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How Do You Do That Airway Voodoo That You Do So Well?

“Okay, so how do you bridge from a King LT airway to an endotracheal tube? I’m not familiar with the procedure, and I’m having trouble visualizing it.”

A reader e-mailed me that question a while back, in response to something I wrote in this post. At first, I thought I’d write a simple reply to him detailing how it’s done, but then I said to myself, “Self, a lot of people might like to know that particular nugget as well, and it gives you a chance to talk out of your ass wax philosophic about airway management.”

First, what qualifies me to talk as an expert about airway management?

Answer: not much.

I have no idea of the number of intubations I’ve performed successfully. I quit counting after my paramedic clinical rotations. During my OR rotations, I went 34 for 34 on intubation attempts. A few years later, I had occasion to review three years worth of run data at the Little Ambulance Service That Could, while I was preparing a proposal to add Rapid Sequence Induction to the scope of practice for Louisiana paramedics.

I discovered that, in the three years I’d been a medic, I’d gotten 37 of 38 intubation attempts. The one I missed, I was able to bag successfully for the twenty minute trip to the hospital.

In the fifteen years I’ve been a medic, there  have been four nasotracheal intubations, a few RSIs, and two memorable occasions where I performed digital intubations – both done lying flat on my back, with the patient suspended above me.

Both of those patients died, by the way, but not for lack of an airway or ventilation.

Add another few dozen ET tubes over the next five years at TLASTC, quite a few more during my years working for the Wal Mart of EMS, and the ones I’ve dropped during my current stint at The Borg. Both of those latter two companies track such things, but I never really bothered to track any number other than the ones I’ve missed.

And that number is seven.

Three of those got Combitubes, one got a King LT airway, and two more got an LMA. The first tube I ever missed  was bagged successfully with just a BVM.

Now, I’ve dropped a few more Kings and LMAs, and even a few Cobra airways over the years, but all of those were done as a first attempt. I never attempted intubation on any of those, and most of those were done, well… unofficially. You guys who have worked rural EMS know what it’s like to be the unofficial Code Team for a rural hospital. I’ve been called to a Bandaid station community hospital ER more than a few times to drop a tube that the doctor couldn’t get himself. On a few of those occasions, I didn’t bother to attempt intubation, opting for a supraglottic airway instead.

So there you have it. In fifteen years, seven missed intubation attempts. And I’ve never had a missed esophageal intubation nor, to my way of thinking, had a failed airway. Every time I’ve needed to ventilate someone, or protect against aspiration, I’ve found a way to do it effectively.

How many successful intubation attempts I’ve done, I have no idea, but the number probably approaches a couple of hundred. It’s certainly not many more than that.

It’s worth noting, however, that the American Society of Anesthesiology  considers the minimum competency for an anesthesiologist to be 200 successful intubation attempts. Viewed in that light, I’m less Airway Samurai than I am rookie practitioner still on the wrong side of marginally competent.

So those are my credentials: probably a good bit less than a medic who has worked a busy urban system for 20 years, and nowhere approaching that of an experienced anesthesiologist. Still, I am not without experience and insight.

Because, you see, it’s not how many notches you’ve carved on your laryngoscope handle, but what you’ve learned from each one of them. As I’ve said before, there are a few medics with twenty years of experience, and many, many more with one year of experience, repeated twenty times. The corollary to that is that there are a few airway experts with a couple thousand successful tubes, and likely many more with twenty successful tubes, repeated a hundred times.

I’ve written about the mindset necessary to effective airway management in the post entitled A Treatise On Marksmanship, and in columns and lectures on The Airway Continuum. If you haven’t read those, I encourage you to go check them out. You may find them enlightening, and I’ll be here when you get back.


Okay, everybody back? Good.

Now, I’m not going to presume to alter anyone’s intubation technique. Aside from the fundamentals, like staying off the teeth, holding the scope in your left hand, and things of that sort, intubation technique is as personal and varied a thing as, say, a golf swing. How pretty it looks isn’t as important as practicing it enough that it’s infinitely repeatable.

Then again, maybe I should talk about technique a bit. After all, not all medics received the same level of instruction. I once had a preceptor, a very experienced CRNA, tell my students that it didn’t matter so much if you broke a few teeth now and then, that sometimes it was inevitable. That same preceptor also took it upon himself to correct a few of my female students’ technique, which actually made it harder for them to intubate someone.

I lost a great deal of respect for that preceptor that day, but I learned a very important lesson: Just because someone has far more experience and training than you, doesn’t mean they’ve learned anything from it.

As I said before, twenty successful intubations, repeated a hundred times.

So, on second thought, I will offer just one critique of what many people consider proper technique. If, when intubating, your left elbow is akimbo, pull it in towards the midline of your body. You should be able to draw a straight line through your shoulder and left forearm, a line that tracks across the left side of your patient’s face,  extending to an imaginary point high on the wall beyond the patient’s feet.

Have you ever seen someone trying to intubate, grunting and straining to displace the jaw forward, with their elbow all cocked to one side, hand and arm shaking with the exertion? Or perhaps you’ve done it yourself. One of the most common refrains I hear from airway novices – petite female nurses, usually –  is, “My arm just isn’t strong enough to do this!”


If you’re relying more on arm strength than finesse, you’re doing it wrong. I can take the biggest snowman out there, with no neck to speak of, and displace his lower jaw enough to pass an endotracheal tube, using nothing more than the index finger and thumb of my left hand. For the infrequent patient where that isn’t sufficient, I have other tricks up my sleeve, which we’ll get to in a minute.

So whether you’re one of those “sweep the tongue to the left” types or the medic who walks the blade down the tongue incrementally, if you find yourself straining to displace  the jaw, pull your left elbow back in line with your body. It makes for much better body mechanics, allowing you to use the strength of your shoulder, and your upper body weight, if need be. Heck, if necessary, brace your left forearm on the patient’s face and forehead. Unless they’ve got massive facial fractures, you’re not going to hurt them by doing it.

Now, for the infrequent patient where manual displacement of the jaw isn’t sufficient, comes the first of my little airway tricks: try external laryngeal manipulation (ELM).

Any medic who has wielded a laryngoscope a few times has either asked for, or provided, cricoid pressure. Sellick’s Maneuver, as it is often called, is an excellent technique for limiting air entry into the esophagus, or just as importantly, for keeping vomit from coming up. When you need to occlude the esophagus, it works well.

But if you’re trying to visualize the glottic opening during laryngoscopy, there’s a better way to do it, and that way is called the BURP technique.

Rather than manipulating the cricoid cartilage, BURP involves directed manipulation of the thyroid cartilage. It stands for Backwards, Upwards, Rightward Pressure.

Facing the patient, place your thumb and index finger on either side of the thyroid cartilage – the Adam’s Apple – and press back towards the spine, up towards the top of the head, and rightward pressure in the direction of the patient’s right ear.

Try this on a manikin, and you’ll see the difference it makes. In clinical practice, it can improve a laryngoscopic view by at least one Cormack and LeHane grade, and sometimes even two. It can make the moderately difficult tubes easy, and the very difficult tubes manageable.

And if you don’t know what Cormack and LeHane grading is, or Mallampati scoring, or LEMON, get thee hence and fill that gaping hole in your airway management knowledge. If you carry paralytics and aren’t intimately familiar with those things, you are, well… dangerous.

If you couple the BURP technique with gentle lip retraction at the right corner of the mouth, you can improve your laryngoscopic view, and the room to manipulate a tube, significantly.

Last, but certainly not least, there is the $5 piece of equipment no airway kit should be without, and that is the Eschmann Intubation Stylet, commonly referred to as a bougie:


Typically, you use a bougie to intubate the trachea when you are faced with one of those folks with a very anterior glottis – typically less than three finger breadth’s across the middle knuckle (roughly 7 cm) of thyromental distance.

[On a side note, next time a colleague blames his difficulty intubating a patient on that “anterior larynx,” check the patient’s thyromental distance to see if it truly is. The anterior larynx is one of the biggest “run home to Momma” excuses in paramedicine, right on up there with “looks like atrial fib” and “I was up against a valve.”]

One usually inserts the Coude tip of the bougie in that anterior glottic opening, feeding it gently forward and feeling it “tick” on the tracheal rings as you do so, until the stylet holds up at the level of the carina. Then, you simply slide a lubricated ET tube of the appropriate size down the bougie, and – voila! – the patient is intubated.

Seriously, it is a very effective tool, and too damned inexpensive not to have one.

Besides being an effective aid to conventional intubation, the bougie is also an effective means of transitioning from a supraglottic airway to an endotracheal tube.

To answer my reader’s original question, one simply feeds the bougie down the King airway -or LMA, or Cobra, for that matter – feeling it “tick” against the tracheal rings for confirmation of endotracheal placement. Then, stabilize the bougie with one hand while deflating the cuff and removing your supraglottic airway with the other. Then, simply slide an endotracheal tube down the bougie and you’ve got the patient intubated. It will work on any supraglottic airway except the PTL and the Combitube.

Practice it on a manikin first, until you feel proficient with the technique. Neck extension and judicious application of cricoid pressure may facilitate lowering of the glottic opening and allowing easier passage of the bougie.

That’s all there is to it!

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