An obese patient (BMI 48) undergoing laparoscopic sleeve gastrectomy has Cormack-Lehane grade 3 laryngoscopy view. The anaesthetist uses a videolaryngoscope with a hyperangulated blade (CMAC D-Blade). Even though the glottis is now visible, tube delivery is difficult. The most appropriate next manoeuvre is:

• A Switch to direct laryngoscopy (standard Macintosh blade)
• B Remove the scope and attempt an LMA
• C Apply external laryngeal manipulation (BURP)
• D Use a styletted tube pre-shaped to match the blade's acutely angled geometry ✓

Explanation

Hyperangulated videolaryngoscope blades (e.g., CMAC D-Blade, GlideScope) provide excellent glottic visualisation but create a more acute angle between the visual axis and the tracheal inlet than standard blades. A routine straight stylet does not navigate this geometry adequately. A pre-shaped or malleable stylet angled to match the blade's curvature (the 'hockey stick' or 'J-shape' for GlideScope) is essential for successful tube delivery into the visible glottis. Direct laryngoscopy would lose the improved glottic view. BURP is primarily a visualisation aid for direct laryngoscopy; it does not address the tube-delivery geometry issue with hyperangulated VL.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.