We’ve all done it. It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. Let’s see how to avoid this pitfall. (All illustrations by Christine Whitten MD, Anyone Can Intubate).
Optimize Head Position
Optimize the patient’s head/neck position as best you can for the situation. This is especially important if the patient is obese. Placing the patient’s head in the optimal sniffing position will make visualizing the larynx easier. A poorly positioned head can make any intubation difficult.
Place ear canals level with sternal notch. You can use folded towels, sheets or even a pillow under the head. Make sure that the head support is not so high that it keeps you from tilting the head backwards.
In infants and toddlers the support should go under the shoulders. Children younger than 2 years often have enough effective sniffing position due to their rounded occiput. You don’t need any additional head lift. In older children, place the support under the head, similar to the adult although the support needs to be smaller.
Optimize Position On The Bed
Don’t be afraid to move the patient if you can’t reach the airway easily. Not only must you be able to be able to manipulate the head and neck for intubation, In addition, if you can’t intubate you also have to be able to ventilate the patient from that position. If the patient is out of reach you make your job at best difficult and at worst impossible.
Avoid Overextension of Head
Overextension of the head makes the larynx appear more anterior and makes it difficult to place the tip of the endotracheal tube in the correct plane to enter the larynx.
Open Mouth As Wide As Possible
If you don’t open the mouth wide you make blade insertion difficult and impair your ability to see what you are doing inside the mouth. You are most likely to do this is the patient is missing their front teeth because you can see often the larynx, you simply haven’t given yourself enough room to maneuver your laryngoscope or your tube.
As you’re opening the mouth as wide as you can, place your fingers as far to the right side of the mouth as you can. This gives you more room to insert your laryngoscope blade initially to the right of the tongue. You will then sweep the tongue to the left and hold it there.
Don’t Insert Your Blade In The Middle Of The Tongue
A blade placed in the middle of the tongue will cause the tongue to mound up on either side, blocking your view and preventing tube insertion. Place your blade to the right of the tongue and then sweep the tongue to the left and out of the way. This movement typically places the blade very close to the midline: a very stable position for lifting, balancing, and controlling the head.
Don’t Insert The Blade Too Deep
Don’t insert the blade too deep. If you can’t see landmarks you may be hiding the entire larynx underneath your blade. Slowing slide the blade back while watching. The larynx will often pop into view .
When inserting your blade watch for the tip of the epiglottis. Once you see it, fine-tune your blade position before you start the final lift.
Don’t Mistake The Esophagus for The Larynx
As you can see in the photo above, when the blade is too deep, you will be looking at the esophagus under tension. Sometimes the triangular tenting of the tissue can mimic the vocal cord opening if you don’t have a clear view. Again, if you’re not sure about landmarks back the blade up slightly while watching.
Don’t Be Afraid To Lift The Head
Don’t be afraid to lift the head. While you may not need to lift the head much if the head is well positioned in the sniffing position, you will often find you need to suspend the head on your blade to straight the intubation path. If you are gentle you will not hurt the patient.
If you need help holding the head up ask your assistant to help you. Make sure your assistant supports the head without moving it, as unexpected shifting of the head during laryngoscopy can break teeth.
And while you are lifting, make sure you’re not pinching the lower lip against the teeth with your blade. You can cut the lip. This same advice also goes for the upper teeth but remember, you are lifting up and away and should not even be pressing against those upper teeth.
Never Rotate Your Blade Against The Teeth
It bears repeating: don’t rotate your blade against the teeth. Always lift upward and away, keeping your wrist stiff and your elbow fairly rigid. Again, don’t be afraid to lift.
Stylets Can Sometimes Prevent ETT Insertion
Stylets are invaluable during intubation, but if too sharply bent they can prevent you from sliding the tube into the trachea. If you can’t advance the tube, fix your tube firmly in position and either back the stylet out several cm with your thumb, or have your assistant pull it back slightly. This makes the tip more flexible, allowing you to advance it.
Slowly rotating the tube often allows the bevel to slip off the anterior commissure and slide down the trachea when it’s caught.
You can always change the shape of your stylet. Sometimes a curved stylet will let you maneuver inside the mouth better. Don’t be afraid to change the shape of your stylet. Stylets make the ETT more rigid. Be gentle when using one.
Don’t bend the stylet so sharply that you will have trouble removing it. Check before you start to see if you can slide the stylet in and out.
I tell my students that intubation is a team sport. Ask your assistants to help you optimize position, stabilize or lift the head, pull the cheek out of the way, provide cricoid pressure. Tell your team what you need them to do.
While it may be difficult to intubate selected patients, careful attention to detail can make most intubations easy.
May The Force Be With You
Christine Whitten MD, author, Anyone Can Intubate 5th Edition