Alternatives to GlideRite(®) for flexometallic endotracheal tube insertion with GlideScope(®).

To the Editor,

GlideScope® Video Laryngoscope (Verathon, Bothell, WA, USA) (GVLS) helps in easier visualization[1] and reduced lifting force[2] of the anterior placed larynx.

GlideScope® Video Laryngoscope is often used in the intubation of patients with cervical spine pathology. Spiral embedded flexometallic cuffed endotracheal tubes (ETTs) (Mallinckrodt™, Covidien™, Covidien Ireland Limited, Tullamore, Ireland), resistant to external compression, are useful in these surgeries. These are floppy tubes requiring a stylet for insertion, and have fixed lengths as the reinforcing wire is sealed tightly against a bonded connector.

GlideScope® specific stylet, GlideRite®, is 35 cm long, which is appropriate for an ETT without connectors. However, a #8.0 mm internal diameter flexometallic ETT measures 39 cm [Figure 1], leaving a 4 cm floppy distal end after full insertion of GlideRite® making intubation difficult. The large blade and an anterior larynx together compounds the difficulty in introduction of the flexometallic ETT.

Figure 1

Flexometallic endotracheal tube with GlideRite®

We found initially placing a Portex Bougie Coudé Tip (Smith Medical International Ltd., Hythe, Kent, UK) [Figure 2] and then rail roading the ETT over it, aids in the placement of the flexometallic tubes with GVLS. The Bougie with its longer length is convenient for rail roading and manipulations to guide the Bougie into the anterior larynx and is easier than with a styleted flexometallic ETT.

Figure 2

Flexometallic endotracheal tube rail roaded over a Portex Bougie

Difficulty in positioning the Bougie, as it tends to unfold and slip posteriorly could be overcome by initially directing the Bougie Coudé toward the laryngeal inlet and then rotating it anticlockwise. Hang up at the posterior arytenoids, which has been described[3] was prevented by anterior lift of the Bougie making the passage of the ETT easier. Thus the commonly used Bougie[4] is an effective alternative to GlideRite® in GVLS aided flexometallic tube insertion. This technique has been described for a different indication-difficult intubation with videolaryngoscopy.[5]

Alternatively an unfolded Mallinckrodt™ Satin Slip stylet may be used after recreating a curvature similar to GVLS. Although not commonly attempted, it is feasible to wrench off the connector from the 8/0 flexometallic ETT and then use a GlideRite®, however, the authors do not recomend this as we noticed dislodgement of the connector as its secure bonding thereafter is not guaranteed.

To our knowledge, the need for longer stylets for GVLS assisted flexometallic ETT insertion has not been addressed.