POSTER 414 / Master the HAVL Intubation Sequence
Make the transitions visible.
Follow the complete HAVL sequence, then isolate the point where the view, gaze, or instrument movement stops being predictable.
At the physical station? Go directly to the Practice Studio.
414 / ROOM 01
Read the whole sequence
The technical roadmap sits inside a complete airway plan: prepare the patient and team, guide blade entry, select a working view, watch tube entry, deliver with device-specific release, confirm placement and continue monitoring.
Before starting, assess anatomical difficulty, aspiration risk and tolerance of apnea; choose the airway strategy, including whether an awake approach is needed. Optimize oxygenation and hemodynamics for the setting. Check suction, monitoring, waveform capnography, equipment and rescue options. Assign the operator, assistant and person watching physiology; identify who will call for help. Agree on when to stop and how to restore oxygenation using the institution's current airway algorithm.
An attempt limit is a ceiling, not a target. Declare failure earlier when needed; worsening oxygenation calls for abandoning the attempt and restoring oxygenation. Do not repeat an unsuccessful attempt without a meaningful change and an agreed plan. Escalate using the local algorithm and available expertise.
Follow the roadmap. Where would you pause or stop if the next movement was unclear or the patient's condition worsened?
Compare your explanation +
Name the gaze transitions and the two release events, then place them within preparation and rescue. A technical sequence is incomplete without a stopping decision and an oxygenation plan.
TAKE THIS FORWARDThe order should be understandable before speed becomes relevant.
414 / ROOM 02
Confirm, then keep watching
Observe tube passage through the vocal cords when possible and confirm sustained exhaled carbon dioxide with waveform capnography. The operator and assistant should communicate what they see. Assess tube depth separately, secure the tube and continue capnographic and physiologic monitoring. A carbon dioxide trace does not by itself exclude endobronchial placement.
An absent or doubtful sustained carbon dioxide trace requires immediate action to exclude esophageal intubation, even after a convincing visual impression. The PUMA default is tube removal and ventilation with a face mask or supraglottic airway. If immediate removal would itself be dangerous, urgently use a valid alternative confirmation method while investigating the absent trace. Remove the tube if esophageal placement cannot be excluded, sustained carbon dioxide cannot be restored, or oxygenation deteriorates. Follow the full PUMA guidance and local rescue algorithm; chest movement or auscultation alone cannot exclude esophageal placement.
The tube appeared to pass the cords, but sustained exhaled carbon dioxide is absent. What must the operator and assistant do next?
Compare your explanation +
A convincing view does not settle the question. Actively exclude esophageal placement with the PUMA/local pathway, restore oxygenation and communicate the uncertainty. Once placement is confirmed, assess depth and continue monitoring.
TAKE THIS FORWARDA completed insertion still needs confirmation, appropriate depth and continuing care.
FROM THE GALLERY TO YOUR HANDS
Rehearse the complete sequence
Verified training assembly, educator and assistant, local algorithm and capnography scenarios.
First action: Brief roles and the stop/rescue plan with your team.
SOURCE CABINET
References & boundaries
Use the current local device instructions and educator-reviewed practice. Study findings apply to their stated settings and comparators.
414 / PRACTICE STUDIO · Coached team simulation
Rehearse the complete sequence
Demonstrate the sequence and respond to failed confirmation or deterioration.
YOU NEED Verified training assembly, educator and assistant, local algorithm and capnography scenarios.
BEFORE YOU BEGIN
Check your setup.
Verified training assembly, educator and assistant, local algorithm and capnography scenarios.
If equipment or instructions do not match, stop and ask the responsible educator. The equipment card identifies the local support and reset owner before the Station opens.
Equipment and support card →DO / STEP 01
Prepare the patient and team in simulation.
Before starting, assess anatomical difficulty, aspiration risk and tolerance of apnea; choose the airway strategy, including whether an awake approach is needed. Optimize oxygenation and hemodynamics for the setting. Check suction, monitoring, waveform capnography, equipment and rescue options. Assign the operator, assistant and person watching physiology; identify who will call for help. Agree on when to stop and how to restore oxygenation using the institution's current airway algorithm.
Review the related Gallery Room →DO / STEP 02
Guide the blade to a working view.
Watch the mouth as the blade enters, protecting teeth and soft tissue. Change to the screen when the blade has passed the posterior tongue and use recognizable anatomy to guide further movement. Recheck the mouth whenever entry or an instrument's path is uncertain. For the GlideScope Go 2 example, identify the epiglottis and guide the blade tip to the vallecula as its manual describes. Avoid excessive depth or lifting for a larger image. Other blades require their own instructions. There is no universal instruction to stop well before the vallecula. Preserve space for the tube; explain your adjustment rather than targeting an exact screen fraction.
Review the related Gallery Room →DO / STEP 03
Watch tube entry and separate the release events.
Look into the mouth as the tube enters alongside the blade, avoiding teeth and soft tissue. Then use the screen to guide its approach. Do not advance blindly through the camera's unseen entry zone. With reusable GlideRite 0803-0009, the stylet must stay out of the glottis. When the tube engages the glottic opening, withdraw the stylet 5 cm using the thumb tab so the tip can soften; advance the tube off the stylet. Position the tube, then remove the stylet completely. Partial release and complete removal are separate events.
Review the related Gallery Room →DO / STEP 04
Respond when the route stops working.
If the tube meets resistance, stop advancing. Reassess the view, blade depth, tube approach and likely contact point. The educator should demonstrate the smallest appropriate correction for the actual assembly. Any rotation must identify the operator's viewing perspective and its purpose; a universal clock-face instruction is insufficient. If the problem persists or physiology worsens, stop the attempt and restore oxygenation through the agreed rescue pathway. An attempt limit is a ceiling, not a target. Declare failure earlier when needed; worsening oxygenation calls for abandoning the attempt and restoring oxygenation. Do not repeat an unsuccessful attempt without a meaningful change and an agreed plan. Escalate using the local algorithm and available expertise.
Review the related Gallery Room →DO / STEP 05
Confirm and continue care.
Observe tube passage through the vocal cords when possible and confirm sustained exhaled carbon dioxide with waveform capnography. The operator and assistant should communicate what they see. Assess tube depth separately, secure the tube and continue capnographic and physiologic monitoring. A carbon dioxide trace does not by itself exclude endobronchial placement.
Review the related Gallery Room →DO / STEP 06
Rehearse absent or doubtful confirmation.
The educator supplies a scenario in which the prior view looked convincing but sustained exhaled carbon dioxide is absent or doubtful. An absent or doubtful sustained carbon dioxide trace requires immediate action to exclude esophageal intubation, even after a convincing visual impression. The PUMA default is tube removal and ventilation with a face mask or supraglottic airway. If immediate removal would itself be dangerous, urgently use a valid alternative confirmation method while investigating the absent trace. Remove the tube if esophageal placement cannot be excluded, sustained carbon dioxide cannot be restored, or oxygenation deteriorates. Follow the full PUMA guidance and local rescue algorithm; chest movement or auscultation alone cannot exclude esophageal placement.
Review the related Gallery Room →AFTER YOUR FIRST REHEARSAL
Choose one improvement.
Return to the specific missed behavior: oral entry (412/413), release (413), or confirmation/rescue (414). Coach and repeat that segment before another integrated attempt.
Rehearse according to what you and your educator observe. Repetition counts do not establish proficiency.
BEFORE YOU LEAVE / THIS REHEARSAL
Show and explain.
Demonstrate the planned sequence, then respond to an absent/doubtful-trace scenario and an early-stop scenario. Have the observer use the practice rubric to identify behaviors needing coaching. Verbal scenarios rehearse decisions; waveform recognition requires actual reviewed traces or a simulator.
Reset for the next learner
Restore the trainer and assembly using their instructions, reset the simulated monitor and role assignments, and leave the current equipment card and algorithm available for the next team.
Knowledge completion, observed simulation performance and supervised clinical transfer are different outcomes. The Studio finish line describes this rehearsal only. Repetition counts, page visits, a quiz or a certificate cannot establish independent clinical competence. Faculty should identify a specific improvement, coach it and reassess the relevant behavior; clinical progression and maintenance follow the institution's supervised process.
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