To reference this electronic educational resource according to the APA
style for Web references, use:
Liem EB (2006): Lighted Stylet Intubation. Retrieved <insert
date of retrieval here>, from University of Florida Department of
Anesthesiology, Center for Simulation, Advanced Learning and Technology,
Virtual Anesthesia Machine Web site: http://vam.anest.ufl.edu/airwaydevice/lightedstylet/index.html
Keywords: Lighted stylet, lightwand, Intubation, difficult
airway, airway management
Also known as Trachlite (Rusch), Trachlight
(Laerdal), Surch-lite (Aaron Medical), "Lightwand"
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Lighted stylet guided intubation can be a useful technique
for oral and nasal intubations in both asleep and awake patients (1,3).
This type of intubation technique has a reported success rate as high
as 99% in experienced hands (3). It can be used in anticipated and unexpected
difficult airways where conventional direct laryngoscopy has failed
(2,7). It can be achieved as fast as conventional direct laryngoscopy
by one skilled in its use (3,4,5). Sufficient skill is obtained after
approximately 15 intubations with the lighted stylet. Manipulation of
the head and neck can be kept minimal and the patient does not require
a wide mouth opening (6-8 mm) which makes this technique extremely useful
in certain subpopulations of patients. This technique may also be helpful
in patients with anterior larynx, scarring, or a bloody airway, because
the lighted stylet has no optical viewing element. A decreased incidence
and severity of sore throat, hoarseness and dysphagia has also been
reported in comparison to direct laryngoscopy (6).
However, because it requires translumination of the soft
tissues in the neck, this type of intubation may be less suited for
environments in which there is too much ambient light. In a dark environment,
a lighted stylet that is correctly positioned in the glottic opening,
will show a bright red, teardrop shaped glow in the anterior neck. This
glow will be visible at the thyroid cartilage or distal to it. In patients
who have a thick or short neck, or are darkly pigmented, identification
of this glow can be more difficult. In the thin patient the opposite
may occur, where an incorrectly positioned lighted stylet (in the esophagus)
still seemingly produces a typical pre-tracheal glow (false-positive).
Since there is no direct visualization of the laryngeal structures,
this technique should be avoided in patients with known anatomical abnormalities
of the upper airway (tumors, polyps, infection, foreign body, upper
airway trauma) (1). A recent review of lighted stylet intubations is
in consistent agreement with our experience and recommendations (8).
Because of the lightbulb size, the particular lighted stylet discussed
here cannot be used in the pediatric population that requires endotracheal
tubes smaller than 5.5 ID.
Reference Article List
One type of lighted stylet currently being used is the
- Select Endotracheal Tube (ETT): smallest possible size for use with
the lighted stylet is 5.5 mm inner diameter.
- Apply a water-based lubricant to ETT opening (e.g. Lidocaine jelly,
K-Y jelly, Hurricaine spray). Lubrication is essential to advance
the ETT without it sticking to the stylet.
- Test lightsource. If the light does not work, the batteries can
be replaced by depressing and twisting the cap switch 90 degrees (although
this is unlikely as these devices are disposable)
- Insert lighted stylet until the lightsource reaches the tip of the
ETT. When the stylet is in the correct position, engage the locking
piece into the ETT connector and secure.
- Bend the ETT/lighted stylet assembly to a sharp angle of slightly
GREATER than 90 degrees. (This is why prior lubrication of the ETT
is an essential step. The sharp angle is necessary if the patient
is going to be intubated with the head in a neutral position.) Two
different approaches are taken in determining the location of the
bend of the ETT/lighted stylet assembly. Some people feel the success
rate of the intubation is higher if the bend is placed at the same
distance as the distance from the patient's thyroid cartilage to the
angle of their mandible. This will essentially measure the distance
from the posterior pharynx to the glottic opening. Others prefer placing
the bend at a relatively shorter distance (just proximal to the cuff)
in order to avoid placing the lighted stylet too posterior and directly
into the esophagus. This also makes maneuverability easier if you
are rotating a smaller "arm" across the soft tissues during
attempts to position the tip at the glottic opening.
Oral Intubation: A
Step by Step Guide
- Induce patient as if for regular intubation; apply cricoid pressure
if Rapid Sequence Intubation is desired.
- Darken the OR (this may include extinguishing overhead, OR, and
X-ray viewbox lights plus covering the windows).
- Position yourself as for regular direct laryngoscopy. Some people
prefer a different approach and like to stand at the side of the patient
near the shoulders so that the pre-tracheal glow can be seen more
easily, but that does require extra help for masking the patient.
- With the patient's head in neutral position, the non-dominant
hand (left for most people) should lift the jaw forward. This
will elevate the tongue and epiglottis. This is an essential step
as this generates the space in the pharynx through which the ETT/lighted
stylet assembly must be navigated.
- Hold the ETT/stylet assembly in the dominant hand and insert it
into the mouth.
- If possible, the lighted stylet should be introduced in midline
and advanced over the base of the tongue. However, this is often not
possible due to the sharp angle of the bend in the ETT/stylet assembly.
Alternatively, the lighted stylet can be turned 90 while staying
midline, then advanced more deeply via the right or left mouth corner
so that it can be brought over the base of the tongue.
- Advance the lighted stylet over the base of the tongue until the
pre-tracheal glow is identified. A red downwards streaking glow should
be seen (jack-o-lantern effect). The brightness of the glow that should
be seen in a particular patient can be gauged before intubation by
shining the light through the patient's cheeks. Identification
of the typical pre-tracheal glow is the most crucial part of the lighted
stylet intubation. A dimmer glow, which is more localized and/or
off to the side, indicates a submental or piriform fossae location.
In that case, withdraw the ETT/stylet assembly slightly and re-advance.
Obtaining the correct glow may require quite a few number of repositionings
and may not be achieved on the first attempt.
- Move non-dominant hand from the mandible to the lighted stylet handle
and advance the ETT which is still being held with the dominant hand
to the desired depth. While advancing the ETT, the pre-tracheal glow
can often be observed to travel with the ETT tip down the neck, as
the ETT acts as a light pipe.
- Remove lighted stylet, confirm ETT position, inflate cuff and proceed
as for regular intubation.
- When withdrawing the lightwand, confirm that the lightbulb is still
Cannot find pre-tracheal glow
Not enough space to maneuver:
Increase mandibular distraction and/or instruct someone to use gauze
to pull on the tongue.
Lighted stylet is stuck in a piriform fossae or in the vallecula:
Advance the lighted stylet over the posterior pharynx instead of tongue
Patient too obese - cannot see glow:
Have an assistant spread the skin of the neck laterally. This will
decrease the distance from the throid cartilage to the skin.
Difficulty advancing the ETT
Stylet may be stuck in the vallecula, giving impression of
a pre-tracheal glow:
Withdraw and re-advance more posteriorly.
The ETT is getting stuck on the vocal cords:
Withdraw and re-advance, change to smaller diameter ETT if necessary.
Webauthor: E.B. Liem
Consultants: D. Gravenstein
Contributors: J. Payabyab, M.E. Mahla
Reference Article List
- Hung-OR, Stewart-RD. Lightwand intubation:
I A new lightwand device. Can-J-Anaesth. 1995 Sep; 42(9): 820-25.
- Hung-OR, Pytka-S, Morris-I, Murphy-M, Stewart-RD
Lightwand intubation: II Clinical trial of a new lightwand for tracheal
intubation in patient with difficult airways. Can-J-Anaesth. 1995
Sep; 42(9): 826-30.
- Hung-OR, Pytka-S, Morris-I, Murphy-M, Launcelott-G,
Stevens-S, MacKay-W, Stewart-RD. Clinical trial of a new lightwand
device (Trachlight) to intubate the trachea. Anesthesiology. 1995
Sep; 83(3): 509-14.
- Ellis-DG; Stewart-RD; Kaplan-RM; Jakymec-A;
Freeman-JA; Bleyaert-A. Success rates of blind orotracheal intubation
using a transillumination technique with a lighted stylet. Ann-Emerg-Med.
1986 Feb; 15(2): 138-42.
- Ellis-DG; Jakymec-A; Kaplan-RM; Stewart-RD;
Freeman-JA; Bleyaert-A; Berkebile-PE. Guided orotracheal intubation
in the operating room using a lighted stylet: a comparison with direct
laryngoscopic technique. Anesthesiology. 1986 Jun; 64(6): 823-6.
- Friedman-PG; Rosenberg-MK; Lebenbom-Mansour-M.
A comparison of light wand and suspension laryngoscopic intubation
techniques in outpatients. Anesth-Analg. 1997 Sep; 85(3): 578-82.
- Holzman-RS; Nargozian-CD; Florence-FB. Lightwand
intubation in children with abnormal upper airways. Anesthesiology.
1988 Nov; 69(5): 784-7.
- Davis-L; Cook-Sather-SD; Schreiner-MS. Lighted
Stylet Tracheal Intubation: A Review. Anesth Analg 2000; 90:745-756.