KingVision  standard blade

Gloves were not worn in this photographic tutorial for the purpose of clarity in the skill

Some helpful tips to apply each time the KingVision is used.

  1. Vomit is the enemy of the laryngoscopist, especially when using video. Always pre-suction the oropharynx before attempting video laryngoscopy. Have the suction running, tested, positioned, and within grasp of the laryngoscopists right hand.
  2. Whenever possible, position the patient at 30 degrees to positively influence postural drainage of secretions and emesis.
  3. Avoid using the KingVision on patients that are breathing spontaneously because the screen will fog.
  4. The KingVision blades are made of light plastic and fracture easily. Do not lift or operate the video laryngoscope forcefully. This practice is both unsafe and unnecessary.
  5. Hold the KingVision blade gently, with the fingertips of the left hand. By doing so, inappropriate lifting is avoided.
  6. Slide down the center of the tongue and do not sweep the tongue.
  7. Rock back gently to visualize anatomical structures on the screen.
  8. For the best results always keep the epiglottis in view. Do so by inserting the tip of the blade into the vellecula.
The standard blade is smaller and lighter

The KingVision standard blade has two distinct advantages over the channeled blade.

  1. The standard blade is smaller, consequently it requires less working space within the oral cavity. The standard blade is an excellent choice when the patient has a large tongue, protruding dentition, or when the mouth opening is limited for any reason.
  2. The clinician has more control and ability to maneuver the endotracheal tube within the oropharynx since there is not a channel limiting endotracheal tube navigation en route to the vocal cords.
Lubricate the tube and the stylette.
The disadvantages of the standard blade: it requires more skill and a bit more preparation by the laryngoscopist.
  1. Use a classic stylette and shape the tube with a 60 degree bend at the proximal cuff. (A gum elastic bougie is not recommended with the standard blade.)
  2. A cheek pull (lip retraction) and External Laryngeal Manipulation (ELM) should be queued by the laryngoscopist and performed by an assistant to facilitate passage of the ETT.
  3. To facilitate passage of the tube through the vocal cords, the laryngoscopist must rotate the tube 20 - 30 degrees counterclockwise when approaching the hyperpharynx.

CREATING THE PERFECTLY SHAPED TUBE FOR THE KINGVISION STANDARD BLADE

1. Use a standard stylette
Step 2: Grasp the tube at the proximal cuff
Step 3: Form a sixty degree bend at the proximal cuff.

THERE ARE TWO WAYS TO CONFIRM YOU HAVE SHAPED THE TUBE CORRECTLY

1. WHEN SHAPED PROPERLY THE TUBE WILL LOOK LIKE A MODIFIED J AS SHOWN IN THE IMAGE BELOW

The modified J. - Grasp tube at the proximal cuff when shaping.

2. WHEN SHAPED PROPERLY, THE TUBE WILL CONFORM CLOSELY TO THE SHAPE OF THE BLADE.

The tube and blade have a similar deflection
The stylette position shown above permits stylette ejection with thumb of the right hand
A standard blade requires a standard stylette. Do not use a bougie with the standard blade. Because the gum elastic bougie is so flexible, the shape needed for navigation into the airway cannot be adequately maintained.

The upcoming images illustrate maneuvers that will ease the tube delivery process and improve anatomical alignment.

cheek pull

ELM

External Laryngeal Manipulation or ELM is the single most effective maneuver at improving glottic exposure. During video laryngoscopy, ELM facilitates alignment of the glottic opening with the endotracheal tube when using both the KingVision standard and the KingVision channeled blades.

ELM

Tube alignment before ELM

As you can see, the blade tip is properly inserted into the valeculla yet the glottic opening remains slightly anterior, making passage of the tube through the vocal cords difficult at best. In order to correct this issue the laryngoscopist applies gentle downward pressure to move the glottic opening to a more posterior position. Ask the assistant to maintain the position while the tube is placed. The opposing forces applied to the anterior neck drive the tip of the blade deeper into the valeculla activating and stretching the hyoepiglottic ligament. The epiglottis then lifts, precipitating optimal alignment of the glottic opening with the endotracheal tube as shown in the image below.

Tube alignment after ELM
Helpful option: ELM with assistants hand on thyroid cartilage first

Ask an assistant to place their hand over the thyroid cartilage before insertion of the blade. During visualization, the laryngoscopists right hand is positioned over top of the assistants hand. By executing subtle movements at the anterior neck the laryngoscopist may achieve an improved laryngoscopic grade (in this case a grade 1), which can easily be maintained by the assistant. Since the assistants hand was placed directly on the thyroid cartilage first, there is no risk of failure to maintain the laryngoscopic grade achieved by ELM.

POCPOM

Combining ELM with a cheek pull and a manual pull of the mandible will ease intubation when using the KingVision standard blade. By asking an assistant positioned on the right to pull out the right cheek and pull open the mandible (POCPOM), you will have ample room to maneuver the tube into the airway and pass the tube through the vocal cords. All of these maneuvers should be queued before the first attempt for optimal results and first pass success.

Pull out cheek, pull open mandible aka. POCPOM
Pull open the mandible
Pull out the cheek, still not a lot of room

The cheek pull and mandible pull can be performed separately or together depending on the needs and clinical judgment of the laryngoscopist. As you can see from the image above, there is little room to manipulate the tube in the airway. By pulling open the mandible the laryngoscopist could have gained more ET tube maneuverability, ultimately simplifying endotracheal tube placement.

What a difference a jaw pull makes
Video laryngoscopy with the KingVision is a skill that varies considerably from its direct laryngoscopy counterpart. Just getting started can be challenging unless you have adequately rehearsed the skill. Practice makes proficient.
Using lubricant is a must
Pre suction the airway for best results

It's a good idea to suction the airway before you begin any attempt at video laryngoscopy. Secretions of any variety can land on the lens and obstruct the view. Position the patient with 20 - 30 degrees head of bed elevation to promote postural drainage of secretions and to prevent blood or vomitus from collecting in the airway. The laryngoscopist can limit the effect secretions will have on obstructing the lens by positioning the distal blade in the valeculla. The valeculla is the highest, most appropriate location for the blade tip.

Getting Going 1

left: KingVision insertion method. right: Epiglottis visible for best alignment and ease of tube insertion

(Above) The laryngoscopist handles the blade gently with the fingertips. 1. Enters the airway by rotating the KingVision blade 90 degrees into the mouth. 2. Tilts the blade forward slightly to move the blade deeper into the airway, guiding and controlling rate of insertion with the right thumb. 3. Gently tilts the blade back to reveal (blade) tip location in the airway. 4. Gently moves blade tip into the valeculla by slowly sliding blade down tongue and glides into place using thumb. Note: the epiglottis remains visible for best results. These steps must not be rushed. Go slowly, identify structures, be successful!

Getting Going 2

Alternative KingVision blade insertion method

When using the LUCAS or when the patient's body habitus prevents insertion of the blade with the KingVision fully assembled, simply insert the blade into the mouth until the screen can be connected, then power-up the device. Usually the blade only has to be inserted about half way down the tongue to attach the screen.

Perform a cross finger or chin / jaw pull to open the airway
Sliding the blade into the mouth and straight down the center of the tongue is how most intubations with the KingVision begin
"With the KingVision video laryngoscope a tongue sweep is not recommended. Slide the blade right down the center of the tongue."
KingVision can be inserted like an OPA
Blade tip firmly seated in valeculla with a laryngoscopic grade 1 view of the airway
And look how much room there is to pass the ETT
WHEN READY TO BEGIN TUBE INSERTION, BRIEFLY LOOK INTO THE MOUTH TO MAKE SURE THE TUBE ENTERS THE OROPHARYNX BESIDE THE BLADE. THIS IS A VERY IMPORTANT STEP.
Keep the tube next to the blade until it is rotated toward the video scope and the vocal cords

Observe the tube insertion and rotation techniques in the upcoming images

Begin tube insertion by scraping the cheek as shown: as the distal end of the tube reaches the uvula, continue insertion, slowly start to rotate the tube counterclockwise towards the screen.

Starting the Tube

Altenative tube insertion trajectory

Tube insertion can begin either as shown in the image above or as shown in the image to the right. In either case, be certain the tube glides next to the blade. You must first look in the mouth to verify the tube has been inserted correctly. In other words, take your eyes off of the screen and physically look into the mouth to be certain the tube is adjacent to the blade and not underneath it. The tube should not go under the blade until after you have started its rotation.

Since the ETT has reached the pillars, rotation towards the screen ensues, and the distal end of the endotracheal tube passes under the blade and rides up into the airway. This helps to explain why the 60 degree ETT shape is critical.

As you can see in the image above, the ETT appears out of alignment with the airway. However, once the tube rotation has been completed, the airway and the endotracheal tube will realign.

A little ELM will result in successful placement of the ETT.

Use the thumb to eject the stylette
While advancing the ETT with the four fingers
Alternatively, leave the blade in place, move the the ETT to the left hand, hold tube and scope securely, and remove the stylette with the right hand.
Thank you!

Please email Gary Ackerman to schedule time in the lab for one on one practice.

gackerman@virtua.org

Created By
Gary Ackerman
Appreciate

Credits:

Gary Ackerman

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