First Pass Intubation: When You Can’t See The Cords

Failure of first pass intubation occurs about 10% of the time. The most common reasons, as I’ve described in a previous article (Avoiding Difficult Intubation Of The Easy Airway), is failure to pre-position the patient or optimally use our intubation tools.

I recently got an email from a first year resident who had elected to turn some intubations over to her instructors when she couldn’t see the cords. The instructors then had the same problems that she had had visualizing the larynx in those particular patients. Her instructors were successful in intubating despite not being able to see well and she was wondering how common it was to have poor visualization of the cords. She was also wondering if she was stepping aside too soon when she couldn’t see the cords. Maybe she should be trying a little longer.

Those were excellent questions. I thought it might be helpful to describe some of the thought process that goes behind the steps I take when I look but can’t see the cords —or when my student can’t see the cords.

Incidence Of First Pass Intubation Failure

Difficult intubation is defined by the American  Society of Anesthesiologists as “the need for more than 3 intubation attempts by a trained provider or attempts at intubation that last longer than 10 minutes”. In 2010, there were an estimated 25 million intubations in the United States and more than 50 million worldwide (1). The incidence of difficult intubation has been reported as 0.15% . That sounds like a small number, but it calculates to 1.5 in 1,000 intubations, or multiplied by 25 million, would theoretically predict 37,500 occurrences per year in the United States alone. (2)

For intubations in Emergency Departments, some studies have shown that more than two thirds (68%) of the intubations were successful on the first attempt, and about 10% of cases required three or more intubation attempts. Less experienced providers tended to require more intubation attempts. In one study of 2,833 patients (3), CA-1 residents had a 14.5% incidence vs 6% incidence for their staff attendings. More than 99% of these intubations were completed orally.

As you can see from those statistics, it’s not just novice intubators who fail to see the larynx on their first intubation pass. When we can’t see the cords during laryngoscopy,  our heart rate and blood pressure instantaneously rises as our level of anxiety soars. We know that first pass success is associated with a relatively small incidence of complications. As the number of intubation attempts increases, the incidence of complications increases substantially.  One Emergency Department study of 1,828 intubations showed that the incidence of adverse events such as hypoxia or physical injury during intubation was about 14% for one attempt, 47% for two attempts,  64% for three attempts, and 71% for four or more attempts (4).

Failure to see the cords on the first pass is scary. When we can’t see the larynx, we don’t know at that moment whether we will be able to see the larynx on the next pass, or if indeed we are starting down the terrifying road to can’t intubate/can’t ventilate.

The 4Ps of Preparation

You can read a more detailed approach to avoiding difficult intubation in my clinical review article in Airway Management (Always Prepare for Failure: 10 Rules for Approaching Difficult Intubation).(5) But it is worthwhile at least mentioning that the  best way to minimize the risk of getting into a situation where you can’t see the cords  is to optimize intubating conditions before you start. Perform the 4 Ps of preparation. For myself, I often find that I am much more likely to encounter difficulty if I have skipped these steps — which is unfortunately tempting to do in today’s fast paced turnover environment.

  • Past medical history:
    • ask the patient for history of any anesthetic problems
    • look at their old anesthesia records when you can
  • Perform an exam: look for potential anatomical problems
  • Position: place the head and neck in the best sniffing position
  • Preoxygenate well: because you never know when you will have problems

However, there is no question that you can do all of these steps and still fail to see the cords on your first try. Assuming you cannot see enough anatomical landmarks to make a reasonable attempt, what should you do next? Note that some of these steps are occurring simultaneously or in rapid succession.

Stop and Ventilate The Patient

Ventilating the patient gives you a moment to think about next steps. This is a big decision point. Most likely your next attempt will succeed, but if not, then you need to be prepared. If intubation attempts continue to fail,  you will need to decide to either:

  • keep trying – and if so what additional tools or helpers might you need
  • wake the patient up,
  • use a supraglottic airway to either proceed with the case or as an adjunct to intubation
  • consider an emergency airway

Now is the time to optimize oxygenation because further attempts at intubation may take time depending on the circumstances. You also need to ensure that your patient’s medical condition, vital signs, and lack of awareness are optimized.

Ventilating the patient immediately verifies, (and reassures), that you are not (yet) in a “can’t intubate/can’t ventilate” scenario. If you can’t ventilate, then you need to immediately jump further down the algorithm of options.

The ease with which you can ventilate should be factored into how long you will continue further attempts and indeed which steps you might take. If my patient is easy to ventilate, and I saw a fair amount of recognizable anatomy, then I will feel more comfortable trying a simple change in head position and a change in laryngoscope blades. If ventilation is difficult, then I’m much more likely to ask immediately for a videolaryngoscope, ask for another intubator to be called as a back up, or consider waking the patient up.

Communicate With Your Team

As you remove the laryngoscope from the patient’s mouth and begin to ventilate the patient, alert your team to what’s going on. If those team members are doing other tasks in the operating room, call them back to the bedside. Now is not the time to be the strong silent type and solve this problem heroically on your own. You want their attention and help before the patient potentially desaturates.

Quickly Assess What Went Wrong

As soon as you abort an intubation attempt you should be asking yourself: “What went wrong?” What could you see? What couldn’t you see? What can you do to make the next time successful? Start planning ahead.

Change Something On The Next Attempt!

The definition of insanity is to do the same thing that just failed again. Unless you had a perfect view of the cords and the light went out on your laryngoscope right before passing the tube, you must change at least one thing on your next attempt.

What Can You Change?

There are many things that you can change on your next pass, and depending on what you saw the first time you may want to change more than one thing.

  • Type or size of laryngoscope blade
  • Use of, or shape of a stylet
  • Position of the patient
  • Sniffing position improved
  • Addition of cricoid pressure
  • Head tilt
  • How high you’ve lifted the head off the bed
  • Height of the bed
  • The technique of how you’re using the blade
    • e.g. positioning of the tip of a curved blade on the hyoepiglottic ligament

Remember you have helpers who cannot read your mind. Talk to them, tell them what you’re doing and how you need them to help.

What If You Can’t See On The Second or Third Pass?

The recommendation of the ASA Task Force on the Management of the Difficult Airway is to limit laryngoscopic attempts to three before switching to an alternative method in order to avoid the risk of considerable patient injury that may occur. The slippery slope that is sometimes encountered is: Is that three attempts by one provider? Does it matter if the first provider is a novice — e.g. does the count start over when the attending steps in? How many times do you then attempt with the alternate method?

Alternate Intubation Methods

Perhaps as soon as a first pass intubation fails, and certainly when a second pass intubation fails, you should at least start running through the back of your mind what alternate methods you have and what you need to do to use them. What equipment might you need? Where is that equipment? When should you send for the equipment? Should I ask for the difficult airway cart? Is there another skilled intubation who might be called?

Get The VideoLaryngoscope

If your facility has a video laryngoscope, think about asking for it to be brought early. Having it in the room, even if you end up not needing it, saves precious moments if you patient does desaturate. The risk of complications rises with each attempt. Being able to switch quickly to the videolaryngoscope decreases the potential for a truly prolonged intubation attempt. You can read more on the techniques of successfully using one type of videolaryngoscope, the Glidescope here (Glidescope: Tricks For Successful Intubation)

Videolaryngoscopy is quickly becoming the tool of choice for when you can’t see the cords. As costs of videolaryngsocopes come down and their availability increases, I predict that they will eventually become the primary tool for first pass intubation. However, at present they are expensive and not everyone has easy access to one.

Use A Bougie

When you don’t have a videolaryngoscope immediately available, the bougie is a wonderful tool for intubation. It must be used carefully to avoid complication, but if you can’t see the cords it offers you a quick solution. You can read more about the bougie and precautions in its use here (The Bougie: Use Wisely To Avoid Rare But Serious Complications)

Supraglottic Airway Assisted Intubation

Using an LMA to assist with intubation is a nice option. A device such as the Fastrach gives you the ability to ventilate during the intubation process. Details on use of the Fastrach intubating Airway can be found here (Tips for Mastering the LMA Fastrach)


Intubation with the fiberoptic bronchoscope is best done electively before one starts so that the airway can be optimized with topical anesthesia, and a drying agent. In an unanticipated intubation, consider using the Fiberoptic early rather than later, before the airway is traumatized and excessive secretions stimulated. Blood and saliva in the airway make visualization very difficult.

Prepare Alternate Equipment Before you Start

When I begin an elective intubation, I always have Plan B and C. I try to have at least some of the equipment close by. I will have still in their sterile wrappers:

  • a second type of blade out on my station
  • a laryngeal mask airway of he correct size
  • a bougie in the room

I (and my team) will know where the glide scope is kept for emergencies. If I’m worried about the airway I often have the GlideScope outside the door ready to grab. It saves a lot of time and anxiety to know that I have alternate methods of intubation and ventilation immediately to hand and ready to go.

If I am running to an emergency intubation on the ward, my intubation box contains alternate methods such as a bougie and an LMA. I will often bring the portable GlideScope with me. Especially when dealing with critically ill and deteriorating patients, first pass i intubation success is especially important.

When To Stop Intubation Attempts

It is difficult to know when to change to a different technique, to ask someone else to try, or to stop the attempt. Failure to recognize the potential point of no return on the way to loss of the airway can be very hard. The temptation is strong to protect your ego by proving to yourself, and your audience of staff members, that you are skilled at performing that technique. “This should work, I’ve done it before; I will make it work now.” I’ve watched colleagues repeat spinal attempts at the same interspace over and over without changing anything, yet expecting success with each new needle pass. As has been said, “The definition of insanity is doing the same thing over and over again, expecting different results.”

Another confounding factor in deciding to abandon a technique, or even the entire intubation attempt, is the fact that one simply is not aware of time passing in the middle of an emergency. What seems like 1 to 2 minutes can really be 10 to 15. Force yourself to keep track of the clock. the longer an intubation attempt persists, the risk of complications increases and indeed the risk of of a “can’t intubate/can’t ventilate” scenario increase as well.

flowchart Difficult Airway Society Guideline for Unanticipated Difficult Intubation 2015

Difficult Airway Society Guideline for Unanticipated Difficult Intubation 2015

Working With A Student Who Misses The First Pass Intubation

The resident who emailed me was wondering what criteria should be used for when the student’s first pass intubation fails and when the next intubation attempt should be turned over to the attending. When I’m working with a student, the timing of when I take over will depend on:

  • my assessment as to how much stimulation the patient will tolerate
  • the experience of the student (and their past success rate)
  • the student’s intubation technique
  • how gentle he or she is being with the patient
  • how well she or he is communicating with me

Patient safety comes first. If I have a high risk patient and an inexperienced student, I will do the intubation and demonstrate the techniques with a running commentary. If my student has more experience and has demonstrated previous success, then I will often try to talk them through the changes I think they need to make on the second ad perhaps third attempt.

One important factor, apart from their technique and how gentle they are, that often gives me more patience in giving them another pass is how well they are communicating with me. I am much more likely to approve another pass from a student who tells me what she sees, explains what she thinks she needs to change, and then describes her proposed next steps.

May The Force Be With You!

Christine E Whitten MD, author

Anyone Can Intubate: A Step by Step Guide
Pediatric Airway Management: A Step By Step Guide

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  Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon    Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten


  1. American Society of Anesthesiologists: Presentation by Chunyuan Qui, MD, CEO of Qscope. Presented at: Elsevier Business Intelligence IN3 West Conference; March 4-5, 2010; Las Vegas, NV.
  2. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth.2012;109 suppl 1:i68-i85.
  3. Mort TC. Emergency Tracheal Intubation: Complications Associated with Repeated Laryngoscopic Attempts. Anesth Analg 2004;99:607–13
  4. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71–78. doi:10.1111/acem.12055
  5. Whitten CE. Prepare For Failure: 10 Rules forApproaching Difficult Intubation. Airway Management. Suppler to Anesthesiology News 2019-2020

Airway Management Review Article Published: 10 Common Pediatric Airway Problems — And Their Solutions

My latest review article has just been published in Airway Management from Anesthesiology News: 10 Common Pediatric Airway Problems — And Their Solutions.  Anesthesiologists who perform fewer than 100 pediatric cases on infants and young children per year are five times more likely to experience complications compared with anesthesiologists who do more than 200 cases per year.This article reviews the most important differences the you need to take into account as you care for the airway of a small child.

The trend to only use pediatric providers has a seriously negative unintended consequence: It deprives other providers of routinely caring for children, making them less prepared for when they do inevitably have to care for a small child.

Don’t Let Fear Stop You From Providing Care to a Child!

Although it’s normal to be intimidated when treating an infant or a small child, most children have easily managed airways. It is essential that your pediatric patient stays oxygenated and ventilated. If you prepare what you need ahead of time, take the differences in anatomy and physiology into account, and are methodical and gentle, you will not hurt the baby. Continue reading

To Open The Airway, Optimally Position The Head and Neck

The most basic of airway skill is knowing how to open the airway. Sick patients may be breathing spontaneously, but be unable to maintain an open airway, leading to hypoxia. Hypoxia can easily lead to bradycardia and cardiac arrest, especially in children. Mastering basic airway management skills is essential to avoid serious complications. Continue reading

Preventing Airway Emergencies

I’m in Egypt at the 35th International Conference Egyptian Anesthesia 2019. I was given the great honor of presenting my article on the 10 Rules For Approaching Difficult Intubation: Always Prepare For Failure. That article was the most read review article on the Anesthesia News site in 2018, another honor. Thank you readers. A link to that article can be found here. Please feel free to share it with your students.

I have attended many lectures at the Egyptian Conference, and the overarching emphasis on patient safety and continuously improving care is impressive.

It’s been estimated that there are at least 25 million intubations in the United States per year and 50 million worldwide. Even though the percent risk of failed airway is very small, when multiplied by large numbers of intubations the estimates of potential number of critical airway events is impressive.

During my presentation, I referred to 3 recurring themes.

  • Preparation is key
    • You can’t prevent every difficult airway situation – but you can prevent most of them
  • Your decisions, and how you make them are important
    • You can always make a bad situation worse
  • Teamwork and Communication are key
    • You cannot and should not do this alone

Let’s look at these more closely. Continue reading

Pediatric Airway Risks: Inefficient Mechanics of Breathing

Inefficient mechanics of breathing is one major risk factor for infants and young children because it increases work of breathing. In many ways pediatric anatomy and physiology predisposes a child to respiratory distress and respiratory failure. This article reviews the mechanics of breathing and discusses the differences in the pediatric airway that makes them more vulnerable to respiratory failure. Continue reading

ETCO2: Valuable Vital Sign To Assess Perfusion

Like pulse oximetry before it alerting us to changes in oxygenation, end-tidal CO2 monitoring, or ETCO2, is rapidly becoming an additional vital sign. We routinely use ETCO2 to provide information on ventilation. But ETCO2 can also provide valuable information on the adequacy of cardiac perfusion. It can be an essential tool in ensuring optimal, high quality chest compressions during cardiac resuscitation. Continue reading

# 1 Review Article for Anesthesiology News 2018: 10 Rules for Approaching Difficult Intubation by Christine Whitten

And the numbers are in, my review article for Anesthesiology News was actually THE MOST viewed article on the site for the whole year!

I’m afraid working overtime over the holidays and family trips have gotten in the way of posting this December but I’m already hard at work for 2019, including a new article for Anesthesiology News.

In the meantime please enjoy this review on the “10 Rules for Approaching Difficult Intubation: Always Prepare for Failure.”

Continue reading

Conscious Sedation: Is Your Patient Breathing?

Change in mental status can occur from conscious sedation or opioid administration, hypotension, sepsis, head trauma, acid-base imbalance, alcohol, drugs, or toxins. Change in level of consciousness often affects breathing, sometimes to the point of causing severe hypoxia, arrythmias and cardiac arrest. Let me repeat that. Anything that alters consciousness can alter respiration, which can lead to the vicious cycle of hypoventilation, hypercarbia, and hypoxia. If you don’t recognize inadequate respiration —and treat it— the patient can suffer injury or die. Let’s look at a common clinical example of altered consciousness — conscious sedation.

Everyday, in all of our practices, we purposefully try to alter our patient’s level of consciousness in order to tolerate a procedure. We often take the safety of procedural conscious sedation for granted. After all, we’re only giving a little sedation to make the patient relaxed, calm and more comfortable. Although problems are rare, patients can become hypoxic, hypercarbic, and apneic with conscious sedation, and some have died. The deaths of the celebrities Michael Jackson in 2009, and Joan Rivers in 2014 were related to hypoxia from loss of the airway under deep sedation. Respiratory depression represents the principal potential risk introduced with conscious sedation. If left unrecognized and untreated, it can be the cause of serious complications. Continue reading

The MAC Blade, The Vallecula, and the Hyoepiglottic Ligament

Correct placement of the tip of the MacIntosh , or MAC, blade is critical to successful intubation. When learning to intubate, novice intubators often prefer the MAC blade because:

  • curved shape makes it easier to insert under the upper teeth,
  • wide area makes it easier to balance the head on the blade during the lift,
  • easier to control the tongue with the side flange.

However, if you don’t have the tip of the blade positioned properly in the vallecula, you wil not lift the epiglottis and you will have a poorly view of the larynx. Why is this?

How The MacIntosh (MAC) Blade Works

Continue reading

Learning Intubation: Head Position Effects Laryngeal View

When first learning intubation,  a beginner often concentrates on memorizing the key laryngeal anatomy. This is important of course. If you can’t recognize the vocal cords, you will not be able to successfully intubate. However, even more important to learning intubation is understanding how the larynx relates to the other structures in the head and neck. In order to intubate you must manipulate those other structures to bring the larynx into view.

A prior post, When Learning Intubation Is Hard, described in detail some of the most common barriers to learning to intubate. Here I will concentrate on helping you see how head position effects your ability to see the larynx. Continue reading

Announcing My Latest Article Has Been Published: “10 Rules for Approaching Difficult Intubation”

I’m excited. My latest article, titled, “10 Rules for Approaching Difficult Intubation,
Always Prepare for Failure” has just been released in the journal supplement Airway Management, published by Anesthesiology News.

Managing the difficult airway is one of the most challenging, risk ridden, and downright scary clinical problems in anesthesia. The article makes the point that although we all know that a “can’t intubate, can’t ventilate” scenario can happen to anyone at anytime, many of us practice as though it will never happen to us. We must always prepare for failure. In the article, I’ve provided practical information from my 38 years of experience on how to recognize, manage, and protect our patients with challenging airways.

While there is a lot of information for the novice, there are also clinical pearls for the experienced intubator. I’m hoping you will find this information helpful to you, and to your trainees.

You can find the article on-line here, where you can also download a pdf version to share:

In addition to my article, please read the others as well. This issue is full of helpful, well written submissions. I have always found Anesthesiology News to provide interesting and timely updates and well written reviews, and this issue is no exception.

May The Force Be With You

Christine E. Whitten MD. author
Anyone Can Intubate, A Step By Step Guide
Pediatric Airway Management, A Step By Step guide

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten     Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

Please preview my books at by clicking on the covers.


Bilateral Tension Pneumothorax: Harder To Diagnose

Tension pneumothorax is a life-threatening emergency. We all know the signs of tension pneumothorax:

  • unilateral breath sounds (breath sounds absent on affected side),
  • thorax may be hyperresonant,
  • jugular venous distention,
  • tracheal deviation to the opposite side,
  • maximum heart sounds shifted to the opposite side, and often
  • tachycardia
  • hypotension

However diagnosis is more difficult if the patient is suffering from bilateral tension pneumothoraces. We think about bilateral tension pneumothorax occurring with trauma cases. Yet the three cases I’ve seen in my career were complications of intubation and emergency airway management. Continue reading

PostObstructive Pulmonary Edema

Patients with postobstructive pulmonary edema (or P.O.P.E.) develop sudden, unexpected and potentially life-threatening pulmonary edema after relief of airway obstruction.  It can be mild or severe. My first experience with it was in 1983.

The Case

In 1983, we didn’t have pulse oximetry, end-tidal carbon dioxide monitoring or even automated blood pressure cuffs. The patient was a healthy 6’3” tall and 250 lbs , 20 year old man. All muscle and clearly in great shape. He had just had knee surgery under general anesthesia and was on the verge of waking up.

He was coughing vigorously on the endotracheal tube. Four people held him down. My resident, fearful he night hurt himself or the team, extubated him while he was still coughing and before he was following commands. Unfortunately the patient was still in stage 2, when the airway reflexes are hyperdynamic.

Within seconds the patient went into laryngospasm, intense spasmodic closure of the vocal cords and other laryngeal muscles. There followed several minutes of struggling to re-establish an open airway. Finally the spasm broke with the use of positive pressure and the patient awoke.

However the mood in the room quickly turned from relief to concern. Our patient started to panic, claiming that he couldn’t breathe. His color was poor. He was wheezing badly, with pink frothy sputum bubbling out of his mouth. He was awake enough to communicate with us but so panicked that he started to fight the team of caregivers. Continue reading

Anatomic Dead Space Affects Hypoventilation

Understanding anatomic dead space is important to recognizing subtle hypoventilation. Hypoventilation from sedation, pain medications, anesthesia in the immediate postoperative period is common. The most obvious sign is slowing of the rate of breathing. A more subtle sign is that tidal volume becomes shallower. Having a tidal volume close to, or smaller than the patient’s dead space can lead to significant hypercarbia, hypoxia, and respiratory failure. This article discusses the concept of dead space and it’s clinical use in recognizing hypoventilation and preventing hypoxia and hypercarbia. Continue reading

GlideScope Technique For Intubation In Small Mouths

The GlideScope Video Laryngoscope (GVL) is an extremely useful tool for managing challenging intubations, but it can be more difficult to use if your patient has a small mouth and a high arched, narrow palate. The problem: once the GlideScope is in place in a small mouth, maneuvering the endotracheal tube around it and into the posterior pharynx can be challenging. If you can pass the endotracheal tube (ETT) at all, the cuff tends to scrape against the teeth, risking rupture. However, there is a modified GlideScope technique you can use in those situations. Continue reading

Difficult Intubation In A Newborn

Difficult neonatal intubation can occur unexpectedly. We’re ready to perform neonatal resuscitation in the delivery room. We may be less ready to have to deal with a difficult neonatal airway at the same time. Recently I, and my colleagues, had to manage an unanticipated difficult neonatal intubation in labor and delivery.

The Case

The baby was born extremely edematous, and in respiratory distress. Although it was easy to ventilate the baby using the NeoPuff, airway swelling prevented the neonatologist  from identifying the epiglottis and vocal cords. The anatomy was too distorted. Following protocol when faced with a difficult intubation, the neonatologist called a “Code White”, an overhead page that in my hospital summons help from anesthesia, nursing, respiratory care and pharmacy to assist with either a emergency pediatric cardiac arrest or emergency intubation.

As a responding anesthesiologist, I too was unable to see landmarks during laryngoscopy. Continue reading

Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide, by Christine E. Whitten MD.

Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary. Continue reading


When I was training, we used nitrous oxide on just about every anesthetic. It was easy to use. It was inexpensive. It didn’t tend to effect hemodynamics so it was useful in less stable patients when combined with an opioid. It helped speed induction through the second gas effect. It was not metabolized so renal and liver insufficiency were of less concern.

However, with all of the more recent investigation into reasons for cognitive dysfunction or decline in infants and the elderly following anesthesia, a lot more is now known about the pharmacologic disadvantages of nitrous oxide (1, 2, 3). Continue reading

Intubation During Cardiac Resuscitation

Intubation during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. If you don’t intubate often, you’re likely to be nervous. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us, rather than against us.

Step one, therefore, is to remain in control of your own sense of alarm. The leaders, which includes the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.

Step two is to quickly assess the situation. Is the patient being ventilated? Ventilation takes priority over intubation. Is there suction available? Without suction you many not be able to see the glottis, and you won’t be able to manage emesis. What help do you have? The intubator almost always needs some assistance in having someone hand equipment, or assist with cricoid pressure, among other tasks. As I tell my students, intubation is a team sport.

Finally you need to assess what position the patient is in, and how can you optimize that position. The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Illustrations are copyright from Anyone Can Intubate, 5th Edition.  Continue reading

When Learning Intubation Is Hard

Learning to intubate is easier for some people than for others. Sometimes, no matter how knowledgeable you are about the theory of the intubation technique, the novice can still struggle to bring it all together to pass the endotracheal tube. The anatomy can be confusing. Understanding how to place the laryngoscope blade and manipulate that anatomy can be challenging. And all the while you must be ever vigilant to protect those precious front teeth, avoid hypertension and tachycardia, and breathe for the patient at regular intervals.

I believe there are 4 chief barriers that inhibit learning how to intubate:

  1. Failure to visualize how the outside anatomy links with the inside anatomy makes it hard to predict how deeply to insert the blade.
  2. A mistaken belief that placing the laryngoscope blade itself is all that is needed to align the axes of the airway and reveal the larynx.
  3. Failure to grasp the dynamic nature of the larynx, and the need to actively manipulate it during intubation.
  4. A lack of understanding that intubation is not a sequence of isolated steps, but is instead a complex dance of interacting steps, each setting the stage for the next.

This discussion is going to assume some knowledge of the basic intubation technique. If you’d like to review those basics you can find links for multiple prior in depth discussions at the end of this article. (Illustrations and animation from Anyone Can Intubate, 5th edition, C Whitten MD.) Continue reading