How To Do Orotracheal Intubation Using Video Laryngoscopy

Hypoxia or hypoventilation requiring assisted ventilation to maintain oxygenation and ventilation

Apnea or impending respiratory arrest (initial emergency treatment)

Elective anesthesia (selected cases)

Need for prolonged mechanical ventilation

Situations where bag-valve-mask ventilation is difficult or impossible (eg, in patients with severe facial deformity, thick beard, or other factors that interfere with the face mask seal) or upper airway obstruction due to soft tissues

Need to prevent aspiration (eg, in obtunded or comatose patients) or for repeated airway suction

There is no medical contraindication to providing ventilatory support to a patient; however, a legal contraindication (do-not-resuscitate order or specific advance directive) may be in force

Restricted mouth opening that blocks tube insertion (nasotracheal intubation or a surgical airway would be indicated in this case)

Impassable upper airway obstruction (surgical airway would be indicated in this case)

Consciousness or presence of a gag reflex (patients should be unconscious or receive one or more drugs to aid intubation Drugs to Aid Intubation Pulseless and apneic or severely obtunded patients can (and should) be intubated without pharmacologic assistance. Other patients are given sedating and paralytic drugs to minimize discomfort... read more before ET tube insertion)

Dental or oropharyngeal soft tissue trauma during tube insertion

Vomiting and aspiration during tube insertion

Incorrect tube placement (eg, esophageal intubation)

Hypoxia during the intubation attempt

Gloves, mask, gown, and eye protection (ie, universal precautions)

Syringe for balloon cuff inflation

Sterile water-soluble lubricant or anesthetic jelly

Endotracheal tube, appropriately sized to patient Tube Selection and Preparation for Intubation Most patients requiring an artificial airway can be managed with tracheal intubation, which can be Orotracheal (tube inserted through the mouth) Nasotracheal (tube inserted through the nose)... read more , and rigid introducing stylet

Video laryngoscope

Suctioning apparatus, Yankauer catheter, and Magill forceps, to clear the pharynx as needed

Bag-valve apparatus

Oxygen source (100% oxygen, 15 L/minute)

Pulse oximeter and appropriate sensors

Capnometer (end-tidal carbon dioxide monitor)

Drugs to aid intubation Drugs to Aid Intubation Pulseless and apneic or severely obtunded patients can (and should) be intubated without pharmacologic assistance. Other patients are given sedating and paralytic drugs to minimize discomfort... read more (typically an induction agent and paralytic to enable rapid sequence intubation)

Ventilation face mask, oropharyngeal/nasopharyngeal airways, appropriately sized to patient

Nasogastric tube

In case laryngoscopy fails, equipment to insert a supraglottic airway How To Insert an Esophageal-Tracheal Double Lumen Tube (Combitube) or a King Laryngeal Tube The esophageal-tracheal double lumen tube (Combitube) and the King laryngeal tube are supraglottic airway devices (also called retroglottic airway devices). (See also Tracheal Intubation, Airway... read more or perform a cricothyrotomy How To Do a Percutaneous Cricothyrotomy Cricothyrotomy, whether traditional surgical cricothyrotomy or percutaneous cricothyrotomy using a guidewire, uses an incision through the skin and cricothyroid membrane through which an artificial... read more

Optimally, each attempt at endotracheal intubation should last no longer than 30 seconds, preceded by pre-oxygenation.

If oxygen saturation falls below 90%, interim ventilation may be needed (see bag-valve-mask ventilation Bag-Valve-Mask Devices If no spontaneous respiration occurs after airway opening and no respiratory devices are available, rescue breathing (mouth-to-mask or mouth-to-barrier device) is started; mouth-to-mouth ventilation... read more ).

Aligning the external auditory canal with the sternal notch should align the airway axis to provide an optimal view of the airway.

The degree of head elevation that best aligns the ear and sternal notch varies (eg, none in children because the occiput is relatively large; a large degree in patients with obesity).

The sniffing position is the optimal position for endotracheal tube insertion; however, if the neck cannot be positioned this way, the laryngoscope camera often provides adequate visualization.

Position the patient supine on the stretcher.

Place folded towels or other materials under the head, neck, and shoulders, flexing the neck so as to elevate the head until the external auditory meatus lies in the same horizontal plane as the sternal notch. Then tilt the head so that the face aligns on a parallel horizontal plane; this second plane will be above the first. In patients with obesity, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck (see figure Head and neck positioning to open the airway Head and neck positioning to open the airway ).

Position the patient supine or at a slight incline on the stretcher.

Maintain in-line stabilization to avoid moving the neck and use only the jaw thrust maneuver How To Do Head Tilt–Chin Lift and Jaw-Thrust Maneuvers Part of pre-intubation and emergency rescue breathing procedures, the head tilt–chin lift maneuver and the jaw-thrust maneuver are 2 noninvasive, manual means to help restore upper airway patency... read more or chin lift How To Do Head Tilt–Chin Lift and Jaw-Thrust Maneuvers Part of pre-intubation and emergency rescue breathing procedures, the head tilt–chin lift maneuver and the jaw-thrust maneuver are 2 noninvasive, manual means to help restore upper airway patency... read more without head tilt to manually facilitate opening of the upper airway.

Prepare the necessary equipment, including ancillary equipment such as a suction device. Be prepared to use an alternate technique (eg, laryngeal mask airway How To Insert a Laryngeal Mask Airway Laryngeal mask airway (LMA) ventilation is a method for providing rescue ventilation to unconscious patients or patients without a gag reflex that is technically easier than use of most other... read more , bag-valve-mask ventilation How To Do Bag-Valve-Mask (BVM) Ventilation Bag-valve-mask (BVM) ventilation is the standard method for rapidly providing rescue ventilation to patients with apnea or severe ventilatory failure. (See also Airway Establishment and Control... read more , or surgical airway [ cricothyrotomy How To Do a Percutaneous Cricothyrotomy Cricothyrotomy, whether traditional surgical cricothyrotomy or percutaneous cricothyrotomy using a guidewire, uses an incision through the skin and cricothyroid membrane through which an artificial... read more ]) if laryngoscopy fails.

Correctly position the patient (see figure Head and neck positioning to open the airway Head and neck positioning to open the airway and manual maneuvers Positioning Endotracheal (ET) tubes are flexible tubes with a standard flange for attaching an oxygen source at the proximal end and a beveled tip and inflatable balloon cuff at the distal end. Under visualization... read more ).

Establish IV access.

Ventilate and pre-oxygenate the patient with 100% oxygen (oxygenation with a non-rebreather mask is adequate if the patient is spontaneously breathing; if the patient does not have adequate spontaneous ventilations, use bag-valve-mask ventilation with supplemental passive nasal cannula [or high-flow nasal cannula if available]

Turn on the video laryngoscope, and verify the light and camera are working.

Inflate the balloon cuff of an appropriately sized endotracheal tube to verify it does not leak.

Position the patient’s head and neck, if possible, as you would for standard orotracheal intubation How To Insert an Oropharyngeal Airway Oropharyngeal airways are rigid intraoral devices that conform to the tongue and displace it away from the posterior pharyngeal wall, thereby restoring pharyngeal airway patency. (See also Airway... read more .

Do rapid sequence intubation (ie, using drugs to aid intubation Drugs to Aid Intubation Pulseless and apneic or severely obtunded patients can (and should) be intubated without pharmacologic assistance. Other patients are given sedating and paralytic drugs to minimize discomfort... read more ). If the airway is anticipated to be difficult and the patient has an intact gag reflex, use an induction agent such as ketamine or etomidate to first visualize the vocal cords before administering paralytics.

Clear the oropharynx, if necessary, of obstructing secretions, vomitus, or foreign material.

Continue oxygenation. For spontaneously breathing patients, apply a non-rebreather mask at 100% fraction of inspired oxygen (FiO2) for 3 to 5 minutes before intubation. For patients who are not spontaneously breathing, give about 8 vital capacity breaths at maximum oxygen concentration using a bag-valve-mask.

Insert the video laryngoscope blade into the patient's mouth, following the curve of the tongue. Once the tip of the video laryngoscope blade is behind the patient's tongue, look at the video laryngoscope monitor and manipulate the blade so the glottic opening is in the middle of the upper half of the video screen.

Optimize the view with bimanual laryngoscopy. This is accomplished by manipulating the larynx with the operator's right hand while operating the video laryngoscope with the left hand. Applying backwards, upward, and rightward pressure on the thyroid cartilage will usually optimize the view. The operator can position an assistant's hand to maintain the view while inserting the endotracheal tube.

Looking away from the screen and back at the patient, insert the endotracheal tube in the right side of the mouth and pass it behind the tongue, carefully avoiding damaging the balloon on the teeth. At this point, watch the monitor to guide the tip of the tube through the vocal cords. Because some stylets used with certain video laryngoscopes are rigid, this maneuver may require having an assistant pull the stylet out 1 to 2 cm while the tube is gently advanced. Then advance the tube an additional 3 to 4 cm.

Inflate the cuff and fully remove the stylet.

Ventilate the patient (8 to 10 breaths/minute, each about 6 to 8 mL/kg or 500 mL and lasting about 1 second).

If unable to intubate, use of adjuncts such as the bougie may be helpful. If adjunct use does not result in a successful airway, quickly pursue an alternate airway, which may involve rescue bag-valve-mask ventilation How To Do a Percutaneous Cricothyrotomy Cricothyrotomy, whether traditional surgical cricothyrotomy or percutaneous cricothyrotomy using a guidewire, uses an incision through the skin and cricothyroid membrane through which an artificial... read more as an interim either to a supraglottic airway (eg, laryngeal mask airway, King laryngeal tube How To Insert an Esophageal-Tracheal Double Lumen Tube (Combitube) or a King Laryngeal Tube The esophageal-tracheal double lumen tube (Combitube) and the King laryngeal tube are supraglottic airway devices (also called retroglottic airway devices). (See also Tracheal Intubation, Airway... read more , esophageal-tracheal double lumen tube How To Insert an Esophageal-Tracheal Double Lumen Tube (Combitube) or a King Laryngeal Tube The esophageal-tracheal double lumen tube (Combitube) and the King laryngeal tube are supraglottic airway devices (also called retroglottic airway devices). (See also Tracheal Intubation, Airway... read more [Combitube]) or to cricothyrotomy Cricothyrotomy If the upper airway is obstructed because of a foreign body or massive facial trauma or if ventilation cannot be accomplished by other means, surgical entry into the trachea is required. Historically... read more .

Obtain a chest x-ray to verify proper placement of the endotracheal tube.

It is imperative to use the appropriate rigid stylet designed for the curvature of a specific video laryngoscope so it follows the curvature of the blade. Use of traditional malleable stylets may result in a failed intubation attempt, especially on anterior airways.

When removing the stylet, securely hold the endotracheal tube while an assistant pulls the stylet out, rotating the stylet handle caudally toward the chest, not pulling straight upward, to facilitate easier removal of the stylet and minimizing the risk of dislodging the endotracheal tube.

All cuffs, adult or pediatric, should be inflated only to the extent necessary to prevent movement; overinflation leads to necrosis.

With difficult airways, use of traditional intubation techniques, such as sweeping the tongue toward the left and applying slight upward and outward elevation, can help facilitate a better view.

If an assistant is available, have the assistant insert a finger into the mouth and pull the cheek laterally; this may provide a better view with more intubating space.

When looking at the video screen after inserting the endotracheal tube into the mouth, focus on the vocal cords. The view of the vocal cords should be lost only for a brief second while the tube passes through the cords.

The video laryngoscope may also be used to more easily place an orogastric tube after intubation, particularly in patients with difficult anatomy.