The correspondence “Hyperangulated videolaryngoscopy: styletiquette” by Jane L Orrock and Patrick A Ward discusses two techniques for hyperangulated videolaryngoscopy (VL) using stylets: the in-plane and out-of-plane techniques. It critiques the in-plane method for its potential pitfalls while promoting the out-of-plane approach for its advantages, especially in challenging airway scenarios. The authors emphasize the importance of finesse and technique refinement to minimize trauma and optimize first-pass success rates.

The In-Plane Technique 

The in-plane technique involves advancing the stylet/tracheal tube alongside the videolaryngoscope blade, followed by a posterior tilt to align the tracheal tube. While this approach can be effective, it presents certain challenges, particularly for inexperienced practitioners. Excessive or poorly timed tilting can cause the stylet to pivot against the tongue base, resulting in a loss of angulation and potential posterior tube placement. Additionally, this technique carries a risk of trauma to the right lateral maxillary incisors during the posterior tilting maneuver, as highlighted by previous studies. These issues underscore the need for experienced handling and precision when employing the in-plane technique.

The Out-of-Plane Technique 

The out-of-plane technique, which the authors advocate as their preferred method, involves introducing the stylet/tracheal tube at the angle of the mouth (90° to the midline or 3 o’clock position). The tracheal tube is then advanced until its tip appears on the videolaryngoscope screen, followed by a controlled anti-clockwise rotation towards the midline. This method avoids blind rotation and offers several practical advantages. It is particularly beneficial for patients with restricted mouth openings, requires no additional time, and ensures that the tracheal tube tip typically aligns at the glottis level rather than below it. The trajectory facilitated by this approach is often more favorable for smooth passage through the glottis. To optimize performance, the authors recommend holding the stylet/tracheal tube as proximally as possible, which enhances maneuverability. Additionally, they stress the importance of matching the stylet size to the tracheal tube diameter to avoid unintended tube rotation and loss of directional control.

Refined Videolaryngoscope Grip 

The authors propose a refined grip technique for the videolaryngoscope handle, advocating the use of the thumb, index, and middle finger (three-finger grip) instead of the traditional full-palm grip. This adjustment improves the maneuverability of the blade and enhances control, making it easier to perform fine movements. The three-finger grip also helps deter excessive blade advancement or lifting force, reducing the risk of trauma. For learners transitioning from Macintosh-style VL, this approach clearly differentiates hyperangulated VL techniques. By allowing simultaneous fine adjustments of the blade tip and stylet, the grip facilitates smooth alignment of the glottic orientation with the tracheal tube trajectory, ultimately improving first-pass intubation success while minimizing complications.

Training and Flexibility 

The authors emphasize the importance of mastering both in-plane and out-of-plane techniques to enhance flexibility in airway management. They draw a parallel to ultrasound-guided procedures, where proficiency in both in-plane and out-of-plane methods allows for greater adaptability to various clinical situations. This flexibility is especially valuable when dealing with variable anatomical and pathological challenges during airway management. Training in both techniques ensures that practitioners can select the most appropriate approach based on patient-specific factors.

Conclusion

The article provides a clear and structured comparison between two hyperangulated videolaryngoscopy (VL) techniques, offering practical recommendations to optimize success rates while minimizing complications. The emphasis on refined techniques, such as proximal holding of the stylet and the three-finger grip, underscores the importance of precision and control. Additionally, the authors promote flexibility by encouraging the mastery of both in-plane and out-of-plane methods, which is particularly beneficial for difficult airway scenarios. However, the article relies heavily on anecdotal experience and preferences without robust clinical data, with comparisons drawn primarily from manikin studies that may not fully reflect real-world airway management challenges. Furthermore, while discouraging blind rotation during the out-of-plane technique, the authors could have provided additional guidance on troubleshooting difficult visualizations. Overall, the authors deliver a thorough analysis, advocating for the out-of-plane approach due to its efficiency, adaptability, and reduced risk of complications. By emphasizing refined techniques and promoting versatility, the article offers valuable insights for improving first-pass success rates and enhancing patient safety in complex airway situations.

Key Takeaways for Practice 

1. The out-of-plane technique is particularly advantageous for restricted mouth openings and challenging airways. 

2. Use a three-finger grip for hyperangulated VL to improve control and reduce trauma risk. 

3. Ensure proper stylet size and proximal grip for optimal tube maneuverability. 

4. Train in both in-plane and out-of-plane techniques to enhance versatility. 

find the original article on https://doi.org/10.1111/anae.16408

Disclosure: parts of this review was written with the help of AI software(s)