Routine intubation
Rescue for failed direct laryngoscopy
Anticipated difficult intubation (abnormal anatomy, reduced mouth opening, history of difficult intubations, cervical spine precautions, obesity)
Intubation with desire for teaching or supervision of physician trainees
RELATIVE CONTRAINDICATIONS
Brisk bleeding or copious secretions
No oral access (angioedema)
Provider discomfort or lack of training with indirect laryngoscopy and intubation
DEVICES
Multiple devices are available
Devices are broadly grouped into acutely curved blades (GlideScope, King Vision, C-MAC D-blade, Pentax airway scope) or traditionally shaped blades (C-MAC, GlideScope teaching blade)
Traditionally shaped blades can be used as a direct and video laryngoscope to facilitate mechanical memory for direct laryngoscopy
Some devices require free-hand placement of the endotracheal tube (ETT) (GlideScope, C-MAC, McGrath Series 5), while others have integrated ETT channels that require the device and ETT to be inserted together (King Vision, Pentax airway scope)
SUPPLIES
Video laryngoscope system
ETT
ETT stylet (malleable or rigid)
ETT lubricant
10-cc syringe for cuffed ETTs
End-tidal carbon dioxide detector
Tube securing device
Bag-valve mask
Oral and/or nasal airways
Equipment for preoxygenation (facemask oxygen with reservoir)
TECHNIQUE—RAPID SEQUENCE INTUBATION
Preparation
Vascular access
Monitoring: Cardiac monitor, blood pressure monitoring, and pulse oximetry
Suction device
Assemble necessary equipment (see above)
Obtain rapid sequence intubation (RSI) medications
Perform an airway assessment for difficulty
Preoxygenation
Preoxygenate with nonrebreathing mask or bag-valve mask
Nasal cannula for passive oxygenation during intubation, especially for rapid desaturators
Positioning
Cervical spine extension and head elevation if no contraindication
In-line cervical spine neutrality for patients with cervical spine precautions
Perform “Time Out”
Ensure that the team agrees on medications and dosing, devices to be used, and plan for a failed intubation
Administer Induction and Paralytic Agents
Perform Intubation
Traditionally shaped video system blades (C-MAC, GlideScope teaching blade)
Open mouth with a finger/scissor or similar technique
Insert the blade in the right paralingual gutter of the mouth, sweeping the tongue to the left
Advance the blade in traditional technique with the goal of identifying epiglottis first (epiglottoscopy), followed by placement of the tip of the blade in the base of the vallecula
Using an upward motion, lift up on the handle and blade to obtain a view of the vocal cords by manipulating the hyoepiglottic ligament
If an optimal direct view is not seen under direct vision, the operator may attempt optimization maneuvers such as backward upward rightward pressure, or “BURP,” to improve view
Alternatively, the intubator can opt for early recourse to the video screen to assess glottic view and intubate using the video screen
Stylet should be shaped with a gentle curve to approximate the trajectory the blade has taken to the airway
Curved “indirect” video systems (standard GlideScope, C-MAC D-blade, McGrath video laryngoscope, Pentax airway scope, King Vision video laryngoscope)
Open mouth with a finger/scissor or similar technique
Insert the device in the midline, staying opposed to the dorsal surface of the tongue
Advance and rotate the blade around the tongue, staying in the midline, while watching on the video screen to identify key midline airway landmarks (uvula and tip of epiglottis)
Advance until the blade rests in the vallecula
Gently tilt the blade and cranially bring the vocal cords into view on the screen. Do not place the device too close to the glottic inlet as this impedes tube passage.
If the device has a channel to hold and launch the ETT, gently push the tube through the channel and past the vocal cords after first ensuring the vocal cords are in the center of the video screen
If the device requires the use of a stylet, preference should be made for a rigid preshaped stylet as these do not deform during intubation. Malleable stylets should be shaped with a more aggressive curve to mimic the shape of and trajectory taken by the blade.
Place the stylet-loaded tube in the right corner of the mouth with the length of the tube parallel to the ground (3 o’clock position). Advance the tube while rotating the tube in a counterclockwise position until the tube aligns with the curvature of the blade (12 o’clock position). Advance the tube through the vocal cords. If unable to fully pass the tube, withdraw the stylet slightly to allow for more mobility. Withdraw the stylet.
Inflate the cuff (for cuffed tubes)
Proof of Intubation
Confirm tube placement with breath sounds, chest rise, and colorimetric or quantitative end-tidal carbon dioxide
Postintubation Care
Secure the ETT
Order portable chest x-ray
Connect to a mechanical ventilator, if appropriate
Strategy for ongoing sedation
COMPLICATIONS
Failed intubation with hypoxic insult
Need for surgical cricothyrotomy
Esophageal intubation
Airway bleeding and swelling
Damage to vocal cords
Damage to teeth, lips, or tongue
Hemodynamic decompensation following RSI medications
SAFETY/QUALITY TIPS
Procedural
Your eyes should start out looking in the mouth for blade placement, then shift to the screen for optimal blade advancement, then back to the mouth to place the tube near the tip of the blade, then back to the screen to deliver the tube through the cords.
When using video laryngoscopy, do not place the blade too close to the vocal cords as this limits the ability to easily pass the ETT. In practice, this means not trying to get the “best view of the cords” on the screen, rather, keeping a slightly suboptimal view of the cords on the bottom of the screen, which makes tube delivery much easier.
If you are having difficulty passing the tube through the vocal cords, withdraw the stylet and advance the tube
When able, use the proprietary stylet and adjunctive equipment. The proprietary stylets are designed to exactly match the curvature of the blade.
Cognitive
Standard geometry video laryngoscopes will provide an excellent view of the glottis in most cases, can function using direct or indirect technique, and offer comparatively easy tube delivery. Hyperangulated geometry blades provide an excellent view of the cords in almost every case, including cases where standard geometry view is inadequate, but can only be used by the indirect/video approach, and tube delivery can be more challenging.
If the ETT needs to be adjusted, consider doing so under video guidance
Practice with the video laryngoscopy system before using it clinically, especially if the device features a hyperangulated geometry blade
Select the right device for the right patient. Standard geometry video laryngoscopy allows for direct visualization if secretions or blood obscure the screen. Hyperangulated geometry requires less lifting force and may be easier in patients requiring cervical spine immobilization.