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Direct Laryngoscopy

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Bimanual Laryngoscopy

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Trachea vs Esophagus


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Techniques for Nasal Intubation
Techniques for Nasal Intubation

Direct Laryngoscopy

Curved Blade Laryngoscopy Technique

image #75

Opening the mouth using a scissor technique:

1) First and third fingers, as shown above, provide more mechanical advantage than the first and second fingers.

2) The fingers should be removed after blade insertion and identification of the epiglottis edge.


Epiglottoscopy – the key to first pass intubation success:


image image

Initial blade insertion is with the laryngoscope handle pointed at the patient’s feet. The tongue and jaw are distracted downward to insert the blade. Minimal force is required for downward jaw distraction, assuming the head is not overextended.

The tip of the blade gets around base of tongue, permitting change in angle of lifting and better mechanical advantage. Epiglottis edge is lifted off the pharyngeal wall. The epiglottis is often camouflaged against the mucosa of the posterior pharynx.

With full insertion of the curved blade into the vallecula the angle of lifting changes to ~40 degrees from the horizontal. Once the tip is fully in the vallecula, the lifting force can be increased as needed. Tip position (not force) is the main determinant of glottic exposure.


Epiglottis identification is essential

Tongue control and epiglottis identification occur almost simultaneously. If the epiglottis is not seen, back out, use a midline approach to methodically advance down the tongue to find the epiglottis edge, and then control the tongue.

1) Without epiglottis identification, it is impossible to reliably progress to the next landmarks.

2) The appearance of the epiglottis is identical to the mucosa of the posterior pharynx; only by lifting the edge of the epiglottis off the posterior pharynx does the epiglottis become visible. Blood, secretions, and vomitus all pool in the posterior pharynx and make epiglottis identification more challenging.

Pocket Guide Image # 79 Pocket Guide Image # 80

Minimal change in force and position of the laryngoscope blade tip can effect a significant change in the visibility of the epiglottis edge. The epiglottis frequently lies on the posterior pharyngeal wall. Excessive atlanto-occipital extension will push tongue and epiglottis backward; head elevation opens up hypopharyngeal space. Have suction ready for blood and secretions.


Pocket Guide Image # 79 Pocket Guide Image # 80

(Above): Laryngeal landmarks through an anterior neck dissection. White arrowhead marks the interarytenoid notch.



image #82The epiglottis is the physical and visual bridge from the tongue (where laryngoscopy starts) to the glottic opening (the goal). It is the most superior aspect of the laryngeal inlet. The next structures seen after the epiglottis will be the posterior cartilages and the interarytenoid notch. The glottic opening and vocal cords are more anterior inside the larynx.

After the epiglottis is identified the blade is repositioned toward the right side, allowing the tongue to fall toward the left side of the mouth.


In actual practice, tongue control and epiglottis identification occur almost simultaneously. If needed, a methodical midline advancement of the blade down the tongue is a reliable way to find the epiglottis.


Expert laryngoscopists identify the epiglottis with initial blade insertion; novices move the tip of the laryngoscope in and out repeatedly, taking more time and moving the blade more.


Tongue control after finding the epiglottis is not difficult if minimal upward force is initially applied to distract the jaw.



Laryngoscopy is a predictable sequence of progressively visualized structures

(1) tongue and uvula

(2) epiglottis

(3) posterior cartilages, interarytenoid notch

(4) glottic opening

(5) vocal cords

84 85


205 87

The interarytenoid notch is visible as a thin vertical cleft between the rounded prominences of the posterior cartilages.The interarytenoid notch marks the most posterior aspect of the laryngeal inlet. Above this notch is the glottic opening and below this landmark is the upper esophagus.

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The posterior portion of the glottic opening comes into view before the vocal cords, which are more anterior and deeper within the larynx.The vocal cords have a distinctive white appearance. They are often poorly illuminated in curved blade laryngoscopy because of shadowing by the epiglottis.


Images # 90-91 Pocket Guide Images # 90-91 Pocket Guide

Curved blade laryngoscopy entirely depends upon how the tip of the blade fits within the vallecula. Pressure on the underlying hyoepiglottic ligament causes the epiglottis to lift upward. External laryngeal manipulation – bimanual laryngoscopy (large arrow) – effectively drives the tip of the blade into proper position (improving indirect epiglottis elevation) and moves the larynx down into the line of sight.


Straight Blade Laryngoscopy Technique

Sequential landmarks and tube delivery with a Miller blade

striaght sequence
Note the position of the blade all the way to the right (right of the right nostril), and tube delivery using the extreme right corner of the mouth.


Effective control of the tongue is critical for straight blade use.  The small flange height prevents any ability to sweep the tongue.  Proper position is achieved with straight blades by deliberately directing the blade to the right paraglossal space. No tongue should be present to the right of the blade.  Full insertion of the blade should occur through the right lateral mouth, over the molar dentition, and while the distal blade may then be directed medially, the proximal blade should never be brought back towards the midline, otherwise it will hit the central incisors.

After the epiglottis edge is identified, the handle must be tilted forward (e.g., the tip moves backward, toward the posterior hypopharynx). The blade is then inserted slightly farther (~1-2 cm), and the tip passed under the epiglottis.  Once the epiglottis is “trapped” under the blade tip, the blade is rocked slightly backward (handle brought slightly more upright) and then the lifting force increased.

The distal tip of the Miller blade is invisible to the operator when viewed down the long axis (because it is upturned).  Often the laryngoscopist does not know if the blade has been advanced far enough to trap the epiglottis until the blade is rocked backward; sometimes the tip of the epiglottis is not trapped, and the advancement and tilting maneuver needs to be repeated.

Bimanual laryngoscopy and head elevation are both helpful in straight blade laryngoscopy.  Bimanual laryngoscopy helps by moving the larynx posteriorly into the operator’s line of sight (it has no mechanical effect on the epiglottis, since the epiglottis is already trapped under the tip of the straight blade).  Tube delivery should be done using the extreme right corner of the mouth, and come up from below the line of site.  An adult tube will not fit through the lumen of a Miller blade (and should not be attempted).

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