Endotracheal intubation using the Airtraq optical laryngoscope when the glottis is off-center of the viewfinder: are the options of optimization exhausted?

he leading cause of anesthesia-related injury is the nability to intubate the trachea and secure the airway.1 mprovements in video and optical laryngoscopy have llowed to obtain an indirect view of the glottis in a ore simple way but sometimes this advantage occurs ogether with a difficult or impossible endotracheal tube ETT) insertion.2 This is because indirect techniques do not equire the alignment of the oral, pharyngeal, and tracheal xes. In this sense the optical laryngoscope Airtraq® (Prodol editec S.A., Vizcaya, Spain) provides an improved indirect iew of the upper airway. However, successful intubation equires optimal positioning of the glottis in the middle of he viewfinder. There are maneuvers of optimization when he glottis is off-center. They can be classified into two roups.3--5 (1) Adjustment of the distal position of device nvolving external laryngeal manipulation or withdrawal the irtraq laryngoscope, and (2) adjustment of the distal posiion or the output of the ETT respect the Airtraq using intubating stylet, the Endoflex ETT (Merlyn Associates, ustin, CA, USA) or a flexible fiberoptic bronchoscope. Howver, occasionally, these maneuvers are not sufficient. We report the successful tracheal intubation with the irtraq laryngoscope in six adult patients whose glottis as off-center of the viewfinder after initial failure in pite of using the described optimization maneuvers. All f them gave written informed consent for the publicaion of this article. Tracheal intubation with a styletted tandard polyvinyl chloride or standard wire-reinforced TT was attempted using the regular Airtraq as the first ine approach. The vocal cords were visualized off-center s t c w