Laryngoscopy is a skill that takes time to develop, and there is unfortunately no shortcut. The first few months will be inordinately challenging. Eventually, you’ll experience an “aha” moment when the unique mechanics of the MAC 3 blade click into place, and from then on, things become smoother. Until this occurs, you can focus on safe, atraumatic, effective mask ventilation.

Proactively identifying airway challenges is key to patient safety. Refer to the “Patient Evaluation” section for guidance on recognizing predictors of a difficult airway.

During your initial intubation attempts, move slowly and methodically. Rather than making brisk movements, ask if you’re unsure how to maneuver the blade. Maintain clear communication with your supervisor throughout. “I can’t see anything” is not shameful; it’s expected early in your training. If you don’t see familiar structures, gently move the blade forward, backward, or side to side. Lifting the epiglottis to expose the glottic opening takes practice. Once you’ve done it a few dozen times, it will start to become second nature.

You should never force the blade. If you’re applying significant force, you’re likely pushing in a direction that will not ultimately prove successful. At the level of the oropharynx, even minor oral or dental trauma can rapidly snowball into a bloody mess, not to mention be very upsetting to the patient after the fact. At the tracheal level, avoid pushing an ETT against the tracheal wall if you are struggling to advance it. The tracheal wall has cartilaginous and smooth muscle portions and can tear (a catastrophic complication). A gentle turning of the tube will usually do the trick. If it does not, stop and consider an alternative method.

Missing an intubation attempt is not a failure. True failure is repeating the same technique, expecting a different outcome.

Repeated attempts by the same provider, using the same blade, are more likely to cause trauma than success. Once you have failed, return to mask ventilation, reassess, and modify your next approach. Options include:

• improving patient positioning—aim for the “sniffing” position;
  
• changing blade type (e.g., MAC to Miller);
  
• switching to videolaryngoscopy or fiberoptic scope; and
  
• changing providers.

If you’ve tried twice without success, hand the airway off to your supervisor or switch to a videolaryngoscope. Airway disasters often stem from repeated, unmodified attempts. Handing off the airway shows professionalism and a commitment to patient safety and does not indicate personal failure.

Each instrumentation increases the risk of swelling, bleeding, or trauma. Any of these complications can lead to difficulty mask ventilating, and ultimately, the dreaded scenario of “can’t intubate, can ventilate.”

When you hand over the reins to someone else, avoid the temptation to stand defeated. Stay present: provide ancillary help by assessing whether the patient needs more anesthesia (often overlooked in prolonged attempts), start to assemble backup techniques (LMA, call for fiberoptic), and call for help.

Observe experienced providers when they intubate. Note how they stand upright, not hunched over. Note how they keep movements simple and avoid excess force. Experienced intubators make only a few, precise movements.

Videolaryngoscopy has revolutionized airway management. By placing the visual “eye” at the tip of the blade, it radically improves your ability to visualize vocal cords in even very challenging airways.

That said, there are several important considerations. The videolaryngoscope occupies more space in the mouth, which becomes significant in patients with small openings, large tongues, or prominent dentition. Because some videolaryngoscope blades are hyperangulated, the endotracheal tube (ETT) may not align naturally with the glottis as it would with a standard MAC blade. The fix is simple: first, shape the stylet to match the curvature of the videolaryngoscope blade. Second, once the tube is in the mouth, align the ETT and videolaryngoscope side by side. This positioning facilitates smooth tracheal entry.

Many trainees achieve an excellent view of the cords, but then struggle to advance the tube. The result is often an awkward “jab-and-flail” sequence, with the tube repeatedly forced toward the glottis until it finally passes through. This technique is common among early trainees or infrequent intubators, but it can injure airway structures and cause bleeding or swelling. Precision, not persistence, is key. Think of it like parallel parking: you don’t bang into the cars in front and behind you until you fit. Never advance the tube until it’s properly aimed.

Injuries from poor videolaryngoscope technique are well characterized and include:

• tonsillar trauma;
  
• arytenoid puncture;
  
• uvular laceration;
  
• palatoglossal arch tears; and
  
• vocal cord bruising.

Try to avoid videolaryngoscopy unless it’s absolutely necessary. Your fear of traditional blades is understandable, and you may think your supervisor is happier for you to use video. But it’s critical to train using the most low-tech equipment you have, so that you can master the basic skillset. Technology should be used to augment your capability, not to compensate for inexperience.

Many experienced providers still prefer MAC and Miller blades because you can accomplish the task in fewer motions. This is especially true with double-lumen tubes (DLTs), since they don’t conform well to the hyperangulated shape of the videolaryngoscope, making them harder to pass through the glottis without twisting or other awkward movements.

It bears repeating that if the ETT does not pass smoothly into the trachea, never apply brute force.

Videolaryngoscopy has made us better at many things, but it has also contributed to the atrophy of fiberoptic intubation skills. When possible, try intubating with a fiberoptic scope. These can be done asleep or awake with topical local anesthetic application. This allows you to build the dexterity and coordination needed for when you encounter difficult airways. Practicing on asleep patients first builds confidence and familiarity for when awake intubation is required.

When first learning fiberoptic intubation, your main focus should be maintaining a steady, centered view. Beginners often advance the scope before properly aligning the target on the screen, causing the camera to bump into surrounding structures and obscure the image. Keep your goal (the vocal cords or tracheal lumen) centered at all times, and advance in small, deliberate movements. After each advancement, pause and re-center the scope. To improve visualization and minimize obstruction from soft tissues, have your assistant provide a jaw thrust and gently retract the tongue with a piece of gauze.