscope and a flexible fiberscope. It is also called
tube channel and the fiberoptic bundles end 1 inch from the tip “combination intubating device”.33
of the blade. The power source is a conventional battery handle. The rigid blade part consists of a handle, main blade and a
The proximal part has also the eyepiece with diopter adjustment bivalve element. All the three parts have to be assembled and
which can be attached to a snap on camera. This tube channel then attached to the fiberscope body. The main blade and the
can take an ETT up to 8.5 mm internal diameter. UpsherScope bivalve element have corresponding grooves that when attached
comes in only one adult size (Fig. 47).31 form two passageways: (1) The fibercord passageway and (2)  a
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Fig. 47  UpsherScope laryngoscope Fig. 48  Augustine Scope laryngoscope 157

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Section 5: Airway Equipment

Advantages
• The blade can be used to lift the epiglottis and the image
bundles then face the larynx directly. Thus indirect
laryngoscopes are useful in visualizing around the corners in
difficult intubation. Indirect rigid laryngoscopes have been

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used in morbid obesity, tonsillar hypertrophy, Treacher
Collins syndrome in pediatric patients36-38
• As alignment of oral, pharyngeal and tracheal axis is not
required, there is minimal cervical movement with these
laryngoscopes39
• The working channel is an advantage. Blood and secretions

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can be suctioned and clarity of image maintained. Local
anesthetics can be instilled and oxygen supplemented
• The traction for laryngoscopy is minimal thus well tolerated

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by patients for awake intubation
• Bullard laryngoscope having a blade thickness of only
0.64  mm can be introduced with ease in restricted mouth
Fig. 49  WuScope laryngoscope
opening
• Nasal intubation is also possible with Bullard laryngoscope
larger ETT passageway. Both these pieces are “arc” shaped. • Double lumen tubes have been inserted with Bullard

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This assembly is then attached to the cone-shaped handle. The
axis of the handle and blade are at 110°. An oxygen channel is
present alongside the fibercord passageway. The vertical height
laryngoscope and WuScope.

Disadvantages
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of the assembled blade is 16–18 mm and thus requires a mouth
opening of at least 20–25 mm. • Bulky devices and as in case of WuScope time to assemble
Two sizes are available: (1) an adult size and (2) an extra-large the scope is present
adult size. Adult size can take a tube up to 8.5 mm and the extra- • Though larynx is under vision, introducing the ETT may
large adult blade takes up to 9.5 mm and is meant for patients require blade adjustment and take time
more than 70 kg (Fig. 49). • Minimum mouth opening of 20–25 mm required in all
indirect scopes except Bullard laryngoscope
• A learning curve is present; experience increases the success
Technique of Use
of intubation
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As the image bundles in the indirect laryngoscopes directly face • Expensive and may not be available everywhere.
the larynx, the alignment of the airway axis is not required. Thus
intubation with these scopes is in the neutral position. Optical Intubating Stylets
The handle is held parallel to the patient and the blade is
introduced in the mouth and curved along the tongue till the Stylet with fiberoptic cable in the stainless steel body are called
as optical intubating stylets, optical stylets, intubating fiberoptic
vallecula is visualized. The handle should now be perpendicular
stylets, stylet laryngoscopes, or visual scopes. This is the modified
to the patient. The epiglottis may be lifted by “scooping”
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version of intubating stylet. Because of the image bundle in the


mechanism of the blade as in the Bullard and UpsherScope.
distal tip, the larynx can be visualized as the ETT is railroaded
Once the larynx is under vision, the ETT is advanced either
over it.5
through the tube channel as in the UpsherScope and Augustine
Scope or over a catheter as in the WuScope or over a stylet as in
Bullard laryngoscope. The Bonfils Retromolar Intubation Fiberscope40
The ETT tip can also be guided in the larynx using a flexible This optical stylet was first described by Bonfils in 1983 that used
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tip stylet.34 it to intubate children with Pierre Robin syndrome. The Bonfils
The quality of the image may get affected by the condensation Retromolar Intubation Fiberscope is a rigid, straight fiberoptic
of warm expired gases on the lens. An antifogging method is device with a 40° curved tip. It is 40 cm long. The 40° angle
always necessary in an indirect laryngoscope. The common permits targeted intubation. It has 110° angle of view. A handle
antifogging methods used are— with an eyepiece is provided at the proximal end which can be
• Immersion of the fiberoptic end of the blade in warm water at connected to a camera. It can be used with an external light
temperature 40–50° prior to use source or a battery handle. It comes in three sizes—an adult size
• Use of antifogging solution with outer diameter of 5 mm and two pediatric sizes with 3.5 mm
• Use of oxygen at 6–8 L/minute from the working channel.35 and 2 mm outer diameter (Fig. 50).
158

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Chapter 12: Laryngoscopes

be called laryngoscopes for difficult intubation. For difficult


intubation, the aid of optics is necessary to “look around the
corners”. These indirect laryngoscopes have a learning curve. So
the authors feel that to master laryngoscopy, sufficient number
of direct laryngoscopy and adequate practice with indirect
laryngoscopes in normal patients will bring the best result in

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situation of a difficult intubation.

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