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How To Do Orotracheal Intubation Using Video Laryngoscopy

By

Bradley Chappell

, DO. MHA, Harbor-UCLA Medical Center

Reviewed/Revised Feb 2023
View PATIENT EDUCATION
Topic Resources

Endotracheal (ET) tubes are flexible tubes with a standard flange for attaching an oxygen source at the proximal end and a beveled tip and inflatable balloon cuff at the distal end. Under visualization, using either direct laryngoscopy or one of various types of video laryngoscopy, the ET tube is inserted into the mouth and directed into the trachea (orotracheal intubation). Less commonly, the ET tube is inserted into the nose (nasotracheal intubation).

Endotracheal tubes are the definitive method of airway management for most patients with apnea or severe ventilatory failure.

Orotracheal intubation was long done using direct laryngoscopy. However, video laryngoscopy is a useful method of endotracheal intubation because it can provide better visualization of the glottis than direct laryngoscopy. A video laryngoscope has a small camera on the end of a laryngoscope blade that transmits an image to a screen that may be incorporated into the device handle or separate from the device.

Indications for Orotracheal Intubation Using Video Laryngoscopy

Orotracheal intubation, with or without the assistance of video laryngoscopy, is indicated for patients with:

  • Hypoxia or hypoventilation requiring assisted ventilation to maintain oxygenation and ventilation

  • Apnea or impending respiratory arrest (initial emergency treatment)

  • Elective anesthesia (selected cases)

  • Need for prolonged mechanical ventilation

  • Situations where bag-valve-mask ventilation is difficult or impossible (eg, in patients with severe facial deformity, thick beard, or other factors that interfere with the face mask seal) or upper airway obstruction due to soft tissues

  • Need to prevent aspiration (eg, in obtunded or comatose patients) or for repeated airway suction

Video assistance should be used when available, and it is particularly useful when anatomic factors make direct laryngoscopy difficult and/or when injuries preclude the head and neck movement required for proper positioning.

Contraindications for Orotracheal Intubation Using Video Laryngoscopy

Absolute contraindications

  • There is no medical contraindication to providing ventilatory support to a patient; however, a legal contraindication (do-not-resuscitate order or specific advance directive) may be in force

  • Restricted mouth opening that blocks tube insertion (nasotracheal intubation or a surgical airway would be indicated in this case)

  • Impassable upper airway obstruction (surgical airway would be indicated in this case)

Relative contraindications

If orotracheal intubation is not contraindicated, there are no additional contraindications to the use of video assistance.

Complications of Orotracheal Intubation Using Video Laryngoscopy

Complications include

  • Dental or oropharyngeal soft tissue trauma during tube insertion

  • Vomiting and aspiration during tube insertion

  • Incorrect tube placement (eg, esophageal intubation)

  • Hypoxia during the intubation attempt

Equipment for Orotracheal Intubation Using Video Laryngoscopy

Additional Considerations for Orotracheal Intubation Using Video Laryngoscopy

Relevant Anatomy for Orotracheal Intubation Using Video Laryngoscopy

  • Aligning the external auditory canal with the sternal notch should align the airway axis to provide an optimal view of the airway.

  • The degree of head elevation that best aligns the ear and sternal notch varies (eg, none in children because the occiput is relatively large; a large degree in patients with obesity).

Positioning for Orotracheal Intubation Using Video Laryngoscopy

  • The sniffing position is the optimal position for endotracheal tube insertion; however, if the neck cannot be positioned this way, the laryngoscope camera often provides adequate visualization.

The sniffing position is used only in the absence of a cervical spine injury:

  • Position the patient supine on the stretcher.

  • Place folded towels or other materials under the head, neck, and shoulders, flexing the neck so as to elevate the head until the external auditory meatus lies in the same horizontal plane as the sternal notch. Then tilt the head so that the face aligns on a parallel horizontal plane; this second plane will be above the first. In patients with obesity, many folded towels or a commercial ramp device may be needed to sufficiently elevate the shoulders and neck (see figure Head and neck positioning to open the airway Head and neck positioning to open the airway Head and neck positioning to open the airway ).

Head and neck positioning to open the airway

A: The head is flat on the stretcher; the airway is constricted. B: Establishing the sniffing position, the ear and sternal notch are aligned, with the face parallel to the ceiling, opening the airway. Adapted from Levitan RM, Kinkle WC: The Airway Cam Pocket Guide to Intubation, ed. 2. Wayne (PA), Airway Cam Technologies, 2007.

Head and neck positioning to open the airway

If cervical spine injury is a possibility:

Step-by-Step Description of Orotracheal Intubation Using Video Laryngoscopy

How To Do Orotracheal Intubation Using Video Laryngoscopy
VIDEO

Maneuvers to create a patent airway and to ventilate and pre-oxygenate the patient are always indicated before attempting tracheal intubation. Once a decision to intubate has been made, do the following:

Aftercare for Orotracheal Intubation Using Video Laryngoscopy

  • Obtain a chest x-ray to verify proper placement of the endotracheal tube.

Warnings and Common Errors for Orotracheal Intubation Using Video Laryngoscopy

  • It is imperative to use the appropriate rigid stylet designed for the curvature of a specific video laryngoscope so it follows the curvature of the blade. Use of traditional malleable stylets may result in a failed intubation attempt, especially on anterior airways.

  • When removing the stylet, securely hold the endotracheal tube while an assistant pulls the stylet out, rotating the stylet handle caudally toward the chest, not pulling straight upward, to facilitate easier removal of the stylet and minimizing the risk of dislodging the endotracheal tube.

  • All cuffs, adult or pediatric, should be inflated only to the extent necessary to prevent movement; overinflation leads to necrosis.

Tips and Tricks for Orotracheal Intubation Using Video Laryngoscopy

  • With difficult airways, use of traditional intubation techniques, such as sweeping the tongue toward the left and applying slight upward and outward elevation, can help facilitate a better view.

  • If an assistant is available, have the assistant insert a finger into the mouth and pull the cheek laterally; this may provide a better view with more intubating space.

  • When looking at the video screen after inserting the endotracheal tube into the mouth, focus on the vocal cords. The view of the vocal cords should be lost only for a brief second while the tube passes through the cords.

  • The video laryngoscope may also be used to more easily place an orogastric tube after intubation, particularly in patients with difficult anatomy.

View PATIENT EDUCATION
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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