喉頭鏡

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a medical instrument for examining the larynx

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喉頭(こうとう)鏡

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/07/08 19:34:26」(JST)

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Laryngoscopy (larynx + scopy) is a medical procedure that is used to obtain a view of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation or for procedures on the larynx or other parts of the upper tracheobronchial tree.

Direct laryngoscopy

Anatomical parts seen during laryngoscopy

Direct laryngoscopy is carried out (usually) with the patient lying on his or her back; the laryngoscope is inserted into the mouth on the right side and flipped to the left to trap and move the tongue out of the line of sight, and, depending on the type of blade used, inserted either anterior or posterior to the epiglottis and then lifted with an upwards and forward motion ("away from you and towards the roof "). This move makes a view of the glottis possible. There are at least ten different types of laryngoscope used for this procedure, each of which has a specialized use for the otolaryngologist and medical speech pathologist. This procedure is most often employed in direct diagnostic laryngoscopy with biopsy. It is extremely uncomfortable and is not typically performed on conscious patients, or on patients with an intact gag reflex.

Indirect laryngoscopy

Indirect laryngoscopy is performed whenever the provider visualizes the patient's vocal cords by a means other than obtaining a direct line of sight. For the purpose of intubation, this is facilitated by fiberoptic bronchoscopes, video laryngoscopes, fiberoptic stylets and mirror or prism optically-enhanced laryngoscopes.

History

The laryngoscopy. From García, 1884

Some historians (for example, Morell Mackenzie) credit Benjamin Guy Babington (1794–1866), who called his device the "glottiscope", with the invention of the laryngoscope.^[1] Philipp von Bozzini (1773–1809)^[2]^[3] and Garignard de la Tour were other early physicians to use mouth mirrors to inspect the oropharynx and hypopharynx.^[4]

In 1854, a Spanish vocal pedagogist named Manuel García (1805–1906) became the first man to view the functioning glottis and larynx in a living human. García developed a tool that used two mirrors for which the Sun served as an external light source.^[5]^[6] Using this device, he was able to observe the function of his own glottic apparatus and the uppermost portion of his trachea. He presented his findings at the Royal Society of London in 1855.^[7]^[8]

All previous observations of the glottis and larynx had been performed under indirect vision (using mirrors) until 23 April 1895, when Alfred Kirstein (1863–1922) of Germany first described direct visualization of the vocal cords. Kirstein performed the first direct laryngoscopy in Berlin, using an esophagoscope he had modified for this purpose; he called this device an autoscope.^[9] It is believed that the death in 1888 of Emperor Frederick III^[10] motivated Kirstein to develop the autoscope.^[11]

In 1913, Chevalier Jackson was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate the trachea.^[12] Jackson introduced a new laryngoscope blade that had a light source at the distal tip, rather than the proximal light source used by Kirstein.^[13] This new blade incorporated a component that the operator could slide out to allow room for passage of an endoracheal tube or bronchoscope.^[14]

That same year, Henry H. Janeway (1873–1921) published results he had achieved using another new laryngoscope he had recently developed.^[15] An American anesthesiologist practicing at Bellevue Hospital in New York City, Janeway believed that direct intratracheal insufflation of volatile anesthetics would provide improved conditions for surgery of the nose, mouth and throat. With this in mind, he developed a laryngoscope designed for the sole purpose of tracheal intubation. Similar to Jackson's device, Janeway's instrument incorporated a distal light source. Unique however was the inclusion of batteries within the handle, a central notch in the blade for maintaining the tracheal tube in the midline of the oropharynx during intubation, and a slight curve to the distal tip of the blade to help guide the tube through the glottis. The success of this design led to its subsequent use in other types of surgery. Janeway was thus instrumental in popularizing the widespread use of directand tracheal intubation in the practice of anesthesiology.^[11]

Applications

Helps in intubation during the administration of general anaesthesia or for mechanical ventilation.
Detects causes of voice problems, such as breathing voice, hoarse voice, weak voice, or no voice.
Detects causes of throat and ear pain.
Evaluates difficulty in swallowing : a persistent sensation of lump in the throat, or mucous with blood.
Detects strictures or injury to the throat, or obstructive masses in the airway.

Conventional laryngoscope

Laryngoscope handles with an assortment of Miller blades (large adult, small adult, pediatric, infant, and neonate)

Laryngoscope handle with an assortment of Macintosh blades (large adult, small adult, pediatric, infant, and neonate)

The vast majority of tracheal intubations involve the use of a viewing instrument of one type or another. Since its introduction by Kirstein in 1895,^[9] the conventional laryngoscope has been the most popular device used for this purpose. Today, the conventional laryngoscope consists of a handle containing batteries with a light source, and a set of interchangeable blades.

Laryngoscope blades

Early laryngoscopes used a straight "Magill Blade", and this design is still the standard pattern veterinary laryngoscopes are based upon; however the blade is difficult to control in adult humans and can cause pressure on the vagus nerve, which can cause unexpected cardiac arrhythmias to spontaneously occur in adults.

Two basic styles of laryngoscope blade are currently commercially available: the curved blade and the straight blade. The Macintosh blade is the most widely used of the curved laryngoscope blades,^[16] while the Miller blade^[17] is the most popular style of straight blade.^[18] Both Miller and Macintosh laryngoscope blades are available in sizes 0 (neonatal) through 4 (large adult). There are many other styles of curved and straight blades (e.g., Phillips, Robertshaw, Sykes, Wisconsin, Wis-Hipple, etc.) with accessories such as mirrors for enlarging the field of view and even ports for the administration of oxygen. These specialty blades are primarily designed for use by anesthetists, most commonly in the operating room.^[19]

The Macintosh blade is positioned in the vallecula, anterior to the epiglottis, lifting it out of the visual pathway, while the Miller blade is positioned posterior to the epiglottis, trapping it while exposing the glottis and vocal folds. Incorrect usage can cause trauma to the front incisors; the correct technique is to displace the chin upwards and forward at the same time, not to use the blade as a lever with the teeth serving as the fulcrum.

The Miller, Wisconsin, Wis-Hipple, and Robertshaw blades are commonly used for infants. It is easier to visualize the glottis using these blades than the Macintosh blade in infants, due to the larger size of the epiglottis relative to that of the glottis.

Blade	Named for	Year introduced	Comments
Cranwall^{[citation needed]}	George D. Cranton and Barry L. Wall	1963	straight, no flange
Jackson	Chevalier Jackson		straight
Janeway	Henry H. Janeway		straight
Reduced Flange (RF Mac)^{[citation needed]}	George D. Cranton	1999	curved reduced flange at heel
Macintosh^[20]	Robert Reynolds Macintosh	1943	curved
Magill^[21]	Ivan Magill	1921	straight
Miller	Robert A. Miller	1941	straight
Parrott	C.M. Parrott	1951	curved
Phillips		1973	straight
Robertshaw			straight
Seward			straight
Siker		1956	curved, with integrated mirror
Soper	R.I. Soper	1947	straight
Wis-Hipple			straight
Wisconsin			straight

Fiberoptic laryngoscopes

Besides the conventional laryngoscopes, many other devices have been developed as alternatives to direct laryngoscopy. These include a number of indirect fiberoptic viewing laryngoscopes such as the flexible fiberoptic bronchoscope. The flexible fiberoptic bronchoscope or rhinoscope can be used for office-based diagnostics or for tracheal intubation. The patient can remain conscious during the procedure, so that the vocal folds can be observed during phonation. Surgical instruments passed through the scope can be used for performing procedures such as biopsies of suspicious masses. These instruments have become indispensable within the otolaryngology, pulmonology and anesthesia communities.

Other available fiberoptic devices include the Bullard scope,^[22] UpsherScope,^[23]^[24] and the WuScope.^[25] These devices are widely employed for tracheal intubation, especially in the setting of the difficult intubation (see below).

Video laryngoscope

Glidescope video laryngoscope, showing 60-degree angulated blade. The CMOS active pixel sensor (CMOS APS) video camera and light source are located at the point of angulation of the blade. An anesthesia machine is visible on the high resolution LCD monitor.

The conventional direct laryngoscope uses a line of sight provided by a rigid viewing instrument with a light on the blade or intra-oral portion which requires a direct view of the target larynx; this view is clearly seen in 80-90% of attempts. The frequent failure of direct laryngoscopy to provide an adequate view for tracheal intubation led to the development of alternative devices such as the lighted stylet, and a number of indirect fiberoptic viewing laryngoscopes, such as the fiberscope, Bullard scope, Upsher scope, and the WuScope. Though these devices can be effective alternatives to direct laryngoscopy, they each have certain limitations, and none of them is effective under all circumstances. One important limitation commonly associated with these devices is fogging of the lens.^[26] In an attempt to address some of these limitations, Dr. Jon Berall, a New York City internist and emergency medicine physician, designed the camera screen straight video laryngoscope in 1998.

The Digital Revolution has brought new technology to the practice of tracheal intubation. Several manufacturers have developed video laryngoscopes which employ digital technology such as the CMOS active pixel sensor (CMOS APS) to generate a view of the glottis so that the trachea may be intubated. The Glidescope video laryngoscope is one example of such a device. Other examples include the McGrath laryngoscope, Daiken Medical Coopdech C-scope vlp-100, the Storz C-Mac, Pentax AWS, and the Berci DCI laryngoscopes.

Glidescope

Anesthesiologist using Glidescope video laryngoscope to intubate the trachea of a patient with challenging airway anatomy

In 2001, the Glidescope (designed by vascular and general surgeon John Allen Pacey) became the first commercially available video laryngoscope. It incorporates a high resolution digital camera, connected by a video cable to a high resolution LCD monitor. It can be used for tracheal intubation to provide controlled mechanical ventilation, as well as for removal of foreign bodies from the airway. The Glidescope owes its superior results to a combination of five key factors:

The steep 60-degree angulation of its blade improves the view of the glottis by reducing the requirement for anterior displacement of the tongue.
The CMOS APS digital camera is located at the point of angulation of the blade (rather than at the tip). This placement allows the operator to more effectively view the field in front of the camera.
The video camera is recessed for protection from blood and secretions which might otherwise obstruct the view.
The video camera has a relatively wide viewing angle of 50 degrees.
The heated lens innovation helps to prevent fogging of the lens, which might otherwise obscure the view.

Tracheal intubation with the GlideScope can be facilitated by the use of the Verathon Stylet, a rigid stylet that is curved to follow the 60° angulation of the blade.^[27] To achieve a 99% successful rate of intubation with the GlideScope requires the operator to acquire a new skill set with this stylet.

In a 2003 study, the authors noted that the GlideScope provided adequate vision of the glottis (Cormack and Lehane grade I-II) ^[28]^[29] even when the oral, pharyngeal and laryngeal axes could not be optimally aligned due to the presence of a cervical collar. Despite this significant limitation, the average time to intubate the trachea with the GlideScope was only 38 seconds.^[27] In 2005, the first major clinical study comparing the Glidescope to the conventional laryngoscope was published. In 133 patients in whom both Glidescope and conventional laryngoscopy were performed, excellent or good laryngeal exposure was obtained in 124/133 (93%) of Glidescope laryngoscopy patients, compared with only 98/133 (74%) of patients in whom conventional laryngoscopy was used. Intubation was successful in 128/133 (96%) of Glidescope laryngoscopy patients.^[30] These early results suggest that this device may be a useful alternative in the management of difficult tracheal intubation.

The Verathon design team later produced the Ranger Video Laryngoscope for a United States Air Force requirement that is now rolling forward into EMS and military use. The Cobalt series of Glidescopes then introduced a single use variant that encompasses weights from 1000 grams to morbid obesity and is successful in many airway syndromes as well. The Glidescope Ranger is a variant designed for use in pre-hospital airway management including air, land, and sea applications. This device weighs 1.5 pounds, and is waterproof as well as airworthy to 20,000 feet altitude. The Glidescope Cobalt is a variant that has a reusable video camera with light-emitting core which has a disposable or single use external shell for prevention of cross infection.

In August 2009, the team at Verathon collaborated with Professor John Sakles from the University of Arizona Emergency Department in achieving the world's first tracheal intubation conducted with the assistance of telemedicine technology. During this demonstration, Dr. Sakles and the University of Arizona Telemedicine service guided physicians in a rural hospital as they performed a tracheal intubation using the Glidescope.

Other noninvasive intubation devices

Other "noninvasive" devices which can be employed to assist in tracheal intubation are the laryngeal mask airway^[42]^[43]^[44]^[45]^[46]^[47]^[48] (used as a conduit for endotracheal tube placement), the lighted stylet,^[49]^[50] and the AirTraq.^[51] Due to the widespread availability of such devices, the technique of blind digital intubation^[52] of the trachea is rarely practiced today, though it may still be useful in emergency situations under austere conditions such as natural or man-made disasters.^[53]

Complications

Cases of mild or severe injury caused by rough and inexperienced use of laryngoscopes have been reported. These include minor damage to the soft tissues within the throat which causes a sore throat after the operation to major injuries to the larynx and pharynx causing permanent scarring, ulceration and abscesses if left untreated.^{[citation needed]} Additionally, there is a risk of causing tooth damage.

References

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^ Stark, James (2003). Bel canto: a history of vocal pedagogy. University of Toronto Press, p. 5. ISBN 0-8020-8614-4
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^ http://www.rtve.es/alacarta/videos/con-ciencia/ciencia-manuel-patricio-garci/2352708/
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^ Somchai Amornyotin, Ungkab Prakanrattana, Phongthara Vichitvejpaisal, Thantima Vallisut, Neunghathai Kunanont, and Ladda Permpholprasert (2010). "Comparison of the Clinical Use of Macintosh and Miller Laryngoscopes for Orotracheal Intubation by Second-Month Nurse Students in Anesthesiology". Anesthesiology Research and Practice 2010: 1–5. doi:10.1155/2010/432846. PMC 2911595. PMID 20700430. Retrieved 27 August 2010.
^ James M. Berry (2007). "Chapter 16: Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single-lumen tube)". In Benumof JL. Benumof's airway management: principles and practice (2nd ed.). Philadelphia: Mosby-Elsevier. pp. 379–392. ISBN 978-0-323-02233-0. Retrieved 28 August 2010.
^ Robert Reynolds Macintosh (1943). "A new laryngoscope". The Lancet 1 (6): 205. doi:10.1016/S0140-6736(02)95524-8.
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^ Fridrich P, Frass M, Krenn CG, Weinstabl C, Benumof JL, Krafft P (1997). "The UpsherScope in routine and difficult airway management: a randomized, controlled clinical trial". Anesthesia & Analgesia 85 (6): 1377–81. doi:10.1097/00000539-199712000-00036. PMID 9390612.
^ Wu TL, Chou HC (1994). "A new laryngoscope: the combination intubating device". Anesthesiology 81 (4): 1085–7. doi:10.1097/00000542-199410000-00044. PMID 7943825.
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^ ^a ^b ^c ^d Agrò F, Barzoi G, Montecchia F (May 2003). "Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization". Br J Anaesth 90 (5): 705–6. doi:10.1093/bja/aeg560. PMID 12697606.
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^ Ernst Zadrobilek (28 October 2009). "The Cormack-Lehane classification: twenty-fifth anniversary of the first published description". Internet Journal of Airway Management 5. Retrieved 4 August 2010.
^ ^a ^b Cooper RM, Pacey JA, Bishop MJ, McCluskey SA (February 2005). "Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients". Can J Anaesth 52 (2): 191–8. doi:10.1007/BF03027728. PMID 15684262.
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^ Daiken Medical Co., Ltd. (2007). "Coopdech video laryngoscope portable VLP-100". Osaka, Japan: Daiken Medical Co., Ltd. Retrieved 27 August 2010.
^ Boedeker BH, Berg BW, Bernhagen MA, Murray WB (2009). "Endotracheal intubation comparing a prototype Storz CMAC and a glidescope videolaryngoscope in a medical transport helicopter - a pilot study". Studies in Health Technology and Informatics 142: 37–9. PMID 19377109. Retrieved 27 August 2010.
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^ Inada T, Fujise K, Tachibana K, Shingu K (1995). "Orotracheal intubation through the laryngeal mask airway in paediatric patients with Treacher-Collins syndrome". Paediatr Anaesth 5 (2): 129–32. doi:10.1111/j.1460-9592.1995.tb00260.x. PMID 7489423.
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^ Maharaj CH, Costello JF, McDonnell JG, Harte BH, Laffey JG (2007). "The Airtraq as a rescue airway device following failed direct laryngoscopy: a case series". Anaesthesia 62 (6): 598–601. doi:10.1111/j.1365-2044.2007.05036.x. PMID 17506739.
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External links

Wikimedia Commons has media related to Laryngoscope.

Videos of direct laryngoscopy recorded with the Airway Cam (TM) imaging system, a head mounted camera system
Photos of Flexible Laryngoscopy and Its Variations
Phisick Pictures and information about antique laryngoscopes
Yahoo Health on Laryngoscopy
Transnasal Flexible Laryngoscopy (TFL)
Fiber Optic MacIntosh Laryngoscope Set

UpToDate Contents

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1. 成人における直接喉頭鏡および気管挿管 direct laryngoscopy and tracheal intubation in adults
2. 成人における緊急気道マネージメントの困難時に使用するデバイス devices for difficult emergency airway management in adults
3. 気管内挿管が困難な小児用のデバイス devices for difficult endotracheal intubation in children
4. 全身麻酔導入における気道管理 airway management for induction of general anesthesia
5. 緊急挿管用の気管チューブイントロデューサ（ガムエラスティックブジ） endotracheal tube introducers gum elastic bougie for emergency intubation

English Journal

Forces generated by Macintosh and GlideScope(®) laryngoscopes in four airway-training manikins.

Lee C, Russell T, Firat M, Cooper RM.SourceUniversity of Toronto, Toronto General Hospital, Toronto, ON, Canada.
Anaesthesia.Anaesthesia.2013 May;68(5):492-6. doi: 10.1111/anae.12209.
We measured forces generated by Macintosh and GlideScope(®) laryngoscope blades during airway intubation by 16 participants in four manikins: Laerdal(®) SimMan; TruCorp AirSim™ Advance; Laerdal(®) Airway Management Trainer; and Ambu(®) Airway Man. Both laryngoscopes generated the least force i
PMID 23573844

Nasotracheal intubation with three indirect laryngoscopes assisted by standard or modified Magill forceps.

Staar S, Biesler I, Müller D, Pförtner R, Mohr C, Groeben H.SourceDepartment of Anaesthesia, Critical Care Medicine and Pain Therapy, Kliniken Essen-Mitte, Essen, Germany.
Anaesthesia.Anaesthesia.2013 May;68(5):467-71. doi: 10.1111/anae.12175. Epub 2013 Mar 11.
We assessed the effect of modifying standard Magill forceps on the laryngeal introduction of an Eschmann stylet during nasotracheal intubations with three indirect laryngoscopes (Airtraq™, C-MAC(®) or GlideScope(®) ) in patients with predicted difficult intubation. We allocated 50 participants t
PMID 23480441

Japanese Journal

線維性骨異形成症患者の全身麻酔において困難な喉頭展開と鼻腔狭窄により経鼻挿管を断念した1例

湯浅あかね,高杉嘉弘,大内謙太郎,松下容子,鹿島悠子
日本歯科麻酔学会雑誌 39(1), 26-30, 2011-01-15
NAID 10027850760

GlideScope--ブレードサイズと視野

島田宣弘,平林由広,瀬尾憲正
麻酔 60(10), 1221-1223, 2011-10
NAID 40019005185

Related Pictures

★リンクテーブル★

リンク元

「喉頭鏡」

Laryngoscopy
	Intervention
	View of the glottis as seen during laryngoscopy
ICD-9-CM	31.42
MeSH	D007828
OPS-301 code:	1-610
MedlinePlus	007507

　　[★]

英: laryngoscope
関: 気管挿管

マッキントッシュ喉頭鏡 Macintosh laryngoscope
マッコイ喉頭鏡 McCoy laryngoscope
ブラード喉頭鏡 Bullard laryngoscope

http://www.jstage.jst.go.jp/article/jjsca/27/3/234/_pdf/-char/ja/

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laryngoscope