A Tale of Exposure & Delivery
The Essentials
Embarking on the journey of laryngoscopy can feel daunting, but with the right guidance, you’ll navigate it with confidence. We’re here to walk you through each critical step of the laryngoscopy procedure—from the initial mouth opening to the precise placement of the tube.
The First Rule of Laryngoscopy
Imagine trying to reach your destination by skipping key waypoints; you’d likely get lost. Similarly, in laryngoscopy, bypassing essential anatomical landmarks can lead to complications. This hasty method, often dubbed the “plunge and pray” technique, is a common pitfall. Instead, adopt a progressive laryngoscopy approach that breaks each step into management increments, ensuring you identify and navigate each landmark methodically and paving the way for a successful, safe intubation.
Don’t Do This
What happens when you bypass important anatomic landmarks? These two videos by AirwayOnDemand demonstrate the dangers of overshooting key anatomic landmarks and illustrate why an incremental approach to laryngoscopy is essential.
An Incremental Approach Matters
Each landmark in the sequence ensures safe progress toward the goal of developing an optimal view of the glottic opening to facilitate endotracheal tube advancement. While there are some differences between direct and video laryngoscopy, this basic principle of progressive identification of key anatomic landmarks remains the same. Here are the important landmarks.
Before Entering the Mouth
“A laryngoscope is always held in the left hand. No exceptions.”
Before you start, there are a couple of key things that you can do to make things easier for yourself. How you hold the laryngoscope, how you position your patient, and how you open the mouth can all have a positive (or negative) impact on what you will do next. So, we cover them briefly here.
Expert Tip: Adjust Your Grip 🤙
light and low
Learn how to hold the laryngoscope correctly. For improved fine motor control, hold the device lightly at the base of the handle. This will allow you to gently place the blade gently into the mouth without overriding the important anatomic landmarks. It will also afford you improved control of structures like the tongue.
Correct Positioning
Patient positioning is critical. It can improve your patient’s oxygenation and safe apnea time, but it can also be the difference between an easy intubation and a hard one. Our Own the Head of the Bed learning space covers this in more detail.
The Steps of Progressive Laryngoscopy
1. Make Room
Distract the Jaw
Before the epiglottis or the vallecula, before the vocal cords or tracheal rings, there’s another anatomical structure to address: the mouth and how to open it. Here’s some valuable clinical anatomy and a technique that will pay dividends for you down the road.
2. Find Your First Landmark
The Uvula is the North Star of Laryngoscopy
The north star
Diving too deep too quickly into the oropharynx with your laryngoscope 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 toward the epiglottis.
With the uvula identified, it is time to hug the base of the tongue and advance the blade slowly until you identify your next landmark.
4. The Golden Epiglottis
Once you’ve identified the epiglottis, you’re golden. That’s because the epiglottis is the key navigational landmark for successful and safe intubation. Finding it means you know where you are and where your target, the glottic opening, is hiding. You don’t need to see all of it. Hug the base of the tongue and advance the tip of the blade until the tip of the epiglottis comes into view.
Watch this great video from 5MinuteAirway. Another great resource for your learning network.
With the epiglottis identified it is time to begin the next step in laryngoscopy:
5. Optimizing your view
Once you’ve identified the epiglottis, the next step is to get the view of the glottic opening you want. Remember that when using a video laryngoscope, getting the best view may not be the optimal view (but we will get into that later). For now, try to get at least a 50% view of the vocal cords (with the arytenoid cartilage visible below) in the upper 50% of the screen.
Do You Valleculate?
The most important skill for laryngeal exposure is seating the blade in the vallecula and engaging the hyoepiglottic ligament. We cover the finer details of these anatomic structures in our airway anatomy learning space here and in the next section. Please review the material below to understand what it looks like.
Build Your Learning Network. Check out the two great resources shown here.
6. Tube Delivery & Tracheal Access
Getting to the Target
The final stage is tube delivery, typically facilitated by a stylet or a tube introducer, such as a bougie. These airway devices are covered in detail elsewhere. Once you have your preferred view of the glottis, ensure you do not obstruct your line of sight and that you allow sufficient room for tube delivery.
Remember the Curves
Remember, this process of progressive laryngoscopy isn’t just about the landmarks you need to find. It’s about helping you navigate the curves to your goal.
- For direct laryngoscopy you are pushing that first curve of the tongue out of the way for a direct line of site
- For video laryngoscopy, you are looking around that first curve, so you will have to finesse that turn down the second curve when you deliver the tube.
The Bottom Line
Follow a structured, incremental approach to laryngoscopy—progressive identification and navigation of key anatomical landmarks—rather than rushing (“plunge and pray”). This includes: preparation (grip, positioning, mouth opening), the systematic sequence of landmarks (uvula → epiglottis → optimized glottic view → tube delivery), and the principle that successful and safe intubation comes from methodically moving through these steps to achieve optimal visualization and a pathway for the tube.
Key Points
- Laryngoscopy should be incremental and progressive, not rushed.
- Preparation matters: proper grip, positioning, and mouth opening set the stage for success.
- Start with the uvula as a guiding landmark to orient the approach.
- Next, identify the epiglottis to confirm you’re on the right path.
- Optimize your view of the vocal cords before attempting tube delivery.
- Each step builds on the prior one; skipping landmarks increases risk.
- The sequence aligns with a structured framework that supports safer, more reliable intubation.
What’s Next
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