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1) Place tracheal tube (preferably Endotrol or Parker articulating tip tube) blindly to a depth of 14-16 cm.
With tube advanced to 14-16 cm at nare, tube tip should be just above larynx. Breath sounds should be audible through the tracheal tube.
2) After additional anesthesia directed at larynx (topical lidocaine), and adjunctive medications (as needed, such as 10 mg aliquots of ketamine, or benzodiazepines with narcotics), run the long scope through the tube, visualize the larynx and pass between the cords, to the carina. The goal of using a tube-first approach is to minimize the duration the fiberscope is between the cords, and also abbreviate the time required to advance the tube into the larynx.
3) With the carina visualized, tube advancement off scope requires counter-clockwise rotation (90-180ยบ) to reduce the gap between tube and scope, which would otherwise cause resistance at right aryepiglottic fold (see images below, shown below with a bougie, but the same principle applies).This CCW rotation is only needed with tracheal tubes that have an asymmetric left-sided bevel---it is not needed with a Parker ski-tip shaped tracheal tube. The final depth of insertion of the tracheal tube should be 26-28 cm at the nare. |
