A new approach to difficult airway management in Thoracic surgery with Totaltrack® videolaryngoscope and bronchial blockers
Granell M, Pereira F, Broseta A, Biosca E, Nieto S, De Andres J. 
Background: TotalTrack® Video Laryngeal Mask (VLM) is a new generation of supraglottic devices which combine the facility of a laryngeal mask and of a videolaringoscope (1). Patients who undergo thoracic surgery often have impaired pulmonary function which decreases the apnea time available for airway management (2). One of the main multi-functions of this device is to ventilate and oxygenate the patient while managing the airway (3).
Case Reports: We describe the use of TotalTrack® VLM in two cases of high risk thoracic surgery patients with predicted difficult airways: a 65-year-old male with Mallampati IV and discrete neck extension limitation and a 71-year-old male with documented Cormack-Lehane III laryngoscopy, proposed for a high-risk thoracic surgery with lung isolation. The first intubation attempt failed in both situations and an upwards and backwards traction maneuver and a bougie were necessary. However, this device allowed continuous successful ventilation in laryngeal mask mode during intubation attempts and, also during bronchial blocker placement.
Discussion: TotalTrack® VLM has potential advantages in thoracic patients with predictable difficult airways. This device offers the possibility to ventilate through all the airway management process and avoid hypoxemia, which gives the clinician more time to achieve his goal. However, with this device the glottic view is impaired once the endotracheal tube is advanced. More studies need to be undertaken to establish its role in the difficult airway patient and in high risk thoracic surgery.

References:
1.	Br J Anaesth. 2015;115(5):798–799.
2.	Anesthesiol Clin . 2012 December; 30(4): 759–784
3.	Rev Esp Anestesiol Reanim. 2016;63(1):1-2




Learning points:
-	Lung isolation may be technically difficult and time demanding, so having the possibility to ventilate during the process and avoid hypoxemia offers the clinician more time to achieve his goal.
-	TotalTrack® “rescues itself”: laryngeal mask ventilation can be restored and another intubating attempt planned without having to change to a rescue device.
-	When using TotalTrack® VLM it seems good practice to help intubation with a bougie in cases of predicted or confirmed difficult airway.

A novel approach to difficult airway management in Thoracic surgery with Totaltrack® videolaryngoscope and bronchial blockers