The Signposts & Roadmap of Intubation
The Essentials
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In this space, we focus on airway anatomy and geometry that determine success in laryngoscopy and endotracheal intubation. A deep anatomical knowledge base is valuable, but at the bedside, you need something more practical: the clinically relevant landmarks that serve as signposts, and a clear understanding of airway geometry and the spatial relationships that define the path you must follow. This is about translating anatomy into action, seeing what matters, and using those visual cues to guide deliberate, controlled movement toward tracheal access.
To help you stay focused on what’s important, we break down airway anatomy into two core topics:
- Anatomy – or specific, identifiable landmarks that will guide your way.
- Geometry – or the serpentine path you need to take from the mouth to the trachea.
Anatomy – Progressive Identification of Landmarks
Successful laryngoscopy is not about “finding cords.” It is about progressively identifying and confirming known anatomic landmarks in sequence, moving from familiar to deeper structures without skipping steps. When done this way, the airway stops being mysterious. It becomes a predictable pathway.
1. The Uvula – Your North Star
Diving too deep too quickly into the oropharynx with your laryngoscope (what we call the “plunge & pray” technique) makes finding your way harder. One way to avoid this is to ensure you see the uvula first. The uvula can be your North Star and point you in the direction of the epiglottis.
Uvula = Entry Confirmation
The uvula is the first midline structure confirming you are centered in the oropharynx.
- It reassures you that you are not buried in the tongue or off to one side.
- If the uvula is not visible, reassess blade position and mouth opening.
This is orientation, not exposure.
2. Base of Tongue – Create Space
Once you’ve identified the Uvula it’s time to navigate around the tongue. Use the tip of the blade to hug the base of the tongue. Advance with controlled lifting..
- Inadequate tongue control leads to poor views downstream.
At this stage, you are not looking for the cords. You are following a path to the next key structure:
3. The Epiglottis – The Cornerstone of Laryngoscopy
The epiglottis is considered the cornerstone of landmark identification during laryngoscopy. So much so, that it was nicknamed “epiglottoscopy” to highlight the importance of the epiglottis as an anatomic landmark. This is because once the epiglottis is identified, the intubator can be assured that the larynx (and the trachea beyond it) are nearby: located just posterior and inferior. .
Finding the Key
As you can see here from this great video from 5 Minute Airway (another great FOAMed resource) a slow progressive movement with the blade around the base of the tongue reveals the tip of the epiglottis which leads ultimately to great laryngeal exposure. For most experts, identifying the epiglottis is the first critical step in laryngoscopy.
4. The Vallecula – The Lever for Laryngeal Exposure
Once the epiglottis is identified, seating the blade in the vallecula (the anatomic groove above the epiglottis) and engaging the hyoepiglottic ligament will usually give you great laryngeal exposure.
In this video by AIME Airway, you can see how an incremental and deliberate movement around the base of the tongue into the valeculla helps “lift” the epiglottis to expose the larynx.
This space and the hyoepiglottic ligament are the lever you need to reveal the next key landmark.
5. Glottic Opening – Target Acquisition
After proper engagement of the Vallecula, the vocal cords appear. If you see only arytenoids or posterior structures, you may need small adjustments within the vallecula.
- You should see arytenoids posteriorly
- Vocal cords spanning anteriorly
- The dark glottic aperture leading to the trachea
Summary
If you notice, we have not even mentioned the vocal cords as a key anatomic landmark until the very end. Instead, we’ve highlighted the anatomic structures that will help you find them.
If there is one pearl we want you to take from this anatomy lesson, it’s to look for the structures below first; then the view above will come more easily and more consistently.
Now that you know how to identify the key signposts along the way to the trachea, it is time to define the road you’re on.
Geometry – The Two Curve Theory
Airway management, particularly laryngoscopy and endotracheal intubation, requires more than identification of structures. It requires a visual understanding of the spatial relationships between those structures.
The airway is not straight. It is a curved pathway formed by two dominant arcs. Successful intubation depends on recognizing these curves and navigating them deliberately.
To do that, clinicians must shift from a static mindset, “the mouth is here and the larynx is there,” to a dynamic one, “how do I move around these curves to reach the trachea?”
That shift begins with understanding the Two-Curve Theory.
The airway is divided into two curves:
- Primary Curve (Oropharyngeal Curve): Extends from the oral cavity through the oropharynx.
- Secondary Curve (Pharyngo-Glotto-Tracheal Curve): Spans from the pharynx, past the glottis, and into the trachea.
The point of inflection, where these two curves meet, is typically located near the base of the epiglottis.
🎧 Deep Cuts
The essentials give you the foundation.
This is where we sharpen it.
Here you’ll find high-impact clinical pearls, deeper analysis, and carefully curated learning resources that expand what matters most in real practice. Explore as much as you like. When you’re ready, step back into the essentials and continue the journey at the next poster.
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Signposts & Roads:
The Geometery of Airway Navigation
🎧 Listen:
Spend four minutes listening to this great discussion on airway anatomy and its spatial relationships. When you’re done, you will come away with a clear understanding of the role they play in airway management on an incredibly high level.
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