Styletubation： A Video Intubating Stylet Technique for Endotracheal Intubation

This book is a review of our clinical experience with optical stylets, with the Shikani Optical stylet and the Shikani technique for intubation (Styletubation). In this monograph (volume 1), we collected several published articles covering several topic as follows.

 Chapter 1─Chapter 5: The history and development of styletubation
 Chapter 6─Chapter 8: The technical pearls and tips of styletubation
 Chapter 9─Chapter 14: The role of styletubation in various difficult airway scenarios
 Chapter 15─Chapter 20: The role of styletubation during COVID-19 pandemic

Hsiang-Ning Luk, MD, MS, PhD, CIP

●Education:
MD National Defense Medical Center, Taiwan
MS Pharmacology, National Defense Medical Center, Taiwan
PhD Physiology, Leuven University, Belgium
CIP Certified IRB Professional, CCIP, USA

●Academic Position:
National Defense Medical Center, Taipei
National Yang-Ming University, Taipei
National Taipei Nursing College, Taipei
Chang Gung University, Linkou
Chung Shan Medical University, Taichung
Catholic Providence University, Taichung

●Professional Career:
1975–1982: MD (National Defense Medical Center, Taiwan)
1982–1984: CA1, CA2 (Anesthesia, Tri-Service General Hospital, Taiwan)
1984–1986: MS (Pharmacology, National Defense Medical Center, Taiwan)
1986–1988: Instructor (Pharmacology, National Defense Medical Center, Taiwan)
1988–1993: PhD (Physiology, Leuven University, Leuven, Belgium)
1993–1998: Associate Professor (Pharmacology, National Defense Medical Center)
1998–2000: CA3, CA4 (Anesthesia, Taipei-Veterans General Hospital, Taiwan)
2000–2001: Anesthesiologist (Taipei-Veterans General Hospital, Taiwan)
2001–2003: Anesthesiologist (Chang Gung Memorial Hospital, Linkou, Taiwan)
2003–2004: Chair (Anesthesia, Chang Gung Memorial Hospital, Kaohsiung)
2004–2007: Chair (Anesthesia, Taichung-Veterans General Hospital, Taiwan)
2008–2009: Vice-Chair, TC-VGH IRB (Taichung-Veterans General Hospital, Taiwan)
2008–2020: Western IRB (International Fellow-Group 10; IRB board member)
2004–2011: Anesthesiologist (Anesthesia, Taichung-Veterans General Hospital, Taiwan)
2007–2015: WHO-FERCAP surveyor
2011–2012: Staff physician, Western IRB, USA
2012–2012: Vice-Chair, Western IRB, Olympia, Wa, USA
2013–2016: Anesthesiologist (Anesthesia, China Medical University-Beigang Hospital, Taiwan)
2016–: Anesthesiologist, Vice-Chair, Chair (Anesthesia, Hualien Tzu-Chi Hospital, Hualien, Taiwan)

●Publication:

Anesthesiology 1988, 69, 667-676.
Anesthesiology 1996, 84, 626-635
Anesthesiology 2002, 96, 651-658.
Anesthesiology 2003, 98, 1031-1032.
Anesthesiology 2003, 98, 579-581.
Anesthesiology 2004, 100,1630-1631.


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3. Anesth.Res. 2024, 1, 8-23.
4. Healthcare 2023, 11, 2256.
5. Healthcare 2023, 11, 891.
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7. Asian J Anesthesiol 2023, 61,102-106.
8. J Chin Chem Soc 2023,1-10.
9. J Chin Chem Soc 2023,70,928.
10. Advances in Tracheal Intubation; IntechOpen: London, UK, 2022.
11. Healthcare 2022,10,2175.
12. Healthcare 2022,10,1688.
13. Healthcare 2022,10,1105.
14. Healthcare 2022,10,741.
15. Healthcare 2022,10,388.
16. Minerals 2022,12,1145.
17. Chem Biol Interact 2022,Jan 7;354:109810.
18. Encyclopedia 2021,1,1058-1075.
19. Asian J Anesthesiol 2021,59,117-121.
20. Cell Transplant 2021,Jan-Dec;30.
21. Healthcare 2021,9,1727.
22. Environ Toxicol 2021,36,1567-1575.
23. Probiotics Antimicrob Proteins 2021,13,1044-1053.
24. Catalysts 2021,11,1083.
25. Anesth Analg 2020,131,e97-e99.
26. J Nanosci Nanotechnol 2020, 20, 2705-2712.
27. J Chin Chem Soc 2020,1–6.
28. Clin Neurol Neurosurg 2020,192,105725.
29. J Chin Chem Soc. 2019,66:75-80.
30. J Nanosci Nanotechnol 2018,18,4728-4733.
31. J Nanosci Nanotechnol 2017,17,3026-3032.
32. Acta Anaesthesiologica Taiwanica 2015,53, 29-40.
33. J Chin Chem Soc 2014,61,1365-1370.
34. Int J Computer Mathematics 2014,91,1986-2009.
35. Chin J Physiol 2012,55,169-177.
36. J Nanosci Nanotechnol 2011,11,4667-4674.
37. Talanta 2010, 81, 228-234.
38. Heart Rhythm 2010, 7, 110-116.
39. Sensor Letters 2009, 7, 1093 -1099.
40. Int J Obstet Anesth 2009, 18, 413-416.
41. Reg Anesth Pain Med 2009, 34,181.
42. J Chin Med Assoc 2008, 71, 610-618.
43. J Clin Anesth 2008, 20, 25-29.
44. Sensors & Actuators: A. Physical 2008, 141, 109-119.
45. Sensors & Actuators: B. Chemical 2007, 126, 387-393.
46. J Chin Med Assoc 2007, 70, 456-459.
47. Acta Anaesthesiol Taiwan 2007, 45, 117-120.
48. Int J Cardiol 2006, 107, 417-418.
49. Int J Obstet Anesth 2006, 15, 149-151.
50. Acta Anaesthesiol Taiwan 2006, 44, 169-171.
51. Acta Anaesthesiol Taiwan 2006, 44, 47-50.
52. Acta Cardiol Sin 2005, 21, 214-222.
53. Int J Cardiol 2005, 104, 59-66.
54. Can J Anaesth 2005, 52, 1002-1003.
55. J Clin Anesth 2005, 17, 339-343.
56. Acta Anaesthesiol Taiwanica 2005, 43, 109-112.
57. Transpl Int 2005 18, 396-400.
58. J Clin Anesth 2005, 17, 147.
59. J Clin Anesth 2005, 17, 124-127.
60. Anesthesiology 2004, 100,1630-1631.
61. Int J Cardiol 2004, 97, 303-304.
62. J Biomed Sci 2004, 11, 303-314.
63. Cardiovasc Res 2004, 62, 96-104.
64. Transplantation 2004, 77, 1394-1398.
65. Acta Anaesthesiol Scand 2004, 48, 663.
66. Can J Anaesth 2004, 51, 856-857.
67. Acta Anaesthesiol Taiwan 2004, 42, 41-44.
68. Int J Cardiol 2003, 89, 187-195.
69. Anesthesiology 2003, 98, 1031-1032.
70. Anesthesiology 2003, 98, 579-581.
71. Can J Anesth 2003 50, 36-41.
72. Transplant Int 2003, 16:510-514.
73. Liver Transplant 2003, 9, 760-763.
74. J Clin Anesth 2003, 15, 545-548.
75. World J Surg 2003, 27, 761-764.
76. J Surg Res 2003, 110, 378-382.
77. Blood 2002, 100, 2249-2252.
78. Cardiovasc Res 2002, 55:290-299.
79. Anesthesiology 2002, 96, 651-658.
80. J Biomed Sci 2002, 9, 321-326.
81. Br J Pharmacol 2002, 135, 1383-1392.
82. Acta Anaesthesiol Sin 2002, 40:165-172.
83. Zhonghua Yi Xue Za Zhi 2002, 65, 570-579.
84. Anesth Analg 2002, 95, 1169-1172.
85. Acta Anaesthesiol Sin 2001, 39, 195-198.
86. J Electrocardiol 2001, 34, 325.
87. Acta Anaesthesiol Scand 2001, 45, 255-257.
88. Acta Anaesthesiol Scand 2001, 45, 123-126.
89. Acta Anaesthesiol Sin 2000, 38, 195-200.
90. Can J Anesth 2000, 47, 638-641.
91. Crit Care Med 2000, 28, 1713-1720.
92. Circulation 1999, 99, 3056-3062.
93. Clin Exp Pharmacol Physiol 1998, 25, 585-591.
94. Biochim Biophys Acta 1997, 1336, 445-454.
95. Can J Anaesth 1997, 44, 775-781.
96. Biochem Biophys Res Commun 1997, 235, 74-78.
97. Biochem Biophys Res Commun 1996, 223, 598-603.
98. Anesthesiology 1996, 84, 626-635.
99. Eur J Pharmacol 1996, 297, 27-33.
100. J Electrocardiol 1995, 28, 332-333.
101. J Biomed Sci 1994, 1, 139-146.
102. Pflugers Arch 1990, 416, 766-768.
103. Anesth Analg 1989, 68, 479-485.
104. Anesthesiology 1988, 69, 667-676.
105. Br J Pharmacol 1988, 93, 192-198.
106. Eur J Pharmacol 1987, 136, 409-413.
107. Ma Tsui Hsh Tsa Chi Anaesthesiologica Sinica 1985, 23, 124-130.

The authors also wish to acknowledge the contribution made by publishers who accomplish the knowledge sharing of the publications we presented in this monograph. The book has been written expressly for the providers with a solid background in airway management, in order to serve as a reference while they accumulate additional experience in intubation. Experience is the best teacher in airway management.
It is our intention to provide basic, practical and tested maneuvers to manage the airway in the real world. Our contribution to this book is to share the result of personal experience gained over many years of clinical practice. It is a statement earned by personal observation, building upon the knowledge of those who taught us.

Management of the upper airway and endotracheal intubation are provided by a variety of specialists including anesthesiologists, otorhinolaryngologists, emergency physicians, and pulmonary physicians. Fibreoptic and video technologies are widely used for airway management. Optical stylets, which incorporate flexible fibreoptic imaging elements in an intubation stylet, are gradually becoming the preferred intubation tools for a growing number of specialists. The ideal optical stylet should provide illumination and an image of high clarity, familiar handling with malleability and additional tip flexion, and low cost so that it becomes available to the larger community of airway providers.

The Shikani Optical stylet (SOS) was introduced in 1999 as a novel intubating stylet which has a lens at the distal end, a fiberoptic cable inside and is connected to a camera and a video monitor, hence allowing continuous visualization of the airway during introduction of the tube into the glottis [Shikani AH. New "seeing" stylet-scope and method for the management of the difficult airway. Otolaryngol Head Neck Surg. 1999 Jan;120(1):113-6. doi: 10.1016/S0194-5998(99)70380-3.]. The SOS allowed the introduction of the Shikani technique for intubation (Styletubation), which allows endotracheal intubation without the need of the rigid laryngoscope blade to retract the base of the tongue, hence minimizing the risk of trauma to the glottis or dentition. The SOS and Shikani technique for intubation (Styletubation) have been used in millions of patients worldwide (mainly in Asia), published in more than 100 articles and cited in many more.

Preface

Autobiography／Shinn-Zong, John, Lin, MD, PhD, FAAAS, FNAI, IFAANS, CPI
Autobiography／Alan H. Shikani, MD, FACS
Autobiography／Jason Zhensheng Qu, M.D.
Autobiography／Hsiang-Ning Luk, MD, MS, PhD, CIP

Table of Contents

Chapter 1／The early history and development of the Shikani Optical stylet and Shikani Method of Intubation (Styletubation)
Alan H. Shikani, MD, FACS

Chapter 2／The Holy Grail for Endotracheal Intubation in the 21st Century
Hsiang-Ning Luk, San-Qing Jin, Jason Zhensheng Qu, Alan Shikani

Chapter 3／A Paradigm Shift of Airway Management: The Role of Video-Assisted Intubating Stylet Technique
Luk, H.-N., Luk, H.-N., Zhensheng Qu, J., & Shikani A.

Chapter 4／Styletubation: The Paradigmatic Role of Video-Assisted Intubating Stylet Technique for Routine Tracheal Intubation
Luk HN, Qu JZ, Alan H. Shikani A.

Chapter 5／Styletubation versus Laryngoscopy: A New Paradigm for Routine Tracheal Intubation
Luk, H.-N, Qu, J.Z.

Chapter 6／An Approach to Improve the Effectiveness of the Video-Assisted Intubating Stylet Technique for Tracheal Intubation: A Case Series Report
Lan CH, Luk HN, Qu JZ, Alan H. Shikani

Chapter 7／Four Approaches of Styletubation for Handling the Orotracheal Intubation: A Technical Tip
Cheong MW, Luk HN, Qu JZ, Shikani A.

Chapter 8／Video-Twin Technique for Airway Management, Combining Video-Intubating Stylet with Videolaryngoscope: A Case Series Report and Review of the Literature
Jhuang BJ, Luk HN, Qu JZ, Alan H. Shikani

Chapter 9／Video-Assisted Intubating Stylet Technique for Difficult Intubation: A Case Series Report
Tsay PJ, Yang CP, Luk HN, Qu JZ, Shikani A.

Chapter 10／Styletubation for Routine Tracheal Intubation for Ear-Nose-Throat Surgical Procedures
Luk HN, Qu JZ, Shikani A.

Chapter 11／The Use of the Shikani Video-Assisted Intubating Stylet Technique in Patients with Restricted Neck Mobility
Shih TL, Koay KP, Hu CY, Luk HN, Qu JZ, Shikani A.

Chapter 12／Styletubation in Bariatric Surgery: A Case Report
Wu BG, Luk HN, Qu JZ, Shikani A.

Chapter 13／Structured Routine Use of Styletubation for Oro-Tracheal Intubation in Obese Patients Undergoing Bariatric Surgeries-A Case Series Report
Lee HC, Wu BG, Chen BC, Luk HN, Qu JZ.

Chapter 14／Combined Styletubation with Videolaryngoscopy for Tracheal Intubation in Patients Undergoing Thyroidectomy with Intraoperative Neuromonitoring
Pan, H.-S.; Corey, T.; Luk, H.-N.; Qu, J.Z.; Shikani, A.

Chapter 15／Adaptation to the Plastic Barrier Sheet to Facilitate Intubation During the COVID-19 Pandemic
Yang YL, Huang CH, Luk HN, Tsai PB.

Chapter 16／Plastic Sheet and Video Intubating Stylet: A Technical Note
Tsai PB, Luk HN.

Chapter 17／Application of Plastic Sheet Barrier and Video Intubating Stylet to Protect Tracheal Intubators During Coronavirus Disease 2019 Pandemic: A Taiwan Experience
Luk H-N, Yang Y-L, Tsai PB.

Chapter 18／Sheet Barrier and Intubating Stylet
Tsai, P.B.; Luk, H.-N.

Chapter 19／Video-Assisted Stylet Intubation with a Plastic Sheet Barrier, a Safe and Simple Technique for Tracheal Intubation of COVID-19 Patients
Huang CH, Su IM, Jhuang BJ, Luk HN, Qu JZ, Shikani A.

Chapter 20／The Use of a Video-Assisted Intubating Stylet Technique in a Critically Ill and Contagious COVID-19 Patient
Yang CP, Luk HN, Qu JZ, Shikani A.

Method of Intubation (Styletubation)
Alan H. Shikani, MD, FACS

The history of the Shikani Optical stylet started in 1996. I was approached at the time by Tom Barthel, the CEO of Clarus Medical, who wanted to know whether I could use a neuro-endoscopy fiberoptic cable which Clarus promoted for neurosurgical procedures, in endoscopic pituitary surgery. Tom had learned about me through a paper that I had recently published in the Journal of Otolaryngology, describing an utterly novel pituitary surgery technique [1]. Until that time all pituitary surgery in the US had been done following the traditional transeptal transsphenoidal hypophysectomy technique introduced by Harvey Cushings at Johns Hopkins at the turn of the century, and that involves removing pituitary tumors through an incision made under the upper lip and nasal cavity, to expose the piriform aperture and the rostrum of the maxilla, allowing access to the sella turcica for tumor resection (for review, see [2]). During my training in Otolaryngology-Head and Neck surgery at Johns Hopkins, between 1985 and 1991, I had become proficient in functional endoscopic sinus surgery for chronic sinusitis, a technique invented by Prof Walter Messerklinger in Austria [3] and introduced to the United States by Dr David Kennedy at Johns Hopkins. Sinus surgery was however a totally different procedure than pituitary surgery. In 1991, I ventured to perform a case of endoscopic surgery for a pituitary tumor, a minimally invasive surgical procedure done through the nose and sphenoid sinus, offering a less invasive approach compared to the traditional Cushings technique and I published the paper in the Journal of Otolaryngology [1]. At the time, it was the first pituitary case ever done endoscopically. Since then, endoscopic transsphenoidal surgery has become the norm and replaced the Cushings technique as the preferred surgical approach for removing pituitary tumors.

After evaluating the Clarus fiberoptic cables, I informed Tom Barthel that I could foresee a more interesting use for their technology, by incorporating a fiberoptic cable into an optical stylet for the purpose of endotracheal intubation and airway management. The concept of airway management using intubating fiberoptic scopes had been previously described, however transforming the blind bougie used in endotracheal intubation into a “seeing” stylet would be unique and novel. I designed the Shikani Optical stylet (SOS), a new intubating stylet which has a lens at the distal end, a fiberoptic cable inside and is connected to a camera and a video monitor, hence allowing continuous visualization of the airway during introduction of the tube into the glottis (Figure 1). I used the SOS in 120 patients and published the first paper in 1999 in the Journal Otolaryngology-Head and Neck Surgery [4]. This new “seeing” stylet would prove to combine the advantages of a fiberoptic scope and the semi-rigidity of a classic metal stylet. Its advantage over the flexible fiberoptic scope would be that it can keep its semi-rigid shape, allowing better maneuvering around a large epiglottis that is flopping against the posterior pharyngeal wall, which in the supine position, may constitute an insurmount¬able problem using a flexible scope. In addition, it would offer the advantages of the light wand but would be superior to it in that it acts not only as a source of illumination but also allows visualization and helps direct the course of the endotracheal tube.