critical care medicine
Tracheal Intubation
Alternative Intubation Devices
A number of devices and techniques can be used for intubation after failed laryngoscopy or as a primary means of intubation. Devices include How To Do Orotracheal Intubation Using Video Laryngoscopy None Laryngeal Mask Airways (LMA) (LMAs) with a passage that allows tracheal intubation Other supraglottic airways Fiberoptic scopes and optical stylets Tube introducers Each device has its own subtleties; practitioners who are skilled in standard laryngoscopic intubation techniques should not assume they can use one of these devices (especially after the patient as been given muscle relaxants) without becoming thoroughly familiarized with it. Video laryngoscopesenable practitioners to look around the curvature of the tongue and usually provide excellent laryngeal views. However, some video laryngoscopes require that the endotracheal tube have an exaggerated bend angle to go around the tongue and thus may be more difficult to manipulate and insert. have a passage to allow endotracheal intubation. To pass an endotracheal tube through a Laryngeal Mask Airways (LMA) , practitioners must understand how to optimally position the mask over the laryngeal inlet; there are sometimes mechanical difficulties passing the endotracheal tube. Supraglottic airwayscan allow placement of an airway if an optimal laryngeal view cannot be obtained or an endotracheal tube cannot be passed through the cords (eg, abnormal anatomy, subglottic stenosis). Flexible fiberoptic scopes and optical styletsare very maneuverable and can be used in patients with abnormal anatomy. However, practice is required to recognize laryngeal landmarks from a fiberoptic perspective. Compared with video laryngoscopes, fiberoptic scopes are more difficult to master and are more susceptible to problems with blood and secretions; also, they do not separate and divide tissue but instead must be moved through open channels. Tube introducers(commonly called gum elastic bougies) are semirigid stylets that can be used when laryngeal visualization is suboptimal (eg, the epiglottis is visible, but the laryngeal opening is not). In such cases, the introducer is passed along the undersurface of the epiglottis; from this point, it is likely to enter the trachea. Tracheal entry is suggested by the tactile feedback, noted as the tip bounces over the tracheal rings. An endotracheal tube is then advanced over the introducer. During passage over a tube introducer, the tube tip sometimes catches the right aryepiglottic fold. Rotating the tube 90° counterclockwise often frees the endotracheal tube tip and allows it to pass smoothly. 