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Learning Objectives
Tools of the Trade – The Direct Laryngoscope
A Universal Approach – Progressive Laryngoscopy
Your approach should be consistent, regardless of your chosen device (VL or DL). Progressive laryngoscopy is a structured approach that enhances visualization of the larynx while minimizing patient trauma and maximizing the chances of successful intubation. This method consists of incremental steps to improve visualization and achieve optimal glottic exposure before attempting tube insertion. You can find the essentials of progressive laryngoscopy here if you need to review them before moving on to the DL-specific skills discussed below.
DL Specific Skills
The necessity of maintaining a direct line of sight in direct laryngoscopy (DL) dramatically affects the methods and skills required for effective intubation, especially when compared to video laryngoscopy (VL). Here are the key ways this requirement influences the intubation process:
Positioning
Alignment of the Oral, Pharyngeal, and Tracheal Axes:
For successful DL, positioning is paramount. In direct laryngoscopy (DL), successful visualization of the vocal cords requires a direct line of sight from the mouth to the glottis. This is achieved by aligning the oral, pharyngeal, and laryngeal axes, which optimizes the airway’s geometry for clear visualization.
Why Alignment Matters in Direct Laryngoscopy
Since DL requires a straight-line view of the glottis, alignment of these three axes is essential for:
- Optimizing the laryngeal view for easier intubation.
- Minimizing the force needed to manipulate soft tissues with the laryngoscope.
- Reducing the risk of airway trauma from excessive force.
- Improving first-pass success rates by achieving an optimal view of the glottis.
Sniffing Position
The sniffing position aligns the oral, pharyngeal, and tracheal axes in a relatively straight line. This alignment minimizes anatomical obstructions and provides a more direct path for the laryngoscope blade to visualize the glottic structures.
Tricks of the trade
How do you get your patient in that ideal sniffing position? Here’s an easy technique that can make it a whole lot easier.
How to Hold a DL Device
To achieve optimal performance when using a DL laryngoscope, it’s crucial to hold the device correctly. Here are key points to consider:
• Light and Low Grip: Hold the laryngoscope so that it feels light in your hand with a low grip on the handle so that your fifth digit rests on the base of the blade. This positioning allows for better control and reduces the risk of over-insertion.
• Avoiding Excessive Pressure: Holding the device too tightly can hinder your fine motor control. Aim for a relaxed grip that allows for precise movements.
• Progressive Identification: With the correct grip, you can progressively identify anatomical landmarks and smoothly guide the blade’s tip into the vallecula.
How to HOLD A DIRECT LARYNGOSCOPE
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Second Grip
With DL, once the blade is seated correctly in the vallecula, you may need to apply more force to obtain laryngeal exposure than you would with VL. Novices tend to rock the handle back towards them to improve their view. DON’T DO THIS. Instead, adjust your grip, holding the handle as shown above and lifting it up and away. If you initially engage the hyo-epiglottic ligament correctly, then you won’t need that much force.
External Laryngeal Manipulation
External Laryngeal Manipulation (ELM) can be used during DL to improve the visualization of the glottis by externally adjusting the position of the larynx. It involves applying manual pressure to the thyroid cartilage or cricoid cartilage to optimize the alignment of the airway structures, enhancing the view of the vocal cords for intubation.
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Tube Delivery Essentials for DL
Tube delivery during DL starts with proper stylet shaping. Then, to ensure a clear view of the target, insert the tube at the side of the mouth rather than the middle and advance it below your line of sight, guiding the tip toward the target.
- Proper Stylet Shaping prior to DL intubation.
- Make Room on the right side of the mouth to insert the tube.
- Come From the Side of the mouth (not the middle) to keep the cords in view.
- Advance Below the Line of Sight to maintain a view of your target.
Basic DL Technique
Summary
End of Section
Congratulations! You’ve reviewed and practiced your skills with all three upper airway lifelines (FMV, SAD, ETT) and their adjunct devices. Now, it’s time to master the fourth all-important surgical lifeline—the final critical skill to become a citizen of the oxygenation.
What’s Next
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