Articles by Rich Levitan, MD
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
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.
Films and Scans
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
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
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.
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