Kovac's Sign
TLDR
Use a 3 blade, regardless of patient size, for video laryngoscopy.
A worse view, in terms of Cormack–Lehane, is better for ETT delivery with VL and actually prevents the situation where an airway appears "too anterior" for the rigid stylette.
Kovac's sign refers to when the cricoid ring is clearly visible and indicates over insertion. The goal to avoid positive Kovac sign is easily accomplished by keeping the vocal cords confined to top 1/3 of display rather than filling it.
The VL3 blade makes this easier to accomplish as the initial view.
To highlight this point: I will pay $50 cash to any resident using the VL3 and VL4 needed during intubation.
TLDR
Use a 3 blade, regardless of patient size, for video laryngoscopy.
A worse view, in terms of Cormack–Lehane, is better for ETT delivery with VL and actually prevents the situation where an airway appears "too anterior" for the rigid stylette.
Kovac's sign refers to when the cricoid ring is clearly visible and indicates over insertion. The goal to avoid positive Kovac sign is easily accomplished by keeping the vocal cords confined to top 1/3 of display rather than filling it.
The VL3 blade makes this easier to accomplish as the initial view.
To highlight this point: I will pay $50 cash to any resident using the VL3 and VL4 needed during intubation.
It was an anterior airway…
While in residency I first started with direct laryngoscopy (DL) until I felt I had it down. Then I progressed to learning video laryngoscopy (VL). My impression was VL would be "easy" in comparison DL and for awhile it sure seemed to be the case.
Then I found a few situations where despite a picture perfect Class 1 view I couldn't seem to get the tube high enough to pass. I was holding the rigid stylette correctly—but still couldn't get it. Incredibly frustrating when it appeared to be the best view possible. My seniors explained it was an "anterior" airway. Had to watch out for those and be prepared.
This happened sporadically to other residents and all kinds of theories were hypothesized. For example, one of my senior residents was convinced they were sending the incorrect rigid stylettes after they had a simliar experience. Others just seemed to think some people had extremely anterior airways. If any of my mentors knew that this wasn't a tough airway issue and rather a knowledge gap I can't say for sure. I know I had never ever heard of Kovac's sign which was the solution
Kovac's sign refers to when the cricoid ring is clearly visible during VL (Pictured below in bottom row).
Kovac's sign indicates over insertion. I
In VL, the best grade (by Cormack-Lehane) is actually one of the most dangerous views as it can make the angle of tube delivery so steep (seems too anterior to the proceeduralist) that it is impossible without an adjustment.
If cricoid rings (AKA Kovac's sign) is encountered, the next step is to carefully back out the laryngoscope out of the mouth until a view with no cricoid ring is obtained. A good rule of thumb is to aim for the cords occupy only the top 1/2-1/3 of the display.
Comments
Kovac's Sign
TLDR
Use a 3 blade, regardless of patient size, for video laryngoscopy.
A worse view, in terms of Cormack–Lehane, is better for ETT delivery with VL and actually prevents the situation where an airway appears "too anterior" for the rigid stylette.
Kovac's sign refers to when the cricoid ring is clearly visible and indicates over insertion. The goal to avoid positive Kovac sign is easily accomplished by keeping the vocal cords confined to top 1/3 of display rather than filling it.
The VL3 blade makes this easier to accomplish as the initial view.
To highlight this point: I will pay $50 cash to any resident using the VL3 and VL4 needed during intubation.
It was an anterior airway…
While in residency I first started with direct laryngoscopy (DL) until I felt I had it down. Then I progressed to learning video laryngoscopy (VL). My impression was VL would be "easy" in comparison DL and for awhile it sure seemed to be the case.
Then I found a few situations where despite a picture perfect Class 1 view I couldn't seem to get the tube high enough to pass. I was holding the rigid stylette correctly—but still couldn't get it. Incredibly frustrating when it appeared to be the best view possible. My seniors explained it was an "anterior" airway. Had to watch out for those and be prepared.
This happened sporadically to other residents and all kinds of theories were hypothesized. For example, one of my senior residents was convinced they were sending the incorrect rigid stylettes after they had a simliar experience. Others just seemed to think some people had extremely anterior airways. If any of my mentors knew that this wasn't a tough airway issue and rather a knowledge gap I can't say for sure. I know I had never ever heard of Kovac's sign which was the solution
Kovac's sign refers to when the cricoid ring is clearly visible during VL (Pictured below in bottom row).
Kovac's sign indicates over insertion. I
In VL, the best grade (by Cormack-Lehane) is actually one of the most dangerous views as it can make the angle of tube delivery so steep (seems too anterior to the proceeduralist) that it is impossible without an adjustment.
If cricoid rings (AKA Kovac's sign) is encountered, the next step is to carefully back out the laryngoscope out of the mouth until a view with no cricoid ring is obtained. A good rule of thumb is to aim for the cords occupy only the top 1/2-1/3 of the display.
Comments