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Laryngeal papillomas: Not so innocent! C- MAC D-blade to the rescue

Authors:
Shagun Bhatia Shah at Rajiv Gandhi Cancer Institute & Research Centre
Shagun Bhatia Shah
Ajay Kumar Bhargava at Rajiv Gandhi Cancer Institute
Ajay Kumar Bhargava
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Abstract

Laryngeal papillomatosis is a rare throat infection which is potentially fatal without treatment as it leads to varying degrees of airway obstruction. CO2 LASER removal is the most common mode of treatment used. Anaesthesia for laser surgery entails two major complications, namely airway fires and difficult ventilation. The C-Mac D-blade is a valuable new addition to the anaesthetist's armamentarium to overcome critical events like sudden airway obstruction by laryngeal papillomas.
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Laryngeal papillomas: Not so innocent! C- MAC D-blade to the rescue
S B Shah
1*
, A K Bhargava
2
Consultant
1
, Director
2
, Department of Anaesthesia,
Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, Delhi, India.
*Corresponding author: drshagun_2010@rediffmail.com
Laryngeal papillomatosis is a rare throat infection which is potentially fatal without treatment as it
leads to varying degrees of airway obstruction. CO
2
LASER removal is the most common mode of
treatment used. Anaesthesia for laser surgery entails two major complications, namely airway fires
and difficult ventilation. The C-Mac D-blade is a valuable new addition to the anaesthetist’s
armamentarium to overcome critical events like sudden airway obstruction by laryngeal
papillomas.
Keywords: laryngeal papillomas; airway obstruction; C-Mac D-blade
Introduction
Laryngeal papillomatosis is a rare medical
condition caused by HPV (Human Papilloma
Virus types 6 and 11) infection of the throat. It is
potentially fatal without treatment as uncontrolled
growth of papillomata could obstruct the airway.
Papillomas recur frequently and may require
repetitive surgery and antiviral therapy.
1,2
Symptoms in adults are a hoarse or strained voice
dictated by the size and placement of the tumors.
In small children breathing difficulties occur more
commonly and symptoms include a weak cry,
difficulty in swallowing, noisy breathing, and
chronic cough.
1,3,4
The diagnostic confirmatory
method is a biopsy done under general anaesthesia
followed by histopathology for HPV. Laryngeal
papillomatosis is most often misdiagnosed
as asthma, croup, or chronic bronchitis with
serious consequences. Papillomas partially
obstructing the airway cause these symptoms and
should be removed immediately. Carbon dioxide
laser removal is the most common method used.
4,5
Case Report
We present the case of a robust 50year old, 60kg
Nepali Police Officer. His presenting complaint
was change of voice for the last 6 months. He was
a chronic alcoholic, and a known diabetic and
hypertensive for the past 10 years. There was no
history suggestive of obstructive sleep apnoea. His
airway was assessed as Mallampati grade III.
Rhinophyma was an incidental finding. Direct
fibreoptic laryngoscopy by the ENT surgeon
revealed a small polypoidal growth seemingly
amenable to laser excision.
The patient was premedicated with midazolam
1mg i.v. five minutes before induction. A
6.5mmID microlaryngeal surgery (MLS) tube was
made laser proof by wrapping an aluminium foil
ribbon. Inhalational induction with sevoflurane
was commenced and intravenous fentanyl 60µg
was given. Once assisted ventilation was assessed
to be adequate, 30mg atracurium was given
intravenously. Suddenly, the patient’s airway got
obstructed, manual ventilation became ineffective
and the pulse oximeter displayed a decreasing
saturation. The C-Mac D-Blade was used to
visualize the larynx where a large ominous –
looking pedunculated polyp was seen acting like a
ball- valve. On its either side minor papillomas
were seen, three on the right and two on the left
side (Figure 1).
Figure 1 View of laryngeal inlet prior to
intubation
Before waiting for the single twitches to disappear
on the peripheral nerve stimulator the MLS tube
was introduced into the trachea, without pushing
the polyp inwards, resulting in prompt relief of the
airway obstruction. The MLS tube cuff was
inflated with methylene blue dye and its position
confirmed by auscultation and capnography.
During Laser excision oxygen concentration was
reduced to 25% in air and sevoflurane.
Hydrocortisone 100mg was given intravenously.
Prior to reversal a direct laryngoscopy was
performed with a McIntosh laryngoscopic blade
and all secretions were cleared. The airway was
Cormack and Lehanne grade 3. After reversal of
neuromuscular blockade the patient was
spontaneously inspiring a tidal volume of 350ml
per breath with a respiratory rate of 15-16bpm.
On extubation, the patient developed stridor. On
visualization with a C -Mac D- blade (without an
anaesthetic) there were numerous small stumps as
well as a whole pedunculated papilloma
obstructing the larynx (Figure 2).
Figure 2 View of laryngeal inlet after extubation
The trachea was immediately intubated with a
cuffed endotracheal tube. A percutaneous
dilatational tracheostomy was then performed as a
temporary measure. Two days later the patient was
subjected to laser excision of remaining laryngeal
papillomas. The tracheostomy tube was removed
after five days and the patient was able to maintain
his airway adequately.
Discussion
Laser surgery offers several advantages to the
surgeon and patient: microscopic precision, a
bloodless operative field, and sterility. A
preoperative visit to determine the degree of
existing airway obstruction is mandatory in
deciding the safest anaesthetic technique for
microlaryngeal surgery.
6,7
Assessment of the
degree of obstruction is typically accomplished
clinically by evaluating the patient’s use of
accessory muscles, quality of voice, respiratory
rate, and resting oxygen saturation. Elective
tracheostomy is avoided to limit the spread of the
virus. A surgical airway is still part of the
emergency airway algorithm for these patients.
5,6
Continued communication and cooperation
between the surgeon and anaesthesiologist
throughout the procedure will help minimize the
conflicting needs for airway access and
ventilation.
The recently introduced D- blade (Karl Storz,
Tuttlingen, Germany) was essentially designed for
the management of a difficult airway.
8,9,10
It
extends the assortment of different blade forms
adaptive for the videolaryngoscopic C-Mac system
and shows a pronounced angulation of 40º. Like
all C-Mac blades, the D-blade incorporates a small
camera chip with an embedded optical lens with
an aperture angle of 80º, located laterally in the
distal third of the steel blade. The D Blade’s
camera and light socket is located nearer (40mm)
to its tip, which is bent for another 20º. A high
power LED serves as a light source.
9,10
Presence of
the rhinophyma prompted us to choose
inhalational induction using C-Mac D-blade over
awake nasal fibreoptic intubation.
Two serious events occurred in the management of
this case. Firstly during induction, we encountered
an inability to ventilate situation despite having
assessed ventilation prior to administering a long
acting relaxant. The existence of a large
pedunculated polyp was missed by the surgical
colleagues during their assessment. The C- Mac
videolaryngoscopy helped to examine the
laryngeal inlet in an already difficult airway
(Mallampati III) and also helped in intubating with
precision.
Secondly, during the reversal and subsequent
extubation we encountered airway obstruction.
This time it was due to inadequate laser removal
of the polyps which had been pushed deeper
beyond the vocal cords by the MLS tube on
intubation and had reemerged on extubation, along
with the tube. A subsequent intubation with the C-
Mac D-blade followed by a percutaneous
dilatational tracheostomy helped to tide over the
crises.
Conclusion
The C- Mac D- blade proved to be an asset during
both critical events leading to airway obstruction,
as the exact nature of the obstructing lesion was
magnified and displayed clearly on the screen.
Videolaryngoscope can also prove to be a useful
learning tool by recording such rare critical events
for future reference.
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... Inflation of the pilot balloon angulates the ETT tip slightly upwards/anteriorly towards the larynx and may help in select situations (Fig. 4). 3: An anterior larynx. The backwards upwards rightwards pressure (BURP manoeuvre or external laryngeal pressure) applied by an assistant improves the visualization of an anterior larynx. ...
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A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia
Article
Full-text available
  • Mar 2011
  • BMC Anesthesiol
The C-MAC® (Karl Storz, Tuttlingen, Germany) has recently been introduced as a new device for videolaryngoscopy guided intubation. The purpose of the present study was to compare for the first time the C-MAC with conventional direct laryngoscopy in 150 patients during routine induction of anaesthesia. After approval of the institutional review board and written informed consent, 150 patients (ASA I-III) with general anaesthesia were enrolled. Computer-based open crossover randomisation was used to determine the sequence of the three laryngoscopies: Conventional direct laryngoscopy (HEINE Macintosh classic, Herrsching, Germany; blade sizes 3 or 4; DL group), C-MAC size 3 (C-MAC3 group) and C-MAC size 4 (C-MAC4 group) videolaryngoscopy, respectively. After 50 patients, laryngoscopy technique in the C-MAC4 group was changed to the straight blade technique described by Miller (C-MAC4/SBT). Including all 150 patients (70 male, aged (median [range]) 53 [20-82] years, 80 [48-179] kg), there was no difference of glottic view between DL, C-MAC3, C-MAC4, and C-MAC4/SBT groups; however, worst glottic view (C/L 4) was only seen with DL, but not with C-MAC videolaryngoscopy. In the subgroup of patients that had suboptimal glottic view with DL (C/L≥2a; n = 24), glottic view was improved in the C-MAC4/SBT group; C/L class improved by three classes in 5 patients, by two classes in 2 patients, by one class in 8 patients, remained unchanged in 8 patients, or decreased by two classes in 1 patient. The median (range) time taken for tracheal intubation in the DL, C-MAC3, C-MAC4 and C-MAC4/SBT groups was 8 sec (2-91 sec; n = 44), 10 sec (2-60 sec; n = 37), 8 sec (5-80 sec; n = 18) and 12 sec (2-70 sec; n = 51), respectively. Combining the benefits of conventional direct laryngoscopy and videolaryngoscopy in one device, the C-MAC may serve as a standard intubation device for both routine airway management and educational purposes. However, in patients with suboptimal glottic view (C/L≥2a), the C-MAC size 4 with straight blade technique may reduce the number of C/L 3 or C/L 4 views, and therefore facilitate intubation. Further studies on patients with difficult airway should be performed to confirm these findings.
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Papillomatosis of the larynx: Treatment with CO2 laser
Article
Full-text available
  • Feb 2006
We report our experience treating papillomatosis of the larynx using CO2 laser which has a lower risk of post surgical complications. Papillomatosis has a high incidence of recurrence after surgical treatment. We treated 42 patients (10 adults and 32 children) affected by multiple papillomatosis of the larynx. Smaller papillomas were vaporized with a 7-8 Watt CO2 laser and larger papillomas were resected at the base of their implantation. A strict follow-up during the first 3 years after surgical treatment was necessary to manage recurrences with CO2 laser endoscopy. All patients presented with recurrences after the first surgical treatment, but within 18-60 months all patients presented a solution of their pathology. Post-operative complications were observed in patients who did not comply with the strict follow-up protocol and presented with large lesions requiring more invasive surgery. CO2 laser endoscopy, although it did not prevent recurrences of papillomatosis in the larynx, is a valid surgical approach in the management of this pathology.
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Indirect videolaryngoscopy with C-MAC D-Blade and GlideScope: A randomized, controlled comparison in patients with suspected difficult airways
Article
  • Oct 2012
  • MINERVA ANESTESIOL
Background: Recently, indirect videolaryngoscopes have become increasingly important devices in difficult airway management. The aim of the present study was to investigate laryngoscopic view and intubation success using the new C-MAC® D-Blade in comparison to the established GlideScope® videolaryngoscope and conventional direct laryngoscopy in a randomized controlled trial. Methods: Ninety-six adult patients with expected difficult airways undergoing elective ear, nose and throat surgery (ENT) requiring general anesthesia were investigated. Repeated laryngoscopy was performed using a conventional direct Macintosh laryngoscope (DL), C-MAC D-Blade (DB) and GlideScope (GS) in a randomized sequence before patients were intubated with the last device used. Results: Both videolaryngoscopes showed significantly better C/L (Cormack-Lehane) classes than DL. Insufficient laryngoscopic view, defined as C/L ≥ III, was experienced in 18 patients (19.2%) with DL, in two patients with GS (2.1%) and in none with DB (0%). Time to best achievable laryngoscopic view did not differ between devices. Intubation time was significantly longer with both videolaryngoscopes (Median [Range] DB: 18 [8-33] s, and GS: 19 [9-34] s) than with DL (11 [5-26] s). However, intubation success was 100% for both DB and GS, whereas four patients could not be intubated using conventional direct laryngoscopy. Conclusion: Compared to direct Macintosh laryngoscopy, both C-MAC® D-Blade and GlideScope® comparably resulted in an improved view of the glottic opening with successful tracheal intubation in all patients.
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Anesthesia management in pediatric patients with laryngeal papillomatosis undergoing suspension laryngoscopic surgery and a review of the literature
Article
  • Sep 2011
Objective: The excision of laryngeal papillomas poses a great challenge for both the anesthesiologist and the surgeon. The narrowness of the airways and the great variability of the pathological lesions necessitate close collaboration between the surgical and anesthesia teams to provide optimal operating conditions and ensure adequate ventilation and oxygenation. Our aim was to explore perioperative anesthesia management in pediatric patients during the excision of laryngeal papillomas with a suspension laryngoscope. Methods: Fifty-eight pediatric patients suffering from laryngeal papillomas were included in this retrospective study. These patients had degrees of laryngeal obstruction from I to III and underwent suspension laryngoscopic surgery to excise laryngeal papillomas between January 2007 and December 2010. The American Society of Anesthesiologists (ASA) physical status of the patients ranged from I to III. Anesthesia was induced by intravenous administration. Once the child was unconscious, a 2% lidocaine aerosol solution was sprayed over the laryngeal area directly under the laryngoscope. For patients to tolerate suspension laryngoscopy, it is necessary to maintain spontaneous breathing and ensure adequate anesthesia depth. The airway was secured, and sufficient ventilation was established throughout a tracheal tube (ID 2.5 or 3.0) which was placed close to glottis and connected to Jackson Rees system. Hemodynamic parameters and pulse oxygen saturation (SpO(2)) were closely monitored, and adverse events were recorded. Results: Most of the patients 89% (52/58) were hemodynamically stable during the perioperative period. Laryngospasm and laryngeal edema occurred in several children during emergence from the anesthesia. Tracheal intubations were performed in six patients (10.3%). Tracheotomies were performed in two patients. One patient had to be sent to the ICU for comprehensive therapy. Conclusion: The most important consideration for anesthesia during suspension laryngoscopy is (1) the maintenance of adequate ventilation, (2) to permit surgical exposure, and (3) to maintain suitable depth of anesthesia which relaxes the vocal band, avoids laryngeal spasms (reflex closure), reduces cardiovascular reaction and wakes up quickly after operation. Any factors that aggravate laryngeal obstruction and dyspnea should be avoided.
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Airway management in pediatric patients undergoing suspension laryngoscopic surgery for severe laryngeal obstruction caused by papillomatosis
Article
  • Dec 2010
  • PEDIATR ANESTH
To review perioperative airway management and ventilation strategy during the surgical removal of papilloma under suspension laryngoscopy in pediatric patients with severe airway obstruction. Seventy pediatric patients with degree III and IV laryngeal obstruction who underwent suspension laryngoscopy to remove laryngeal papillomatosis, between July 2005 and March 2009, were included in the study. All patients were intubated initially to secure the airway. Controlled ventilation through an endotracheal (ET) tube was used during the papilloma debulking near the glottis vera. Spontaneous ventilation or apneic technique was adopted based on the stage of the surgical procedure and the location of the remaining tumor. Hemodynamic parameters, pulse oxygen saturation (SpO(2)), and CO(2) were closely monitored, and adverse events were recorded. The duration of the surgical operation and the duration of the extubation period were 5-35 min and 5-20 min, respectively. Thirty cases with degree III and twenty cases with degree IV laryngeal obstruction received inhalation induction. Sixteen cases with degree III laryngeal obstruction were given an intravenous induction. Four patients admitted with a comatose status were emergently intubated without any anesthetics. The ET tube size was determined by assessing the opening through the tumor mass or glottic aperture under direct laryngoscopy. SpO(2) was maintained above 97% after the airway was secured and sufficient ventilation established. Controlled ventilation was used in all children during the bulk removal of tumor. Spontaneous respiration and apneic technique were adopted for the removal of the remaining tumor in the hypolarynx or trachea in 16 and 28 cases, respectively. Three patients had to be re-intubated postoperatively because of persistent desaturation or laryngospasm. Key points of perioperative airway management in pediatric patients with papillomatosis-induced severe laryngeal obstruction include careful preoperative airway evaluation; the proper choice of induction methods, and ET tube size; maintenance of an adequate depth of anesthesia; and flexible ventilation strategy, continuous and close monitoring during the extubation and postextubation period; and prompt management of adverse events.
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Anesthesia for Microlaryngeal Surgery: The Case for Subglottic Jet Ventilation
Article
  • Sep 1994
Although the techniques for surgery on the endolarynxusing suspension and the operating microscope have been fully developed, 1–4 the safest, and least obtrusive anesthetic technique has yet to be manifested, as evidenced by more than 200 references to anesthesia for microlaryngoscopy in the world literature. This study reviews the physiology, physics, and problems of each anesthetic technique. In light of this review, animal and human studies are reported demonstrating the utility and safety of subglottic ventilation when provided with proper monitoring using an automatic ventilator. A modified Ben‐Jet tube is reported, ⁵ which has a 1‐mm ID channel to monitor Pco 2 and tracheal pressure. This self‐centering 3.0‐mm tube, which extends 6 to 8 cm below the glottis, is unobtrusive for the surgeon. The subglottic tube, which is much less likely to be malaligned, is much more acceptable to the anesthesiologist. Anesthesia, by intravenous sedation, utilizes neuromuscular blockade while ventilating through the jet tube powered by an automatic ventilator with an automatic shutdown feature attached to the monitor tube to prevent inadvertent barotrauma. The third phase of this study compared fluoroplastic, used in a prototype jet ventilation tube, with 6‐mm Silastic®, Red Rubber, and polyvinyl chloride (PVC) tubes when struck by maximum power of CO 2 , Nd‐YAG, and K‐532 lasers. The test was performed in a closed chamber in which concentrations of oxygen and nitrogen were controlled. Although damaged by the CO, laser beam, the fluoroplastic tubes did not continue burning when the laser was turned off in 100% oxygen, even when coated by blood. The other three tubes continued to burn in 23% oxygen. Neither the KTP nor Nd‐YAG laser damaged the Teflon tube, while they ignited a sustained flame in 30% oxygen. This study supports the use of fluoroplastic for a laser safe jet ventilation tube. It also demonstrates the danger of tube fires, even in low oxygen concentrations, when using Silastic, rubber, and PVC tubes in laser laryngeal surgery. There was no difference in the flammability of Silastic, rubber or PVC when struck by these lasers in this study. For these reasons, subglottic ventilation using a fluoroplastic, monitored, self‐centering, subglottic, jet ventilation tube driven by an automatic ventilator with a shutdown feature, in the event of excessive pressure buildup, is proposed for anesthetizing healthy patients undergoing suspension microlaryngoscopy, and who have no airway obstructing lesion. A large tube with inflatable cuff is indicated when a supraglottic lesion may obstruct the airway.
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Microlaryngoscopy-airway management with anaesthetic techniques for CO(2) laser
Article
  • Feb 2004
Carbon dioxide laser microlaryngoscopy requires planning and cooperation of both the anaesthesiologist and surgeon. While there are potentially significant complications, such as fire and difficulty ventilating the patient, laser microlaryngoscopy techniques provide the benefit of allowing for precise management of a wide range of upper airway conditions. Laryngoscopy and bronchoscopy require that the surgeon and anaesthesiologist cooperate in order to maximize exposure for the surgeon and allow for adequate ventilation of the patient. The type of airway the anaesthesiologist may use is dictated by whether access is needed to the hypopharynx, supraglottis, larynx, or subglottis. When the carbon dioxide laser is used for airway surgery, ventilation techniques that may be used include jet ventilation (subglottic or supraglottic) and intermittent or continuous endotracheal intubation, with a variety of tubes. The major complication to be avoided is airway fire. Each technique has advantages and disadvantages for avoiding fire and providing adequate ventilation. Fire is not a concern when the carbon dioxide laser bronchoscope is used, but the humidifier must be eliminated from the anaesthesia circuit to avoid vapour obstructing the bronchoscope coupler.
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HspE7 Treatment of Pediatric Recurrent Respiratory Papillomatosis: Final Results of an Open-Label Trial
Article
  • Sep 2005
We sought to evaluate the effectiveness of HspE7, a recombinant fusion protein of Hsp65 from Mycobacterium bovis BCG and E7 protein from human papillomavirus 16, to improve the clinical course of pediatric patients with recurrent respiratory papillomatosis. An open-label, single-arm intervention study was conducted in 8 university-affiliated medical centers. Twenty-seven male and female patients with recurrent respiratory papillomatosis, ages 2 to 18 years, were enrolled and followed up to 60 weeks. Before enrollment, these patients required surgery on average every 55 days. After a baseline debulking surgery, the patients received HspE7 500 microg subcutaneously monthly, for 3 doses over 60 days. The primary end point was the length of the interval from the last surgery during the treatment period until the first debulking surgery in the posttreatment period, compared with the median intersurgical interval (ISI) of the 4 surgeries before the treatment. The mean of the first posttreatment ISI increased 93% (from 55 days to 106 days; p < .02). The median ISI for all surgeries after treatment was similarly prolonged (mean, 107 days; p < .02), indicating a sustained treatment effect, and was associated with a significant decrease in the number of required surgeries (p < .003). Unexpectedly, the treatment effect was most striking in the 13 female patients, who had statistically significant increases in both the first posttreatment ISI (142%; p < .03) and the median ISI (147%; p < .03). The most common adverse events were mild-to-moderate injection site reactions. Treatment with HspE7 appears to significantly improve the clinical course in pediatric patients with RRP insofar as it reduces the frequency of required surgeries. These results warrant a confirmatory phase III trial.
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Microdebrider Versus CO2 Laser Removal of Recurrent Respiratory Papillomas: A Prospective Analysis
Article
  • Feb 2003
To compare postoperative patient discomfort, voice quality, and procedure time and cost for removal of recurrent respiratory papillomas using the microdebrider versus the CO2 laser. A randomized prospective study comparing children undergoing excision of recurrent respiratory papillomas by CO2 laser versus excision by microdebrider. For the 6-month study, patients for whom removal of recurrent respiratory papillomas was indicated were randomly assigned by birth year to microdebrider or CO2 laser therapy. Disease severity was scored as the sum of ratings of 1+ (minimal), 2+ (moderate), or 3+ (severe) for involvement of 27 areas of the aerodigestive tract by direct microlaryngoscopy immediately before treatment. Parents scored patient discomfort and improvement in voice quality 24 hours after surgery, using a 5-point (0 = no pain; 4 = worst pain) and a 10-point (1 = minimal change; 10 = significant improvement) scale, respectively. Nineteen patients ranging in age from 2.5 to 20 years underwent 32 procedures in all. Groups did not differ significantly in age, sex, or severity of disease. For disease of equivalent severity, microdebrider treatment was associated with equivalent 24-hour-postoperative pain scores, greater improvement in voice quality, shorter procedure times, and lower overall procedure cost. Immediate postoperative results indicate that the microdebrider may be as safe as and, at some institutions, might be more cost-effective than the CO2 laser for removal of recurrent respiratory papillomas.
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Direct versus indirect laryngoscopic visualization in human endotracheal intubation: a tool for virtual anesthesia practice and teleanesthesiology
Article
  • Jan 2008
  • Stud Health Tech Informat
When performing the ABC's of care for the trauma patient, airway management is of paramount importance. Management of the airway is often difficult because medical personnel caring for the patient do not commonly intubate patients or manage airways. To accomplish endotracheal intubation, a direct line of sight must be accomplished through the mouth, pharynx and larynx to the glottic opening. This is anatomically challenging in patients with a small mouth, large tongue, lack of cervical mobility, cervical trauma, protruding incisors or small mandible. This investigation compares indirect laryngoscopy, which allows the laryngoscopist to "see around the corner" during intubation, to standard direct laryngoscopy. This indirect view is a virtual view of the airway accomplished by projecting the view from an image device on the end of the laryngoscope to a monitor viewed by the laryngoscopist. The virtual (indirect) laryngoscopy improved the view of the glottic opening by an average 1.28 (p<0.001) Cormack-Lehane grades, consistant with existing literature. Indirect laryngoscopy results in improved glottic visualization compared to direct laryngoscopy. This difference will prove critically important for medical personnel who infrequently intubate and for students learning intubation skills in a clinical setting. The results of our study confirm the value of videolaryngoscopy as a standard method for hands-on airway management training of medical personnel. Indirect "virtual" laryngoscopy is an advanced technology method which will advance the development of teleanesthesiology practice. Videolaryngoscopy is an enabling technology for development of remote telementoring of trainee intubation skills curricula using video enabled distributed learning systems. This research was conducted following an approved University of Nebraska Medical Center institutional review board protocol.
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