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Endotracheal Intubation

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An “incremental” approach to laryngoscopy will dramatically improve your success. Let us walk you through some of the key features of this approach before you get started on your hands on training.

The First RuleFind Landmarks
Optimize ViewDeliver Tube
What’s NextTo Lifelines
The first rule of laryngoscopy


The first rule of laryngoscopy? Don’t plunge and pray. If you dive in thinking that your goal is to find the cords, then you will overshoot important anatomic landmarks that can guide you safely to your target. Overshooting those landmarks in a moment of stress is all too easy, and will lead to disorientation and bad results. These two videos by AirwayOnDemand are excellent and provide great examples of what we are talking about. We highly recommend adding them to your learning network.

Hold it light and low

Before anything else. Learn how to hold the laryngoscope correctly. Hold it in your non-dominant hand, and for improved fine motor control hold the device lightly at the base of handle. This will allow you to place the blade in the mouth gently without overriding the important anatomic landmarks. It will also allow you better control structures like the tongue and guide the tip of the blade into the vallecula.


The landmarks

Step one of laryngoscopy is sometimes called “epiglottoscopy” to highlight the point that the goal at this stage of the procedure is to identify the epiglottis not the cords. This is because once the epiglottis is identified, the intubator can be assured that the larynx (and the trachea beyond it) are just posterior to that epiglottis.

Watch this great video from 5MinuteAirway. Another great resource for your learning network.

laryngeal exposure – get your preferred view

2 Once you have identified your important landmarks it’s time to get the view of the glottic opening you want. It’s important to remember that when using a video laryngoscope getting the best view my not be the preferred view depending on the device you are using to intubate, but we will get into that later. For now, during your hands on training sessions try to get at least a 50% view of the cords. We will show you some techniques on how to do that here.

Important anatomy

The most important gesture in laryngeal exposure is seating the blade in the vallecula and engaging the hyoepiglottic ligament. This is what it looks like.

knowledge- leveraged 💪.

Let a knowledge of clinical anatomy work for you! This is an example of what usually occurs when you perform this maneuver correctly. This resource is from 5MinuteAirway Take a deeper dive on this topic with this post, and then add them to your learning network.

troubleshooting valleculoscopy

A great post from AIME on how to do valleculoscopy right.

Tracheal access & tube delivery

3 Once you have your preferred view of the glottic opening it’s time to access that trachea and deliver the tube. This can be done with either a styletted endotracheal tube or a tube introducer like the bougie. This requires some understanding of stylet shaping, tube introducers, and how the different types of laryngoscopes work that is a topic all by itself, but we give you the essentials here.

Don’t obscure your view!

Tubes are just big floppy pieces of soft plastic. Great for gas exchange, but by themselves are difficult to place. Plenty of evidence exists to tell us that first pass success rates go up if you use a stylet.

Maintaining a view of the larynx during tube delivery is important and requires some technique. Straight-to-cuff stylet shaping prevents the tube from obscuring your view of the larynx while it is being inserted. Watch this video by Dr. Levitan. Another great airway network builder.

the bottom line

  • Don’t plunge & pray!
  • Use a methodical and progressive laryngoscopy technique
    • Find your landmarks (epiglottoscopy)
    • Expose the larynx (valleculoscopy)
    • Deliver the tube
  • Learn the optimization techniques within each of these steps to improve your intubation success
what’s next

Congratulations on completing this portion of Join the OxygeNATION. You’re well on your way. Go ahead and explore more of this learning space by visiting any of the related posters or clicking on the poster images below. Then make sure you visit the hands on guided practice stations and expert coaches in this space for feedback on your skills.

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