How does screen placement affect the success of intubation when using a GlideScope (video laryngoscope)?

Optimal Screen Placement for GlideScope Success During Intubation

Operators must adopt a 'patient-screen-patient' approach when using a GlideScope, avoiding fixation on the screen alone to optimize intubation success. 1

Screen Positioning Considerations

Types of Video Laryngoscope Screens

Video laryngoscopes can be broadly categorized by their screen configuration:

• Devices with screens mounted on the handle (compact VLs)
• Devices connected to a remote screen 1

Optimal Screen Placement

1. Distance from Airway

   • Using a videolaryngoscope with a separate screen enables the operator to stay further from the airway, which is the recommended technique for those trained in their use 1
   • Maintaining appropriate distance from the patient improves operator safety while allowing optimal technique 1

2. Visibility to Team Members

   • Screen should be positioned where external laryngeal manipulation can be guided by team members who can see the screen 1
   • This facilitates better team coordination during difficult intubations

3. Line of Sight Considerations

   • The screen should be positioned to allow the "patient-screen-patient" approach 1
   • This enables visualization of both the tube entering the oral cavity and the glottic view on the screen

Technical Aspects of GlideScope Use

View Management

• Paradoxically, a deliberately restricted view of the larynx (< 50% of glottic opening visible) may result in faster and easier tracheal intubation compared to maintaining a full glottic view 2
• The best glottic view may not correspond with the best chance of passing the tracheal tube easily 1
• In some situations, withdrawing the blade slightly may be beneficial for tube passage 1

Equipment Considerations

• When using a hyperangulated blade (like GlideScope), a stylet is required 1
• Shape the stylet to match the curvature of the blade being used 1
• For hyperangulated blades, a 60° curve is typically recommended 1

Common Pitfalls and Solutions

Fixation Error

• Pitfall: Becoming fixated solely on the screen view
• Solution: Adopt the "patient-screen-patient" approach to observe both the entry of the tube into the oral cavity and its path on the screen 1

View vs. Intubation Success

• Pitfall: Assuming an excellent glottic view guarantees successful intubation
• Solution: Recognize that videolaryngoscopes may provide excellent views but don't necessarily facilitate easy tube passage 1
• Consider deliberately restricting the view for easier tube passage 2

Training and Proficiency

• Pitfall: Inadequate training with specific devices
• Solution: Regular practice with the same device is essential for proficiency 1
• Departments should standardize equipment to allow staff to develop expertise 1

Special Considerations

Difficult Airways

• In patients with predicted difficult airways, videolaryngoscopy significantly increases first-attempt intubation success 1
• The McGrath Mac appears to be the best validated VL for difficult intubation in intensive care 1
• For patients with neck pathology (surgical scars, radiation changes, masses), be prepared with alternative intubation methods as these are strong predictors of GlideScope failure 3

Team Training

• Training should emphasize the importance of screen positioning for all team members 1
• Simulation training improves knowledge, shortens procedure duration, and enhances technical skills 1

By following these guidelines for optimal screen placement and avoiding common pitfalls, clinicians can maximize the success rate of intubation when using a GlideScope video laryngoscope.