Agrò et al.: UPDATE ON TL INTUBATION
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anticipated and unanticipated situations (Table II).
TABLE I Advantages of the Trachlight™ over the older versions
of the lightwand
Successful use of the TL has been reported in
patients with difficult airways.1,4,7,8 With DL, visual-
ization of the glottis is generally difficult in patients
who have a limited mandibular protrusion, a short
mentohyoid distance, a large neck circumference, or a
high Mallampati grade airway.1 2 All of these anatomic
characteristics do not appear to influence the success
of intubation with the TL.1,4
The lightwand intubating technique is recom-
mended as the first-line option in patients who can be
ventilated but have had a failed laryngoscopic intuba-
tion (e.g., patients with Treacher-Collins,3 Pierre-
Robin,3,13 or with copious secretions or blood in the
oropharynx).3,6,14
Intubation with the TL appears to be associated
with minimal trauma. A low incidence of mucosal
injury (ten out of 479 patients using the TL vs 37 out
of 471 patients using laryngoscopy) has been report-
ed.3 In addition, there was no evidence of dental trau-
ma associated with TL intubation. Thus, intubation
using the TL may be also advantageous for patients
with fixed dental appliances.
Ease of use (can be used with one hand only)
Brighter light source
Anterior and lateral projection of the light emitted
Intubation possible under ambient light
Less heat production (blinking of the lightbulb after 30 sec)
Ability to accomodate different lengths of endotracheal tubes
Ability to shape the device in a “hockey stick” configuration
Retraction of the stiff stylet facilitates advancement of the ETT
Allows both oral and nasal intubation
TABLE II Main clinical uses of the Trachlight™
Difficult or impossible direct laryngoscopic intubation in cases of:
Congenital abnormalities of upper airway (Treacher-Collins
syndrome, Pierre-Robin syndrome, etc.)
Acquired abnormalities of upper airway (trauma, etc.)
Limited mandibular protrusion
Short mentohyoid distance
Short neck
High Mallampati grade
Secretions or blood in the oropharynx
Patients with fixed dental appliances
Since brightness of the TL lightbulb allows intuba-
tion under ambient light, the TL is useful even in the
pre- hospital environment.1–4,10
be confirmed with end-tidal CO and auscultation.
2
Associated techniques
Nasal intubation
The TL can also be used together with other devices,
such as the laryngeal mask airway (LMA),14–17 the intu-
bating LMA (Fastrach™, Laryngeal Mask Company
North America Inc., California, USA),1 8 DL,1 9 and a
retrograde intubating technique5 (Figures 6, 7, 8).
Asai and Latto suggested that intubation with the
TL via the LMA is simple and effective.1 5 Usefulness
of the TL in this context is especially related to the
ability to assess the position of the tip of the ETT dur-
ing insertion by transillumination of the neck.
Due to the design of the intubating LMA which
permits the use of a larger ETT than the “classic”
LMA, the success rate of blind TI through this device
is substantially improved when compared to the clas-
sic LMA. Transillumination using the TL can further
improve the success rate of intubation1 8 with the intu-
bating LMA.
The most difficult aspect of a blind NTI is to align the
tip of the ETT with the glottis during intubation.
Transillumination can assist NTI.2,9,10,11
Removal of the stylet before insertion of the TL
into the ETT makes the ETT-TL pliable. A water-sol-
uble lubricant is applied to the nostril to facilitate the
passage of the ETT-TL. After advancing the tip of the
ETT-TL into the oropharynx, the light is switched on
and NTI is performed using transillumination as
described in the oral intubating technique.
A potential limitation of NTI with the TL (without
the internal rigid stylet) may be related to the difficulty
in controlling the ETT-TL unit. The following options
have been proposed to avoid this problem:6,9,10 neck
flexion during intubation; the use of a specialized ETT
(Endotrol®, Mallinckrodt Inc, Pennsylvania, USA);
inflation of the ETT cuff and the use of the rigid inter-
nal stylet. While these techniques may improve the light-
guided NTI technique, its success still relies on the
preparation of the patient and the skill of the operator.
Biehl and Bourke1 9 showed that the TL could
improve the view in the hypopharynx, and transillu-
mination could assist in guiding the ETT into the tra-
chea with DL.
In 27 patients with cervical spine instability, it has
been reported that the TL can facilitate retrograde
intubation.5 TI was successful in all patients using
these techniques in association.
Clinical applications
The TL may be a useful option in the case of a diffi-
cult or impossible laryngoscopic intubation for both