| Introduction | The First Rule | Avoid This |
| Do This | Find Landmarks | Optimize View |
| Valleculate | Deliver Tube | What’s Next |
Mastering the Essentials of Laryngoscopy
Embarking on the journey of laryngoscopy can feel daunting, but with the right guidance, you’ll navigate it with confidence. At The Protected Airway, 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.
Why an Incremental Approach Matters
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, adopting a progressive laryngoscopy approach ensures you identify and navigate each landmark methodically, paving the way for a successful and safe intubation.
Setting the Stage: Preparation is Key
Before you even pick up the laryngoscope, consider these foundational steps:
- Grip Matters: Hold the laryngoscope lightly at the base of the handle. This grip offers better control, allowing for gentle navigation and minimizing trauma to delicate tissues.
- Patient Positioning: Proper positioning isn’t just about comfort; it significantly impacts your field of view and access. Ensuring the patient is optimally positioned can make the difference between a challenging procedure and a smooth one.
- Mouth Opening Technique: Employing the correct method to open the mouth, such as the scissor technique, provides ample space and visibility, setting you up for success.
Navigating the Key Landmarks
Embarking on the laryngoscopy journey involves recognizing and traversing specific anatomical landmarks:
- Spotting the Uvula: Think of the uvula as your guiding north star. The uvuvla points the way to the epiglottis. By identifying it first, you establish a reference point, ensuring you’re on the right path.
- Identifying the Epiglottis: Once the uvula is in sight, the next milestone is the epiglottis. Recognizing this structure confirms you’re nearing your target—the glottic opening.
- Optimizing Your View: With the epiglottis located, fine-tune your technique to achieve a clear view of the vocal cords, facilitating accurate tube placement.
Remember, each step builds upon the previous one. By methodically progressing through these landmarks, you enhance the safety and efficacy of the procedure. Let’s get started.
The First Rule of Laryngoscopy
Before you get started, here is a word of caution about laryngoscopy. Trying to get from point A to point D without stopping at points B and C is an unsafe but common practice that many clinicians are guilty of during laryngoscopy. We call this the “plunge and pray” technique, which should be avoided.
Don’t Do This
What happens when you bypass important anatomic landmarks? These two videos by AirwayOnDemand demonstrate the dangers of overshooting the key anatomic landmarks and provide excellent examples of why an incremental approach to laryngoscopy is essential.
Do This Instead
An INCREMENTAL approach
This approach to laryngoscopy, where one anatomic landmark helps direct the way to the next, is called “progressive” laryngoscopy. 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
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.
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. 🛣️
Key Concept
scissor Technique
The Steps of Progressive Laryngoscopy
Alright, now it’s time to review the key anatomic landmarks and the sequence they follow for the effective performance of progressive laryngoscopy
1. Your First Landmark
The Uvula is the North Star of Laryngoscopy
your 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.
2. 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.
3. Optimize 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 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.
| The 5 Minute Airway | 👉 5MinuteAirway |
| Aime Airway | 👉 AIME Airway |
4. Tracheal Access
Delivering the Endotracheal Tube
The last stage is tube delivery, which is usually facilitated by a stylet or a tube introducer like the bougie. These airway devices are covered in detail elsewhere. Once you have your preferred view of the glottis, ensure that you do not block your line of sight and that you give yourself enough room for tube delivery.
The Bottom Line
What’s Next
Find Or Click Me
Nice work—you’re through this section! To keep going, scan the QR code on the physical poster at the next station in our pop-up training space to access the next set of digital content. Prefer to stay online? Just click the poster image here to continue your journey.
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