Chapter 17

Laryngoscopic Orotracheal and

Nasotracheal Intubation
JAMES M. BERRY STEPHEN HARVEY

I. A Short History of Endotracheal Intubation III. Laryngoscopic Nasotracheal Intubation

A. Preparation
II. Laryngoscopic Orotracheal Intubation
B. Laryngoscopy
A. Preparation and Positioning
C. Endotracheal Intubation
B. Preoxygenation
D. Securing the Endotracheal Tube
C. Laryngoscopy
D. Endotracheal Tube IV. Conclusions
E. Verification of Correct Placement
V. Clinical Pearls
F. Securing the Endotracheal Tube

Creation subside, for the space of an hour or more, after his

Our very breath, pre-language of the lingus, Thorax had been so display’d, and his Aspera Arteria
Unspoken and unseen, lies all around us; cut off just below the Epigolotis, and bound on upon the
It tunnels through a darkened path to bring us nose of the Bellows
Before the guarded gates that would confound us:
Dentition, palate, epiglottic folds
Are navigated as the case is started The use of tracheal cannulation for the administration
And followed through to cartilage that holds of anesthetics and provision of a patent airway was first
The two true cords, those gleaming pillars, parted; reported in 1858 by John Snow in On Chloroform and
Here human hands, left trembling with creation, Other Anaesthetics,2 in which he described a tracheos-
Are re-creating life as it began, tomy and cannulation for the administration of chloro-
Beginning with the step of intubation, form in a spontaneously breathing rabbit. The first
The God-breathed breath of life blown into man. human use of tracheostomy for anesthesia and protec-
Stephen Harvey tion against aspiration was reported by Trendelenburg in
1869, and it also was accompanied by spontaneous ven-
I. A SHORT HISTORY OF tilation.3 In the next 10 years, numerous investigators
ENDOTRACHEAL INTUBATION developed nonsurgical techniques and apparatus for can-
nulation of the trachea for surgical (ear, nose, throat) or
As we participate in the 21st century practice of medi- medical (diphtheria) indications. Matas was among the
cine, it is useful to recollect the origin and development first to advocate the use of PPV through a tracheal
of some of the techniques commonly used for airway cannula to avoid the catastrophic consequences of pneu-
management. It is remarkable that modern airway tech- mothorax for a spontaneously ventilating patient during
niques are less than 50 years old but are derived from thoracotomy.5
physiologic experiments done primarily in the 18th and Endotracheal anesthesia came into its own during and
19th centuries. Skilled airway management is a central immediately after World War I because of the volume of
pillar of the practice of anesthesiology, resuscitation, and facial and mandibular injuries treated in England, espe-
critical care, and an appreciation of the evolution and cially at the hospital in Sidcup. In 1936, I.W. Magill wrote
development of airway techniques can improve our one of many descriptive treatises on intubation in
understanding and application of these essential skills. anesthesia5:
Cannulation of the trachea, or aspera arteria, as it was
called by Robert Hooke,1 was initially described as a The maintenance of a free airway has long been
technique for positive-pressure ventilation (PPV): recognized as a first principle in general anesthesia and
the danger of complete laryngeal obstruction has always
… the Dog being kept alive by the Reciprocal blowing been obvious. On the other hand, the cumulative effects
up of his Lungs with Bellowes, and they suffered to of partial respiratory obstruction have, in the past, been
346
 CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation      347

frequently overlooked and it is not improbable that BOX 17-1 Basic Equipment for Endotracheal
many of the surgical difficulties, postoperative Intubation
complications, and even fatalities attributed to the
anesthetic agent have been primarily due to an Preoxygenation and Ventilation
imperfect airway. It may be said without exaggeration 1. Oxygen (O2) source
that in remedying this defect endotracheal anesthesia 2. Ventilation bag or anesthesia circuit (for positive-
has proved as great a factor in the advances of pressure ventilation)
3. Appropriately sized face mask
anesthesia as the discovery of new drugs or the
4. Appropriately sized oropharyngeal and
development of improved apparatus. nasopharyngeal airways
5. Tongue blade
Immediately thereafter, Magill inserts a caveat:
Endotracheal Tubes
… owing to the ease of control it affords, there is a 6. Appropriately sized endotracheal tubes (at least twp)
tendency towards its employment in every operation, 7. Malleable stylet
8. Syringe for tube cuff, 10 mL
regardless of other considerations. This tendency is to be
9. Jelly and/or ointment, 4% lidocaine (Xylocaine)
deprecated, especially in the teaching of students. The
novice should learn airway control by simple methods Drugs
in the first instance, for he may be called to administer 10. Intravenous anesthetics and muscle relaxants (ready to
an anesthetic in circumstances in which artificial administer)
devices are not available. Moreover, as the method 11. Reliable, free-flowing intravenous infusion (some
involves instrumentation, which is not devoid of the risk pediatric exceptions)
12. Topical anesthetics and vasoconstrictors (for
of trauma, even though it may be slight, intubation
nasotracheal intubation)
should only be attempted when the necessity for it has
been considered carefully. Laryngoscopy
13. Working suction apparatus with tonsil tip
The historical lesson here is that, no matter how 14. Assortment of Miller blades with functioning battery
routine endotracheal intubation becomes, it is still an handle
invasive procedure with nontrivial risks and significant 15. Assortment of Macintosh blades with functioning
battery handle
complications. It should be used for specific indications
16. Bolsters (folded sheets, towels) for positioning of head
and only after careful consideration of the balance of risks and shoulders
to and benefits for the patient.
Fixation of the Endotracheal Tube
17. Tincture of benzoin
18. Appropriate tape or tie
II. LARYNGOSCOPIC 19. Stethoscope
OROTRACHEAL INTUBATION 20. End-tidal carbon monoxide (ETCO2) monitor
21. Pulse oximeter
The conventional orotracheal route is the simplest and
most direct approach to tracheal cannulation. Done
under direct laryngoscopic vision, this technique is the
easiest and most straightforward for the purposes of
administering general anesthesia, ventilation of critically The proper sequence of events before laryngoscopy
ill patients, and cardiopulmonary resuscitation. The vocal should be followed:
cords are visualized with the aid of a handheld laryngo-
scope, and the endotracheal tube (ETT) is introduced and 1. Adequate access to the head of the bed or table is
positioned in the trachea under continuous direct obser- essential. Removal of side rails and headboard (if
vation. After confirmation of correct placement, the tube outside the operating room) ensures freedom of
is secured in place and ventilation assisted or controlled movement; confirming that the bed or table is
as indicated. locked in position prevents unnecessary and stress-
inducing pursuit of the patient around the room.
The height of the surface should be adjusted to the
A. Preparation and Positioning
level of the laryngoscopist’s chest. An experienced
Box 17-1 lists the basic materials required for conven- aide should be in constant attendance to provide
tional orotracheal intubation. The materials are grouped items such as suction lines, airways, tubes, and drugs
according to the temporal sequence of events. All items to the primary laryngoscopist, as well as to apply
are required for routine intubation, dealing with common optimal external laryngeal manipulation (OELM),
difficulties, or preventing complications. Redundancy is as needed.
the key in preparing for a critical event, such as endotra- 2. The patient must be properly positioned before
cheal intubation. All essential equipment (e.g., laryngo- laryngoscopy. Patients who are uncooperative, agi-
scope handles, ETTs) should have readily available tated, or otherwise mobile may require rapid and
back-up counterparts in case of unexpected failure. An efficient positioning after sedation. Pads or rolls
assortment of laryngoscope blades, both straight (Miller) should be prepared in advance and be readily at
and curved (Macintosh), should be available. hand.
348      PART 4 The Airway Techniques

Head and neck position and the axes of the head and neck upper airway

Head on bed, Head elevated on pad,

neutral position neutral position
OA
OA
PA
PA
LA
35°
LA Slight (35°) flexion
of neck on chest
A B
Head elevated on pad, Head on bed,
head extended on neck head extended on neck
(sniff position)
PA OA
LA OA
15°

80°
PA
Severe (80°) extension of LA
head on neck
C D
Figure 17-1 Schematic diagrams show the alignment of the oral axis (OA), pharyngeal axis (PA), and laryngeal axis (LA) in four different
head positions. Each head position is accompanied by an inset that magnifies the upper airway (oral cavity, pharynx, and larynx) and
superimposes (bent bold line) the continuity of these three axes within the upper airway. A, The head is in the neutral position with a marked
degree of nonalignment of the LA, PA, and OA. B, The head is resting on a large pad that flexes the neck on the chest and aligns the LA
with the PA. C, The head is resting on a pad (which flexes the neck on the chest). Concomitant extension of the head on the neck brings
all three axes into alignment (sniffing position). D, Extension of the head on the neck without concomitant elevation of the head on a pad,
which results in nonalignment of the PA and LA with the OA. (From Benumof JL, editor: Airway management: principles and practice, St. Louis,
1996, Mosby, p 263.)

The earliest attempts at laryngoscopy used the classic height.14 Others have advocated for an extension-extension
positioning of full extension. Described by Jackson in position, in which the head and neck are extended by
1913, this position required full extension of the head lowering the head of the table 30 degrees, proposing that
and neck on a flat surface.6 After 20 years, he amended direct laryngoscopy requires less axial force in this posi-
his view to one that supported the contemporary sniffing tion than in the sniffing position.15 Whether the lower
position of flexion at the neck and extension at the head.7 cervical spine is flexed, extended, or neutral, the exten-
This was accomplished by supporting the head on a sion of the atlanto-occipital joint remains the critical
pillow that was at least 10 cm thick. Numerous investiga- factor for optimal positioning. The reasonable option in
tors have examined radiographs of subjects to determine view of conflicting evidence (and patients’ variability) is
the optimal positioning for orotracheal access. Various to position the patient with the occiput on a pad (tradi-
theoretical models of positioning for intubation have tional sniffing position) and be prepared to remove the
been proposed. For the past 60 years, the three-axis pad (convert to simple extension) if the initial laryngos-
theory has proposed that the oral, pharyngeal, and laryn- copy becomes inadequate (Fig. 17-2).
geal axes should be brought into approximate alignment Obese patients often require more extensive padding
to best facilitate orotracheal visualization and intubation (planking) starting at the midpoint of the back to the
(Fig. 17-1). Proposed by Bannister and MacBeth in 1944, head to assume an optimal position for laryngoscopy.
this model presumes that laryngoscopy is done in the Occasionally, it is necessary to place towels and blankets
midline (two-dimensional model) and that laryngeal axis under the scapula, shoulders, nape of the neck, and head
alignment is necessary for proper intubation.8 This idea to flex the neck on the chest (see Figs. 17-1B and 17-2)
has been challenged by the work of Adnet and colleagues and extend the head on the neck (see Figs. 17-1C and
in imaging studies and clinical comparisons.9-11 17-2). In this instance, the purpose of the scapula, shoul-
Adnet’s conclusion, however, has been questioned at der, and neck support is to give the head room so that it
length.12 Greenland and colleagues reexamined the issue, may be extended on the neck. When in doubt, the final
finding “the sniffing position the most favorable for direct assessment of the position should be from a lateral view
laryngoscopy” as determined by magnetic resonance of the patient, because only a lateral view enables precise
imaging (MRI).13 This perspective has been corroborated assessment of the chest, neck, face, and head axes (see
by evidence indicating 9 cm as the optimal pillow Figs. 17-1C and 17-2).
 CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation      349

A B
Figure 17-2 A, In some obese patients, placing the head on a pillow does not result in the sniffing position; in the obese patient shown and
as illustrated by the overlying bold black line, the oral and laryngeal axes are perpendicular to one another, the neck is not flexed on the
chest, and the head is not extended on the neck at the atlanto-occipital joint. B, In the same patient, placing support (e.g., blankets, towels)
under the scapula, shoulders, nape of the neck, and head results in a much better sniffing position; the oral, pharyngeal, and laryngeal axes
form only a slightly bent curve, the neck is flexed on the chest, and the head is extended on the neck at the atlanto-occipital joint. (From
Benumof JL, editor: Airway management: Principles and practice, St. Louis, 1996, Mosby, p 264.)

B. Preoxygenation circuit-bag system to the patient’s airway and the effec-

tive delivery of 100% O2. The use of an air-mask-bag unit
Instrumentation of the airway may be done on an awake, (AMBU) without an expiratory valve may not provide
spontaneously breathing patient. This sometimes is the optimal preoxygenation.19
safest and most prudent approach, but most commonly, The effectiveness of preoxygenation in preventing
laryngoscopy and intubation are performed on an anes- hypoxia during laryngoscopy is significantly reduced in
thetized and (usually) apneic patient. Because this the morbidly obese patient. Even with the most careful
requires some finite period of time, the patient is at risk preoxygenation, the duration of apnea before the onset
for arterial desaturation and hypoxic injury. Preoxygen- of hypoxia is one half of the duration seen in patients
ation is done before laryngoscopy to minimize this risk. with normal body weight. This situation is attributed to
Administration of 100% oxygen (O2) through a tight- the considerable reduction in FRC and VC in the obese
fitting face mask may occur by means of the patient’s patient and to the additional reduction attributable to the
spontaneous respirations or by PPV by a bag-mask unit. cephalad diaphragmatic shift related to supine position-
In either case, adequate ventilation must occur to “wash ing.20 This places morbidly obese patients at significantly
out” alveolar nitrogen (N2) and fill the lungs with O2. The increased risk for injury if any difficulty with ventilation
goal is to fill the alveoli used in normal tidal breathing or intubation is encountered.
and the remaining alveoli and airways constituting the Pharyngeal insufflation of O2 can significantly prolong
functional residual capacity (FRC). This additional O2 the safe duration of apnea. In a typical adult, approxi-
serves as a reservoir to delay the onset of arterial hypoxia mately 250 mL/min of O2 is transferred from the lungs
for as long as 5 minutes. A number of guidelines have into the bloodstream, while only 200 mL/min of CO2
been proposed to accomplish this potentially lifesaving enters the lungs from the bloodstream (respiratory quo-
goal. tient = 0.8). This alveolar gas deficit causes alveolar pres-
Depending on the minute ventilation of the patient sures to become slightly subatmospheric. If the airway is
(spontaneous or assisted), the time to complete effective patent, there is a net flow of gas from the pharynx into
preoxygenation varies from 1 to 5 minutes; although in the alveoli (apneic oxygenation). If, after adequate pre-
an awake and cooperative patient, this may be mostly oxygenation, the pharynx is filled with O2, the onset of
accomplished with three or four full, vital capacity (VC) hypoxia is delayed because O2, rather than air, is drawn
breaths.16,17 Work has documented the increased efficacy into the lungs by this mechanism. Pharyngeal insufflation
of eight full breaths in about 60 seconds, with times to may be conveniently achieved by passing a catheter into
desaturation approaching those of the more traditional the pharynx through a nasopharyngeal airway and attach-
3- to 5-minute preoxygenation.18 A higher minute venti- ing an O2 source at 2 to 3 L/min. Alternatively, some
lation level leads to more rapid and complete preoxygen- laryngoscopes have a side port suitable for attachment of
ation. Measures of the adequacy of preoxygenation O2 tubing. When preoxygenation is followed by pharyn-
include real-time gas analysis of expired O2 concentration geal insufflation as previously described, in normal but
(goal = 95%) and analysis of expired N2 (goal < 5%). apneic patients, the O2 saturation from pulse oximetry
Essential to either of these measurements is the presence [SpO2] remains equal to 98% for 10 or more minutes
of a capnograph waveform with a plateau reflecting the (although at the end of 10 minutes the arterial carbon
expected alveolar carbon dioxide (CO2) concentration. dioxide tension [PaCO2] may be expected to be about
This documents the presence of an effective seal of the 80 mm Hg).21
350      PART 4 The Airway Techniques

C. Laryngoscopy and variations, they are all lighted, handheld retractors

for oropharyngeal soft tissues.
The purpose of direct laryngoscopy is to provide ade- Although contact with the upper incisors from the
quate visualization of the glottis to allow correct place- laryngoscope blade should be avoided, some patients
ment of the ETT with the minimum effort, elapsed time, with limited mouth opening, front caps, or obvious decay
and potential for injury to the patient. Considerable are at risk for damage by even the most innocuous, tran-
effort has been expended to develop laryngoscopic tech- sient trauma. If the possibility of incisor trauma exists, it
niques and equipment to facilitate this important proce- seems prudent to provide some protection for the upper
dure. Although this textbook outlines numerous teeth. Several materials have been used in the past to
techniques for tracheal cannulation, the facilitative use guard the upper teeth: a folded strip of lead (introduced
of direct laryngoscopy is by far the most common by Magill and now obsolete), folded tape, cardboard or
technique. alcohol wipe, or a purpose-built mouth guard (as used in
Two basic types of laryngoscope blades are the curved contact sports). The disadvantage of any of these is
blade (Macintosh) and the straight blade with a curved that they occupy a few millimeters of the available
tip (Miller).22,23 They are designed for right hand– mouth opening, reducing the available aperture for
dominant use; the laryngoscope is held in the left hand laryngoscopy.
while the right hand manipulates the ETT. Historically, Two methods are used to open the mouth and facili-
either hand (or both) could be initially used, shifting the tate the introduction of the blade. First, extension of the
laryngoscope to the left hand while the right hand manip- head on the neck (by pressure from the right hand at the
ulated the tube. Both blade styles include a flange on the vertex) causes the lips to part and the mouth to open
left side of the blade for lateral retraction of the tongue (see Fig. 17-4). Alternatively, the thumb of the right hand
and contain a light-emitting area (bulb or fiberoptic tip). can press down on the right lower molar teeth, and the
Each blade has a channel with an open right side for index finger of the right hand can simultaneously press
visualization of the larynx and for insertion of the ETT up on the right upper molar teeth (scissors maneuver)
(Figs. 17-3 to 17-10). Despite numerous modifications (see Fig. 17-5).

Conventional Laryngoscopy with a Curved Blade

Insert the laryngoscope blade into the Advance the laryngoscope blade toward the
A right side of the mouth B midline of the base of the tongue by rotating wrist

1
2
3
4

Approach the base of the tongue and lift Engage the vallecula and continue to lift the blade
C the blade forward at a 45° angle D forward at a 45° angle
Figure 17-3 Schematic diagrams show how to perform laryngoscopy with a Macintosh blade (curved blade). A, As shown in lateral and
frontal views, the laryngoscope blade is inserted into the right side of the mouth so that the tongue is to the left of the flange. B, In the lateral
view, the blade is advanced around the base of the tongue, in part by rotating the wrist so that the handle of the blade becomes more
vertical (arrows). C, In the lateral view, the handle of the laryngoscope is lifted at a 45-degree angle (arrow) as the tip of the blade is placed
in the vallecula. D, In the lateral view, continued lifting of the laryngoscope handle at a 45-degree angle results in exposure of the laryngeal
aperture. The epiglottis (1), vocal cords (2), cuneiform part of arytenoid cartilage (3), and corniculate part of arytenoid cartilage (4) are
identified in the frontal view. (From Benumof JL, editor: Airway management: Principles and practice, St. Louis, 1996, Mosby, p 267.)
 CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation      351

Figure 17-4 The mouth can be opened wide

by extending the head on the neck with the
right hand while the small finger and medial
border of the left hand simultaneously push the
anterior aspect of the mandible in a caudad
direction (extraoral technique). As the blade
approaches the mouth, it should be directed
toward the right side of the mouth. Gloves
should be worn during laryngoscopy because
the hands may come in contact with patient’s
secretions. (From Benumof JL, editor: Airway
management: Principles and practice, St. Louis,
1996, Mosby, p 265.)

Lateral view

Frontal view

The laryngoscope blade is inserted into the right side incisor or gum, injury is likely to result. With the patient
of the mouth (see Fig. 17-3A). During the insertion of properly positioned, the direction of force necessary to
the laryngoscope, the patient’s lower lip should be pulled lift the mandible and tongue and expose the glottis is
away from the lower incisors (with the right hand or by along an approximately 45-degree straight line above the
an assistant) to prevent injury to the lower lip by entrap- long axis of the patient. The best aid for inexperienced
ment of the lower lip between the laryngoscope blade laryngoscopists learning laryngoscopy may be a 10-pin
and the lower incisor teeth. The blade is simultaneously bowler’s wrist brace, which immobilizes the wrist.
advanced forward toward the base of the tongue and After the epiglottis is visualized, the next step depends
the tip directed centrally toward the midline so that the on the type of laryngoscope blade being used. If the blade
tongue is completely displaced to the left side of the is curved (Macintosh), the tip should be placed in the
mouth by the flange of the laryngoscope blade (see Fig. vallecula (space between the base of the tongue and the
17-3B). After the blade has been applied to the base of pharyngeal surface of the epiglottis) (see Fig. 17-3D).
the tongue, the laryngoscope is lifted to expose the epi- Subsequent forward and upward movement of the blade
glottis (see Fig. 17-3C). During this process, the left wrist tenses the hyoepiglottic ligament, causing the epiglottis
should remain straight, with all lifting done by the left to move upward like a trapdoor, first exposing the aryte-
shoulder and arm. If the laryngoscopist follows a natural noid cartilages and then allowing more and more of the
inclination to radial-flex the wrist further, thereby using glottic opening and vocal cords to come into view (see
the laryngoscope like a lever whose fulcrum is the upper Fig. 17-3D).

Figure 17-5 The mouth can be opened wide by pressing

the thumb of the right hand on the right, lower, posterior
molar teeth in a caudad direction while the index finger of
the right hand simultaneously presses on the right, upper,
posterior molar teeth in a cephalad direction (intraoral
technique). Gloves should be worn during laryngoscopy
because the hands may come into contact with patient’s
secretions. (From Benumof JL, editor: Airway management:
Principles and practice, St. Louis, 1996, Mosby, p 266.)

Frontal view Lateral view

352      PART 4 The Airway Techniques

Place blade posterior to

(beneath) the epiglottis

Figure 17-7 Insertion of the laryngoscope blade too deeply into the
pharynx may result in elevation of the entire larynx so that the
opening of the esophagus rather than the glottic aperture is visual-
Figure 17-6 Conventional laryngoscopy with a straight blade. A ized. The esophagus is located just to the right of the midline and
straight laryngoscope blade (Miller blade) should be passed under- posteriorly, and the esophageal opening is round and puckered
neath the laryngeal surface of the epiglottis. The handle of the with no structure around it. (From Benumof JL, editor: Airway man-
laryngoscope then should be elevated at a 45-degree angle, similar agement: Principles and practice, St. Louis, 1996, Mosby, p 268.)
to the lifting that takes place with the use of a curved laryngoscope
blade. (From Benumof JL, editor: Airway management: Principles and
practice, St. Louis, 1996, Mosby, p 268.)
epiglottis or an anterior larynx. Straight blades are pre-
ferred in infants, pediatric patients, and patients with an
anterior larynx. Use of a longer blade (curved or straight)
is more appropriate in very large patients and patients
The ability to identify the epiglottis and then lift ante- with a very long thyromental distance.
riorly to reveal progressively more of the glottic aperture Four major common problems are encountered in per-
has led to a convenient system for grading the laryngo- forming laryngoscopy. First, with either laryngoscope
scopic view of any patient.24,25 A grade I laryngoscopic blade, inserting the blade too deeply into the pharynx
view consists of visualization of the vocal cords in their may elevate the entire larynx so that the opening of the
entirety. A grade II laryngoscopic view is visualization of esophagus is visualized rather than the glottic aperture
the posterior portion of the laryngeal aperture (arytenoid (see Fig. 17-7). Insertion of a curved blade too far into
cartilages) but not any portion of the vocal cords. A grade the vallecula and continued rotation of the handle to the
III laryngoscopic view is visualization of the epiglottis but vertical may push the epiglottis down over the glottic
not the posterior portion of the laryngeal aperture, and a opening, resulting in limited exposure of the larynx (see
grade IV laryngoscopic view is visualization of the soft Fig. 17-8). The tracheal and esophageal openings are
palate but not the epiglottis. This grading system is neces- usually easily distinguished. The esophagus is located just
sarily subjective and skill dependent, but it does correlate to the right of the midline and more posteriorly, and the
somewhat with difficult intubation. esophageal opening is round and puckered, with no
If the blade is straight (Jackson, Wisconsin, or Miller
blades), the tip should extend just behind (posterior to)
or beneath the laryngeal surface of the epiglottis (see Fig.
17-6). As with a curved laryngoscope blade, subsequent
forward and upward movement of the straight blade
(exerted along the axis of the handle, not by pulling back
on the handle) exposes the glottic opening (see Fig. 17-6).
The use of a curved blade is thought to be less stimu-
lating to the patient and possibly less traumatic to the
epiglottis for two reasons. First, the tip of a curved blade
does not normally touch the epiglottis. Second, the pha-
ryngeal surface of the epiglottis is innervated by the glos-
sopharyngeal nerve, whereas the superior laryngeal nerve
supplies the laryngeal surface of the epiglottis. Stimula-
tion of the laryngeal surface of the epiglottis is thought
to predispose to laryngospasm and bronchospasm more
than stimulation of the pharyngeal surface of the epiglot-
tis. Curved blades are thought to be less traumatic to the Figure 17-8 Insertion of the laryngoscope blade too deeply into the
vallecula may push the epiglottis down over the laryngeal aperture,
teeth and to provide more room for passage of the ETT diminishing exposure of the vocal cords. (From Benumof JL, editor:
through the oropharynx. However, straight blades provide Airway management: Principles and practice, St. Louis, 1996, Mosby,
a better view of the glottis in a patient with a long, floppy p 267.)
 CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation      353

Figure 17-9 The tongue should be to the left

of the laryngoscope blade. A, The flange on
the laryngoscope blade should keep the
tongue completely to the left side of the
mouth. If this is accomplished, the tongue
does not obstruct the view of the vocal
cords. The tracheal rings on the anterior
aspect of the trachea are evident. B, If the
tongue slips over the laryngoscope blade
and occupies part of the right side of the
mouth, the view of the vocal cords is
obscured by the part of the tongue that is
on the right side of the mouth. (From Benumof
JL, editor: Airway management: Principles
and practice, St. Louis, 1996, Mosby, p 269.)

Tongue to the left of the Tongue on both sides of the laryngoscope

A laryngoscope blade flange B blade will obscure the laryngeal aperture

structures around it. The glottis is located in the midline, reduce the incidence of a grade III view from 9% to
has a triangular shape, and contains the prominent knobs between 1.3% and 5.4%.26 Although backward, upward,
of the arytenoids posteriorly and the pale white true and rightward pressure (BURP) placed on the thyroid
vocal cords bilaterally. cartilage is typically the most useful OELM, it is best for
Second, it is important to keep the tongue completely the laryngoscopist to determine what form of external
to the left side of the mouth with the flange of the laryn- manipulation is optimal. This can best be accomplished
goscope blade. Many difficult or failed intubations result using his or her right hand when it becomes free after
from the tongue protruding over the flange of the blade the patient’s head is properly positioned (extended) and
toward the right side of the mouth, obstructing a clear mouth fully opened (see Fig. 17-10).
path through which the vocal cords must be visualized
and the ETT passed (see Fig. 17-9B). Vision is obscured D. Endotracheal Tube
further when the ETT occupies part of the view. With a
partially obstructed (tunnel) view the endoscopist can Insertion of the ETT is frequently easy after the vocal
partially visualize but not instrument the larynx. All of cords are exposed and the tongue is out of the way (see
the tongue must be to the left of the blade (Fig. 17-9A). Fig. 17-9A). However, endotracheal intubation is often
Third, in an effort to keep the tongue to the left, the problematic even if the vocal cords are visualized. Adult
blade tip may be displaced to the right of the midline. tracheas readily accept ETTs with 7- to 10-mm internal
This position obscures the view of the epiglottis and may diameters (IDs) (see Chapter 36 for pediatric sizes). If it
precipitate trauma and bleeding from friable tissue in the is thought that fiberoptic bronchoscopy (FOB) will be
tonsillar bed. Especially with the use of the straight blade, necessary subsequently for diagnosis or therapy, an 8-mm
the shaft of the blade can be to the right of midline (over or larger ETT should be used. If it is thought that the
the right molars), but the tip must reside exactly in the space between the upper and lower teeth will be small,
midline of the hypopharynx. An assistant may be useful allowing the cuff of the tube to come in contact with the
in retracting the right cheek and enlarging the space to teeth, the distal part of the tube and cuff should be
the right of the blade, facilitating visualization of the lubricated to facilitate orotracheal intubation and protect
larynx, and introduction of the ETT. the cuff from tearing. In the case of limited mouth
Fourth, in barrel-chested, obese, or large-breasted opening, air should be evacuated from the cuff to allow
patients, it may be difficult initially to insert the blade of as low a profile as possible. The tip of the ETT should be
a laryngoscope correctly into the mouth and avoid introduced into the far right corner of the mouth and
obstruction to movement of the handle of the laryngo- passed along an axis that intersects the line of the laryn-
scope by the chest wall. In these patients, further initial goscope blade at the glottis. In this manner, the tube does
neck extension or a 45-degree rotation of the laryngo- not block the view of the vocal cords down the channel
scope handle to the right permits easier introduction of of the blade. The common error of trying to use the
the blade of the laryngoscope into the mouth. Alterna- laryngoscope blade as a midline guide, through which the
tively, a short laryngoscope handle (designed for this situ- tube is passed, violates this principle, obscures vision, and
ation) may be used instead of the full-length handle. is a significant source of difficulty for the inexperienced
The use of OELM can significantly improve the laryn- laryngoscopist. The tube tip is passed through the cords,
goscopic view. For example, routine use of OELM may stopping 2 cm after the tube cuff completely passes
354      PART 4 The Airway Techniques

Determining optimal external layngeal

manipulation with free (right) hand
BOX 17-2 Signs of Endotracheal Intubation
Less Reliable Signs
1. Breath sounds in axillary chest wall
2. No breath sounds over stomach
3. No gastric distention
4. Chest rise and fall
5. Large, spontaneous exhaled tidal volume (VT)
6. Hearing air exit from the endotracheal tube (ETT) when
the chest is compressed
1 7. Reservoir bag having the appropriate compliance
3
2 8. Maintenance of arterial saturation by pulse oximetry
H
More Reliable Signs
T
1. Carbon dioxide (CO2) excretion waveform
C 2. Rapid expansion of a tracheal indicator bulb
Most Reliable Signs
1. ETT visualized between vocal cords (laryngoscopy)
2. Fiberoptic visualization of cartilaginous rings of the
trachea and tracheal carina

Figure 17-10 Optimal external laryngeal manipulation (OELM) to

improve the laryngoscopic view is determined by the laryngoscopist inserted and after passage through the vocal cords. In
by quickly pressing in the cephalad and posterior directions with the these circumstances, after the ETT tip is through the
right hand over the thyroid (T) (1), which is most common. The cricoid vocal cords, the stylet should be withdrawn, which returns
(C) (2), and the hyoid cartilages (H) (3). If the laryngoscopic view is
critically improved by this maneuver, the laryngoscopist can use an
the tip of the ETT to its inherent flexibility and permits
assistant’s hands or fingers as an extension of his or her own right further passage distally.
hand to reproduce the OELM. (From Benumof JL, editor: Airway man- After placement of the ETT, the laryngoscope is
agement: Principles and practice, St. Louis, 1996, Mosby, p 268.) removed from the mouth, and the cuff of the tube is
inflated to a cuff pressure of 22 to 32 cm H2O. If a cuff
pressure gauge is unavailable, the tube is inflated until
through the vocal cords. Alternatively, when the external moderate tension is felt in the pilot balloon to the cuff.
tube markings at the level of 22 to 24 cm reach the lower The tube should then be connected to a source of PPV
incisors, the tip of the tube is at the midtrachea.7 The and held in place with one hand. The hand holding the
laryngoscopist must not take his or her eyes off the laryn- ETT in place should be securely resting against the cheek
geal aperture until the cuff disappears just beyond the (as a temporary fixation) until the ETT is secured to
vocal cords. The most common cause of inadvertent prevent any sudden movement from dislodging the ETT.
esophageal intubation is failure to clearly see the tube
pass through the cords (and inspect it in situ after place- E. Verification of Correct Placement
ment). The arytenoid cartilages frequently displace the
tube tip posteriorly into the esophagus unless care is The next, most important task is to determine defini-
taken to pass the tip anteriorly and squarely into the tively that the tube has been inserted into the trachea
tracheal lumen. rather than the esophagus (Box 17-2). This issue is exten-
The use of a stylet may be valuable in controlling the sively discussed in Chapter 16, and only a brief summary
direction of passage of an ETT. By providing increased of the signs of endotracheal intubation is given here.
rigidity and malleability, it allows more control of the Helpful but not absolute signs of endotracheal intubation
tube. However, the ETT cannot be readily reshaped after consist of breath sounds in the axillary chest wall, lack of
it is introduced past the teeth. Insertion of an ETT breath sounds over the stomach, lack of gastric disten-
through the mouth allows only two degrees of free move- tion, chest rise with inspiration, large exhaled tidal
ment: depth of insertion and rotation of the tip. The volumes (Vt), the sound of air exiting from the ETT
direction of the tube tip can be changed only by rotation. when the chest is compressed, and appropriate compli-
The ETT should be inserted as far to the right lateral ance of a reservoir bag during hand ventilation. A pro-
aspect of the mouth as possible to facilitate the motion gressive decrease in SpO2 may indicate failure to intubate
of the tip through torque applied to the connector end the trachea, but it is a very late sign of esophageal intuba-
of the ETT. When speed of intubation is important (e.g., tion (especially on 100% O2), and it may also indicate
in a patient with a full stomach), an ETT should always bronchospasm, endobronchial intubation, aspiration,
be equipped with a stylet. A stylet should be easily mal- kinking of the tube, machine or equipment malfunction,
leable and well lubricated (although plastic-coated stylets or merely the normal response delay inherent in pulse
may be adequately slippery) and not extend beyond the oximetry.
tip of the tube. Occasionally, a curved, styleted ETT More reliable signs of endotracheal intubation are the
impinges on the anterior tracheal wall as it is being presence of a normal CO2 waveform (capnogram) and
 CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation      355

rapid expansion of a large rubber tracheal indicator bulb the tube to the facial skin with adhesive tape is the most
(see Chapter 16). Cardiac arrest (when no CO2 is common method of securing the ETT.
excreted), severe bronchospasm, or kinking or plugging The skin of the maxilla should be considered the
of the ET may prevent the appearance of CO2 in the primary source of fixation for an orotracheal tube because
exhaled gas (false-negative finding), and CO2 may appear it is less mobile and therefore less likely to allow excessive
if the tip of the tube is proximal to but near the larynx motion of the tube within the airway. The tube then lies
(false-positive finding). The self-inflating bulb has high along the palate and is less likely to be displaced by the
sensitivity and specificity in normal patients, but it has a tongue of a conscious patient. The fixation of the tube in
significant false-negative rate in obese patients.27 place can be improved by having the lateral ends of the
The only absolutely reliable methods of definitively tape completely encircle the neck; however, the risk of
determining endotracheal intubation are direct observa- restriction of venous return from the head (especially
tion of the ETT going through the vocal cords and the with intracranial pathology) requires careful consider-
use of FOB. Direct visualization of the tube lying in the ation. Application of tincture of benzoin to the skin
glottic opening may be enhanced by displacing the tube before the tape is applied helps provide a stronger bond
posteriorly, which may pull the glottic opening posteri- between the tape and skin. In case of prolonged intuba-
orly and into a better view. FOB allows visualization of tion, changing the tape and reapplying it to a new area
the cartilaginous rings of the trachea and the tracheal on the face every 2 days helps prevent maceration of
carina but is not an accepted practice for routine deter- the skin.
mination of correct tube placement. In patients with beards or in whom the adhesive tape
If a CO2 waveform, breath sounds, and chest move- fails to stick to the skin, the tube can be tied into the
ment are lacking, the anesthesiologist should remove the place with a length of umbilical tape that is knotted
ETT, ventilate the patient with a mask-bag system several around the tube and then encircles the neck. Adhesive
times with 100% O2, and attempt endotracheal intuba- tape may be used over the umbilical tape for added
tion again after inspecting the used tube for defects or security. A surgical face mask, reversed so that the ties
plugs in the lumen. Changes in the shape or curvature of are in front and the mask at the occiput, can serve as a
the ETT and in the position of the head and neck, as well reasonable, temporary means of fixation. Another reliable
as the need for anterior tracheal pressure, should be con- method of securing an orotracheal tube is to wire the
sidered and coordinated during the period of mask tube to a tooth. One or two layers of adhesive tape are
ventilation. wrapped around the tube at the level of the upper incisor
The next task is to ascertain that the tip of the ETT teeth. Stainless steel wire (25 to 28 gauge) is passed
is above the carina. This is done by observing equal around an upper incisor tooth and twisted around the
expansion of both hemithoraces and by stethoscopic tape on the ETT. In anesthetized patients, a suture may
examination for breath sounds throughout both periph- be passed through the gum and then around a ring of
eral lung fields. However, hearing uniform breath sounds adhesive tape on the ETT (as with wire) or through the
throughout all lung fields does not guarantee correct tube wall of the ETT and then tied to the tube. A bite block,
position. If there is any question about a possible main rolled gauze, or an oropharyngeal airway (used in most
stem bronchus intubation, the physician should retract endotracheal intubations for general anesthesia) should
the tube about 1 cm at a time and reexamine the breath be placed between the teeth to prevent the patient
sounds (stopping before complete withdrawal above the from biting down and occluding the lumen of an oral
vocal cords). In one study, an insertion depth of 20 to tube. Numerous commercial products are available to
21 cm in adult women and 22 to 23 cm in adult men attempt to improve the stability, patient’s comfort,
resulted in no incidence of main stem bronchial intuba- and convenience of stabilizing and immobilizing an
tion.28 Simultaneous palpation of pulsed pressures in the orotracheal tube.
cuff in the suprasternal notch and the pilot balloon of the
cuff is another simple way of determining the location of III. LARYNGOSCOPIC NASOTRACHEAL
the tube in the trachea. FOB is another, but complex, INTUBATION
way of determining the location of the tube in the trachea.
Outside the operating room, it is always advisable to Nasotracheal intubation usually is a more difficult proce-
confirm ETT position by chest radiography. Ideally, the dure than orotracheal intubation. However, nasal tubes
tip of the tube should be 2 to 4 cm above the carina at are thought to be better tolerated than oral tubes, and
the clavicular (midtracheal) level. nasal tubes have been considered the tube of choice for
When the ETT is placed and during taping of the tube, medium-term mechanical ventilation. The issue of naso-
the marking of the ETT at the level of the teeth should tracheal tubes contributing to the development of sinus-
be noted for reference should the tube become itis and pneumonia has been investigated, and existing
displaced. evidence has not demonstrated an association.29 None-
theless, the use of nasotracheal intubation for longer-term
ventilation has been declining in favor of orotracheal
F. Securing the Endotracheal Tube
intubation or early tracheostomy. The use of nasotracheal
After the depth of the ETT at the tooth level has been tubes is currently confined to surgical procedures
confirmed, the tube should be tightly secured in place. requiring free access to the oropharynx (e.g., dental pro-
This is important to prevent accidental extubation and cedures, mandibular fixation) and to some pediatric pro-
to minimize tube movement within the airway. Taping cedures in which stability and security of the tube are of
356      PART 4 The Airway Techniques

overwhelming concern (usually because of proximity to

the surgical field).
The ETT is inserted into a nostril (preferably the right) Right
nares
and then passed through the nasal cavity and nasophar- Superior S
e
ynx to the oropharynx. After the tube has been passed Turbinates Middle p
t
into the oropharynx, it can be guided into the glottis Inferior
u
under conventional direct laryngoscopic vision, or it can m

be grasped by a Magill forceps and directed into the Bevel facing

glottis. Nasotracheal intubation is accompanied by a tran- to the right
sient bacteremia, and endocarditis prophylaxis should be
used in susceptible patients. Bevel faces turbinates
and away from septum
A in patient’s right nostril
A. Preparation
Before insertion of the single-lumen nasotracheal tube,
the nasal mucosa should be sprayed with a vasoconstric-
tor drug. Vasoconstriction of blood vessels in the nasal
mucosa minimizes bleeding related to the unavoidable
Left
trauma, and it increases the diameter of the nasal passages nares
S Superior
by constricting (shrinking) the nasal mucosa. Softening e
Middle Turbinates
the tip of the nasotracheal tube by soaking it in a warm p
t Inferior
saline solution may decrease the incidence of mucosal u
damage and bleeding. The naris selected should be the m

one that the patient thinks is the most patent (because Bevel facing
of the significant incidence of septal deviation in patients). to the left
However, if both nares offer equal resistance, the right Tube is rotated 180°
naris should be chosen because the bevel of the nasotra- (compared to panel A)
cheal tube, when introduced through the right naris, bevel faces turbinates
more easily passes the vocal cords (Fig. 17-11). and away from septum
B in patient’s left nostril
The question of potential trauma to the turbinates by
the open bevel of the tube and the best orientation of Figure 17-11 Insertion of a nasotracheal tube into the nares.
A, When the nasotracheal tube is passed into the right naris, the
the bevel in passing the turbinates has not been resolved. bevel should be facing to the right toward the turbinates (inset). In
There is a risk that the tube tip, in passing the inferior this way, the tip of the tube is against the septum, and the risks of
turbinate, may strike and damage or avulse the turbinate. catching the tip of the tube on a turbinate and tearing or dislocating
In the worst case, the turbinate may be dislodged and it are minimized. In this orientation, the concavity of the tube is point-
occlude the lumen of the tube, causing epistaxis and ing anteriorly. B, When the nasotracheal tube is passed into the left
naris, the bevel should be facing to the left toward the turbinates
complete tube obstruction. Care must be taken to pass (inset). In this way, the tip of the tube is against the septum, and the
the tube along the floor of the nose below the inferior risks of catching the tip of the tube on a turbinate and tearing or
turbinate and to avoid any excessive force in advancing dislocating it are minimized. In this orientation the concavity of the
the tube. Other measures may include preliminary vaso- tube is pointing posteriorly. (From Benumof JL, editor: Airway man-
agement: Principles and practice, St. Louis, 1996, Mosby, p 273.)
constriction, lubrication of the tube, gentle rotation as the
tube is advanced, and evacuation of all air from the cuff
to minimize its effective diameter. Efforts to rationalize
the direction of the bevel as it passes the turbinate have should be aligned to facilitate passage along this curved
not been demonstrated to change the incidence of this course. As the tube passes through the nose into the
complication. nasopharynx, it must be directed inferiorly to pass
In most adults, tubes with a 7.0 to 7.5 mm ID pass through the pharynx. In making this turn, it may strike
easily through the nares. Other prelaryngoscopic maneu- against the posterior nasopharyngeal wall and resist any
vers described under direct-vision orotracheal intubation attempt to push it further. The tube should be pulled
(positioning of the head, suctioning, and preoxygenation) back a short distance, and the patient’s head should be
should be performed for direct-vision nasotracheal intu- extended further to facilitate attempts to pass this point
bation. The nasotracheal tube should be lubricated and smoothly and atraumatically. If this is not performed and
passed through the nose in one smooth, posterior, caudad, the tube is forced, the mucosal covering of the posterior
medially directed movement until resistance to forward nasopharyngeal wall may be torn, and the tube may be
movement significantly decreases as the tube enters the passed into the submucous tissues. This false passage is
oropharynx (usually at a distance of 15 to 16 cm). Sig- accompanied by a boggy feeling and by complete obstruc-
nificant resistance should be overcome not by force but tion of the tube lumen.
by withdrawal, rotation, and reinsertion of the ETT. Dif-
ficult passage should prompt the selection of the opposite B. Laryngoscopy
nostril or of a smaller tube.
The pathway that the nasotracheal tube takes should The laryngoscopy for nasotracheal intubation is identical
be visualized as lying on its side. The curve of the ETT to that described for orotracheal intubation.
 CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation      357

C. Endotracheal Intubation exposed by the laryngoscope held in the left hand, the
tube in full view, a means (using the forceps) of manipu-
After the tube is in the oropharynx, the tip of the tube lating the alignment of the ETT, and a means of advanc-
must be aligned with the glottic opening. This requires ing the tube. However, it is often desirable to have an
that the tip of the tube be visible in the hypopharynx. assistant advance the proximal end of the ETT so that
The tube should be advanced or withdrawn until this is the intubator is free to guide the tube into the larynx
the case. A combination of tube rotation and reposition- without having to pull it with the Magill forceps. The tip
ing of the head may allow clear passage of the tube tip of the tube should be grasped to guide it into the trachea;
into the trachea, but it is likely that the tube will require grasping the cuff area is likely to lead to cuff trauma and
guidance using Magill forceps held in the intubator’s right possible damage. The addition of a small amount of air
hand. into the ETT cuff should center the tube within the
The advantage of the design of these forceps is that glottis, and as the ETT is advanced, the cuff deflates.
when the grasping ends are parallel to the long axis of In some patients, as the ETT enters the trachea, the
the ETT, the handle is outside the right side of the mouth tube’s anterior curvature may direct it against the ante-
and at a right angle to the long axis of the tube. Because rior tracheal wall and interfere with passage past this
the handle is outside the right side of the mouth, it is point. To resolve this difficulty, the head must be lifted
away from the line of sight. As the forceps are grasped (flexed) slowly as the ETT is advanced. A nasotracheal
parallel to the long axis of the tube, a backhand motion tube should be advanced until the cuff is 2 cm below the
of the right hand passes the ETT toward the glottic vocal cords or until the external markings are 24 to
opening (Fig. 17-12). The intubator can have the larynx 25 cm for women and 26 to 27 cm for men (3 cm more
than for oral ETTs) at the nares. The tube’s correct place-
ment must be verified as in any intubation (see “Verifica-
tion of Correct Placement”), but this is particularly
critical with nasotracheal intubations because the relation
Guiding a nasotracheal tube into the to external tube markings and the location of the tip are
larynx using a Magill forceps
not as firmly established as for orotracheal intubations. If
nasal bleeding occurs, it is probably wise to leave the ETT
in place to provide tamponade. If the bleeding is severe,
Rotate hand
the ETT can be retracted and the cuff inflated to provide
(as in a backhand better tamponade.
hit of a ping-pong ball)
D. Securing the Endotracheal Tube
The nasotracheal tube can be secured with adhesive tape
as described for orotracheal intubation. A nasotracheal
tube can be secured by a suture through the nasal septum
and then tied, after being tightly wound around an adhe-
sive band on the tube or passed through the wall of the
tube by a needle and then tied.
Lift laryngoscope
blade forward
at a 45° angle IV. CONCLUSIONS
The art of laryngoscopic endotracheal intubation is one
of infinite variety and unpredictability. We treat a diverse
population of patients with many disease processes, and
when their pathology includes airway abnormalities,
gaining control of the airway can be a life-threatening or
lifesaving process. Ongoing study and practice of airway
techniques are the only protection we have in the intrin-
sically hazardous field of airway management. Mastery of
the art begins with a mastery of the fundamentals.
Although practiced by a wide variety of health profes-
sionals, laryngoscopic intubation is an extraordinarily
complex and continually evolving branch of anesthesiol-
ogy and critical care.

Figure 17-12 A nasotracheal tube can be guided under direct

vision (laryngoscopic control) through the laryngeal aperture with a
V. CLINICAL PEARLS
Magill forceps by rotating the hand as when using a backhand • Redundancy is the key to adequate preparation. All
motion to hit a ping pong ball. The Magill forceps should grab the
nasotracheal tube proximal to the cuff of the ETT. (From Benumof JL,
essential equipment (laryngoscopy handles and ETTs)
editor: Airway management: Principles and practice, St. Louis, 1996, should have back-up counterparts readily available in
Mosby, p 275.) case of unexpected failure.
358      PART 4 The Airway Techniques

• Proper positioning is essential to successful intubation. • The most common cause of inadvertent esophageal
Atlanto-occipital extension is the most critical compo- intubation is failure to clearly visualize the ETT pass
nent of positioning. The sniffing position (with the through the vocal cords.
occiput elevated 9 cm) may provide a more favorable
• Depths of 20 to 21 cm for women and 22 to 23 cm
laryngoscopic view.
for men can safeguard against endobronchial intuba-
• Preoxygenation delays the onset of hypoxemia by deni- tion during orotracheal intubation.
trogenating the lungs and filling the functional residual
• The ETT must be tightly secured to prevent inadver-
capacity (FRC) with O2. The benefit of preoxygenation
tent extubation or tube movement within the airway.
is limited in morbidly obese patients due to a decrease
in FRC and an exaggerated cephalad diaphragmatic • Because nasotracheal intubation is thought to be better
shift related to supine positioning. tolerated and has not been shown to be associated with
an increased incidence of sinusitis, it is preferred over
• Although numerous techniques for tracheal cannula-
orotracheal intubation for medium-term mechanical
tion exist, direct laryngoscopy is by far the most
ventilation. The nasal mucosa should be pretreated
common technique.
with a vasoconstrictor drug to facilitate nasotracheal
• The tip of the laryngoscopic blade is inserted into the intubation and to minimize the risk of trauma. Gentle
right side of the mouth and advanced toward the head flexion may assist in the passage of a nasotracheal
midline base of the tongue, displacing the tongue to tube as it contacts the anterior tracheal wall.
the left side of the mouth. Lifting of the laryngosco-
pist’s arm at a 45-degree angle from the long axis of
the patient without moving the wrist exposes the epi- SELECTED REFERENCES
glottis while minimizing risk of injury to the airway. All references can be found online at expertconsult.com.
The tip of a curved blade is inserted into the vallecula, 6. Jackson C: Bronchoscopy, oesophagoscopy, and gastroscopy, ed 3,
thereby tensing the hypoepiglottic ligament, lifting the Philadelphia, 1934, WB Saunders.
epiglottis, and exposing the arytenoids and glottic 8. Bannister FB, MacBeth RG: Direct laryngoscopy and tracheal intu-
bation. Lancet 2:651, 1944.
opening. The tip of a straight blade is extended beneath 9. Adnet F, Baillard C, Borron SW, et al: Randomized study comparing
the laryngeal surface of the epiglottis, and subsequent the “sniffing position” with simple head extension for laryngoscopic
upward and forward movement of the blade exposes view in elective surgery patients. Anesthesiology 95:836–841,
the glottic opening. 2001.
13. Greenland KB, Edwards MJ, Hutton NJ, et al: Changes in airway
• The use of a curved blade is thought to be less stimu- configuration with different head and neck positions using magnetic
lating and less traumatic to the teeth and epiglottis resonance imaging of normal airways: A new concept with possible
clinical applications. Br J Anaesth 105:683–690, 2010.
than a straight blade, and it may provide more room 17. Gold MI, Duarte I, Muravchick S: Arterial oxygenation in conscious
for passage of the ETT through the oropharynx. A patients after 5 minutes and after 30 seconds of oxygen breathing.
straight blade may provide a better view in a patient Anesth Analg 60:313–315, 1981.
with a long epiglottis or anterior larynx. 20. Jense HG, Dubin SA, Silverstein PI, O’Leary-Escolas U: Effect of
obesity on safe duration of apnea in anesthetized humans. Anesth
• The use of optimal external laryngeal manipulation Analg 72:89–93, 1991.
(OELM) can significantly improve the laryngoscopic 21. Teller LE, Alexander CM, Frumin MJ, Gross JB: Pharyngeal insuf-
flation of oxygen prevents arterial desaturation during apnea. Anes-
view. thesiology 69:980–982, 1988.
• It is essential to confirm endotracheal intubation by 23. Miller RA: A new laryngoscope. Anesthesiology 2:317–320, 1941.
24. Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics.
auscultation of breath sounds, chest wall excursion, Anaesthesia 39:1105–1111, 1984.
lack of gastric sounds or distention, large exhaled Vt 25. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P: Predicting
value, and a normal capnogram finding. difficult intubation. Br J Anaesth 61:211–216, 1988.
 CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation      358.e1

16. Gambee AM, Hertzka RE, Fisher DM: Preoxygenation techniques:

REFERENCES comparison of three minutes and four breaths. Anesth Analg
1. Hooke R: The technique of insertion of intratracheal insufflation 66:468–470, 1987.
tubes. Philos Trans R Soc 2:539, 1667. 17. Gold MI, Duarte I, Muravchick S: Arterial oxygenation in conscious
2. Snow J: On chloroform and other anaesthetics, London, 1858, John patients after 5 minutes and after 30 seconds of oxygen breathing.
Chruchill. Anesth Analg 60:313–315, 1981.
3. Trendelenburg F: Beitrage zur den Operationen an den Luftwegen. 18. Baraka AS, Taha SK, Aouad MT, et al: Preoxygenation: comparison
2. Tamponnade der Trachea. Arch Klin Chir 12:121, 1871. of maximal breathing and tidal volume breathing techniques. Anes-
4. Matas R: I. On the management of acute traumatic pneumothorax. thesiology 91:612–616, 1999.
Ann Surg 29:409–434, 1899. 19. Nimmagadda U, Salem MR, Joseph NJ, et al: Efficacy of preoxy-
5. Magill IW: Endotracheal anesthesia, Am J Surg 24:450–455, 1936. genation with tidal volume breathing. Comparison of breathing
6. Jackson C: Bronchoscopy, oesophagoscopy, and gastroscopy, ed 3, systems. Anesthesiology 93:693–698, 2000.
Philadelphia, 1934, WB Saunders. 20. Jense HG, Dubin SA, Silverstein PI, O’Leary-Escolas U: Effect of
7. Jackson C: An account of an experiment made by M. Hook of obesity on safe duration of apnea in anesthetized humans. Anesth
preserving animals alive by blowing through their lungs with Analg 72:89–93, 1991.
bellows. Surg Gynaccol Obstet 17:507, 1913. 21. Teller LE, Alexander CM, Frumin MJ, Gross JB: Pharyngeal insuf-
8. Bannister FB, MacBeth RG: Direct laryngoscopy and tracheal intu- flation of oxygen prevents arterial desaturation during apnea. Anes-
bation. Lancet 2:651, 1944. thesiology 69:980–982, 1988.
9. Adnet F, Baillard C, Borron SW, et al: Randomized study comparing 22. Macintosh RR: An aid to oral intubation. Br Med J 1:28, 1949.
the “sniffing position” with simple head extension for laryngoscopic 23. Miller RA: A new laryngoscope. Anesthesiology 2:317–320, 1941.
view in elective surgery patients. Anesthesiology 95:836–841, 2001. 24. Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics.
10. Adnet F, Borron SW, Dumas JL, et al: Study of the “sniffing posi- Anaesthesia 39:1105–1111, 1984.
tion” by magnetic resonance imaging. Anesthesiology 94:83–86, 25. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P: Predicting
2001. difficult intubation. Br J Anaesth 61:211–216, 1988.
11. Adnet F, Borron SW, Lapostolle F, Lapandry C: The three axis 26. Knill RL: Difficult laryngoscopy made easy with a “BURP.” Can J
alignment theory and the “sniffing position”: perpetuation of an Anaesth 40:279–282, 1993.
anatomic myth? Anesthesiology 91:1964–1965, 1999. 27. Lang DJ, Wafai Y, Salem MR, et al: Efficacy of the self-inflating bulb
12. Benumof JL: Comparison of intubating positions: The end point for in confirming tracheal intubation in the morbidly obese. Anesthesiol-
position should be measured. Anesthesiology 97:750, author reply ogy 85:246–253, 1996.
754, 2002. 28. Sitzwohl C, Langheinrich A, Schober A, et al: Endobronchial intu-
13. Greenland KB, Edwards MJ, Hutton NJ, et al: Changes in airway bation detected by insertion depth of endotracheal tube, bilateral
configuration with different head and neck positions using magnetic auscultation, or observation of chest movements: randomised trial.
resonance imaging of normal airways: A new concept with possible BMJ 341:c5943, 2010.
clinical applications. Br J Anaesth 105:683–690, 2010. 29. Holzapfel L, Chevret S, Madinier G, et al: Influence of long-term
14. Park SH, Park HP, Jeon YT, et al: A comparison of direct laryngo- oro- or nasotracheal intubation on nosocomial maxillary sinusitis
scopic views depending on pillow height. J Anesth 24:526–530, and pneumonia: Results of a prospective, randomized, clinical trial.
2010. Crit Care Med 21:1132–1138, 1993.
15. Lee L, Weightman WM: Laryngoscopy force in the sniffing position
compared to the extension-extension position. Anaesthesia 63:375–
378, 2008.