Challenging Intubation

CL grade of 3 is noted in this video in which only the epiglottis can be visualized.
How to approach?

• Consider optimisation of patient position. Sniffing position versus onsider ramped position in obese patient to align the oral, pharyngeal and laryngeal axises.
• BURP maneuver (displacement of larynx using Backward, Upward and Rightward Pressure)
• Using a D-blade or FOB for the anterior larynx
• Using a bougie to reach the VC and thread the ETT over the bougie.
• Placing an intubating LMA and intubating through the LMA.

This is an anterior larynx. The operator is placing a bougie first before threading in the ETT. The ETT can be passed under vision by leaving the VL in place and threading the ETT with the help of an assistant.

In this video, the operator is getting a CL grade 3 view mainly with an occasional Grade 2b view. With optimisation of the patient position, a grade 2 view is obtained.

In this video we can appreciate how fogging can drastically reduce vision even in the presence of a CL Grade 1 view. Unfortunately, fogging is not an uncommon problem encountered while using a VL.

In this video, laryngoscopy demonstrates the presence of redundant fragile soft tissue that bleeds with manipulation.

This is a CL grade 3. We can visualize epiglottis but the operator is unable to lift with epiglottis to visualise the glottis.