SECTION 2: Respiratory Procedures 1

CHAPTER 4:
Tracheal Intubation
AIRWAY ANATOMY
Pharynx: the upper part of the throat posterior to the nasal
cavity, mouth, and larynx
1. Nasopharynx: base of the skull to the soft palate
2. Oropharynx: soft palate to the epiglottis
3. Hypopharynx: epiglottis to the cricoid ring
(posteriorly), including the piriform
sinus/recess/fossa PREPARATION
Piriform sinus/recess/fossa: the pockets on both sides of the o Intubation is best accomplished with two operators, one to
laryngeal inlet separated from the larynx by the aryepiglottic perform the intubation and the other to handle equipment,
folds help with positioning, observe the patient and monitor,
Larynx: the anterior structures of the throat (commonly called and keep track of time.
the voice box) from the tip of the epiglottis to the inferior o Before intubating, it is preferable to take the following
border of the cricoid cartilage, including the laryngeal inlet steps in chronologic order:
Laryngeal inlet: the opening to the larynx bounded 1. attach the necessary monitoring devices and
anterosuperiorly by the epiglottis, laterally by the aryepiglottic administer oxygen
folds, and posteriorly by the arytenoid cartilage 2. establish intravenous access
Arytenoid/posterior cartilage: the posterior aspect of the 3. draw up essential medications and label them if time
laryngeal inlet separating the glottis (anterior) from the permits
esophagus (posterior) 4. confirm that the intubation equipment is available and
1. Corniculate cartilage: the medial portion of the functioning
arytenoid/ posterior cartilage 5. reassess oxygenation and maximize preoxygenation
2. Cuneiform cartilage: the lateral prominence of the 6. position the patient correctly
arytenoid/posterior cartilage 7. make sure that all team members are aware of the
3. Interarytenoid notch: the notch between the primary procedural approach and the most likely
posterior cartilage backup plan
Glottis: the vocal apparatus, including the true and false cords
and the glottic opening
Vallecula: the space between the base of the tongue and the
epiglottis
Hyoepiglottic ligament: anterior midline ligament connecting
the epiglottis to the hyoid bone

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 SECTION 2: Respiratory Procedures 2

PREOXYGENATION o Alternatively, if it is not possible to perform preoxygenation

o The goal of preoxygenation is to replace all the nitrogen in for 3 to 5 minutes prior to intubation, instruct the patient
the lungs with oxygen prior to the start of intubation to take eight vital capacity breaths while delivering very
attempts. high flow oxygen, to provide nearly the same result.
- This allows the lungs to act as an oxygen reservoir - Many critically ill patients will not be able to take vital
during the apneic period of RSI. capacity breaths; therefore with time permitting, the
- This provides the intubator with additional time before preferred method is 3 to 5 minutes of tidal breathing.
the onset of hypoxemia, and significantly increases the o Unlike face masks, bag-mask ventilation (BMV) requires
chance for successful intubation on the first attempt. proper equipment and good technique to achieve
o It is not enough to achieve a peripheral oxygen saturation adequate preoxygenation.
(SpO2) value of 100% prior to intubation, because an SpO2 - Bags without one-way valves for inhalation and
of 100% does not necessarily correspond with exhalation will not function properly during
denitrogenation of the lungs; furthermore, partial pressure spontaneous ventilation, and will provide only room
of arterial oxygen (PaO2) at 100% SpO2 can range from air.
approximately 100 mm Hg to 600 mm Hg. - Furthermore, unless flow rates are very high (>40
o Failure to preoxygenate before RSI is often a critical factor L/min), the mask must be sealed perfectly to the
when a straightforward emergency airway becomes an patient’s face.
unexpected airway problem. o If the seal is imperfect, room air will be entrained and FiO2
o Those at greatest risk for rapid desaturation include obese, will be close to that of room air.
pregnant, critically ill, and pediatric patients; these - This is analogous to holding a mask above a patient’s
populations will benefit most from optimal face, which likewise provides oxygen content near that
preoxygenation. of room air.
o Preoxygenate by providing the maximal fraction of inspired o In spontaneously breathing patients, face masks (with a
oxygen (FiO2) with a simple face mask or non-rebreather very high flow rate) are the preferred oxygen delivery
mask for 3 to 5 minutes before intubation. device for preoxygenation.
- The type of mask is less important than the oxygen o To augment oxygen delivery and prepare for apneic
flow rate; oxygenation, apply a nasal cannula (at 15 L/ min) to the
▪ at very high flow rates the FiO2 for any patient during preoxygenation, simultaneously with other
device usually exceeds 90% preoxygenation efforts.
▪ At lower flow rates (< 30 L/min) the FiO2 o The preferred position for preoxygenation is head
will not be high enough for adequate elevation of 20 to 25 degrees.
preoxygenation, so the oxygen flow rate - This position minimizes atelectasis, decreases the
should be at least 30 L/min. pressure of the abdominal contents against the
o When using a standard oxygen flow meter this requires diaphragm, and allows the patient to continue taking
turning it up as high as possible, beyond the marked deep breaths.
maximum of 15 L/min, to the “flush” rate. - In both obese and non-obese adults, this position has
- The flush rate is usually marked on each flowmeter and been demonstrated to be advantageous for
is typically greater than 40 L/min. preoxygenation.
- Oxygen flowmeters that can measure up to 70 L/min, - For patients with spinal immobilization, the bed can
with flush rates up to 90 L/min, are available however, be placed in 25 degrees of reverse Trendelenburg
a flush rate greater than 40 L/min is probably sufficient (head up) to achieve the same effect.
for maximal preoxygenation. o If SpO2 cannot be increased above 93% to 95% after
- Providing high flow oxygen washes out expired CO2, optimal preoxygenation, the addition of positive pressure
fills the dead space of the nasopharynx and upper using noninvasive positive pressure ventilation (NPPV) or
airway with oxygen, compensates for any leak mask ventilation with a positive end-expiratory pressure
between the mask and the patient to avoid valve may improve oxygenation prior to intubation
entrainment of room air during inspiration, and may attempts.
provide low levels (1 to 2 cm H2O) of positive airway o Sometimes patients who will benefit the most from
pressure. preoxygenation are uncooperative because of delirium
- If possible, instruct the patient to exhale maximally from hypoxia, hypercapnia, or other factors.
before beginning preoxygenation. - Application of a face mask or NPPV may be difficult or
impossible.

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 SECTION 2: Respiratory Procedures 3

- These patients may benefit from careful sedation

without suppression of respirations, allowing for
oxygenation with a face mask or NPPV for 2 to 3
minutes before administration of a paralytic agent
(also known as delayed sequence intubation).
- Ketamine (1 to 1.5 mg/kg by slow intravenous push)
has been suggested for this technique.
Apneic Oxygenation During Intubation
o Another method to delay desaturation during RSI is
nasopharyngeal oxygen insufflation without ventilation,
termed apneic oxygenation.
o Perform apneic oxygenation with every tracheal intubation
to decrease the chance of severe hypoxemia.
- Place a standard nasal cannula beneath the main
preoxygenation device (face mask or bag-valve mask).
- If the patient is awake, limit the flow rate to 5 to 15
L/min during the preoxygenation phase because
higher flow rates can be uncomfortable.
- If the patient is comatose or unresponsive, set the
nasal cannula to 15 L/min or higher when initially
placed.
- When the preoxygenation device is removed for
intubation, keep the nasal cannula in place.
- During intubation attempts, set the nasal cannula to at - limited ability to open the mouth (suggested by a
least 15 L/min. space less than three fingerbreadths between the
- It may be beneficial to turn the oxygen flowmeter up upper and lower incisors),
as high as possible because higher flow rates have - short thyromental distance (< 6 cm from the thyroid
been shown to provide higher FiO2. notch to the chin with the neck in extension)
- If there is nasal obstruction, place a nasopharyngeal
airway in one or both nares to facilitate oxygen
delivery to the posterior nasopharynx.
- To optimize gas flow past the upper airway, position
the patient for tracheal intubation, and perform
maneuvers to ensure upper airway patency (i.e., jaw
thrust, head tilt/chin lift).
- Because conventional nasal cannula oxygen delivery is
not humidified, apneic oxygenation at high flow rates
will cause some desiccation of the nasopharynx, but
this should not cause significant harm because of the
short duration of this oxygen supplementation.
Short thyromental distance
ASSESSING FOR A DIFFICULT AIRWAY - a limited direct laryngoscopic view of the laryngeal
o The classic predictors of difficult intubation include: inlet:
- a history of previous difficult intubation,
- prominent upper incisors,
- limited ability to extend at the atlanto-occipital joint,
- poor visibility of pharyngeal structures when the
patient extends the tongue (Mallampati classification
or the tongue-pharyngeal ratio)

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 SECTION 2: Respiratory Procedures 4

- Safety of the technique and skill of the operator

Decision to Perform Rapid-Sequence Intubation (RSI)
o Initially, the main purpose of RSI was to decrease the risk
for aspiration in patients with full stomachs who needed
emergency intubation.
- RSI has now become the most common method of
emergency airway management because paralysis
facilitates optimal intubating conditions in critically ill
- A relatively new test is the upper lip bite test, which
patients.
has been shown in some studies to be more accurate
and specific than older tests.
▪ It is essentially a test of anterior
mandibular mobility, and the less
mobility the more difficult it is to intubate
the patient.
▪ Upper lip bite criteria are as follows:
class I, the lower incisors can bite the
upper lip above the vermilion line;
▪ class II, the lower incisors can bite the
upper lip below the vermilion line; o Risk factors for difficult or impossible BMV have been well
▪ class III, the lower incisors cannot bite the studied and include:
upper lip. - the presence of a beard
o Difficult intubation because distorted anatomy or - obesity
secretions may compromise visualization of the vocal - lack of teeth
cords: - age older than 55 years
- Patients with neck tumors - a history of snoring
- thermal or chemical burns - short thyromental distance
- traumatic injuries involving the face and anterior - limited mandibular protrusion
aspect of the neck o RSI is contraindicated:
- angioedema - in patients who cannot be orally intubated
- infection of pharyngeal and laryngeal soft tissues o It should usually be avoided in patients with
- previous operations in or around the airway laryngotracheal abnormalities caused by tumors, infection,
o Facial or skull fractures may further limit airway options by edema, or a history of cervical radiation therapy.
precluding nasotracheal (NT) intubation. Ideal Versus Emergency Technique
o Patients with ankylosing arthritis or developmental Consider the patient with rapidly increasing upper airway
abnormalities such as a hypoplastic mandible or the large swelling due to angioedema or anaphylaxis, causing impending
tongue of Down’s syndrome are difficult to intubate complete airway obstruction. Because of predicted difficulty
because neck rigidity and problems of tongue with direct and video laryngoscopy, some providers would not
displacement can obscure visualization of the glottis. consider this patient a candidate for RSI.
o One patient type that does not immediately stand out as a o The best course for this patient is likely RSI with modern
difficult intubation, but can be surprisingly so, is a patient video laryngoscopy equipment and a good backup plan,
with an unusually long mandibulohyoid distance (the such as the LMA Fastrach (Teleflex), followed by a
thyroid prominence appearing low in the neck) and a short cricothyrotomy.
mandibular ramus. Failed Airways
EMERGENCY AIRWAY DECISION MAKING Patient is considered to have a failed airway in the following
o The following parameters should be assessed before the situations:
decision is made to establish a definitive airway: 1. inability to maintain oxygenation by BMV or EGA
- Adequacy of current ventilation device;
- Potential for hypoxia 2. failure of three or more intubation attempts by an
- Airway patency experienced operator;
- Need for neuromuscular blockade (uncooperative, full 3. failure of the first attempt in a “forced to act”
stomach, teeth clenching) situation.
- Cervical spine stability

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Emergency Airway Algorithm o STRAIGHT BLADE

- The tip of the straight blade goes under the epiglottis
and lifts it directly.
- The straight blade is often a better choice in pediatric
patients, in patients with an anterior larynx or a long
floppy epiglottis, and in individuals whose larynx is
fixed by scar tissue.
- It is less effective, however, in patients with prominent
upper teeth, and it is more likely to damage dentition.
- Use of the straight blade is also more often associated
with laryngospasm because it stimulates the superior
laryngeal nerve, which innervates the undersurface of
the epiglottis.
- A straight blade may inadvertently be advanced into
the esophagus and initially reveal unfamiliar anatomy
until it is withdrawn.
- The blade has a lightbulb at the tip, which may slightly
hamper vision.
DIRECT LARYNGOSCOPY (DL)
o CURVED BLADE
o DL remains the mainstay of tracheal intubation. DL is a - Whereas the curved blade fits into the vallecula and
crucial skill even in the era of video laryngoscopy, and is less indirectly lifts the epiglottis via engagement of the
prone to problems such as device failure or blood and hyoepiglottic ligament to expose the larynx.
secretions covering the video lens. - The wider, curved blades are helpful in keeping the
o Visual confirmation of the tube going through the vocal tongue retracted from the field of vision and allowing
cords is usually possible. more room for passing the tube through the
INDICATIONS AND CONTRAINDICATIONS oropharynx, and they are generally preferred for
o DL is indicated in any clinical situation in which a definitive uncomplicated adult intubations.
emergency airway is necessary, including routine and - Aside from patient considerations, some clinicians
difficult airways. prefer the curved blade because they find that it
o Relative contraindications to DL include: requires less forearm strength than the straight blade.
- limited mouth opening o The illumination provided by the laryngoscope can make a
- upper airway distortion or swelling big difference in the ability to visualize the laryngeal inlet.
- severe kyphosis Tracheal Tubes
- copious blood or secretions o The standard adult endotracheal (ET) tube measures
EQUIPMENT approximately 30 cm in length.
Laryngoscope o Tube size is typically printed prominently on the tube and
o There are two basic blade designs for DL, curved is based on the internal diameter (ID) and measured in
(Macintosh) and straight (Miller) millimeters.
o The range is 2.0 to 10.0 mm in increments of 0.5 mm.
o The outer tube diameter is 2 to 4 mm larger than the ID.
o Tubes are also imprinted with a scale in centimeters that
indicates the distance from a tube’s distal tip.
o Adult men can generally accept a 7.5- to 9.0-mm
orotracheal tube, and women can usually be intubated
with a 7.0- to 8.0-mm tube.
o Larger tubes are theoretically desirable because airway
resistance increases as tube size decreases, but in practice,
a 7.5-mm tube is adequate for almost all patients.
o In emergency intubations, particularly if a difficult
intubation is anticipated, many clinicians choose a smaller
A. Macintosh B. Miller tube and change to a larger tube later if necessary.

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 SECTION 2: Respiratory Procedures 6

- Though generally an acceptable practice, this should o In children 2 years or older, the following formula is a highly
be avoided in burn patients because swelling may accurate method for determining correct uncuffed and
prohibit subsequent tube placement. cuffed ET tube size:
- For nasal intubation, a slightly smaller (by 0.5 to 1.0
mm) tube may be easier to advance through the nasal
passages.
o Correct tube size is important in the pediatric population.
o For most clinical situations, using the width of the nail of
- It is especially important when using an uncuffed tube
the patient’s little (fifth) finger as a guide is sufficiently
because a good seal is needed between the ET tube
accurate and has been shown to be more precise than
and the upper part of the trachea.
finger diameter.

o A standard tracheal tube uses a high-volume, low-pressure

cuff to avoid pressure necrosis of the tracheal lining.
o A clinical test for determining correct cuff inflation is to
slowly inject air until no air leak is audible while the patient
is receiving bag-tube ventilation.
- This usually occurs with 5 to 8 mL of air if the proper
size tracheal tube has been selected.
- Many clinicians use the tension of the pilot balloon as
o As tube size is based on the ID, a cuffed tube should a guide to cuff inflation.
generally be a half size (0.5 mm) smaller than an uncuffed - Slight compressibility with gentle external pressure
tube. indicates adequate inflation for most clinical
- The smaller ID of an appropriately sized, small cuffed situations.
tube could theoretically make it more prone to - For long-term use, measure and maintain cuff pressure
plugging from secretions. at 20 to 25 mm Hg. Capillary blood flow is
- Cuffed tubes are available down as small as 3 mm ID, compromised in the tracheal mucosa when cuff
although indications for these tubes in neonates and pressure exceeds 30 mm Hg.
infants are rare. o In emergency situations, simply inflate the balloon with 10
- A cuffed tube is used in children with decreased lung mL of air and adjust it when the patient’s condition has
compliance who may require prolonged mechanical stabilized.
ventilation. In a child, the smallest airway diameter is o Interest in design of the tip of the tracheal tube has grown
at the cricoid ring rather than at the vocal cords, as in as the Seldinger technique is increasingly being applied to
adults. intubation.
- Hence, a tube may pass the cords but go no farther. If - When a tracheal tube is passed over a smaller caliber
this should occur, the next smaller size tube should be introducer (Seldinger technique), regardless of
passed. whether it is a tracheal tube introducer or an
- The American Heart Association (AHA) states that endoscope, there is a reasonable chance that the tube
both cuffed and uncuffed tubes are acceptable for will get hung up on the laryngeal soft tissue.
infants and children who are tracheally intubated. If a - A tracheal tube that has been designed to overcome
cuffed tube is placed, careful attention must be paid to this problem has a bevel oriented posteriorly and a
cuff pressures. flexible tip that decreases the distance between the
tube and whatever it is being passed over.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 7

- Head elevated:

- “Sniffing” position with a flexed neck and extended

head. Note that flexing the neck while extending the
head lines up the various axes and allows direct
laryngoscopy.

Note: When a standard tube is inserted in the normal fashion, the

bevel is oriented vertically and toward the patient’s left. The Parker
tube tip bevel faces posteriorly and may avoid getting caught on
laryngeal structures. The flexible tip of the Parker tube also provides a
closer fit on an introducer.
o Check the ET tube cuff for leaks by inflating the pilot
balloon before attempting intubation.
o Prepare the tube for placement by passing a malleable
stylet down the tube to increase its stiffness and enhance
control of the tip of the tube.
o Do not extend the stylet beyond the eyelet of the tube.
o Bend the tube and stylet to create a “straight-to-cuff”
shape with a 35-degree distal bend. Lubricate the tip and - Morbidly obese patients are best intubated in a
cuff of the tube with viscous lidocaine or a water-soluble ramped position with elevation of the upper part of
gel. the back, neck, and head; the ideal position aligns the
Optimal Patient Positioning for DL external auditory canal and the sternum.
o The sniffing position, with the patient’s head extended on
the neck and the neck flexed relative to the torso, has
traditionally been considered the best head position for DL.
- This position aligns the oral, pharyngeal, and laryngeal
axes.
- Neutral position:

o The ideal sniffing position for normal patients as neck

flexion of 35 degrees and atlantooccipital extension such
that the plane of the face is −15 degrees to the horizontal
position.
o In supine patients, neck flexion is achieved by head
elevation. Depending on the size and shape of the patient,

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 8

the amount of head elevation may differ significantly, and o Place the patient in the supine position and place them in
the end point should be horizontal alignment of the the sniffing position, elevate the bed so that the patient’s
external auditory meatus with the sternum. head is at the level of the lower part of your sternum, and
o In normal-size adults it is usually possible to achieve the preoxygenate.
sniffing position with 7 to 10 cm of head elevation.
o Morbidly obese patients require much more head
elevation to achieve the proper sniffing position.
- In these patients, aligning the external auditory
meatus with the sternum requires elevation of the
head and neck, as well as the upper part of the back.
- This can be accomplished by building a ramp of towels
and pillows under the upper torso, head, and neck or
by using a Troop Elevation Pillow or some other device.
- Alternatively, elevating the head to a 25-degree back-
up position (keeping the patient supine while placing
the bed in 25-degree reverse Trendelenburg) may
achieve the same purpose.
o Two studies have shown that elevating the head (flexing
the neck) beyond the sniffing position often improves
visualization of the glottis.
- This is best accomplished by putting your right hand
behind the patient’s head to lift, flex, and extend the
head as needed to bring the glottis into view.
- Optimal positioning of the head and neck is not
possible in trauma patients who require in-line
stabilization of the cervical spine.
- It should also be noted that some patients, especially
those who are obese, are in neck extension when lying - Image above: To maintain the best mechanical
supine because of upper dorsal fat deposition. advantage, keep your back straight and do not hunch
▪ If this is noted, the head can be raised over the patient. Bend only at the knees.
until the head and neck are in neutral - Keep the left elbow relatively close to the body and
position. flex it slightly to provide better support.
Procedure and Technique of DL - In a severely dyspneic patient who cannot tolerate
Adults lying down, perform DL with the patient seated semi-
o Check all equipment, including the light on the erect and the clinician on a stepstool behind the
laryngoscope and the cuff on the endotracheal tube. patient.
Ensure that suction and difficult airway devices are within - Grasp the laryngoscope in the left hand with the back
reach. end of the blade pressed into the hypothenar aspect
of your hand.
o Hold laryngoscope with your left hand. Open the patient’s
mouth with your right hand and introduce the
laryngoscope into the right side of the patient’s mouth.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 9

o Push the tongue to the left side of the mouth, slowly - Locating the epiglottis is a crucial step in laryngoscopy,
advance the blade, and progressively identify the base of and has been termed epiglottoscopy. The laryngeal
the tongue, the epiglottis, and the posterior cartilages. inlet lies just distal and below the epiglottis.
o Instruct an assistant to retract the right cheek for better
visualization. Pass the tube on the right side of the patient’s
mouth. Do not allow the tube to obstruct your view of the
vocal cords during advancement.

o Place the Macintosh blade in the vallecula, or the Miller

blade under the epiglottis (E), and visualize the vocal cords
(VC) and arytenoid cartilages (A). Do not take your eyes off
of the cords once they are identified.
o Under direct visualization, pass the tube 3-4cm beyond the
vocal cords.

o Lift in the direction of the laryngoscope handle. Manipulate

the thyroid cartilage to achieve optimal laryngeal exposure.
o Remove the stylet and inflate the pilot balloon.
Have an assistant maintain that position during intubation.

- As you move the tip of the blade toward the base of o Confirm proper placement with end-tidal CO2 detection,
the tongue, exert force along the axis of the auscultation and a chest radiograph.
laryngoscope handle by lifting upward and forward at
a 45-degree angle.
- The direction of this force is critical because if the force
is too horizontal or too vertical, poor visualization will
result.
- Avoid bending the wrist because it can result in dental
injury if the teeth are used as a fulcrum for the blade.
Slowly advance the blade down the tongue, searching
for the epiglottis.
- It may help to have an assistant retract the cheek
laterally to further expose the laryngeal structures.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 10

Common problems encountered when using a laryngoscope. - If the straight blade is placed too deeply, the entire
larynx may be elevated anteriorly and out of the field
of vision.
- Gradually withdraw the blade to allow the laryngeal
inlet to drop down into view:
▪ If the blade is deep and posterior, the lack
of recognizable structures indicates
esophageal passage; gradually withdraw
the blade to permit the laryngeal inlet to
come into view.
Infants and Children
It is helpful to appreciate the anatomic differences between
children and adults when intubating pediatric patients:

A. The laryngoscope blade is under the middle of the

tongue, with the sides of the tongue hanging down
and obscuring the glottis.
B. The tongue is not pushed far enough to the left and is
obscuring the glottis.
C. Correct blade position with the tongue elevated and
to the left.

- Note that in small children, the neck is shorter and the

larynx is located more cephalad.
- The large head of newborns can result in a posterior
positioning of the larynx that prevents visualization of
the vocal cords.
▪ A small towel under the infant’s
D. Use of the curved (Macintosh) laryngoscope blade.
shoulders should correct this problem.
- The step after visualization of the epiglottis depends
▪ This is not necessary in all children;
on which laryngoscope blade is being used.
rather, the goal of any positioning
- With the curved blade, place the tip into the
maneuvers should be alignment of the
vallecula, the space between the base of the tongue
tragus with the anterior shoulder.
and the epiglottis.
- The head may also be floppy and may benefit from
- Continued anterior elevation of the base of the tongue
stabilization by an assistant.
will partially lift the epiglottis.
- The child’s increased tongue-to-oropharynx ratio and
- With the blade in the midline of the vallecula, engage
shorter neck hinder forward displacement of the
the hyoepiglottic ligament with the tip of the blade to
tongue and, when coupled with a U-shaped epiglottis,
indirectly lift the epiglottis and expose the laryngeal
can make visualization of the glottis difficult.
inlet.
- DL in infants and young children is generally best
- If the tip of the blade is inserted too deeply into the
performed with a straight blade:
vallecula, the epiglottis may be pushed down and
▪ Miller size 0 for premature infants,
obscure the glottis
▪ size 1 for normal-sized infants, and
E. Use of the straight (Miller) blade.
▪ size 2 for older children.
- When using the straight blade, insert the tip under and
- The infant’s larynx lies higher and relatively more
slightly beyond the epiglottis and directly lift it up.
anterior.

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Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 12

Cricoid Pressure, ELM, Bimanual Laryngoscopy, and BURP

Definitions:
Cricoid pressure
o the application of pressure at the anterior cricoid ring to
displace it posteriorly to attempt to occlude the esophagus,
with the intent of preventing regurgitation and aspiration;
o cricoid pressure is not intended to improve visualization
during laryngoscopy.
ELM
o the application of pressure on the thyroid cartilage during
laryngoscopy to help optimize visualization of the glottis.
BURP
o often the best combination of forces that need to be
applied to the thyroid cartilage during ELM.
ELM Step 1: The laryngoscopist optimizes view of the larynx by
Bimanual laryngoscopy
reaching around to the patient’s neck with the right hand and
o refers to use of the right hand to perform ELM.
manipulating the thyroid cartilage while performing
Cricoid Pressure laryngoscopy.
o helps prevent gastric inflation during BMV, though cricoid
pressure during BMV reduces tidal volume, increases peak
inspiratory pressure, and prevents good air exchange.
o If cricoid pressure is utilized, it should be released
immediately if there is any difficulty either intubating or
ventilating a patient in an emergency setting.
o It is reasonable to release or relax cricoid pressure during
insertion of an LMA, during intubation with an ILMA, or if
ventilation with the LMA is difficult.
o The proper technique for applying Sellick’s maneuver is to
place the thumb and middle finger on either side of the
cricoid cartilage and the index finger in the center
anteriorly. Apply 30 N (6.7 lb.) of force to the cricoid
cartilage in the posterior direction.
ELM, Bimanual Laryngoscopy, and BURP ELM Step 2: The assistant’s and replaces the laryngoscopist’s
o ELM is the application of pressure on the thyroid cartilage hand on the anterior aspect of the neck and maintains the
in an attempt to improve the view of the larynx during position of the larynx while the laryngoscopist places the
laryngoscopy. tracheal tube.
o Bimanual laryngoscopy is best because the direction and
amount of force that will optimize laryngeal exposure is o Bimanual laryngoscopy with ELM should be performed
variable. whenever the laryngeal view is not optimal after good
o BURP is sometimes optimal, and it often worsens the laryngoscopic technique.
laryngoscopic view, so it is best to move the larynx in a - To perform this procedure, the intubator applies
variety of directions to determine the optimal ELM. posterior pressure on the thyroid cartilage.
o The best way to quickly apply a variety of different forces - The force vector (right or left, upwards or downwards,
to the larynx to determine the optimal ELM is by and amount of posterior pressure) will vary patient to
manipulation of the larynx with the laryngoscopist’s right patient, and the intubator should find the force vector
hand: that provides the best laryngeal view.
- Once this is established, an assistant applies the same
force vector to the thyroid cartilage as the intubator
removes pressure to free the hand in order to pass the
tracheal tube.
- The assistant holds pressure while the intubator
completes tracheal intubation.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 13

PASSING THE TUBE - recommended for patients in whom visualizing the

o Once the vocal cords have been visualized, the final step is vocal cords was difficult.
to pass the tube through the vocal cords and into the - It has also been shown to be effective when the
trachea under direct vision. laryngeal inlet cannot be visualized at all.
o It is best to use a malleable stylet for all emergency o A variety of tracheal tube introducers are available today.
intubations. The best stylet shape is straight with a 35-
degree hockey-stick bend at the proximal cuff (“straightto-
cuff”).
o Hold the tube in your right hand and introduce it from the
right side of the patient’s mouth. Lateral retraction of the
cheek by an assistant may greatly aid overall visualization.
A. is reusable and comes in curved and straight-tipped
adult forms and a straight pediatric form. The straight
bougies,
B. are 70 cm long and the curved-tipped bougies are 60
cm long. The blue introducer,
C. (Flextrach ETTube Guide, Greenfield Med., Austin, TX)
is polyethylene and designed for single use and comes
only in a curved-tipped adult form (60 cm).
D. Create a 60-degree bend in the distal portion of the
introducer if the laryngeal inlet cannot be seen on
laryngoscopy.
o The original adjunct was called the gum elastic bougie, or
simply “the bougie,” and is currently available in a reusable
Note the assistant manipulating the anterior part of the neck
form for both adult and pediatric patients (Eschmann
and retracting the cheek for better visualization.
Tracheal Tube Introducer, Portex Sims, Kent, UK):
o Advance the tube toward the patient’s larynx below the
- The adult size comes in two forms: a 60-cm (15-Fr)
line of sight with the bend facing upward.
version with a short, 40-degree hockey-stick curve at
- When advanced in this manner, the tube does not
the end, and a straight one that is 70 cm.
obstruct the view of the larynx until the last possible
▪ The adult version can accommodate a
moment before the tube enters the larynx.
5.5-mm ET tube.
o If the patient is not chemically paralyzed, pass the tube
- The pediatric version is 70 cm (10-Fr) and straight and
during inspiration, when the vocal cords are maximally
can accommodate a 4.0-mm tube.
open.
- A polyethylene introducer designed for single use is
o It enters the trachea when the cuff disappears through the
also available and comes only in the 60-cm version
vocal cords.
(Flextrach ET Tube Guide, Greenfield Medical Sourcing,
o Advance the tube 3 to 4 cm beyond this point. It is not
Austin, TX).
enough to see the tube approach the cords; watch the tube
o Consider using a tracheal tube introducer when a difficult
pass through the vocal cords to ensure tracheal placement.
airway is anticipated; it can also be helpful in all intubations
o Directly observing the tube pass through the cords is the
when visualization of the laryngeal inlet is limited.
best way to immediately confirm correct placement. If part
- A trauma patient with cervical spine precautions is a
of the glottis is visualized and it is difficult to pass the tube,
typical example.
consider using a bougie (tracheal tube introducer).
o The presence of blood and vomitus rarely prevents
Tracheal Tube Introducer (Bougie) placement of the bougie into the trachea.
o If DL does not bring the vocal cords fully into view, a o Shaping the introducer may not be necessary in many
tracheal tube introducer may be used to facilitate cases, but with difficult laryngeal views, create a 60-degree
intubation. bend in the distal introducer.
- This adjunct is a long, thin, semirigid introducer that, o Ideally, tracheal tube introducer-assisted intubation is a
with the aid of a laryngoscope, is passed through the two-person procedure:
laryngeal inlet and over which an ET tube is advanced
through the cords and into the trachea.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 14

Two-person tracheal tube introducer technique. o As laryngoscopy begins, the assistant has both a styletted
- The introducer is handed to the clinician after the ET tube and bougie prepared and available.
best glottic view has been obtained. o The intubator performs laryngoscopy in the normal fashion
to obtain the best possible view of the larynx.
o If the cords are in full view, proceed with intubation using
a styletted ET tube.
The clinician places the o If the view is suboptimal, an assistant can pass the tracheal
introducer (the black line tube introducer to the operator for placement anterior to
positioned at the teeth the arytenoids and into the larynx.
indicates the proper o If only the epiglottis is visible, place the introducer, with a
introducer depth to ensure 60-degree distal bend, just under the epiglottis and direct
stable positioning within it anteriorly.
o With the laryngoscope still in place and the introducer
the trachea while providing
stabilized by the operator, the assistant slides the ET tube
enough length to grasp the
over the introducer.
end of the introducer o Pass the tube through the larynx. Just before entering the
before passing the tube). larynx, rotate the tube 90 degrees counterclockwise to
avoid having the tip of the ET tube get caught on the
laryngeal structures:

An assistant passes the

tracheal tube over the
introducer as the clinician
holds the introducer steady.

A common cause of difficulty when railroading an

endotracheal (ET) tube over a tracheal tube introducer.
A. The tip of the ET tube is caught on the right arytenoid
as it is being railroaded over the introducer.
B. Corrective maneuvers: (1) withdrawal of the ET tube
2 cm to disengage the arytenoids and (2)
counterclockwise 90-degree rotation of the ET tube
to orient the bevel posteriorly.
The clinician passes the C. The bevel of the ET tube is facing posteriorly and
tracheal tube with a 90- allows smooth passage through the glottis.
degree counterclockwise o Withdraw the laryngoscope and confirm proper tube
rotation as the tube placement.
approaches the glottis, and o While securing the ET tube, ask the assistant to remove the
the assistant withdraws the introducer.
introducer. o There are a number of findings that confirm successful
introducer placement:

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 15

- If any portion of the arytenoids is visible and the - Fifth, a common error when first using the tracheal
introducer was seen to pass anterior to them without tube introducer is to remove the laryngoscope before
resistance, the introducer is in the airway. passing the ET tube over the introducer.
- Unlike seeing an ET tube “go through the cords” when ▪ This often results in difficulty placing the
in fact the laryngeal inlet may have been momentarily tube because it is displaced posteriorly by
obscured by the tube or balloon, the smaller-caliber the weight of the pharyngeal soft tissues
introducer does not obscure the view of the glottis and and gets hung up on the laryngeal
thus avoids this potential pitfall. structures.
- In addition to better visual confirmation, successful ▪ Reinsert the laryngoscope. Pull the tube
passage is indicated, up to 90% of the time, by feeling back 2 cm to disengage the soft tissue.
clicks produced by the angled tip of the introducer as ▪ Rotate the tube 90 degrees
it strikes against the tracheal rings. counterclockwise and then re-advance it.
- An assistant will also usually feel confirmatory - Sixth, in instances in which it is difficult to get the
movement in the airway if the anterior aspect of the introducer sufficiently anterior to access the laryngeal
neck is palpated. inlet, make sure that the introducer lines up with the
- If there is still any question whether the introducer is operator’s line of vision.
in the airway, gently advance it at least 40 cm, at which ▪ If the introducer enters the mouth at a
point resistance should be felt as the introducer passes significant angle above this line, most
the carina and stops inside a main bronchus. often when the clinician is too close to
- If the bougie does not stop when advanced the patient, it may be deflected
approximately 40 cm, the introducer is most likely in posteriorly by the lip or intraoral
the esophagus. Withdraw it and reattempt placement. structures and escape the attention of
o Several technical points should be emphasized. the operator.
- The first is that it is important to create a curve in the ▪ This creates the impression that the
distal portion of the introducer when the laryngeal introducer is “too floppy.”
inlet is not visible. It is a mistake to think that the o In the prehospital setting, where assistance might not be
factory formed curve at the tip will be sufficient to available, the laryngoscope should be removed to mount
access the glottis in these situations. the ET tube onto the introducer.
- Second, in some cases the bougie will pass through the - Once the tube is on the introducer, reinsert the
cords but will become lodged in the anterior trachea laryngoscope and advance the introducer through the
and not be able to be advanced further. glottic opening.
▪ If this happens, withdraw slightly and - Advance the ET tube while rotating it 90 degrees
rotate the bougie 90 degrees clockwise to counterclockwise to ensure successful passage into
move the curved tip to the patient’s right. the trachea.
▪ This will prevent the tip from striking the - Mounting the tube onto the introducer to insert them
anterior trachea and allow the bougie to as a unit is not advised because it is often difficult to
pass to the carina. direct the introducer into the laryngeal inlet as it
- Third, if there is difficulty passing an ET tube into the moves within the ET tube.
laryngeal inlet, this is most likely because the tip of the Laryngospasm
tube is caught on the right arytenoid cartilage. o If the patient is not paralyzed, laryngospasm, or persistent
▪ In this case, withdraw the tube 2 cm, contraction of the adductor muscles of the vocal cords,
rotate it 90 degrees counterclockwise, may prevent passage of the tube.
and advance it again. o Pretreatment with topical lidocaine may decrease the
- Fourth, although there may be some benefit to likelihood of laryngospasm, though this is not routinely
lubricating the distal end of the introducer, in performed.
emergency intubations, lubricating the full length of o After laryngospasm is noted, one option is to spray
the introducer makes it slippery and hard to handle lidocaine (2% or 4%) directly onto the vocal cords. An
without conferring any obvious advantage. infrequent but effective means of achieving tracheal
▪ Lubricating the ET tube, conversely, anesthesia is transtracheal puncture and injection of 3 to 4
remains critical for smooth passage mL of lidocaine through the cricothyroid membrane.
through the vocal cords. o Laryngospasm is usually brief and often followed by a gasp.
Be ready to pass the tube at this moment.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 16

o Occasionally, the spasm is prolonged and needs to be o After placement of the tracheal tube, auscultate both lungs
disrupted with sustained anterior traction applied at the under positive pressure ventilation. Take care to auscultate
angles of the mandible, as in the jaw-thrust maneuver. posterolaterally because auscultation anteriorly can reveal
o Do not force the tube at any time because it could cause sound that mimic breath sounds and arise from the
permanent damage to the vocal cords. Consider using a stomach.
smaller tube. o With the tube in position and the cuff inflated, secure the
o Prolonged, intense spasm may ultimately require muscle tube in place. Attach commercial ET tube holders, adhesive
relaxation with a paralyzing drug. tape, or umbilical (nonadhesive cloth) tape securely to the
o Pediatric patients are far more prone to laryngospasm than tube and around the patient’s head.
adults. o Position the tube at the corner of the mouth, where the
▪ In a child, if vocal cord spasm prevents tongue is less likely to expel it. This position is also more
passage of the tube, a chest-thrust comfortable for the patient and allows suctioning.
maneuver may momentarily open the - A bite block or oral airway to prevent crimping of the
passage and permit intubation. ET tube or damage from biting is commonly
Positioning and Securing the Tube incorporated into the system used to secure the tube.
o Secure the ET tube in a position that minimizes both the TAPING AN ENDOTRACHEAL TUBE
chance of inadvertent, main stem endobronchial
intubation and the risk for extubation.
o The tip should lie in the midtrachea with room to
accommodate neck movement.
o Because tube movement with both neck flexion and
extension averages 2 cm, the desired range of tip location a. Prepare a piece of 1-inch tape to wrap around the
is between 3 and 7 cm above the carina. patient’s neck.
o The average tracheal length is between 10 and 13 cm. b. Split each side of the tape for 6 to 8 inches.
- On a radiograph, the tip of the tube should ideally be c. Apply a second piece of tape (sticky side down) to the
5 ± 2 cm above the carina when the head and neck are center of the long piece of tape. This prevents the
in a neutral position. tape from sticking to hair.
- On a portable radiograph, the adult carina overlies the
fifth, sixth, or seventh thoracic vertebral body.
- If the carina is not visible, it can be assumed that the
tip of the tube is properly positioned if it is aligned with
the third or fourth thoracic vertebra.
- In children, the carina is more cephalad than in adults,
and it is consistently situated between T3 and T5.
- In children, T1 is the reference point for the tip of the
ET tube.
o Estimate the proper depth of tube placement before
radiographic confirmation by using the following formulas
in which length represents the distance from the tip of the a. Wrap the other split end around the endotracheal
tube to the upper incisors in children and from the upper tube.
incisors or the corner of the mouth in adults: b. Place the center of the tape behind the neck.
c. Bring one side of the tape forward.
d. Place one split end across the top of the mouth while
avoiding the lips.

o One can anticipate that tall male patients will often require
deeper placement, to 24 or 25 cm, and that short women
will often require a shallower placement of 19 or 20 cm.
o Inflate the cuff to the point of minimal air leak with positive
pressure ventilation. In an emergency intubation, inflate
with 10 mL of air and adjust the inflation volume after the
patient is stabilized.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 17

a. Bring the other end of the tape forward.

b. Secure one split end across the top of the mouth, - plastic disposable ET holder firmly secures the ET tube
again avoiding the lips. with a small clamp.

a. Wrap the remaining split and around the tube.

b. A companion oral airway/bite block may be used.
c. Note that the tape completely encircles the head for
maximum security.
- When positioning a patient for transfer to another bed
or for a chest radiograph, ensure the integrity of the ET
tube by placing the right hand firmly against the right
side of the face while holding the tube securely with
the same hand. The other hand immobilizes the neck.
Confirmation of Tracheal Tube Placement
Clinical Assessment
o Confirm tracheal placement clinically by seeing the tube
pass through the vocal cords. (Assessing proper tube
placement table next page).
o If any question remains, apply posterior pressure on the ET
tube while the laryngoscope is still in place and expose the
tube by altering the angle as it passes between the cords.
o Absent or diminished breath sounds, any sound or
vocalization, increased abdominal size, and gurgling sounds
- A commercial disposable tube holder is ideal and
during ventilation are clinical signs of esophageal
preferred to secure an endotracheal (ET) tube without
placement.
the use of messy tape.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 18

- Because of the angles of takeoff of the main bronchi

(continued)Confirmation of Tracheal Tube Placement and the fact that the carina lies to the left of midline in
Clinical Assessment adults, right main stem intubation is most common
o If the patient can moan or groan, the tube is not in the and is indicated by decreased breath sounds on the left
trachea! Critically, esophageal placement is not always side.
obvious. - When asymmetric sounds are heard, deflate the cuff
o One may hear “normal” breath sounds if only the midline and withdraw the tube until equal breath sounds are
of the thorax is auscultated. The presence of condensation present.
of the ET tube as a means of confirming tracheal placement o Bloch and coworkers reported accurate pediatric tracheal
may also be misleading. positioning if after noting asymmetric breath sounds the
o One way to clinically assess tracheal placement after tube is withdrawn a defined distance beyond the point at
several ventilations or during spontaneous respiration is to which equal breath sounds are first heard:
note whether air is felt or heard to exit through the tube - 2 cm in children younger than 5 years
after cuff inflation. If tidal volume is adequate, the exit of - 3 cm in older children
air should be obvious.
o Asymmetric breath sounds indicate probable main stem
bronchus intubation.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 19

Esophageal Detector Device not be used in freezing temperatures because of loss

o An aspiration technique used to determine ET tube location of elasticity.
was first described by Wee in 1988. - Confusion may occur if the esophageal tube is tested
o The technique takes advantage of the difference in tracheal more than once because subsequent inflations may be
and esophageal resistance to collapse during aspiration to silent.
locate the tip of the tracheal tube. - With repeated assessments, false-positive refilling of
o After intubation, attach a large syringe (Positube the bulb may occur as a result of instillation of air
esophageal detector), to the end of the ET tube and during the first attempt. This observation has led to a
withdraw the plunger of the syringe. recommendation that the bulb be compressed before
- If the tube is placed in the trachea correctly, the it is attached to the ET tube.
plunger will pull back without resistance as air is - Delayed, though complete refilling of the bulb may
aspirated from the lungs. occur with bronchial tube placement or placement in
- If the tracheal tube is in the esophagus, resistance is the more pliable pediatric airway.
felt when the plunger is withdrawn because the pliable - The bulb suction modification of the aspiration
walls of the esophagus collapse under the negative technique has not been studied as thoroughly as the
pressure and occlude the end of the tube. syringe technique.
- Another device that uses the same principle as syringe o A significant number of false positives occur with
aspiration is the self-inflating bulb (e.g., Ellick device). esophageal detection devices (the tube is correctly placed
o Before use, always check the esophageal detector device in the trachea, but the device suggests that it is in the
for air leaks. If any connections are loose, the leak may esophagus).
allow the syringe to be withdrawn easily, thereby - These patients are almost uniformly obese.
mimicking tracheal location of the tube. - Endoscopic evaluation found that the tracheal wall
o When using the aspiration technique, apply constant, slow was invaginated into the ET tube because of the
aspiration to avoid occlusion of the tube from tracheal negative pressure.
mucosa drawn up under the high negative pressure. - In such circumstances, if the intubation was felt to be
- If the tracheal tube is placed correctly, 30 to 40 mL of successful, visually re-confirm that the ET tube is
air can be aspirated without resistance. through the cords before removing the ET tube.
- If air was initially aspirated and some resistance is then Alternatively, if the patient has a perfusing rhythm and
encountered, the tracheal tube should be pulled back an expired CO2 device is available, it should be used.
between 0.5 and 1.0 cm and rotated 45 degrees. - In this case there was marked gastric distention from
- This takes the tube out of the bronchus if it has been forceful BMV.
placed too deeply and changes the orientation of the - The esophageal detection device is not reliable in
bevel if the tube has been temporarily occluded with confirming tracheal tube depth and position after
tracheal mucosa. intubation because easy aspiration of air will occur if
- Air is easily aspirated if the tube was in the trachea, but the tip of the tube is located supraglottically (expired
repositioning it will make no difference if the tube was CO2 will also be misleading).
in the esophagus. End-Tidal CO2
- The syringe aspiration technique can be used before or o End-Tidal CO2 detection is probably the best technique,
after ventilation of the patient. apart from visualizing the tube pass through the cords, to
- Inflation of the tube cuff has no effect on the reliability confirm tracheal placement of the ET tube.
of the test. o A high level of CO2 in exhaled air is the physiologic basis for
- This device is reliable, rapid, inexpensive, and easy to capnography and the principle on which end-tidal CO2
use pressure (PETCO2) detectors were developed.
o A squeeze-bulb aspirator is an alternative to the syringe o Continuous waveform capnography is recommended by
technique. the AHA guidelines as the most reliable method of
- Attach the bulb to the ET tube and squeeze; if the tube confirming and monitoring correct placement of an ET
is in the esophagus, it is accompanied by a flatus-like tube.
sound followed by absent or markedly delayed - Continuous waveform capnography is accurate even in
refilling. Insufflation of a tube in the trachea is silent cardiac arrest.
with instantaneous refill. ▪ Patients with prolonged cardiac arrest
- The device is cheap, easy to use, and operated single- will still have a typical square waveform
handedly in less than 5 seconds.166 The bulb should but a low PETCO2 value.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 20

o When waveform capnography is not available, emergency - Passage of the scope through the tube with
providers may have to rely on colorimetric CO2 indicators, visualization of the tracheal rings confirms ET
which correspond to CO2 levels flowing through the device placement and position within the trachea.
when placed on the tracheal tube adapter. - Placement of a lighted stylet down the tracheal tube
and successful transtracheal illumination can also be
used to determine correct ET placement.
COMPLICATIONS OF INTUBATION
o Failure to achieve adequate ventilation and oxygenation is
the most serious complication of tracheal intubation.
o The potential for hypoxia exists:
- just before intubation as more conservative
oxygenation methods are attempted and then fail,
- during difficult intubation when ventilation is halted
for an attempt at intubation,
- after intubation when esophageal intubation goes
- The typical device displays opposite colors (e.g., yellow undetected
and purple) to indicate low levels of CO2 in esophageal o Because irreversible cerebral anoxia occurs within
gas versus the high levels of CO2 exhaled from the minutes, conservative airway management maneuvers
respiratory tree. should be limited to 2 to 3 minutes; failure to achieve
o Glottic positioning may be difficult to detect clinically. adequate oxygenation should lead to a quick decision to
- The only signs may be persistent cuff leak or intubate.
diminished chest rise with ventilation. o As a guide, limit intubation attempts to the amount of time
- Radiographic evidence or direct visualization confirms that a single deep breath can be held by the patient.
the diagnosis. o Historically, the maximum recommended duration of an
Ultrasound Detection of Tracheal Tube Location intubation attempt in an apneic patient has been 30
o If the ET tube is the in the trachea, acoustic shadowing is seconds, followed by a period of BMV before intubation is
seen posterior to the anterior tracheal rings only. attempted again.
o If the ET is in the esophagus, the esophagus is opened by - Longer attempts at intubation are permissible when
the ET tube and shadowing is seen posterior to the anterior guided by accurate data from an oxygen saturation
esophageal wall (as well as the trachea). monitor because oxygen saturation may remain in the
o This method relies on the esophagus being located in the normal range for much longer in patients who have
paratracheal position; if the esophagus is directly posterior been preoxygenated.
to the trachea, then detecting esophageal intubation is - As a general rule, intubation attempts may continue if
very difficult. oxygen saturation is above 90% and should be
o Sonographic sliding signs can also be used immediately interrupted for BMV when oxygen saturation drops
after tracheal intubation is confirmed by waveform below 90%.
capnography to evaluate for main stem intubation prior to o Assessment of tube location is the top priority immediately
obtaining a chest radiograph. after placement. The best assurance of tracheal placement
o Assuming there is no other underlying lung pathology, is to see the tube pass through the vocal cords.
absence of sliding on the left after intubation indicates - If esophageal intubation is discovered, removal of the
probable right main stem intubation. The ET tube can be tube may be followed by emesis.
withdrawn 2 cm, and sliding signs reassessed. - Apply cricoid pressure during tube removal and
Comparison of Detector Devices maintain it until the intubation is successful. Keep a
o In the setting of spontaneous circulation, both syringe large-bore suction tip catheter readily available should
aspiration and PETCO2 detection are highly reliable means vomiting occur.
of excluding esophageal intubation. - Alternatively, leave the first tube in the esophagus to
o In the setting of cardiac arrest, the aspiration method is serve as a temporary gastric-venting device and as a
more reliable than colorimetric CO2 detection, although guide to intubation until tracheal intubation is
waveform capnography remains reliable even in low flow achieved.
states.
o An unequivocal method for determining tracheal tube
location uses the endoscope.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 21

o Though seldom associated with serious complications, - Reinflate the cuff and shut off the stopcock to solve the
unrecognized placement of the tip of the ET tube in the problem.
right main stem bronchus may cause hypoxia, atelectasis, - If the leak involves the pilot balloon or if the distal
pneumothorax, and unilateral pulmonary edema. inflation tube has been inadvertently severed, cut off
- Obtain a chest radiograph soon after intubation to the defective part and slide a 20-gauge catheter into
confirm tube positioning. the inflation tube.
- Persistent asymmetric breath sounds after correct - Then connect the stopcock to the catheter, inflate the
tube positioning suggests unilateral pulmonary cuff, and close the stopcock.
pathology (e.g., main stem bronchus obstruction, o Tracheal stricture used to be a significant late complication
pneumothorax, hemothorax). of long-term intubation with low-volume, high-pressure
o Prolonged efforts to intubate can also cause cardiac cuffs.
decompensation. CONCLUSION: DL is the most common means of securing a
- Pharyngeal stimulation can produce profound definitive airway.
bradycardia or asystole, thereby confirming the need
for an assistant to monitor cardiac rhythm throughout VIDEO AND OPTICAL LARYNGOSCOPES
the intubation. o They provide a better view of the glottis with less effort and
- Keep atropine available to reverse the vagal-induced have a shorter learning curve than DL.
bradycardia that may occur secondary to suctioning or o Only the Macintosh shaped video laryngoscopes are
laryngoscopy. designed to sweep the tongue aside and allow either a
o Prolonged pharyngeal stimulation may also result in direct or video view of the larynx.
laryngospasm, bronchospasm, and apnea. o The other devices are made to look around the curve of the
o If a patient is profoundly hypovolemic and does not need tongue rather than lifting it or pushing it aside, so they are
immediate intubation, it may be best to resuscitate with more angulated.
intravenous fluids prior to intubation to avoid worsening o Adding a tube channel to the blade obviates the need to
hypotension. manipulate the ET tube around the sharp curve but may
o Generally, dentures are removed for intubation but kept in add other complexities.
place for BMV. o Video laryngoscopy is associated with higher first pass
- Check for loose or missing teeth before and after success rates compared to DL, especially in patients with
orotracheal intubation. known or suspected difficult airways.
- Look for any avulsed teeth not found in the oral cavity o Video and optical laryngoscopes can be divided into three
on the postintubation chest film. broad categories:
o Emesis with aspiration of gastric contents is another 1. Video laryngoscopes with standard Macintosh blades
serious complication that can occur during intubation. (Storz C-MAC, GlideScope Titanium MAC, McGrath
- Avoiding BMV when possible may help reduce the risk MAC, Venner A.P. Advance Mac Blade).
of this adverse event. 2. Video laryngoscopes with angulated blades
o In patients who are obtunded or who are at high risk for (GlideScope, McGrath Series 5, Storz D-Blade).
seizures or vomiting, consider tracheal intubation before 3. Video or optical laryngoscopes with a tube channel
the administration of activated charcoal. (Airtraq, Pentax AWS, KingVISION)
o The greatest degree of motion occurs at the atlanto- VIDEO LARYNGOSCOPES WITH STANDARD MACINTOSH
occipital junction and decreases with each sequential
BLADES
interspace, and studies of cervical spine instability at these
o These devices have blades that are exactly the same or very
higher levels have not been performed.
similar to a standard English or German Macintosh direct
o Intubation can be complicated by a persistent air leak.
laryngoscope.
- This is generally caused by failure of either the cuff or
o They all have a digital camera adjacent to the light source a
the pilot balloon or by positioning the cuff balloon
few centimeters proximal to the tip.
between the vocal cords. If the cuff balloon is leaking,
o Each of these devices can be used for either conventional
replace the tracheal tube.
DL or video laryngoscopy.
- If the pilot balloon is determined to be leaking, this can
o The improved laryngeal view provided by the camera is
usually be remedied without changing the tube.
especially helpful in morbidly obese patients and in trauma
- An incompetent one-way balloon valve can be fixed by
patients who require cervical spine immobilization.
placing a stopcock in the inflating valve.
o The latest version of this device, the Storz C-MAC, is
smaller, more portable, and cheaper.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 22

o The C-MAC consists of a one-piece blade, a cable, and a

monitor.
o The Storz C-MAC (Karl Storz, Tuttlingen, Germany) is the
only device in this group that has been sufficiently tested:

Video Laryngoscopes With Angulated Blades

Indications o All these devices have a distal angulation of approximately
o The C-MAC can be used for almost any orotracheal 60 degrees and a digital camera a few centimeters proximal
intubation attempt in an emergency setting. to the tip.
o If laryngoscopy is not predicted to be difficult, the operator o These blades do not allow laryngoscopy by direct
can intubate using DL, with video laryngoscopy visualization.
immediately available if the airway proves to be difficult or o They are designed to follow the natural curvature of the
if there is difficulty passing the tracheal tube introducer or upper airway and look around the tongue rather than
ET tube. displace it.
o The C-MAC allows both direct and video laryngoscopy. o Excellent visualization of the glottis is nearly always
o The C-MAC can be used when DL is difficult. achieved when the distal tip of the blade is in or near the
Contraindications vallecula.
o The video camera is susceptible to obscuration by o Maneuvering the ET tube around the severe angle of the
secretions or blood. blade and into the trachea is more difficult compared to
Complications systems with a Macintosh blade, and this is where
o A complication that may be encountered is blind passage problems can occur.
of the ET tube into the mouth while fixating on the video o In 2001, the original GlideScope video laryngoscope
monitor. became the first commercially available video
o This can result in damage to oral and pharyngeal structures. laryngoscope: Three GlideScope models are now available:
o It is less common with the C-MAC than with the GlideScope - The Titanium: which is the newest version that
and McGrath MAC. features reusable titanium blades or disposable plastic
blades of a similar shape;
- The AVL, which has both single-use and reusable
plastic blades to cover a reusable video baton with a
mountable monitor;
- The Ranger, which has a small portable monitor and
the choice of a reusable blade or a video baton with
disposable blades (Ranger Single Use).

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 23

o A significant advantage of the more angulated video

laryngoscopes is that they can provide a good view of the
larynx when the neck is in the neutral position.
o There may be patients in whom the larynx is so anterior
that devices with a Macintosh blade are unable to
adequately visualize the airway structures; hyperangulated
blades may be especially useful in this situation.
Contraindications
o Blood or secretions on the lens may decrease visualization
of the larynx.
o Fogging was a problem with older endoscopic devices, but
this problem is rare with the newer video devices.
o Limited mouth opening (< 2 cm) can make insertion of
o The McGrath portable video laryngoscope is another these devices more challenging, though they require less
device with similar characteristics but is more compact. mouth opening than devices with Macintosh blades.
o The biggest contraindication is probably lack of experience
or absence of a rigid stylet or tracheal tube introducer to
allow the operator to maneuver the ET tube around the
sharp angle of the blade.
Procedure and Technique
VIDEO LARYNGOSCOPY (GLIDESCOPE)

- Prepare the endotracheal tube.

- Depending on the system that you are using, insert a
- The shape of the blade is very similar to that of the rigid stylet or preload the tube onto the device.
GlideScope, but it has a small video monitor (1.7 inches
diagonally) on the end of the handle.
- It also has an adjustable-length, detachable metal
blade (camera stick) that is covered by a disposable
plastic blade during use, so no part of the handle or
metal blade makes contact with the patient.
- It has no recording capability.
Indications - Check the rest of your equipment, including the light
o Like the C-MAC, video laryngoscopy systems with source and video monitor.
hyperangulated blades can also be used for routine
intubations and have higher success rates than the DL.
o The GlideScope, McGrath Series 5, and Storz D-Blade may
be especially useful when DL is difficult or fails.
o GlideScope and McGrath can facilitate successful awake
intubation in patients with known or suspected difficult
airways.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 24

- Preoxygenate and premedicate the patient as clinically - Under direct visualization (don’t look at the monitor),
indicated. pass the styleted tube through the mouth and into the
posterior pharynx.
- Use a rigid steel GlideRite (Verathon Medical) stylet,
which has the same 60-degree curve as the blade of
the GlideScope, McGrath, and D-Blade.
- Alternatively, a malleable stylet with a 60-degree distal
bend or a bougie may be acceptable, but these devices
may fail if tube passage is challenging.

- Place the blade into the mouth under direct

visualization (don’t look at the video monitor yet).
- Keep the blade in the midline of the tongue
throughout the procedure.

- Look up the video monitor and watch for the tip of the
tube to appear.

- Slowly advance the blade while watching the video

monitor.
- Progressively identify the tongue and epiglottis.
- Place the blade in the vallecula or under the epiglottis,
gently lift, and identify the vocal cords.
- If the glottis is not well visualized, tilt the handle back
slightly to enhance exposure.
▪ If needed, manipulate the neck externally
- Direct the tube through the vocal cords under direct
to enhance visualization.
visualization on the video monitor.
▪ If more exposure is required, place the tip
- Decrease the chance of soft tissue injury by carefully
of the blade under the epiglottis and
passing the ET tube along the side of the GlideScope.
gently lift and tilt back.
When the tip of the ET tube comes into view, direct it
- While attempting to optimize the laryngeal view, be
into the glottis and advance it to the appropriate
careful to not place the blade too close to the laryngeal
depth.
inlet because it may tip the larynx anteriorly and
- If a malleable stylet or bougie is used, it may be difficult
inferiorly, thus making it more difficult to access the
to get the tube to go anterior enough.
laryngeal inlet and pass the tube through it.
- If a malleable stylet must be used, try introducing the
tube from the right side of the patient and rotating it
90 degrees and vertically into a midline position
behind the tongue.
▪ This will help the tip of the stylet maintain
its shape as it passes through the
oropharynx.
▪ Another option is to use a Parker Flex-It
(Parker Medical, Engelwood, CO)
intubation stylet to direct the tip of the ET
tube anteriorly.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 25

- While the operator firmly secures the endotracheal

tube, an assistant removes the stylet as the tube is
passed through the vocal cords.
- The large knob on the proximal end of the GlideRite
stylet is designed to be pushed up by the tip of the
intubator’s thumb, thus making ET tube advancement
and stylet withdrawal a one-handed procedure.
Complications
o There are case reports of injury to the soft palate and
tonsillar pillars, as well as two cases of puncture of the right
palatopharyngeal arch, one requiring surgical repair.
VIDEO AND OPTICAL LARYNGOSCOPES WITH A TUBE o All the channel-guided devices have the same curvature as
CHANNEL the normal upper airway.
o The Airtraq and Pentax AirWay Scope are the only devices - They allow visualization of the glottis by looking
in this group that have been sufficiently tested. around the tongue instead of trying to straighten the
o The ET tube is inserted into the channel before the device airway and push the tongue out of the way.
is placed in the airway, and the channel guides the ET tube - They consistently provide a better view of the glottis
into the trachea once the glottis is visualized. and may lead to less airway trauma and hemodynamic
- This design helps alleviate the most common problem stimulation than occurs with DL.
associated with video and optical laryngoscopy: o The concept of a laryngoscope shaped like the natural
difficulty placing the ET tube despite an excellent view curvature of the upper airway and containing a channel to
of the glottis. guide the ET tube is not new, but the addition of optics and
video just recently made this concept a reality.
o The advantage of these devices is that they provide an
excellent view of the glottis with little need for
maneuvering and they eliminate the requirement for the
hand-eye coordination needed to pass the ET tube around
an acute curve.
Indications
o Difficult intubation with DL is an indication for using a
channel-guided optical or video device. The Airtraq and
Pentax AWS have a high rate of success in patients with
known or predicted difficult airways.
o The Airtraq and Pentax AWS are particularly useful for
difficult airways because of cervical spine immobilization
and morbid obesity.
o The Airtraq is generally used during RSI but may also be
used for awake intubation of patients with difficult airways.
When compared with DL, both the AirTraq and Pentax AWS
consistently provide better visualization of the glottis and
have a higher rate of successful intubation

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 26

Contraindications slightly (while avoiding contact with the upper teeth),

o The greatest drawback of channeled video and optical and then advance the tube again.
devices is that copious amounts of blood or secretions can - Alternatively, pass a bougie through the ET tube (or in
obscure the view. the channel without an ET tube) and direct the curved
- Because they do not allow a direct line of sight to the tip up and through the vocal cords.
larynx, visualization and intubation are dependent on o When using the Pentax AWS, it is important to know that
the video or optical image. the ET tube leaves the channel in line with the tip of the
- If blood or fluid covers the tip of the lens, the image is blade (more anterior than the Airtraq).
obscured. - Therefore when the tip of the AWS blade is in the
- This problem can be minimized by aggressively vallecula, the tube often strikes the epiglottis when it
suctioning the hypopharynx before placing the device is advanced.
in the mouth. - To avoid this problem, advance the tip of the AWS
o Inability to open the mouth or severely limited mouth blade posterior to the epiglottis (as with straight-blade
opening is a contraindication to using the channel-guided laryngoscopy), and lift the epiglottis out of the way
devices just described. before advancing the ET tube.
- If the patient’s mouth opening is at least 2 cm, these Aftercare
devices can succeed in cases in which DL would be o A common mistake when using laryngoscopes with a tube
impossible. channel is to quickly remove the laryngoscope after the ET
- The normal adult-size Airtraq requires 18 mm of tube is advanced into the trachea.
mouth opening, and the pediatric and infant sizes - Because the ET tube is already inside the trachea, it is
require 12.5 mm. best to attach a resuscitation bag and ventilate the
- The Pentax AWS requires approximately 20 mm of patient.
mouth opening. - After giving several breaths, stabilizing oxygenation,
Procedure and confirming tracheal placement with capnography,
o Before beginning the procedure check that you are using slowly and carefully remove the device while providing
the correct size device, ensure that it is functioning ongoing ventilation.
properly, and choose the correct size ET tube for the device o It is appropriate to leave the laryngoscope in place for a few
and the patient. minutes after intubation to allow visual reconfirmation of
o Insert the ET tube into the channel of the device and proper tracheal placement, particularly if there is a
advance it to the end of the channel while ensuring it is not problem with ventilation or oxygenation immediately
advanced so far that it obscures the video or optical lens. following intubation.
o Insert the tip of the blade into the mouth vertically so that o To remove the tube from the channel of these devices, hold
the handle of the device is pointed toward the patient’s the end of the ET tube firmly in the right hand and carefully
feet. wiggle the device to the left.
o Rotate it into the pharynx and hypopharynx along the - When the tube slides out of the channel, slowly rotate
midline of the tongue until the tip is in the vallecula. the laryngoscope out of the patient’s mouth.
- If the glottis is not visualized immediately, try backing - Reconfirm tracheal placement with capnography and
the blade out 1 to 2 cm and lift the device gently in the adjust the depth of the ET tube as needed.
direction of the handle (toward the ceiling). Complications
- A common mistake is to insert the blade too deep o Because the blades of these devices are rigid and cannot be
initially, which offers a narrower view of the glottis and directly visualized after entering the mouth, they have
may make intubation difficult. potential for soft tissue damage.
o When the vocal cords are well visualized in the center of o Complications of other video laryngoscopes are primarily a
the video or optical image, advance the ET tube through result of blind ET tube placement through the mouth and
the cords by sliding it forward within the channel. pharynx, and the tube channel devices eliminate this
- If the ET tube does not go through the cords, pull it problem.
back and realize that you need to adjust the position Intubating Laryngeal Mask Airways
of the entire device to change the trajectory of the o ILMAs are unique devices because they are easy to insert,
tube. provide excellent ventilation and oxygenation (better than
- If the tube tends to go posterior to the vocal cords, lift BMV), and also provide a reliable means of tracheal
the device toward the ceiling and tip the handle back intubation.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 27

- It is impossible to overstate the value of this device for facial trauma, or obesity because none of these factors
failed emergency RSI. inhibit Fastrach placement.
- It has become the primary rescue device for failed RSI o When brisk bleeding above the glottis makes ventilation
in many EDs. and intubation difficult, the Fastrach can prevent aspiration
o The Fastrach is the only device in this group that has been of blood and facilitate blind or endoscopic intubation.
extensively tested and the only ILMA that can reliably o In patients requiring urgent cricothyrotomy or
facilitate blind intubation (without endoscopic guidance). percutaneous needle insertion into the trachea, the ILMA
TYPES OF ILMAS can be used to counteract anterior neck pressure.
- In this capacity, the Fastrach provides temporary
ventilation and aids in stabilization of the cervical spine
during the surgical airway procedure.
Contraindications
o One limitation of the LMA Fastrach is that it cannot be used
in infants and small children because the smallest size, a
No. 3, is not suitable for patients smaller than 30 kg.
o LMAs are contraindicated in patients with less than 2 cm of
mouth opening.
o They are unlikely to be successful in patients with grossly
distorted supraglottic anatomy from disease processes or
postradiation scarring.
o They are also relatively contraindicated in awake patients
because of the high risk for emesis when the gag and
airway reflexes are intact.
Intubation through the LMA Fastrach
o The LMA Fastrach has, by far, been the most used and most
o The majority of intubations through the ILMA are
studied ILMA. It has excellent blind intubation rates, much
performed blindly by using either the designated LMA ET
higher than the Air-Q or i-Gel and there are numerous
tube or a standard ET tube.
investigations detailing its success as a rescue device in
o The LMA ET tube, also known as the LMA Fastrach, is
difficult and failed airways.
designed specifically for the ILMA. There are two versions
o A unique feature of the Fastrach is the metal handle that
of the LMA ET tube: a reusable and a single-use disposable.
makes insertion easier and enables lifting of the device to
- The reusable version is made of silicone and the
create a better seal against the glottis.
single-use version is made of polyvinyl chloride (PVC).
o There are also newer ILMA devices that show promise: the
- The specialized LMA ET tubes are soft and straight and
Air-Q, i-Gel, and Auragain.
have a midline-beveled tip.
o An important feature of newer ILMAs is gastric access
▪ These features are designed to allow the
channels, allowing placement of an orogastric tube through
LMA ET tubes to emerge from the ILMA
the gastric port and into the stomach with the ILMA in
mask at an acute angle and to minimize
place.
potential injury to the vocal cords and
- This is particularly useful in patients with distended
esophagus.
stomachs after prolonged BMV, and in children who
▪ The drawback of the specialized Fastrach
are more prone to gastric insufflation even with
ET tubes is that they have low-volume
shorter BMV times.
high pressure cuffs, which could
o The i-Gel and Auragain both have gastric ports.
potentially cause ischemic damage to the
o The LMA Fastrach does not have gastric access.
trachea, and there are no clinical data on
Indications how long these tubes can remain in place.
o ILMAs are indicated as an alternative to BMV or as a
Procedure and Technique for Blind Intubation
conduit for intubation of difficult airways.
o The LMA Fastrach is the only device that enables reliable
- In the cannot-intubate/ cannot-ventilate scenario, it is
tracheal intubation without the use of a flexible
a reliable rescue device.
endoscope.
o The LMA Fastrach is especially useful in patients with
difficult face mask ventilation because of a beard, severe

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 28

Endotracheal Intubation With the ILMA (Fastrach)

- When the tube has advanced to 15 cm, the tip will start
- Before intubation through the LMA Fastrach, make to emerge from the LMA Fastrach mask.
sure that the patient is ventilating optimally through - Just before advancing the tube, use the frying-pan grip
the device. and apply a slight anterior lift (not a tilt) to further align
▪ Determine this by manually ventilating the aperture of the ILMA with the glottis (see second
the patient while holding the ILMA part of the Chandy maneuver).
handle with a “frying-pan” grip. If any - Do not use a levering action. While holding the handle
resistance is felt, adjust the handle by in this position, gently pass the tracheal tube to
slight rotation in the sagittal plane and approximately 16.5 cm. In this position, the ET tube
then lift the entire device toward the will push the epiglottic elevating bar up and may now
ceiling (chandy maneuver). come in contact with the larynx or esophagus.
- If cricoid pressure is being applied, decrease it because
it may interfere with passage of the ET tube through
the glottis.

- If the ET tube does not pass into the trachea easily,

withdraw the ET tube to the 15-cm mark and readjust
the position of the LMA Fastrach.
- If the tube meets resistance at approximately 17 cm,
this may indicate a fully down-folded epiglottis or
impaction of the tip of the tube against the anterior
- Before inserting the ET tube, lubricate it generously.
laryngeal wall.
Advance the ET tube with the curve opposite that of
- Rotating the tube may overcome impaction of the tip.
the LMA Fastrach curve.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 29

o To correct a down-folded epiglottis, remove the ET tube

and perform the “up-down maneuver” by rotating the
ILMA outward 5 to 6 cm without deflating the mask and
then sliding it back into the hypopharynx.

Using a Standard ET Tube

o The manufacturer warns that using a standard ET tube may
- If these maneuvers are unsuccessful, it is likely that the be associated with a greater likelihood of laryngeal trauma,
wrong size LMA Fastrach is being used. Consider using but there are no reports of such trauma in the literature.
a flexible endoscope to guide intubation. o If using a standard ET tube, insert the ET tube with its
curvature opposite the curvature of the LMA Fastrach tube:

- Once the LMA ET tube has passed into the trachea, - This allows the ET tube to exit the Fastrach at a less
inflate the tube cuff and attempt to ventilate the acute angle and then to advance into the trachea more
patient. easily.
- Check for proper tube placement with a PETCO2 Flexible Endoscopic Intubation through ILMAs
detector. o A flexible bronchoscope can be used to verify the position
- If the tube is in the trachea, deflate the cuff of the of the larynx either before or during intubation.
ILMA. o When intubating through the ILMA over an endoscope, a
- There is no rush to remove the ILMA; it can remain in standard ET tube is sufficient and there is no reason to use
place for an hour or longer if more pressing patient the specialized LMA ET tube.
care issues need to be addressed first. - To use a flexible endoscope to intubate through the
LMA Fastrach, first advance the ET tube through the
ILMA Fastrach to 15 cm.
▪ At a 15-cm depth the view through the
endoscope should show the glottis
beyond the epiglottic elevating bar.
- Advance the ET tube 1.5 cm before advancing the
endoscope.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 30

▪ This protects the camera elements from

being damaged by the epiglottic
elevating bar.
▪ The view at 16.5 cm should show the
vocal cords and trachea.
- Advance the endoscope into the trachea and then pass
the ET tube over the endoscope.
- If the vocal cords are not visualized immediately, see
the LMA Insertion Technique and Maneuvers Guide
(see appendix). - Start by removing the ET tube adapter. Then hold the
o To use a flexible endoscope to intubate through other proximal end of the ET tube in place while rotating the
LMAs, the procedure is similar. ILMA out of the hypopharynx.
- First, place the ET tube approximately halfway to the - As the ILMA passes over the ET tube and out of the
opening in the laryngeal mask bowl. mouth, hold the ET tube in place with a stabilizer rod,
▪ At this point, it may be useful to connect without advancing the tube farther.
a swivel adapter to the ET tube adapter ▪ If a stabilizer rod is not available, a second
that will allow ongoing ventilation with ET tube can also be used to aid in ILMA
the ability to place the flexible endoscope removal.
through the other port. ▪ When the ET tube pilot balloon comes in
▪ If this step is performed, the cuff of the ET contact with the stabilizer rod, remove
tube should be inflated during the stabilizer rod to allow the pilot
endoscopic intubation to minimize the air balloon to travel through the ILMA tube.
leak during ventilation. ▪ Then reattach the ET adapter and resume
- After the ET tube is placed halfway to the opening of ventilation. Adjust the depth of the ET
the laryngeal mask bowl, the endoscope is introduced tube as needed.
into the ET tube and advanced until the laryngeal inlet Intubation through the LMA Classic
is visualized.
o The recommended technique for tracheal intubation
▪ Advance the endoscope into the trachea
through the LMA Classic uses an endoscope and has a high
and then pass the ET tube over the
success rate but requires a smaller ET tube and some
endoscope.
adjustments.
▪ If the laryngeal inlet is not immediately
o After ensuring that the LMA is ventilating properly, place a
visualized, the laryngeal mask should be
well-lubricated ET tube into the LMA tube and advance it
repositioned before attempting
to a depth of 24 cm (No. 5 LMA), so that the tip of the ET
intubation.
tube has just passed the fenestrations.
- For children, the most common flexible bronchoscope
o Pass a lubricated endoscope through the ET tube and
has an outer diameter of 3.6 to 3.8 mm, which enables
advance it through the vocal cords.
intubation of a 4.5 ET tube or larger.
- If the epiglottis is deflected downward, manipulate the
▪ This allows intubation through an ILMA
tip of the endoscope under the epiglottis until the
for children as small as 2 to 3 years old.
vocal cords come into view.
▪ Children younger than this should not be
o Pass the ET tube over the endoscope and into the trachea,
intubated through an ILMA, unless a
and then inflate the ET tube cuff and ventilate the patient.
smaller endoscope is used.
o Check for correct ET tube placement with a PETCO2
ILMA Removal After Intubation detector.
o To remove the ILMA, first deflate the cuff, if present and be o Cricoid pressure may impede placement and intubation
careful to not deflate the ET tube cuff. through the LMA.
- Release cricoid pressure, if necessary, to accomplish
these procedures.
Complications When Intubating through LMAs
Although most patients can be safely intubated blindly through
the ILMA, there is a small chance of injury to the larynx or
esophagus, especially with multiple blind attempts.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 31

FLEXIBLE ENDOSCOPIC INTUBATION o The size of the working channel, the port that allows
o Flexible endoscopic intubation is often the best method for suction, administration of oxygen, and passage of fluid or
intubating awake patients with a known difficult airway. catheters, are also important when evaluating endoscopes.
o It can be accomplished via the nasal or oral route and is - A working channel of approximately 2 mm is desirable
better tolerated than DL. to allow adequate suction of secretions, though
o It usually provides excellent visualization of the airway and working channels are not strictly necessary for
permits evaluation of the airway before placement of the endoscopic intubation.
tube. Indications and Contraindications
o Patients with known or suspected difficult airways are good
candidates for awake or semi-awake endoscopic
intubation.
o Patients with distorted airway anatomy, including swelling
of the mouth or tongue, upper airway abscess or infection,
morbid obesity, cervical spine injury, trismus, and
penetrating and blunt neck trauma, are all good candidates
for awake endoscopic intubation.
o An endoscope can also be helpful when assessing and
intubating patients with airway obstruction from presumed
foreign body aspiration.
- Flexible endoscopic intubation is best used as the
initial approach to tracheal intubation, and it may also
be used as a rescue device when other methods fail.
o Contraindications to the nasal approach are severe midface
trauma and coagulopathy.
o Patients who are likely to receive thrombolytics should also
be excluded.
o Although there are no clear contraindications to
endoscopic orotracheal intubation, active airway bleeding,
excessive oral sections, and vomiting are relative
contraindications because successful endoscopic
intubation is rarely achieved in these settings.
o Hypoxia despite good attempts at oxygenation is another
relative contraindication.
Procedure and Technique
Preparation
o Proper preparation of the upper airway is crucial for
successful awake or semi-awake endoscopic intubation.
o If time permits administration of a drying agent such as
glycopyrrolate 10 to 20 minutes before the procedure will
reduce oral secretions and increase effectiveness of topical
anesthesia.
o Topical anesthesia should be applied to the posterior
oropharynx, hypopharynx, and larynx for all endoscopic
intubations.
o If nasal intubation is planned, administer topical anesthesia
to the selected naris; application of a vasoconstrictor such
as oxymetazoline or phenylephrine is recommended to
o A practical size for an intubating scope is approximately 4 increase the caliber of the nasal passage and reduce the
to 5 mm. Although it is physically possible to pass an ET chance of epistaxis.
tube sized 0.5 mm larger over an endoscope, the fit is tight. o Deliver local anesthetic to the upper airway by one of
o As a rule, the ET tube should be approximately 1 mm larger several methods.
than the intubating scope.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 32

- Application of 4% or 5% lidocaine cream by “buttering” the mucous membranes is probably enhanced if a

the base of the tongue is an effective technique to nasal airway is placed after application. This has the
anesthetize the posterior tongue, vallecula, epiglottis, added benefit of further dilating the nasal passage.
and laryngeal structures. - The maximum dose of lidocaine for airway anesthesia
- The tongue is held in protrusion as the base of the is approximately 4 mg/kg (approximately 250–300 mg
tongue is buttered with 4% or 5% lidocaine cream in an adult).
using a tongue depressor. - Sedation for endoscopic intubation can be
- Because the patient is unable to swallow with a accomplished with ketamine, etomidate, propofol,
protruded tongue, the ointment warms, liquefies, and fentanyl, alfentanil, or midazolam.
moves posteriorly and inferiorly to anesthetize the - The goal of sedation is to preserve spontaneous
laryngeal structures. respiration, but limit patient movement and reaction
- It is contended that the ointment also penetrates the to the procedure.
mucosa to anesthetize the glossopharyngeal and
superior laryngeal nerves.
- Nebulized lidocaine (4 to 6 mL of a 4% solution) can be
used to anesthetize the entire upper airway if time
permits.
- Lidocaine (3 mL of a 4% solution) can be injected
percutaneously through the cricothyroid membrane
via a 20-gauge needle, thereby providing anesthesia to
the larynx and trachea.

- A flexible atomizer device that attaches to a standard

syringe can be used to accurately apply atomized 4%
aqueous lidocaine to the posterior oropharynx and
upper laryngeal structures; tracheal anesthesia can be
accomplished by having the patient inspire as the
medication is sprayed.
- Finally, 4% aqueous lidocaine can be sprayed through
the working channel of the endoscopic scope during
the procedure via the “spray as you go” technique. Attaching a standard swivel adapter (A) to the end of the ET
o Nasal anesthesia can be accomplished by several methods. tube during endoscopic intubation through the intubating
- A flexible atomizer can be passed to the posterior laryngeal mask airway (ILMA) allows the patient to be
nasopharynx, and then 4% aqueous lidocaine is ventilated during the entire procedure (B).
sprayed as the patient sniffs.
- This is repeated several times as the flexible atomizer o The optimal position of the neck is extension, as opposed
is slowly withdrawn. to the slight cervical flexion desired when using DL.
- Nebulized 4% lidocaine can anesthetize the nasal - Extension allows better visualization of the glottis by
passage, assuming the patient is not mouth breathing. elevating the epiglottis off the posterior pharyngeal
Viscous lidocaine gel can be injected with a syringe into wall.
the nasal passage as the patient sniffs; absorption into

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 33

▪ This is especially pertinent in a comatose Nasal Approach

patient who lacks the muscle tone o The nasal approach is technically easier than the oral
necessary to maintain an open airway. approach because the angle of insertion allows better
▪ If problems arise with the tongue and soft visualization of the larynx with minimal manipulation of the
tissues falling back and obscuring the endoscope.
view of the endoscope, apply a jaw-lift o In an unconscious patient, the tip of the scope is also less
maneuver or grasp the tongue and pull it likely to impinge on the base of the tongue with a nasal
forward and away from the soft palate approach.
and posterior pharyngeal wall.
▪ This also moves the epiglottis away from
the posterior pharyngeal wall and
facilitates exposure of the cords. Extend
the head to accomplish the same
objective.
o Endoscopic intubation may be performed with the patient
in the upright, semi-upright, or supine position. Stand
facing the patient or at the patient’s head, depending on
personal preference.
- The upright and semi-upright positions help keep
pharyngeal soft tissue from obstructing the airway.
- The upright position may be more familiar to
emergency clinicians who are skilled at diagnostic
nasopharyngoscopy.
o The greatest impediment to successful endoscopic - This patient with life-threatening angiotensin-
intubation is an inability to visualize the larynx because converting enzyme inhibitor-induced angioedema is in
blood or secretions have covered the optical element and severe distress, and oral intubation is impossible. This
cannot be removed. can be a lethal condition.
- Suction actively just before introduction of the
endoscope.
- Application of a small amount of soap to the lens may
decrease fogging.
o If the endoscope has a working channel, suction minor
secretions through the suction port during the procedure.
o The camera can also be cleaned by pressing the lens against
a moist mucosal surface or having the patient swallow.
o Whereas some advocate oxygen insufflation through the
suction port to blow away secretions, defog the tip, and
increase the inspired oxygen content, there are case
reports of gastric insufflation causing gastric rupture, as
well as pulmonary barotrauma.
- If oxygen insufflation is used to clear secretions, it
should be used for a few seconds at a time.
Supplemental oxygen can be administered separately,
through the nose or mouth.
o Once the scope has entered the trachea, difficulty
advancing the ET tube may be encountered. The tip of the
tube most commonly catches on the right arytenoid
- Endoscopic nasotracheal intubation is a good choice,
cartilage or vocal cord.
but it is very difficult, if not impossible, in a struggling
- To fix this, withdraw the tube 2 cm, rotate it
patient.
counterclockwise 90 degrees, and re-advance the tube
- Ketamine anesthesia is ideal, does not depress
to remedy the problem.
respirations, and allows easy administration of
supplemental oxygen.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 34

- A less ideal option is blind nasotracheal intubation. A o The advantage of first passing the tracheal tube through
surgical airway may be required. the nose is that it avoids the possibility of secretions
- Note: In this case the tracheal tube was premounted covering the scope and positions the scope just above the
on the scope before the scope was passed into the laryngeal inlet.
patient’s nose. Alternatively, the tube may be first o One disadvantage is that it may cause epistaxis, and, in
passed approximately 10 cm through the nose, and some patients, the tube may not pass easily into the
then the scope passed through the tube and into the nasopharynx.
trachea. - However, if the tube will not pass into the nasopharynx
o If conditions permit, choose the most patent nostril. In a it is best to discover this at the beginning of the
cooperative patient, determine this by simply occluding procedure rather than after the trachea has been
each nostril and asking the patient to identify the nostril intubated with the endoscope.
that is easiest to breathe through. o At an insertion depth of 10 cm, the ET tube should have
- Identify the most patent nostril by direct vision or by advanced around the bend into the nasopharynx.
gently inserting a gloved finger that is lubricated with - If negotiating this bend is difficult, place a well-
viscous lidocaine into the nostrils. lubricated endoscope through the tube and into the
- If time is not an issue, an effective method to dilate the oropharynx to serve as a guide for the ET tube.
nasal cavity and administer an anesthetic is to pass a o Once the tracheal tube is in the oropharynx, perform
lidocaine gel–lubricated nasopharyngeal airway (nasal thorough oropharyngeal suctioning before introducing the
trumpet) into the selected nostril. scope into the ET tube.
- Leave this airway in place for several minutes, and o Advance the endoscope toward the larynx.
introduce progressively larger trumpets. o The epiglottis and vocal cords are seen with little or no
o First, place a well-lubricated ET tube in the nostril to a manipulation of the tip of the endoscope in 90% of
depth of approximately 10 cm before passing the scope patients.
through it. o Advance the scope and keep the cords in view by making
- Alternatively, mount the ET tube over the scope and frequent minor adjustments of the tip of the scope.
first pass the scope through the nostril. o In a comatose or obtunded patient, the tongue and other
soft tissues may obscure the view of the larynx.
- This can be alleviated by asking an assistant to pull the
tongue forward or to apply a chin- or jaw-lift
maneuver.
- Advance the scope through the larynx to the carina
and pass the ET tube over the firmly held endoscope
into the trachea.
- Remember that in adults, the average distance from
the naris to the epiglottis is 16 to 17 cm.
- If the scope has been advanced much beyond this
distance and the glottis is still not seen, the scope is
probably in the esophagus.
- If the scope meets resistance at approximately this
same level and only a pink blur is visible, the tip of the
scope is probably in a piriform sinus.
- Transillumination of the soft tissues may confirm this
and indicate the necessary corrective maneuvers.
Oral Approach
o Oral endoscopic intubation is indicated when nasal
intubation is contraindicated, most commonly because of
- Flexible endoscopic intubation. Note that the tracheal severe midface trauma or clinician inexperience.
tube is first premounted on the scope. The fiberoptic o For the less experienced, the oral approach may be more
scope enters the trachea and then serves as a guide difficult because the path of the scope is less defined by the
over which the tracheal tube is passed. Larger image, surrounding soft tissue and the tip of the scope is more
The nasal approach. Inset, Use of an oral intubating likely to impinge on the base of the tongue or vallecula.
airway via the oral approach.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 35

- Keeping the scope in the midline and elevating the soft

tissue by pulling the tongue forward or applying the
jaw-lift maneuver will minimize this difficulty.
- Because the oropharyngeal axis is not as well aligned
with the larynx as the nasopharyngeal axis, more scope
manipulation is required when using the oral
approach.
o Difficulty with the oral approach can be minimized by using
an oral intubating airway.

- Advance the ET tube over the scope and into the

trachea.
▪ This may require the same
counterclockwise maneuver as described
with the nasal approach.
- After successful intubation, the oral airway can be left
in place as a bite block or may be removed over the ET
tube after removal of the tube adapter.
▪ Some oral intubating airways can be
removed from the mouth without
disconnecting the ET tube adapter.
o An alternative, albeit less practical, approach to the
- Examples of oral intubating airways. The Williams traditional oral endoscopic intubation for an anticipated
Airway Intubator (SunMed, Grand Rapids, MI) (left) difficult airway requires two clinicians.
cradles the endotracheal (ET) tube in an open, curved - One performs DL, places the tip of the endoscope
guide, whereas the Ovassapian Fiberoptic Intubating under the epiglottis, and blindly advances it while the
Airway (Teleflex, Buckinghamshire, UK) (right) second clinician, holding the body of the scope, directs
positions the ET tube on the posterior surface of the the tip of the scope through the cords:
intubation airway.
- This adjunct resembles an oropharyngeal airway but is
longer and has a cylindrical passage through which the
endoscope and tracheal tube are passed.
- The tip of this airway lies just above the laryngeal inlet
and ensures midline positioning.
- Make sure that the patient is either adequately
anesthetized or obtunded before the oral airway is
placed to minimize gagging or emesis.
- The Et tube can be placed to the tip of the oral airway
before the oral airway is inserted, and then the scope
passed through the ETtube.
- Alternatively, place a well-lubricated endoscope,
premounted with an ET tube, through the well-
positioned oral intubating airway.
- An assistant holds the oral airway and can make minor
- Two-person fiberoptic intubation for difficult
adjustments to place the tip of the oral airway just
intubation. The laryngoscopist obtains the best
above the laryngeal inlet.
hypopharyngeal exposure and directs the fiberoptic tip
- Once the airway structures are visualized, intubate the
in the direction of the glottis. The second clinician, who
trachea with the scope:
manipulates the tip of the fiberoptic scope, directs the
laryngoscopist to slowly advance the tip until it has
successfully passed through the cords.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 36

Endoscope Technique Summary

o The scope body and endoscope controls are held in one o The primary advantages of endoscopic intubation are the
hand while the other hand stabilizes the sheath as it enters ability to visualize upper airway abnormalities, to negotiate
the ET tube or patient. difficult airway anatomy, and to carefully perform tracheal
o The intubator directs motion in one plane with the intubation under visual guidance.
endoscope controls; to move perpendicular to the plane o Its major limitation is poor visibility because of blood and
under direct control the tip of the scope must be rotated. secretions.
o This is best accomplished by keeping the endoscopic OPTICAL AND VIDEO INTUBATING STYLETS
sheath taut between the scope body and the point of entry
o Intubating stylets are different from other video
into the patient, and performing rotation of the scope body
laryngoscopy devices in two important ways.
to affect rotation at the tip of the scope.
- First, they do not create potential space for tube
- If the sheath is not held taut, rotation of the scope
passage like devices with blades.
body will not cause rotation at the tip because of
- Second, they intubate the trachea directly.
excessive slack in the sheath.
o Intubating stylets can be used in conjunction with DL or as
o Newer endoscope systems with video monitors make it
stand-alone devices. They require laryngoscopic
easier to hold the endoscope and sheath properly:
assistance.
o Visibility can be hampered by blood and secretions, but less
so than with flexible endoscopy.
o The Clarus Video System, Shikani Optical Stylet and Levitan
FPS Scope (Clarus Medical, Minneapolis) are examples of
these malleable optical stylets:

- This technique is difficult on older scopes that utilize

an eyepiece.

o The Bonfils Retromolar Intubation Fiberscope is rigid but

otherwise structurally and functionally similar to the
Shikani.
- Newer systems with a video monitor make it easier to
- The distal end of the Bonfils has a fixed curve of 40
manipulate the endoscope properly.
degrees,
Complications
- Whereas the other scopes are malleable up to 120
o Complications of endoscopic orotracheal intubation
degrees.
include hypoxia from prolonged intubation attempts,
Indications and Contraindications
emesis, and laryngospasm.
o Semirigid fiberoptic stylets are useful when the glottis
o Most complications seen with endoscopically guided NT
cannot be seen readily, and may be a useful adjunct for any
intubation are associated with passing the ET tube through
difficult airway, especially if mouth opening is limited.
the nasopharynx.
o A relative contraindication is the presence of significant
- Epistaxis is the most common, followed by other
blood or oral secretions.
nasopharyngeal injuries.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 37

Procedure and Technique - At this point, guide the stylet–ET tube unit into the
o The semirigid fiberoptic stylet can be used with or without glottis and advance the tube off the stylet.
DL. In either case, place the patient in the sniffing position. OROTRACHEAL INTUBATION WITH A KING LARYNGEAL
- Load an ET tube onto a lightly lubricated stylet so that TUBE (LT) OR COMBITUBE IN PLACE
the ET tube extends 1 to 2 cm beyond the end of the o King LT (Ambu, Ballerup, Denmark) airways are used
stylet. extensively in the prehospital setting because they can be
- If the device is used alone, create an accentuated curve placed quickly and provide reliable oxygenation and
of between 70 and 80 degrees at the proximal aspect ventilation in the vast majority of patients.
of the cuff of the tube so that it can negotiate the o The aperture does not necessarily directly align with the
oropharynx. glottis, even when the device is ventilating properly.
▪ Suction the oropharynx well before o The clinician has the choice of whether to remove the
attempting intubation. functioning retroglottic airway before attempting
- Grasp the mandible with the left hand. Next, raise the intubation, or to leave the device in place during
jaw to lift the tongue and epiglottis off the posterior intubation.
hypopharyngeal wall. - An advantage of leaving the device in place is the
▪ Ask an assistant to apply a jaw-thrust maintenance of oxygenation and ventilation until just
maneuver or grasp the tongue with gauze before the attempt begins, and the ability to reinflate
and retract it anteriorly. the balloons and resume oxygenation immediately
- Place the device into the mouth, and while following after a failed attempt, without having to replace the
the curve of the tongue, bring it up under the epiglottis laryngeal tube.
with fiberoptic or video guidance. o DL with the King LT in place is difficult.
- When the laryngeal inlet is visualized, direct the tip - In contrast, video laryngoscopy usually allows
into the larynx. excellent visualization of the glottis and placement of
- Advance the ET tube as you withdraw the stylet. If an ET tube while the King LT remains in place (with the
resistance is met while advancing the tube, the tip may balloons deflated), and is a reliable method of securing
be catching on the anterior larynx or trachea. the airway with a laryngeal tube in place.
- Rotate the tube clockwise 120 degrees at the proximal - This approach allows providers to avoid the risk of
end, which will result in a 90-degree rotation at the tip. removing a functional airway in a patient who may be
- With the bevel now anterior, allow the tube to difficult to intubate.
advance without catching.
▪ It is important to remember that the
direction of rotation of the ET tube is
clockwise if resistance is encountered
after going through the cords.
▪ For resistance encountered before the
cords, such as occurs with tracheal tube
introducers, fiberoptic scopes, and NT
intubation, rotate the tube
counterclockwise.
o Semirigid optical stylets can be used with DL, either
primarily or after encountering difficulty while using the
device alone.
- With this approach, make the angle of the distal stylet
less acute, at approximately 35 degrees, and introduce
the device only after obtaining maximal visualization Tracheal intubation around a King LT airway using video
with the laryngoscope. laryngoscopy.
- If the epiglottis can be seen, advance the tip of the A. The laryngoscope is placed in the mouth and
stylet just underneath it via direct vision. advanced until the large balloon comes into view.
▪ Be careful to not embed the tip of the ET B. The balloon is deflated. Usually the glottis will
tube in the supraglottic soft tissue immediately appear. If it does not, optimize the view
because it will obscure visibility. by ensuring the laryngoscope blade is in the vallecula
and engaged in the midline hyoepiglottic ligament.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 38

C. Pass a bougie into the trachea. o Some other common examples of a difficult airway to
D. The tube is passed over the bougie. After consider for NT intubation are patients with short thick
confirmation that the endotracheal tube is in the necks, trismus, neck immobility, and oral injuries.
trachea, the King LT airway can be removed. If there o Other conditions that preclude successful orotracheal
is difficulty during the procedure, or if intubation is intubation include severe arthritis, fixed deformities of the
unsuccessful, inflate the King LT balloons and resume cervical spine, or ACE inhibitor-induced angioedema.
ventilation. o Apnea is the major contraindication to blind NT
intubation because attempts to place the tube without
o To perform this procedure, use a video laryngoscope to respirations as a guide are futile.
obtain a view of the large proximal balloon. Deflate the o Avoid nasal intubation in patients with severe nasal or
balloons. midface trauma.
- The glottis will usually come immediately into view. - In the presence of a basilar skull fracture, an NT tube
▪ If it does not, optimize the view using the may inadvertently enter the cranial cavity.
laryngoscope; small adjustments o Blind NT intubation should be avoided in patients with
(rotation or slight retraction) of the expanding neck hematomas and oropharyngeal trauma. If
laryngeal tube may also be needed. the patient has known abnormal glottic anatomy that
o Pass a bougie into the airway, and then have an assistant would impede blind tube passage, other methods will
place an ET tube onto the bougie; intubate the trachea as probably be more successful.
described previously. o Inability to open the mouth (such as a wired jaw) is a
o Inflate the ET tube and confirm placement. relative contraindication because emesis may be induced
o After the tube is known to be in the trachea and patient is and it may be impossible to clear the vomitus; endoscopic
stable, remove the laryngeal tube. guidance may be preferred to reduce the risk of emesis.
Procedure and Technique
BLIND NASOTRACHEAL (NT) INTUBATION o Place the patient in the sniffing position with the proximal
o The primary advantage of the blind technique is that it part of the neck slightly flexed and the head extended on
minimizes neck movement and does not require mouth the neck.
opening. - Apply phenylephrine drops, oxymetazoline (Afrin)
o In extenuating circumstances, it can be accomplished spray, or 4% cocaine spray to both nares to dilate the
without an intravenous line. nasal passages and reduce the risk of epistaxis.
o Blind NT intubation is possible with the patient in the sitting - Topical anesthesia of the nares, oropharynx,
position, a distinct advantage when intubating a patient hypopharynx, and larynx with lidocaine spray (4%) is
with congestive heart failure who cannot tolerate lying flat. also indicated if time permits (as described previously).
- In fact, patients in respiratory distress are the easiest - If available, cocaine is ideal because it is both a
to intubate blindly because their air hunger results in vasoconstrictor and an anesthetic, but caution is
increased abduction of the vocal cords, which necessary in hypertensive patients.
facilitates entry of the tube into the trachea. o Choose the most patent nostril
o The patient cannot bite the tube or manipulate it with the - In a cooperative patient, simply occlude each nostril
tongue. and ask the patient which naris is easier to breathe
o It is better tolerated by the patient, permits easier through.
movement in bed, and produces less reflex salivation than - The most patent nostril can also be identified by direct
an orotracheal tube. vision or by gently inserting a gloved finger lubricated
Indications and Contraindications with viscous lidocaine into the nostrils.
o Patients requiring airway control who have spontaneous o If time permits, pass a nasal airway first and allow it to
respirations can be considered for blind NT intubation. remain in place to physically dilate the passage.
o The typical patient is one with an anticipated difficult o After preparation of the nostril, insert a well-lubricated 7.0-
airway and persistently low oxygen saturation despite or 7.5-mm ET tube along the floor of the nasal cavity.
preoxygenation. - Do not direct the tube cephalad, as one might expect
o Patients with severe chronic obstructive pulmonary from the external nasal anatomy, but rather direct it
disease (COPD) or asthma who have high airway pressures straight backward toward the occiput and along the
and may be difficult to ventilate with a face mask are nasal floor.
another group to consider for NT intubation. - Twist the tube gently to bypass any soft tissue
obstruction in the nasal cavity.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 39

- It is sometimes recommended that the tube’s bevel be o The optimum distance from the external nares to the tip of
oriented toward the septum to avoid injury to the the tube is approximately 28 cm in males and 26 cm in
inferior turbinate. females.
o At 6 to 7 cm, one usually feels a “give” as the tube passes o After verification of tracheal placement, inflate the cuff and
the nasal choana and negotiates the abrupt 90-degree secure the tube.
curve required to enter the nasopharynx. Technical Difficulties
- This is the most painful and traumatic part of the o When the initial pass is unsuccessful, there are four
procedure and must be done gently. potential locations of the tip of the tube:
- If resistance persists despite continued gentle pressure 1. anterior to the epiglottis in the vallecula,
and twisting of the tube, pass a suction catheter or 2. on the arytenoids or vocal cords,
endoscope down the tube and into the oropharynx to 3. in a piriform sinus, or
allow successful passage of the tube over the catheter. 4. in the esophagus.
▪ If this attempt fails, try the other nostril. o To move the ET tube in relation to the laryngeal inlet, it is
To avoid this difficulty from the outset, important to know how the tip of the ET tube responds to
use a controllable-tip tracheal tube. head movements.
▪ The tube allows you to increase the - Flexion of the neck will move the tip posteriorly;
flexion of the tube, thereby facilitating - extension of the neck will move the tip anteriorly;
passage beyond this tight curve. - rotation of the neck to the right and left will move the
o As the tube advances through the oropharynx and tip of the tube contralateral to the direction of
hypopharynx, it approaches the vocal cords, and breath rotation.
sounds from the tube typically become louder. 1. ANTERIOR TO THE EPIGLOTTIS
- Fogging of the tube may also occur. - Difficulty advancing the tube beyond 15 cm or
o At the point of maximal breath sounds, the tube is lying palpation of the tip of the tube anteriorly at the level
immediately in front of the laryngeal inlet. of the hyoid bone suggests an impasse anterior to the
o The tube is most easily advanced into the trachea during epiglottis in the vallecula.
inspiration, when the vocal cords are maximally open. - Withdraw the tube 2 cm, decrease the degree of neck
- As the patient begins to breathe in, advance the tube extension, and readvance the tube.
in one smooth motion. 2. ARYTENOID CARTILAGE AND VOCAL CORD
- If a cough reflex is present, the patient usually coughs - the most common obstacles to advancement of the NT
and becomes stridulous during this maneuver, which tube are the right arytenoid and the vocal cords.
suggests successful tracheal intubation. - If the tube appears to be hanging up on firm
- The absence of such a response should alert the cartilaginous tissue, withdraw the tube 2 cm, rotate it
clinician to probable esophageal passage. 90 degrees counterclockwise, and readvance it.
o Remember that in adults, the average distance from the ▪ This maneuver orients the bevel of the
naris to the epiglottis is 16 to 17 cm; if the scope is tube posteriorly and frequently results in
advanced past this distance and is not in the trachea, it is successful passage.
probably in the esophagus.
o Once the tube is in the trachea, vocalization should cease.
Persistent vocalizations suggest esophageal intubation.
Breath sounds coming from the tube and tube fogging are
other signs of correct ET tube placement.
o Reflex swallowing during blind NT intubation may direct
the tube posteriorly toward the esophagus.
- If this occurs, direct conscious patients to stick out
their tongue to inhibit swallowing and prevent
consequent movement of the larynx.
- Application of laryngeal pressure may also help avoid
esophageal passage.
o After intubation, auscultate over both lungs while applying
positive pressure ventilation.
- If only one lung is being ventilated, withdraw the tube
until breath sounds are heard bilaterally.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 40

- Another technique is to pass a suction catheter down the posterior pharyngeal wall, and can
the tube. It will often pass through the larynx without help angle the tube toward the larynx.
difficulty, and the tube can then be advanced over the ▪ Advance the tube 2 cm.
catheter. ▪ Continued breath sounds indicate a
probable intralaryngeal location.
▪ At this point, deflate the cuff and advance
the ET tube into the trachea.

The tracheal tube is pulled back after passage through the esophagus.

[Link] SINUS
- Bulging of the neck lateral and superior to the larynx
indicates tube location in a piriform sinus.
- Withdraw the tube 2 cm, rotate it slightly away from
the bulge, and then readvance it.
Once breath sounds are heard, the cuff is inflated with 15 mL of air and
- An alternative method is to tilt the patient’s head readvanced into the laryngeal inlet. Once seated in the inlet, the cuff is
toward the side of the misplacement and then deflated and the tube advanced into the trachea.
reattempt placement.
4. ESOPHAGEAL PLACEMENT Laryngospasm
- Esophageal placement is indicated by a smooth o Withdraw the tube slightly and wait for the patient’s first
passage of the tube and the loss of breath sounds gasp to advance the tube.
through the tube. - This is frequently successful because the vocal cords
- The larynx may be seen or felt to elevate as the tube are widely abducted during inhalation.
passes under it. o Assess laryngeal anesthesia, and if topical and nebulized
- Assisted ventilation will usually produce gurgling lidocaine has already been administered without success,
sounds when the epigastrium is auscultated. consider transcricothyroid anesthesia (e.g., 2 mL of 4%
- Withdraw the tube until breath sounds are clearly lidocaine).
heard, and reattempt passage while applying pressure Complications
to the cricoid. Increase extension of the head on the o Epistaxis is the most common complication of blind NT
neck during placement. intubation.
- If attempts continue to result in esophageal o Other immediate complications include turbinate fracture,
misplacement, the following maneuver may result in intracranial placement through a basilar skull fracture,
successful tracheal intubation. retropharyngeal laceration or dissection, and delayed or
▪ From the precise point at which breath unsuccessful placement.
sounds are lost, withdraw the ET tube 1 o Sinusitis in patients with an NT tube is common and can be
cm and inflate the cuff with 15 mL of air, an unrecognized cause of sepsis.
which results in elevation of the tube off

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 41

DIGITAL INTUBATION a stylet for directing the tube anteriorly is to select an ET

Indications and Contraindications tube with a controllable tip.
For the newborn:
o Digital intubation is indicated in a deeply comatose patient
o Only the index finger is used to guide the tube into the
whose larynx cannot be visualized and who has a
larynx. Bend the end of the tube and moisten both the tube
contraindication to NT intubation.
and the finger with sterile water.
o Advantages include speed and ease of placement,
o Use the index finger of the nondominant hand to follow the
immunity to constraints visualizing the larynx, and little
tongue posteriorly and palpate the epiglottis and paired
neck movement.
arytenoids.
o Contraindications are primarily precautions to protect the
o Use the thumb of the same hand to apply cricoid pressure
clinician. Digital intubation should not be attempted in any
and steady the larynx. Hold the ET tube in the dominant
patient with a significant risk of biting.
hand and advance it with the nondominant index finger
Procedure and Technique
used as a guide.
o Place the patient’s head and neck in the neutral position.
Stand at the patient’s right side, facing the patient.
o Introduce your left index and middle fingers into the right
angle of the patient’s mouth and slide them along the
surface of the tongue until the epiglottis is felt.
- The tip of the epiglottis should be palpated 8 to 10 cm
from the corner of the mouth in average adults.
o Use of a stylet in the tube is optional, but the largest
reported series had good success without a stylet.
- If a stylet is used, place it in the tube and bend it into
the form of an open J with the distal end terminating
in a gentle hook. Introduce a lubricated tube from the
patient’s left side between the tongue and the - The tube will encounter subtle resistance as it enters
rescuer’s two fingers. the trachea, and palpation of the tube through the
trachea provides further confirmation of correct
placement.
Complications
o If used in patients with a gag reflex, induction of emesis
with aspiration is a risk.
o A high incidence of left main stem intubation was noted in
a cadaveric study.
o The greatest risk seems to be to the clinician, whose fingers
may be bitten.
RETROGRADE INTUBATION
o Retrograde orotracheal intubation is a technique of guided
ET intubation that involves the use of a wire or catheter
placed percutaneously through the cricothyroid membrane
or high trachea and exiting through the mouth or nose.
o An ET tube is then passed over this guide and advanced
through the vocal cords into the trachea.
Indications and Contraindications
- Cradle the tube between two fingers and guide the tip o Retrograde intubation is indicated when definitive airway
beneath the epiglottis. Apply gentle anterior pressure control is required and less invasive methods have failed.
to direct the tube into the larynx. o Indications include trismus, ankylosis of the jaw or cervical
- If the clinician has sufficiently long fingers, place them spine, upper airway masses or swelling, unstable cervical
posterior to the arytenoids to act as a “backstop” for spine injuries, and maxillofacial trauma. It can be used to
the tube, to both avoid esophageal passage and assist convert transtracheal needle ventilation into a definitive
in laryngeal placement. airway.
o If a stylet has been used, withdraw it at this time while
simultaneously advancing the tube. An alternative to using

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 42

o Contraindications to retrograde intubation include the o If the ET tube has successfully passed through the vocal
availability of a less invasive means of airway control and cords and is being restricted by the guidewire as it traverses
inability to open the mouth. the anterior laryngeal wall, the clinician should feel some
o relative contraindication is an apneic patient who cannot caudally directed tension on the wire at its laryngeal
be effectively ventilated with a bag-valve-mask device. insertion point.
Equipment - If this does not occur, the tip of the ET tube may be
1. local anesthetic and skin preparation material, proximal to the vocal cords, in the vallecula, in a
2. an 18-gauge needle, piriform sinus, or abutting the narrow anterior aspect
3. a 60-cm epidural catheter needle combination or an of the vocal cords.
80-cm (0.88-mm diameter) spring guidewire (J tip - If in doubt, pull the tube back 2 cm, rotate it 90 degrees
preferred), counterclockwise, and then readvance the tube.
4. a hemostat, ▪ This will usually result in successful
5. long forceps (e.g., Magill) for grasping the wire in the passage into the larynx.
pharynx,
6. an ET tube of appropriate size,
7. a syringe for the tube cuff,
8. material for securing the tube
Procedure and Technique
o Locate the three important anatomic landmarks by
palpation:hyoid bone, thyroid cartilage, and cricoid
cartilage.
o Prepare the skin overlying the cricothyroid membrane and
anesthetize it.
o Maintain a cephalad orientation of the needle bevel, and
puncture the lower half of the cricothyroid membrane.
o Direct the needle slightly cephalad. Aspirate air to confirm
position of the tip of the needle within the lumen of the
larynx.
o An alternative entry point is the high trachea, usually
through the subcricoid space, with the same steps being
used as described for the cricothyroid membrane.
o Remove the syringe and pass the wire through the needle.
o Advance it until it is seen in the patient’s mouth or until it
exits the nose.
- A laryngoscope may facilitate this process.
o If the wire is found in the hypopharynx, grasp it with the
Magill forceps and draw it out through the mouth. Remove
the needle from the neck and secure the end of the wire at
the puncture site with a hemostat. The next steps will
depend on whether a plastic sheath, also referred to as an
obturator, is available.
o If no sheath is available, thread the oral end of the wire in
through the ET tube side port (not the end of the tube), and
advance it up the tube until it can be grasped with a second
hemostat.
- Threading the wire through the side port allows the tip
of the tube to protrude 1 cm beyond the point at which
the wire enters the larynx.
- Pull the wire taut and move it back and forth to ensure
that no slack remains.
- Advance the ET tube over the wire until resistance is
met.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 43

Figure 4.44 Replacing a malfunctioning endotracheal tube

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 44

CHANGING TRACHEAL TUBES

A tracheal tube with a leaking cuff is a vexing problem,
especially if the original intubation was difficult. A method of
replacing the tube without losing control of the tracheal lumen
is preferred.
This can be achieved by passing a guide down the defective
tube, withdrawing the tube while leaving the guide in place,
and introducing a new tube over the guide and into the
trachea.
Figure 4.45 Retrograde intubation using a guidewire and
antegrade sheath.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 45

Procedure and Technique

o Preoxygenate the patient before placing the guide through
the existing tube.
o Lubricate the guide and advance it into the defective tube
so that it is well within the tracheal lumen (for adults,
approximately 30 cm).
o While applying cricoid pressure, withdraw the defective
tube over the guide, and take care to not dislodge the guide
when removing the tube.
o Slide the replacement tube over the guide and gently
advance it into the trachea. At this juncture, it may be
helpful to perform a jaw-thrust or chin-lift maneuver to
facilitate passage through the pharynx.
o Resistance may be encountered at the laryngeal inlet or
vocal cords.
- If this occurs, withdraw the tube 1 to 2 cm, rotate it 90
degrees counterclockwise, and then readvance it.
- It may help to perform this step under direct vision
with a video laryngoscope.
o After the tube is visualized clearly in the trachea, remove
the guide, inflate the cuff, and ventilate the patient.
o After correct placement has been verified, secure the new
tube.

Chapter 4: Tracheal Intubation

 SECTION 2: Respiratory Procedures 46

Chapter 4: Tracheal Intubation