Light-Guided Intubation Using Trachlight™
Light-Guided Intubation Using Trachlight™
The Trachlight is a reusable light wand. It consists of three parts-- a handle which houses three AAA batteries, a flexible wand, and a stiff, retractable wire stylet.
To ensure easy traction of the wire stylet following intubation, it is essential to lubricate the retractable wire stylet of the wand using silicone fluid. Similarly, the wand should also be lubricated with the same silicon fluid to facilitate retraction of the light wand from the tube following its placement.
For easy maneuvering during tracheal intubation, cutting the tracheal tube to 26 centimeters in length is recommended. The tube is loaded on to the Trachlight and then locked onto the handle. The length of the wand is adjusted by sliding the wand along the handle to position the light bulb close to, but not protruding beyond the tip of the tracheal tube.
With the Trachlight in place, the tracheal tube is sharply bent at a 90-degree angle just proximal to the cup of the tube in the shape of a field hockey stick.
It's important to oxygenate the patient prior to an intubation attempt. The patient's head and neck should be positioned in a neutral or slightly extended position. In an unconscious patient, the tongue and epiglottis fall posteriorly and obstruct the glottic opening.
To have a clear passage to the glottic opening, it is necessary to perform a jaw lift using the thumb and index finger on the non-dominant hand. This maneuver will lift the tongue and epiglottis away from the posterior pharyngeal wall. After applying the jaw lift, the Trachlight, loaded with the tracheal tube, is then inserted into the midline of the oropharynx. While keeping the Trachlight in a vertical position, the tip of the tracheal tube with the Trachlight is swung from side to side.
When the tip of the Trachlight shines directly over the glottic opening, a cone of light can be seen in the midline indicating the direction of advancement. The tip of the Trachlight, together with the tube, can then be advanced into the glottis. A well-defined, circumscribed glow can be seen in the anterior neck slightly below the laryngeal prominence.
Retracting the inner wire stylet approximately 10 centimeters makes the distal portion of the Trachlight more pliable, allowing advancement of the tube into the trachea. The tip of the tracheal tube is then advanced until the glow begins to disappear at the sternal notch. Following release of the locking clamp, the Trachlight is then removed from the tracheal tube. Correct tube placement should be confirmed using end tidal CO2 and auscultation.
Segment:3 Trouble Shooting.
Segment:4 Trouble Shooting.
While the Trachlight is shown to be an effective and safe intubating device, occasionally following the retraction of the internal wire stylet, the tip of the tracheal tube cannot be readily advanced into the trachea. This occurs because when the tracheal tube was loaded along its natural curvature onto the Trachlight, the tip of the tube has a tendency to bend anteriorly upon retracting the internal stiff stylet, making it difficult to advance the tube into the trachea.
To avoid the hangup of the tracheal tube, it is recommended to soften the two by immersion in a warm, saline solution prior to its use. In addition, reverse loading of the tracheal tube onto the Trachlight may minimize the tendency of the tracheal tube tip to bend anteriorly when attracting the internal stiff stylet of the Trachlight. With the reverse loading, the tip of the tracheal tube is more likely to be directed down the lumen of the trachea, making it easier to advance.
The combination of softening and reverse loading of the tracheal tube is shown in this video. Transillumination of the soft tissues of the neck may be poor in obese patients or patients with a thick neck. Placing the head and neck of the patient in a ramped position with retraction of the neck and chest wall tissue during intubation, will improve transillumination. As shown in this video, dimming of the ambient light will also help transillumination.
Segment:5 Other Uses.
With the internal wire stylet removed, the pliable Trachlight can be used to facilitate a light-guided nasotracheal intubation. The tracheal tube should be softened by immersion in warm, sterile water to decrease the risk of mucosal damage. Application of the vasoconstrictor to the nostril prior to intubation will also minimize bleeding. A water soluble lubricant should be applied to the tube to facilitate entry of the tracheal tube.
As with oral intubation, the jaw lift is needed to elevate the tongue and epiglottis. The Trachlight is switched on once the tip of the tracheal tube was advanced into the oropharynx, It is then positioned in the midline and advanced gently using the light glow as a guide. Because of the natural curvature of the tracheal tube, the tip of the tube may go posteriorly behind the glottis and into the esophagus.
The tube can be directed anteriorly and centered in the hypopharynx by inflating the cup with 20 milliliters of air as shown in this video. When the tracheal tube enters the glottic opening, a well-defined, circumscribed glow is seen below the thyroid prominence. If the cup was inflated to elevate the tip of the tube, it must be deflated to enable the tube to be advanced between the vocal cords.
Following the release of the locking clamp, the Trachlight is then withdrawn from the tracheal tube. Transillumination can also help to improve the overall success rate of fast track intubation. The airway practitioner was unsuccessful in placing the tube in the trachea blindly through the fast track. But after placing the Trachlight without the stiff wire stylet in the tube, the tip of the tube can be visualized and guided into the glottic opening.
Successful intubation using the Trachlight depends on careful patient selection and preparation, preparation of the device, as well as the skills of the airway practitioner. As with all technical skills, there is a learning curve and a skill maintenance requirement for the Trachlight to be a clinical utility. With regular use of the device in patients requiring an endotracheal tube, the Trachlight can be successfully used in patients with anticipated difficult airway.