NextGen Learning To Elevate Your Airway Practice

Introduction

Performance errors in laryngoscopy can decrease first-pass success (fps), increase the time to secure a definitive airway, contribute to peri-intubation complications, and delay other important critical actions during an emergency. A recent Scott Weingart et al. publication creates a “taxonomy of errors” common in daily practice. Many of these errors are well-known to experienced clinicians, but until now, a systematic review of those errors as they occur in real-world intubations has been lacking. This paper provides the groundwork for creating airway training specifically addressing those errors, which we’ve done here.

This space is dedicated to everyone who wants to improve their laryngoscopy performance with a focused practice that addresses the most common errors that occur during laryngoscopy. Start by reviewing the content below in each category of performance errors. Then, head to the coaching station to practice specific performance-enhancing skills for each problem. Improving your laryngoscopy performance isn’t simply about doing it over and over until you finally get better; it’s about getting better, faster, and smarter.

The Taxonomy

Three Categories of Performance Error

Most performance errors within the laryngoscopy procedure can be separated into three buckets. 1. Errors with the identification or recognition of key anatomic landmarks. 2. Errors related to laryngeal exposure and “valleculoscopy.” 3. Errors related to tracheal access and device delivery.

These buckets correlate with the “EVLI” sequence of steps necessary for successful laryngoscopy. If you can’t identify the important anatomy, you won’t be able to manipulate the vallecula, develop a good view of the glottic opening, or then deliver the tube. Knowing where the errors occur will help you troubleshoot in real-time as long as you can identify the type of problem and then apply the correct solution.

Errors of Identification & Recognition

The first category of performance errors most frequently happens during the first phase of intubation right after blade insertion, and they mainly occur because of a failure to identify key anatomic landmarks such as the uvula, epiglottis, and vallecula. The most common reason is forgetting to perform an incremental laryngoscopy technique that focuses on progressively identifying these landmarks before moving on to vocal cord visualization.

• Not Identifying/Recognizing Key Landmarks
• Inserting Blade Off Midline
• Inserting Blade Too Deep
• Inadequate Suction

Example of inserting the blade too deep

In this video, inserting the blade too deeply fails to identify key landmarks.

Errors of Laryngeal Exposure

The next category or performance issues related to laryngeal exposure. Optimizing your view of the larynx is the next critical step of laryngoscopy, and most of these errors are related to inadequate manipulation of the blade within the vallecula.

• Inadequate Lifting Force
• Failure to Engage Midline of Vallecula
• Not Fully Engaged Vallecula
• Failure to Maintain Vallecula Engagement
• Too Much (Downward) Force On Vallecula

Example of a Failure to engage vallecula midline

In this example, you can see that the tip laryngoscope blade is off to the right of the midline vallecular fold, leading to inadequate engagement of the hyoepiglottic ligament and poor laryngeal exposure.

Errors of Tracheal Access

The last category of errors is related to tracheal access issues, where performance errors impact device delivery to the trachea and impede tube delivery. These errors are differentiated from an inability to deliver a tube due to insufficient identification of essential landmarks or poor laryngeal exposure. They are focused solely on difficulty with device delivery.

• Over Rotated View (Kovac’s Sign)
• Bougie Hangup on Insertion
• Tube Delivery Hangup
• Premature Removal of Laryngoscope

Example of Premature Removal of Laryngoscope

The video laryngoscope is often removed too early instead of being used to confirm proper tube placement and function. In this case, with a bougie being used, leaving the laryngoscope in place can assist by displacing tissue that otherwise would obstruct tube delivery. It can ensure that the tube does not get dislodged on bougie removal and confirm correct placement once the cuff is up by visualizing condensation with initial breaths.

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What’s Next

Section 2

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