A new maneuver for endotracheal tube insertion during difficult GlideScope intubation

The GlideScope Video Laryngoscope (Verathon, Bothell, WA) is a video laryngoscopy system that can be used for routine intubation, but is also commonly used as an alternative for difficult or failed airways. Previous reports have identified a very high incidence of grade 1 and grade 2 Cormack-Lehane glottic views, but despite these high-grade views, intubation is sometimes difficult due to the angle of insertion and shape of the endotracheal tube. Several maneuvers have been reported to increase the likelihood of successful endotracheal tube placement in these uncommon cases of failure.

We report the case of a patient who could not be intubated with the GlideScope despite an easily obtained grade 1 laryngoscopic view. The impediment to intubation was identified as a sharp angulation of the trachea with respect to the larynx, such that the trachea formed a steep posterior angle with the laryngeal/glottic axis. Intubation was achieved using a previously unreported maneuver, in which the endotracheal tube with a sharply curved malleable stylet was inserted through the glottis, and then rotated 180 degrees to permit passage down the trachea.

We believe that this maneuver may be useful in other cases of failed GlideScope intubation, when a high-grade laryngeal view is obtained but tube passage is not possible due to a sharp posterior angulation of the trachea.