Despite the expanding array of video and other imaging laryngoscopes there are some fundamental principles that apply to all new airway devices that emergency physicians should know. Below we review four critical concepts: epiglottoscopy and suctioning, lifting to expand the viewing area, tilting the optics toward the ET tube, and two-stage tube delivery.

Thirty years ago a surgical airway was considered the ultimate means of rescue ventilation and rescue intubation. Today, it is neither. The LMA, similar devices, and the King LT (or Combitube) have become the default means of rescue ventilation when mask ventilation fails.

Many EMS providers use devices like the King Laryngeal Tube or Sheridan Combitube as primary or rescue airways (if tracheal intubation fails). The pharyngeal balloons on the King LT or Combitube make them very secure to dislodgement. They are also blindly inserted and require relatively little training.

More than just intubation, a short fiberoptic scope can check for edema, infection, burns, or foreign bodies. And single use and sheathed scopes are bringing the usefulness of this technology back into the ED.

When a tubed patient is delivered by EMS with good oximetry and capnographic readings (clear repeating wave forms), plus bilateral breath sounds over the axillae and easy ventilation through the tube, thank your EMS personnel for a job well done.

Before starting efforts at intubating any airway with laryngeal pathology, it must be appreciated by all caring for the patient that rescue ventilation may not work if the epiglottis or larynx is swollen or distorted. This applies to the LMA, King LT, and mask ventilation. If intubation through the nose or mouth doesn’t work, a rapid surgical airway will likely be required.

With or without fiberoptic assistance, nasal intubation remains a valuable technique in some emergency airway situations, despite its overall decline in use. It is best in patients who are not critically hypoxic and in whom there is obvious oral pathology making intubation and ventilation through the mouth problematic.

How to reduce two of the most common errors of direct laryngoscopy, tube delivery issues, and failing to plan for the epiglottis-only view.

Laryngoscopy in infants and small children is a technically easier procedure than in adults. Mouth opening, jaw joint mobility, and dentition are all more favorable for laryngeal exposure in children vs adults.

A simple modification in practice can protect your patients from hypoxia during emergency intubation. Imagine intubating all of your patients without the high anxiety and low tones (boop, boop, boop…) of a falling pulse oximeter reading. During pre-oxygenation, applying nasal oxygen in addition to a non-re-breather face mask can significantly boost the effective inspired oxygen.