Chapter 17

Laryngoscopic Orotracheal and

Nasotracheal Intubation
JAMES M. BERRY STEPHEN HARVEY

I. A Short History of Endotracheal Intubation

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

Creation
Our very breath, pre-language of the lingus,
Unspoken and unseen, lies all around us;
It tunnels through a darkened path to bring us
Before the guarded gates that would confound us:
Dentition, palate, epiglottic folds
Are navigated as the case is started
And followed through to cartilage that holds
The two true cords, those gleaming pillars, parted;
Here human hands, left trembling with creation,
Are re-creating life as it began,
Beginning with the step of intubation,
The God-breathed breath of life blown into man.
Stephen Harvey

I. A SHORT HISTORY OF
ENDOTRACHEAL INTUBATION
As we participate in the 21st century practice of medicine, it is useful to recollect the origin and development
of some of the techniques commonly used for airway
management. It is remarkable that modern airway techniques are less than 50 years old but are derived from
physiologic experiments done primarily in the 18th and
19th centuries. Skilled airway management is a central
pillar of the practice of anesthesiology, resuscitation, and
critical care, and an appreciation of the evolution and
development of airway techniques can improve our
understanding and application of these essential skills.
Cannulation of the trachea, or aspera arteria, as it was
called by Robert Hooke,1 was initially described as a
technique for positive-pressure ventilation (PPV):
the Dog being kept alive by the Reciprocal blowing
up of his Lungs with Bellowes, and they suffered to

III. Laryngoscopic Nasotracheal Intubation

A. Preparation
B. Laryngoscopy
C. Endotracheal Intubation
D. Securing the Endotracheal Tube
IV. Conclusions
V. Clinical Pearls

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

Thorax had been so displayd, and his Aspera Arteria
cut off just below the Epigolotis, and bound on upon the
nose of the Bellows
The use of tracheal cannulation for the administration
of anesthetics and provision of a patent airway was first
reported in 1858 by John Snow in On Chloroform and
Other Anaesthetics,2 in which he described a tracheostomy and cannulation for the administration of chloroform in a spontaneously breathing rabbit. The first
human use of tracheostomy for anesthesia and protection against aspiration was reported by Trendelenburg in
1869, and it also was accompanied by spontaneous ventilation.3 In the next 10 years, numerous investigators
developed nonsurgical techniques and apparatus for cannulation of the trachea for surgical (ear, nose, throat) or
medical (diphtheria) indications. Matas was among the
first to advocate the use of PPV through a tracheal
cannula to avoid the catastrophic consequences of pneumothorax for a spontaneously ventilating patient during
thoracotomy.5
Endotracheal anesthesia came into its own during and
immediately after World War I because of the volume of
facial and mandibular injuries treated in England, especially at the hospital in Sidcup. In 1936, I.W. Magill wrote
one of many descriptive treatises on intubation in
anesthesia5:
The maintenance of a free airway has long been
recognized as a first principle in general anesthesia and
the danger of complete laryngeal obstruction has always
been obvious. On the other hand, the cumulative effects
of partial respiratory obstruction have, in the past, been

346
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CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation 347

frequently overlooked and it is not improbable that

many of the surgical difficulties, postoperative
complications, and even fatalities attributed to the
anesthetic agent have been primarily due to an
imperfect airway. It may be said without exaggeration
that in remedying this defect endotracheal anesthesia
has proved as great a factor in the advances of
anesthesia as the discovery of new drugs or the
development of improved apparatus.
Immediately thereafter, Magill inserts a caveat:
owing to the ease of control it affords, there is a
tendency towards its employment in every operation,
regardless of other considerations. This tendency is to be
deprecated, especially in the teaching of students. The
novice should learn airway control by simple methods
in the first instance, for he may be called to administer
an anesthetic in circumstances in which artificial
devices are not available. Moreover, as the method
involves instrumentation, which is not devoid of the risk
of trauma, even though it may be slight, intubation
should only be attempted when the necessity for it has
been considered carefully.
The historical lesson here is that, no matter how
routine endotracheal intubation becomes, it is still an
invasive procedure with nontrivial risks and significant
complications. It should be used for specific indications
and only after careful consideration of the balance of risks
to and benefits for the patient.

II. LARYNGOSCOPIC
OROTRACHEAL INTUBATION
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
ill patients, and cardiopulmonary resuscitation. The vocal
cords are visualized with the aid of a handheld laryngoscope, and the endotracheal tube (ETT) is introduced and
positioned in the trachea under continuous direct observation. After confirmation of correct placement, the tube
is secured in place and ventilation assisted or controlled
as indicated.

A. Preparation and Positioning

Box 17-1 lists the basic materials required for conventional orotracheal intubation. The materials are grouped
according to the temporal sequence of events. All items
are required for routine intubation, dealing with common
difficulties, or preventing complications. Redundancy is
the key in preparing for a critical event, such as endotracheal intubation. All essential equipment (e.g., laryngoscope handles, ETTs) should have readily available
back-up counterparts in case of unexpected failure. An
assortment of laryngoscope blades, both straight (Miller)
and curved (Macintosh), should be available.

BOX 17-1 Basic Equipment for Endotracheal

Intubation

Preoxygenation and Ventilation

1. Oxygen (O2) source
2. Ventilation bag or anesthesia circuit (for positivepressure ventilation)
3. Appropriately sized face mask
4. Appropriately sized oropharyngeal and
nasopharyngeal airways
5. Tongue blade
Endotracheal Tubes
6. Appropriately sized endotracheal tubes (at least twp)
7. Malleable stylet
8. Syringe for tube cuff, 10mL
9. Jelly and/or ointment, 4% lidocaine (Xylocaine)
Drugs
10. Intravenous anesthetics and muscle relaxants (ready to
administer)
11. Reliable, free-flowing intravenous infusion (some
pediatric exceptions)
12. Topical anesthetics and vasoconstrictors (for
nasotracheal intubation)
Laryngoscopy
13. Working suction apparatus with tonsil tip
14. Assortment of Miller blades with functioning battery
handle
15. Assortment of Macintosh blades with functioning
battery handle
16. Bolsters (folded sheets, towels) for positioning of head
and shoulders
Fixation of the Endotracheal Tube
17. Tincture of benzoin
18. Appropriate tape or tie
19. Stethoscope
20. End-tidal carbon monoxide (ETCO2) monitor
21. Pulse oximeter

The proper sequence of events before laryngoscopy

should be followed:
1. Adequate access to the head of the bed or table is
essential. Removal of side rails and headboard (if
outside the operating room) ensures freedom of
movement; confirming that the bed or table is
locked in position prevents unnecessary and stressinducing pursuit of the patient around the room.
The height of the surface should be adjusted to the
level of the laryngoscopists chest. An experienced
aide should be in constant attendance to provide
items such as suction lines, airways, tubes, and drugs
to the primary laryngoscopist, as well as to apply
optimal external laryngeal manipulation (OELM),
as needed.
2. The patient must be properly positioned before
laryngoscopy. Patients who are uncooperative, agitated, or otherwise mobile may require rapid and
efficient positioning after sedation. Pads or rolls
should be prepared in advance and be readily at
hand.

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348 PART 4 The Airway Techniques

Head and neck position and the axes of the head and neck upper airway
Head on bed,
neutral position

Head elevated on pad,

neutral position
OA

OA
PA

PA

LA
35
Slight (35) flexion
of neck on chest

LA

Head elevated on pad,

head extended on neck
(sniff position)
PA OA
LA
15

80

Severe (80) extension of

head on neck

Head on bed,
head extended on neck
OA

PA
LA

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

positioning of full extension. Described by Jackson in
1913, this position required full extension of the head
and neck on a flat surface.6 After 20 years, he amended
his view to one that supported the contemporary sniffing
position of flexion at the neck and extension at the head.7
This was accomplished by supporting the head on a
pillow that was at least 10cm thick. Numerous investigators have examined radiographs of subjects to determine
the optimal positioning for orotracheal access. Various
theoretical models of positioning for intubation have
been proposed. For the past 60 years, the three-axis
theory has proposed that the oral, pharyngeal, and laryngeal axes should be brought into approximate alignment
to best facilitate orotracheal visualization and intubation
(Fig. 17-1). Proposed by Bannister and MacBeth in 1944,
this model presumes that laryngoscopy is done in the
midline (two-dimensional model) and that laryngeal axis
alignment is necessary for proper intubation.8 This idea
has been challenged by the work of Adnet and colleagues
in imaging studies and clinical comparisons.9-11
Adnets conclusion, however, has been questioned at
length.12 Greenland and colleagues reexamined the issue,
finding the sniffing position the most favorable for direct
laryngoscopy as determined by magnetic resonance
imaging (MRI).13 This perspective has been corroborated
by evidence indicating 9cm as the optimal pillow

height.14 Others have advocated for an extension-extension

position, in which the head and neck are extended by
lowering the head of the table 30 degrees, proposing that
direct laryngoscopy requires less axial force in this position than in the sniffing position.15 Whether the lower
cervical spine is flexed, extended, or neutral, the extension of the atlanto-occipital joint remains the critical
factor for optimal positioning. The reasonable option in
view of conflicting evidence (and patients variability) is
to position the patient with the occiput on a pad (traditional sniffing position) and be prepared to remove the
pad (convert to simple extension) if the initial laryngoscopy becomes inadequate (Fig. 17-2).
Obese patients often require more extensive padding
(planking) starting at the midpoint of the back to the
head to assume an optimal position for laryngoscopy.
Occasionally, it is necessary to place towels and blankets
under the scapula, shoulders, nape of the neck, and head
to flex the neck on the chest (see Figs. 17-1B and 17-2)
and extend the head on the neck (see Figs. 17-1C and
17-2). In this instance, the purpose of the scapula, shoulder, and neck support is to give the head room so that it
may be extended on the neck. When in doubt, the final
assessment of the position should be from a lateral view
of the patient, because only a lateral view enables precise
assessment of the chest, neck, face, and head axes (see
Figs. 17-1C and 17-2).

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CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation 349

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
Instrumentation of the airway may be done on an awake,
spontaneously breathing patient. This sometimes is the
safest and most prudent approach, but most commonly,
laryngoscopy and intubation are performed on an anesthetized and (usually) apneic patient. Because this
requires some finite period of time, the patient is at risk
for arterial desaturation and hypoxic injury. Preoxygenation is done before laryngoscopy to minimize this risk.
Administration of 100% oxygen (O2) through a tightfitting face mask may occur by means of the patients
spontaneous respirations or by PPV by a bag-mask unit.
In either case, adequate ventilation must occur to wash
out alveolar nitrogen (N2) and fill the lungs with O2. The
goal is to fill the alveoli used in normal tidal breathing
and the remaining alveoli and airways constituting the
functional residual capacity (FRC). This additional O2
serves as a reservoir to delay the onset of arterial hypoxia
for as long as 5 minutes. A number of guidelines have
been proposed to accomplish this potentially lifesaving
goal.
Depending on the minute ventilation of the patient
(spontaneous or assisted), the time to complete effective
preoxygenation varies from 1 to 5 minutes; although in
an awake and cooperative patient, this may be mostly
accomplished with three or four full, vital capacity (VC)
breaths.16,17 Work has documented the increased efficacy
of eight full breaths in about 60 seconds, with times to
desaturation approaching those of the more traditional
3- to 5-minute preoxygenation.18 A higher minute ventilation level leads to more rapid and complete preoxygenation. Measures of the adequacy of preoxygenation
include real-time gas analysis of expired O2 concentration
(goal = 95%) and analysis of expired N2 (goal < 5%).
Essential to either of these measurements is the presence
of a capnograph waveform with a plateau reflecting the
expected alveolar carbon dioxide (CO2) concentration.
This documents the presence of an effective seal of the

circuit-bag system to the patients airway and the effective delivery of 100% O2. The use of an air-mask-bag unit
(AMBU) without an expiratory valve may not provide
optimal preoxygenation.19
The effectiveness of preoxygenation in preventing
hypoxia during laryngoscopy is significantly reduced in
the morbidly obese patient. Even with the most careful
preoxygenation, the duration of apnea before the onset
of hypoxia is one half of the duration seen in patients
with normal body weight. This situation is attributed to
the considerable reduction in FRC and VC in the obese
patient and to the additional reduction attributable to the
cephalad diaphragmatic shift related to supine positioning.20 This places morbidly obese patients at significantly
increased risk for injury if any difficulty with ventilation
or intubation is encountered.
Pharyngeal insufflation of O2 can significantly prolong
the safe duration of apnea. In a typical adult, approximately 250mL/min of O2 is transferred from the lungs
into the bloodstream, while only 200mL/min of CO2
enters the lungs from the bloodstream (respiratory quotient = 0.8). This alveolar gas deficit causes alveolar pressures to become slightly subatmospheric. If the airway is
patent, there is a net flow of gas from the pharynx into
the alveoli (apneic oxygenation). If, after adequate preoxygenation, the pharynx is filled with O2, the onset of
hypoxia is delayed because O2, rather than air, is drawn
into the lungs by this mechanism. Pharyngeal insufflation
may be conveniently achieved by passing a catheter into
the pharynx through a nasopharyngeal airway and attaching an O2 source at 2 to 3L/min. Alternatively, some
laryngoscopes have a side port suitable for attachment of
O2 tubing. When preoxygenation is followed by pharyngeal insufflation as previously described, in normal but
apneic patients, the O2 saturation from pulse oximetry
[SpO2] remains equal to 98% for 10 or more minutes
(although at the end of 10 minutes the arterial carbon
dioxide tension [PaCO2] may be expected to be about
80mm Hg).21

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350 PART 4 The Airway Techniques

C. Laryngoscopy
The purpose of direct laryngoscopy is to provide adequate visualization of the glottis to allow correct placement of the ETT with the minimum effort, elapsed time,
and potential for injury to the patient. Considerable
effort has been expended to develop laryngoscopic techniques and equipment to facilitate this important procedure. Although this textbook outlines numerous
techniques for tracheal cannulation, the facilitative use
of direct laryngoscopy is by far the most common
technique.
Two basic types of laryngoscope blades are the curved
blade (Macintosh) and the straight blade with a curved
tip (Miller).22,23 They are designed for right hand
dominant use; the laryngoscope is held in the left hand
while the right hand manipulates the ETT. Historically,
either hand (or both) could be initially used, shifting the
laryngoscope to the left hand while the right hand manipulated the tube. Both blade styles include a flange on the
left side of the blade for lateral retraction of the tongue
and contain a light-emitting area (bulb or fiberoptic tip).
Each blade has a channel with an open right side for
visualization of the larynx and for insertion of the ETT
(Figs. 17-3 to 17-10). Despite numerous modifications

and variations, they are all lighted, handheld retractors

for oropharyngeal soft tissues.
Although contact with the upper incisors from the
laryngoscope blade should be avoided, some patients
with limited mouth opening, front caps, or obvious decay
are at risk for damage by even the most innocuous, transient trauma. If the possibility of incisor trauma exists, it
seems prudent to provide some protection for the upper
teeth. Several materials have been used in the past to
guard the upper teeth: a folded strip of lead (introduced
by Magill and now obsolete), folded tape, cardboard or
alcohol wipe, or a purpose-built mouth guard (as used in
contact sports). The disadvantage of any of these is
that they occupy a few millimeters of the available
mouth opening, reducing the available aperture for
laryngoscopy.
Two methods are used to open the mouth and facilitate the introduction of the blade. First, extension of the
head on the neck (by pressure from the right hand at the
vertex) causes the lips to part and the mouth to open
(see Fig. 17-4). Alternatively, the thumb of the right hand
can press down on the right lower molar teeth, and the
index finger of the right hand can simultaneously press
up on the right upper molar teeth (scissors maneuver)
(see Fig. 17-5).

Conventional Laryngoscopy with a Curved Blade

Insert the laryngoscope blade into the

right side of the mouth

Advance the laryngoscope blade toward the

midline of the base of the tongue by rotating wrist

1
2
3
4

Approach the base of the tongue and lift

the blade forward at a 45 angle

Engage the vallecula and continue to lift the blade

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.)

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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 patients
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

of the mouth (see Fig. 17-3A). During the insertion of
the laryngoscope, the patients lower lip should be pulled
away from the lower incisors (with the right hand or by
an assistant) to prevent injury to the lower lip by entrapment of the lower lip between the laryngoscope blade
and the lower incisor teeth. The blade is simultaneously
advanced forward toward the base of the tongue and
the tip directed centrally toward the midline so that the
tongue is completely displaced to the left side of the
mouth by the flange of the laryngoscope blade (see Fig.
17-3B). After the blade has been applied to the base of
the tongue, the laryngoscope is lifted to expose the epiglottis (see Fig. 17-3C). During this process, the left wrist
should remain straight, with all lifting done by the left
shoulder and arm. If the laryngoscopist follows a natural
inclination to radial-flex the wrist further, thereby using
the laryngoscope like a lever whose fulcrum is the upper

incisor or gum, injury is likely to result. With the patient

properly positioned, the direction of force necessary to
lift the mandible and tongue and expose the glottis is
along an approximately 45-degree straight line above the
long axis of the patient. The best aid for inexperienced
laryngoscopists learning laryngoscopy may be a 10-pin
bowlers wrist brace, which immobilizes the wrist.
After the epiglottis is visualized, the next step depends
on the type of laryngoscope blade being used. If the blade
is curved (Macintosh), the tip should be placed in the
vallecula (space between the base of the tongue and the
pharyngeal surface of the epiglottis) (see Fig. 17-3D).
Subsequent forward and upward movement of the blade
tenses the hyoepiglottic ligament, causing the epiglottis
to move upward like a trapdoor, first exposing the arytenoid cartilages and then allowing more and more of the
glottic opening and vocal cords to come into view (see
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 patients
secretions. (From Benumof JL, editor: Airway management:
Principles and practice, St. Louis, 1996, Mosby, p 266.)

Frontal view

Lateral view

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352 PART 4 The Airway Techniques

Place blade posterior to

(beneath) the epiglottis

Figure 17-6 Conventional laryngoscopy with a straight blade. A

straight laryngoscope blade (Miller blade) should be passed underneath the laryngeal surface of the epiglottis. The handle of the
laryngoscope then should be elevated at a 45-degree angle, similar
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.)

The ability to identify the epiglottis and then lift anteriorly to reveal progressively more of the glottic aperture
has led to a convenient system for grading the laryngoscopic view of any patient.24,25 A grade I laryngoscopic
view consists of visualization of the vocal cords in their
entirety. A grade II laryngoscopic view is visualization of
the posterior portion of the laryngeal aperture (arytenoid
cartilages) but not any portion of the vocal cords. A grade
III laryngoscopic view is visualization of the epiglottis but
not the posterior portion of the laryngeal aperture, and a
grade IV laryngoscopic view is visualization of the soft
palate but not the epiglottis. This grading system is necessarily subjective and skill dependent, but it does correlate
somewhat with difficult intubation.
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 stimulating 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 pharyngeal surface of the epiglottis is innervated by the glossopharyngeal nerve, whereas the superior laryngeal nerve
supplies the laryngeal surface of the epiglottis. Stimulation of the laryngeal surface of the epiglottis is thought
to predispose to laryngospasm and bronchospasm more
than stimulation of the pharyngeal surface of the epiglottis. Curved blades are thought to be less traumatic to the
teeth and to provide more room for passage of the ETT
through the oropharynx. However, straight blades provide
a better view of the glottis in a patient with a long, floppy

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 visualized. The esophagus is located just to the right of the midline and
posteriorly, and the esophageal opening is round and puckered
with no structure around it. (From Benumof JL, editor: Airway management: Principles and practice, St. Louis, 1996, Mosby, p 268.)

epiglottis or an anterior larynx. Straight blades are preferred 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
with a very long thyromental distance.
Four major common problems are encountered in performing laryngoscopy. First, with either laryngoscope
blade, inserting the blade too deeply into the pharynx
may elevate the entire larynx so that the opening of the
esophagus is visualized rather than the glottic aperture
(see Fig. 17-7). Insertion of a curved blade too far into
the vallecula and continued rotation of the handle to the
vertical may push the epiglottis down over the glottic
opening, resulting in limited exposure of the larynx (see
Fig. 17-8). The tracheal and esophageal openings are
usually easily distinguished. The esophagus is located just
to the right of the midline and more posteriorly, and the
esophageal opening is round and puckered, with no

Figure 17-8 Insertion of the laryngoscope blade too deeply into the
vallecula may push the epiglottis down over the laryngeal aperture,
diminishing exposure of the vocal cords. (From Benumof JL, editor:
Airway management: Principles and practice, St. Louis, 1996, Mosby,
p 267.)

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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

laryngoscope blade flange

structures around it. The glottis is located in the midline,

has a triangular shape, and contains the prominent knobs
of the arytenoids posteriorly and the pale white true
vocal cords bilaterally.
Second, it is important to keep the tongue completely
to the left side of the mouth with the flange of the laryngoscope blade. Many difficult or failed intubations result
from the tongue protruding over the flange of the blade
toward the right side of the mouth, obstructing a clear
path through which the vocal cords must be visualized
and the ETT passed (see Fig. 17-9B). Vision is obscured
further when the ETT occupies part of the view. With a
partially obstructed (tunnel) view the endoscopist can
partially visualize but not instrument the larynx. All of
the tongue must be to the left of the blade (Fig. 17-9A).
Third, in an effort to keep the tongue to the left, the
blade tip may be displaced to the right of the midline.
This position obscures the view of the epiglottis and may
precipitate trauma and bleeding from friable tissue in the
tonsillar bed. Especially with the use of the straight blade,
the shaft of the blade can be to the right of midline (over
the right molars), but the tip must reside exactly in the
midline of the hypopharynx. An assistant may be useful
in retracting the right cheek and enlarging the space to
the right of the blade, facilitating visualization of the
larynx, and introduction of the ETT.
Fourth, in barrel-chested, obese, or large-breasted
patients, it may be difficult initially to insert the blade of
a laryngoscope correctly into the mouth and avoid
obstruction to movement of the handle of the laryngoscope by the chest wall. In these patients, further initial
neck extension or a 45-degree rotation of the laryngoscope handle to the right permits easier introduction of
the blade of the laryngoscope into the mouth. Alternatively, a short laryngoscope handle (designed for this situation) may be used instead of the full-length handle.
The use of OELM can significantly improve the laryngoscopic view. For example, routine use of OELM may

Tongue on both sides of the laryngoscope

blade will obscure the laryngeal aperture

reduce the incidence of a grade III view from 9% to

between 1.3% and 5.4%.26 Although backward, upward,
and rightward pressure (BURP) placed on the thyroid
cartilage is typically the most useful OELM, it is best for
the laryngoscopist to determine what form of external
manipulation is optimal. This can best be accomplished
using his or her right hand when it becomes free after
the patients head is properly positioned (extended) and
mouth fully opened (see Fig. 17-10).

D. Endotracheal Tube
Insertion of the ETT is frequently easy after the vocal
cords are exposed and the tongue is out of the way (see
Fig. 17-9A). However, endotracheal intubation is often
problematic even if the vocal cords are visualized. Adult
tracheas readily accept ETTs with 7- to 10-mm internal
diameters (IDs) (see Chapter 36 for pediatric sizes). If it
is thought that fiberoptic bronchoscopy (FOB) will be
necessary subsequently for diagnosis or therapy, an 8-mm
or larger ETT should be used. If it is thought that the
space between the upper and lower teeth will be small,
allowing the cuff of the tube to come in contact with the
teeth, the distal part of the tube and cuff should be
lubricated to facilitate orotracheal intubation and protect
the cuff from tearing. In the case of limited mouth
opening, air should be evacuated from the cuff to allow
as low a profile as possible. The tip of the ETT should be
introduced into the far right corner of the mouth and
passed along an axis that intersects the line of the laryngoscope blade at the glottis. In this manner, the tube does
not block the view of the vocal cords down the channel
of the blade. The common error of trying to use the
laryngoscope blade as a midline guide, through which the
tube is passed, violates this principle, obscures vision, and
is a significant source of difficulty for the inexperienced
laryngoscopist. The tube tip is passed through the cords,
stopping 2cm after the tube cuff completely passes

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354 PART 4 The Airway Techniques

Determining optimal external layngeal
manipulation with free (right) hand

H
T
C

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
7. Reservoir bag having the appropriate compliance
8. Maintenance of arterial saturation by pulse oximetry
More Reliable Signs
1. Carbon dioxide (CO2) excretion waveform
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
by quickly pressing in the cephalad and posterior directions with the
right hand over the thyroid (T) (1), which is most common. The cricoid
(C) (2), and the hyoid cartilages (H) (3). If the laryngoscopic view is
critically improved by this maneuver, the laryngoscopist can use an
assistants hands or fingers as an extension of his or her own right
hand to reproduce the OELM. (From Benumof JL, editor: Airway management: Principles and practice, St. Louis, 1996, Mosby, p 268.)

through the vocal cords. Alternatively, when the external

tube markings at the level of 22 to 24cm reach the lower
incisors, the tip of the tube is at the midtrachea.7 The
laryngoscopist must not take his or her eyes off the laryngeal aperture until the cuff disappears just beyond the
vocal cords. The most common cause of inadvertent
esophageal intubation is failure to clearly see the tube
pass through the cords (and inspect it in situ after placement). The arytenoid cartilages frequently displace the
tube tip posteriorly into the esophagus unless care is
taken to pass the tip anteriorly and squarely into the
tracheal lumen.
The use of a stylet may be valuable in controlling the
direction of passage of an ETT. By providing increased
rigidity and malleability, it allows more control of the
tube. However, the ETT cannot be readily reshaped after
it is introduced past the teeth. Insertion of an ETT
through the mouth allows only two degrees of free movement: depth of insertion and rotation of the tip. The
direction of the tube tip can be changed only by rotation.
The ETT should be inserted as far to the right lateral
aspect of the mouth as possible to facilitate the motion
of the tip through torque applied to the connector end
of the ETT. When speed of intubation is important (e.g.,
in a patient with a full stomach), an ETT should always
be equipped with a stylet. A stylet should be easily malleable and well lubricated (although plastic-coated stylets
may be adequately slippery) and not extend beyond the
tip of the tube. Occasionally, a curved, styleted ETT
impinges on the anterior tracheal wall as it is being

inserted and after passage through the vocal cords. In

these circumstances, after the ETT tip is through the
vocal cords, the stylet should be withdrawn, which returns
the tip of the ETT to its inherent flexibility and permits
further passage distally.
After placement of the ETT, the laryngoscope is
removed from the mouth, and the cuff of the tube is
inflated to a cuff pressure of 22 to 32cm H2O. If a cuff
pressure gauge is unavailable, the tube is inflated until
moderate tension is felt in the pilot balloon to the cuff.
The tube should then be connected to a source of PPV
and held in place with one hand. The hand holding the
ETT in place should be securely resting against the cheek
(as a temporary fixation) until the ETT is secured to
prevent any sudden movement from dislodging the ETT.

E. Verification of Correct Placement

The next, most important task is to determine definitively that the tube has been inserted into the trachea
rather than the esophagus (Box 17-2). This issue is extensively discussed in Chapter 16, and only a brief summary
of the signs of endotracheal intubation is given here.
Helpful but not absolute signs of endotracheal intubation
consist of breath sounds in the axillary chest wall, lack of
breath sounds over the stomach, lack of gastric distention, chest rise with inspiration, large exhaled tidal
volumes (Vt), the sound of air exiting from the ETT
when the chest is compressed, and appropriate compliance of a reservoir bag during hand ventilation. A progressive decrease in SpO2 may indicate failure to intubate
the trachea, but it is a very late sign of esophageal intubation (especially on 100% O2), and it may also indicate
bronchospasm, endobronchial intubation, aspiration,
kinking of the tube, machine or equipment malfunction,
or merely the normal response delay inherent in pulse
oximetry.
More reliable signs of endotracheal intubation are the
presence of a normal CO2 waveform (capnogram) and

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CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation 355

rapid expansion of a large rubber tracheal indicator bulb

(see Chapter 16). Cardiac arrest (when no CO2 is
excreted), severe bronchospasm, or kinking or plugging
of the ET may prevent the appearance of CO2 in the
exhaled gas (false-negative finding), and CO2 may appear
if the tip of the tube is proximal to but near the larynx
(false-positive finding). The self-inflating bulb has high
sensitivity and specificity in normal patients, but it has a
significant false-negative rate in obese patients.27
The only absolutely reliable methods of definitively
determining endotracheal intubation are direct observation of the ETT going through the vocal cords and the
use of FOB. Direct visualization of the tube lying in the
glottic opening may be enhanced by displacing the tube
posteriorly, which may pull the glottic opening posteriorly and into a better view. FOB allows visualization of
the cartilaginous rings of the trachea and the tracheal
carina but is not an accepted practice for routine determination of correct tube placement.
If a CO2 waveform, breath sounds, and chest movement are lacking, the anesthesiologist should remove the
ETT, ventilate the patient with a mask-bag system several
times with 100% O2, and attempt endotracheal intubation again after inspecting the used tube for defects or
plugs in the lumen. Changes in the shape or curvature of
the ETT and in the position of the head and neck, as well
as the need for anterior tracheal pressure, should be considered and coordinated during the period of mask
ventilation.
The next task is to ascertain that the tip of the ETT
is above the carina. This is done by observing equal
expansion of both hemithoraces and by stethoscopic
examination for breath sounds throughout both peripheral lung fields. However, hearing uniform breath sounds
throughout all lung fields does not guarantee correct tube
position. If there is any question about a possible main
stem bronchus intubation, the physician should retract
the tube about 1cm at a time and reexamine the breath
sounds (stopping before complete withdrawal above the
vocal cords). In one study, an insertion depth of 20 to
21cm in adult women and 22 to 23cm in adult men
resulted in no incidence of main stem bronchial intubation.28 Simultaneous palpation of pulsed pressures in the
cuff in the suprasternal notch and the pilot balloon of the
cuff is another simple way of determining the location of
the tube in the trachea. FOB is another, but complex,
way of determining the location of the tube in the trachea.
Outside the operating room, it is always advisable to
confirm ETT position by chest radiography. Ideally, the
tip of the tube should be 2 to 4cm above the carina at
the clavicular (midtracheal) level.
When the ETT is placed and during taping of the tube,
the marking of the ETT at the level of the teeth should
be noted for reference should the tube become
displaced.

F. Securing the Endotracheal Tube

After the depth of the ETT at the tooth level has been
confirmed, the tube should be tightly secured in place.
This is important to prevent accidental extubation and
to minimize tube movement within the airway. Taping

the tube to the facial skin with adhesive tape is the most
common method of securing the ETT.
The skin of the maxilla should be considered the
primary source of fixation for an orotracheal tube because
it is less mobile and therefore less likely to allow excessive
motion of the tube within the airway. The tube then lies
along the palate and is less likely to be displaced by the
tongue of a conscious patient. The fixation of the tube in
place can be improved by having the lateral ends of the
tape completely encircle the neck; however, the risk of
restriction of venous return from the head (especially
with intracranial pathology) requires careful consideration. Application of tincture of benzoin to the skin
before the tape is applied helps provide a stronger bond
between the tape and skin. In case of prolonged intubation, changing the tape and reapplying it to a new area
on the face every 2 days helps prevent maceration of
the skin.
In patients with beards or in whom the adhesive tape
fails to stick to the skin, the tube can be tied into the
place with a length of umbilical tape that is knotted
around the tube and then encircles the neck. Adhesive
tape may be used over the umbilical tape for added
security. A surgical face mask, reversed so that the ties
are in front and the mask at the occiput, can serve as a
reasonable, temporary means of fixation. Another reliable
method of securing an orotracheal tube is to wire the
tube to a tooth. One or two layers of adhesive tape are
wrapped around the tube at the level of the upper incisor
teeth. Stainless steel wire (25 to 28 gauge) is passed
around an upper incisor tooth and twisted around the
tape on the ETT. In anesthetized patients, a suture may
be passed through the gum and then around a ring of
adhesive tape on the ETT (as with wire) or through the
wall of the ETT and then tied to the tube. A bite block,
rolled gauze, or an oropharyngeal airway (used in most
endotracheal intubations for general anesthesia) should
be placed between the teeth to prevent the patient
from biting down and occluding the lumen of an oral
tube. Numerous commercial products are available to
attempt to improve the stability, patients comfort,
and convenience of stabilizing and immobilizing an
orotracheal tube.

III. LARYNGOSCOPIC NASOTRACHEAL

INTUBATION
Nasotracheal intubation usually is a more difficult procedure than orotracheal intubation. However, nasal tubes
are thought to be better tolerated than oral tubes, and
nasal tubes have been considered the tube of choice for
medium-term mechanical ventilation. The issue of nasotracheal tubes contributing to the development of sinusitis and pneumonia has been investigated, and existing
evidence has not demonstrated an association.29 Nonetheless, the use of nasotracheal intubation for longer-term
ventilation has been declining in favor of orotracheal
intubation or early tracheostomy. The use of nasotracheal
tubes is currently confined to surgical procedures
requiring free access to the oropharynx (e.g., dental procedures, mandibular fixation) and to some pediatric procedures in which stability and security of the tube are of

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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)
and then passed through the nasal cavity and nasopharynx to the oropharynx. After the tube has been passed
into the oropharynx, it can be guided into the glottis
under conventional direct laryngoscopic vision, or it can
be grasped by a Magill forceps and directed into the
glottis. Nasotracheal intubation is accompanied by a transient bacteremia, and endocarditis prophylaxis should be
used in susceptible patients.

A. Preparation
Before insertion of the single-lumen nasotracheal tube,
the nasal mucosa should be sprayed with a vasoconstrictor drug. Vasoconstriction of blood vessels in the nasal
mucosa minimizes bleeding related to the unavoidable
trauma, and it increases the diameter of the nasal passages
by constricting (shrinking) the nasal mucosa. Softening
the tip of the nasotracheal tube by soaking it in a warm
saline solution may decrease the incidence of mucosal
damage and bleeding. The naris selected should be the
one that the patient thinks is the most patent (because
of the significant incidence of septal deviation in patients).
However, if both nares offer equal resistance, the right
naris should be chosen because the bevel of the nasotracheal tube, when introduced through the right naris,
more easily passes the vocal cords (Fig. 17-11).
The question of potential trauma to the turbinates by
the open bevel of the tube and the best orientation of
the bevel in passing the turbinates has not been resolved.
There is a risk that the tube tip, in passing the inferior
turbinate, may strike and damage or avulse the turbinate.
In the worst case, the turbinate may be dislodged and
occlude the lumen of the tube, causing epistaxis and
complete tube obstruction. Care must be taken to pass
the tube along the floor of the nose below the inferior
turbinate and to avoid any excessive force in advancing
the tube. Other measures may include preliminary vasoconstriction, 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
not been demonstrated to change the incidence of this
complication.
In most adults, tubes with a 7.0 to 7.5mm ID pass
easily through the nares. Other prelaryngoscopic maneuvers described under direct-vision orotracheal intubation
(positioning of the head, suctioning, and preoxygenation)
should be performed for direct-vision nasotracheal intubation. The nasotracheal tube should be lubricated and
passed through the nose in one smooth, posterior, caudad,
medially directed movement until resistance to forward
movement significantly decreases as the tube enters the
oropharynx (usually at a distance of 15 to 16cm). Significant resistance should be overcome not by force but
by withdrawal, rotation, and reinsertion of the ETT. Difficult passage should prompt the selection of the opposite
nostril or of a smaller tube.
The pathway that the nasotracheal tube takes should
be visualized as lying on its side. The curve of the ETT

Superior
Turbinates

Middle
Inferior

Right
nares

S
e
p
t
u
m

Bevel facing
to the right

Bevel faces turbinates

and away from septum
in patients right nostril

S
e
p
t
u
m

Left
nares

Superior
Middle

Turbinates

Inferior

Bevel facing
to the left

Tube is rotated 180

(compared to panel A)
bevel faces turbinates
and away from septum
in patients left nostril

Figure 17-11 Insertion of a nasotracheal tube into the nares.

A, When the nasotracheal tube is passed into the right naris, the
bevel should be facing to the right toward the turbinates (inset). In
this way, the tip of the tube is against the septum, and the risks of
catching the tip of the tube on a turbinate and tearing or dislocating
it are minimized. In this orientation, the concavity of the tube is pointing anteriorly. B, When the nasotracheal tube is passed into the left
naris, the bevel should be facing to the left toward the turbinates
(inset). In this way, the tip of the tube is against the septum, and the
risks of catching the tip of the tube on a turbinate and tearing or
dislocating it are minimized. In this orientation the concavity of the
tube is pointing posteriorly. (From Benumof JL, editor: Airway management: Principles and practice, St. Louis, 1996, Mosby, p 273.)

should be aligned to facilitate passage along this curved

course. As the tube passes through the nose into the
nasopharynx, it must be directed inferiorly to pass
through the pharynx. In making this turn, it may strike
against the posterior nasopharyngeal wall and resist any
attempt to push it further. The tube should be pulled
back a short distance, and the patients head should be
extended further to facilitate attempts to pass this point
smoothly and atraumatically. If this is not performed and
the tube is forced, the mucosal covering of the posterior
nasopharyngeal wall may be torn, and the tube may be
passed into the submucous tissues. This false passage is
accompanied by a boggy feeling and by complete obstruction of the tube lumen.

B. Laryngoscopy
The laryngoscopy for nasotracheal intubation is identical
to that described for orotracheal intubation.

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CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation 357

C. Endotracheal Intubation
After the tube is in the oropharynx, the tip of the tube
must be aligned with the glottic opening. This requires
that the tip of the tube be visible in the hypopharynx.
The tube should be advanced or withdrawn until this is
the case. A combination of tube rotation and repositioning of the head may allow clear passage of the tube tip
into the trachea, but it is likely that the tube will require
guidance using Magill forceps held in the intubators right
hand.
The advantage of the design of these forceps is that
when the grasping ends are parallel to the long axis of
the ETT, the handle is outside the right side of the mouth
and at a right angle to the long axis of the tube. Because
the handle is outside the right side of the mouth, it is
away from the line of sight. As the forceps are grasped
parallel to the long axis of the tube, a backhand motion
of the right hand passes the ETT toward the glottic
opening (Fig. 17-12). The intubator can have the larynx

Guiding a nasotracheal tube into the

larynx using a Magill forceps

Rotate hand
(as in a backhand
hit of a ping-pong ball)

exposed by the laryngoscope held in the left hand, the

tube in full view, a means (using the forceps) of manipulating the alignment of the ETT, and a means of advancing the tube. However, it is often desirable to have an
assistant advance the proximal end of the ETT so that
the intubator is free to guide the tube into the larynx
without having to pull it with the Magill forceps. The tip
of the tube should be grasped to guide it into the trachea;
grasping the cuff area is likely to lead to cuff trauma and
possible damage. The addition of a small amount of air
into the ETT cuff should center the tube within the
glottis, and as the ETT is advanced, the cuff deflates.
In some patients, as the ETT enters the trachea, the
tubes anterior curvature may direct it against the anterior tracheal wall and interfere with passage past this
point. To resolve this difficulty, the head must be lifted
(flexed) slowly as the ETT is advanced. A nasotracheal
tube should be advanced until the cuff is 2cm below the
vocal cords or until the external markings are 24 to
25cm for women and 26 to 27cm for men (3cm more
than for oral ETTs) at the nares. The tubes correct placement must be verified as in any intubation (see Verification of Correct Placement), but this is particularly
critical with nasotracheal intubations because the relation
to external tube markings and the location of the tip are
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,
the ETT can be retracted and the cuff inflated to provide
better tamponade.

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 adhesive 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 intrinsically hazardous field of airway management. Mastery of
the art begins with a mastery of the fundamentals.
Although practiced by a wide variety of health professionals, laryngoscopic intubation is an extraordinarily
complex and continually evolving branch of anesthesiology and critical care.

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

vision (laryngoscopic control) through the laryngeal aperture with a
Magill forceps by rotating the hand as when using a backhand
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,
editor: Airway management: Principles and practice, St. Louis, 1996,
Mosby, p 275.)

V. CLINICAL PEARLS
Redundancy is the key to adequate preparation. All
essential equipment (laryngoscopy handles and ETTs)
should have back-up counterparts readily available in
case of unexpected failure.

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358 PART 4 The Airway Techniques

Proper positioning is essential to successful intubation.

Atlanto-occipital extension is the most critical component of positioning. The sniffing position (with the
occiput elevated 9cm) may provide a more favorable
laryngoscopic view.
Preoxygenation delays the onset of hypoxemia by denitrogenating the lungs and filling the functional residual
capacity (FRC) with O2. The benefit of preoxygenation
is limited in morbidly obese patients due to a decrease
in FRC and an exaggerated cephalad diaphragmatic
shift related to supine positioning.
Although numerous techniques for tracheal cannulation exist, direct laryngoscopy is by far the most
common technique.
The tip of the laryngoscopic blade is inserted into the
right side of the mouth and advanced toward the
midline base of the tongue, displacing the tongue to
the left side of the mouth. Lifting of the laryngoscopists arm at a 45-degree angle from the long axis of
the patient without moving the wrist exposes the epiglottis while minimizing risk of injury to the airway.
The tip of a curved blade is inserted into the vallecula,
thereby tensing the hypoepiglottic ligament, lifting the
epiglottis, and exposing the arytenoids and glottic
opening. The tip of a straight blade is extended beneath
the laryngeal surface of the epiglottis, and subsequent
upward and forward movement of the blade exposes
the glottic opening.
The use of a curved blade is thought to be less stimulating and less traumatic to the teeth and epiglottis
than a straight blade, and it may provide more room
for passage of the ETT through the oropharynx. A
straight blade may provide a better view in a patient
with a long epiglottis or anterior larynx.
The use of optimal external laryngeal manipulation
(OELM) can significantly improve the laryngoscopic
view.
It is essential to confirm endotracheal intubation by
auscultation of breath sounds, chest wall excursion,
lack of gastric sounds or distention, large exhaled Vt
value, and a normal capnogram finding.

The most common cause of inadvertent esophageal

intubation is failure to clearly visualize the ETT pass
through the vocal cords.
Depths of 20 to 21cm for women and 22 to 23cm
for men can safeguard against endobronchial intubation during orotracheal intubation.
The ETT must be tightly secured to prevent inadvertent extubation or tube movement within the airway.
Because nasotracheal intubation is thought to be better
tolerated and has not been shown to be associated with
an increased incidence of sinusitis, it is preferred over
orotracheal intubation for medium-term mechanical
ventilation. The nasal mucosa should be pretreated
with a vasoconstrictor drug to facilitate nasotracheal
intubation and to minimize the risk of trauma. Gentle
head flexion may assist in the passage of a nasotracheal
tube as it contacts the anterior tracheal wall.
SELECTED REFERENCES
All references can be found online at expertconsult.com.
6. Jackson C: Bronchoscopy, oesophagoscopy, and gastroscopy, ed 3,
Philadelphia, 1934, WB Saunders.
8. Bannister FB, MacBeth RG: Direct laryngoscopy and tracheal intubation. Lancet 2:651, 1944.
9. Adnet F, Baillard C, Borron SW, et al: Randomized study comparing
the sniffing position with simple head extension for laryngoscopic
view in elective surgery patients. Anesthesiology 95:836841,
2001.
13. Greenland KB, Edwards MJ, Hutton NJ, et al: Changes in airway
configuration with different head and neck positions using magnetic
resonance imaging of normal airways: A new concept with possible
clinical applications. Br J Anaesth 105:683690, 2010.
17. Gold MI, Duarte I, Muravchick S: Arterial oxygenation in conscious
patients after 5 minutes and after 30 seconds of oxygen breathing.
Anesth Analg 60:313315, 1981.
20. Jense HG, Dubin SA, Silverstein PI, OLeary-Escolas U: Effect of
obesity on safe duration of apnea in anesthetized humans. Anesth
Analg 72:8993, 1991.
21. Teller LE, Alexander CM, Frumin MJ, Gross JB: Pharyngeal insufflation of oxygen prevents arterial desaturation during apnea. Anesthesiology 69:980982, 1988.
23. Miller RA: A new laryngoscope. Anesthesiology 2:317320, 1941.
24. Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics.
Anaesthesia 39:11051111, 1984.
25. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P: Predicting
difficult intubation. Br J Anaesth 61:211216, 1988.

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CHAPTER 17 Laryngoscopic Orotracheal and Nasotracheal Intubation 358.e1

REFERENCES
1. Hooke R: The technique of insertion of intratracheal insufflation
tubes. Philos Trans R Soc 2:539, 1667.
2. Snow J: On chloroform and other anaesthetics, London, 1858, John
Chruchill.
3. Trendelenburg F: Beitrage zur den Operationen an den Luftwegen.
2. Tamponnade der Trachea. Arch Klin Chir 12:121, 1871.
4. Matas R: I. On the management of acute traumatic pneumothorax.
Ann Surg 29:409434, 1899.
5. Magill IW: Endotracheal anesthesia, Am J Surg 24:450455, 1936.
6. Jackson C: Bronchoscopy, oesophagoscopy, and gastroscopy, ed 3,
Philadelphia, 1934, WB Saunders.
7. Jackson C: An account of an experiment made by M. Hook of
preserving animals alive by blowing through their lungs with
bellows. Surg Gynaccol Obstet 17:507, 1913.
8. Bannister FB, MacBeth RG: Direct laryngoscopy and tracheal intubation. Lancet 2:651, 1944.
9. Adnet F, Baillard C, Borron SW, et al: Randomized study comparing
the sniffing position with simple head extension for laryngoscopic
view in elective surgery patients. Anesthesiology 95:836841, 2001.
10. Adnet F, Borron SW, Dumas JL, et al: Study of the sniffing position by magnetic resonance imaging. Anesthesiology 94:8386,
2001.
11. Adnet F, Borron SW, Lapostolle F, Lapandry C: The three axis
alignment theory and the sniffing position: perpetuation of an
anatomic myth? Anesthesiology 91:19641965, 1999.
12. Benumof JL: Comparison of intubating positions: The end point for
position should be measured. Anesthesiology 97:750, author reply
754, 2002.
13. Greenland KB, Edwards MJ, Hutton NJ, et al: Changes in airway
configuration with different head and neck positions using magnetic
resonance imaging of normal airways: A new concept with possible
clinical applications. Br J Anaesth 105:683690, 2010.
14. Park SH, Park HP, Jeon YT, et al: A comparison of direct laryngoscopic views depending on pillow height. J Anesth 24:526530,
2010.
15. Lee L, Weightman WM: Laryngoscopy force in the sniffing position
compared to the extension-extension position. Anaesthesia 63:375
378, 2008.

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

comparison of three minutes and four breaths. Anesth Analg
66:468470, 1987.
17. Gold MI, Duarte I, Muravchick S: Arterial oxygenation in conscious
patients after 5 minutes and after 30 seconds of oxygen breathing.
Anesth Analg 60:313315, 1981.
18. Baraka AS, Taha SK, Aouad MT, et al: Preoxygenation: comparison
of maximal breathing and tidal volume breathing techniques. Anesthesiology 91:612616, 1999.
19. Nimmagadda U, Salem MR, Joseph NJ, et al: Efficacy of preoxygenation with tidal volume breathing. Comparison of breathing
systems. Anesthesiology 93:693698, 2000.
20. Jense HG, Dubin SA, Silverstein PI, OLeary-Escolas U: Effect of
obesity on safe duration of apnea in anesthetized humans. Anesth
Analg 72:8993, 1991.
21. Teller LE, Alexander CM, Frumin MJ, Gross JB: Pharyngeal insufflation of oxygen prevents arterial desaturation during apnea. Anesthesiology 69:980982, 1988.
22. Macintosh RR: An aid to oral intubation. Br Med J 1:28, 1949.
23. Miller RA: A new laryngoscope. Anesthesiology 2:317320, 1941.
24. Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics.
Anaesthesia 39:11051111, 1984.
25. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P: Predicting
difficult intubation. Br J Anaesth 61:211216, 1988.
26. Knill RL: Difficult laryngoscopy made easy with a BURP. Can J
Anaesth 40:279282, 1993.
27. Lang DJ, Wafai Y, Salem MR, et al: Efficacy of the self-inflating bulb
in confirming tracheal intubation in the morbidly obese. Anesthesiology 85:246253, 1996.
28. Sitzwohl C, Langheinrich A, Schober A, et al: Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral
auscultation, or observation of chest movements: randomised trial.
BMJ 341:c5943, 2010.
29. Holzapfel L, Chevret S, Madinier G, et al: Influence of long-term
oro- or nasotracheal intubation on nosocomial maxillary sinusitis
and pneumonia: Results of a prospective, randomized, clinical trial.
Crit Care Med 21:11321138, 1993.

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Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2016. Elsevier Inc. Todos los derechos reservados.