Problem-Solving the laryngoscope through the mind of an expert intubator

Doing the same thing over and over again and expecting a different result may be the definition of insanity, but attempting intubation again and again without understanding why you failed in the first place may be even crazier.

If your initial attempt at intubation fails, standard wisdom is you should change something in your approach before trying again, but for airway educator Richard Levitan @airwaycam, this axiom falls far short as practical advice for a physician facing an unexpected difficult intubation. You need to build

If in the face of initial failure during laryngoscopy your answer to the problem is, “just change something, anything!” the likelihood that you will hit on the right change is low. As the stress builds, even experienced physicians can find that “best” solution to be elusive if you don’t have an organized approach to problems frequently encountered during laryngoscopy.

“Don’t just do something different! Do something SMART!” – Dr Richard Levitan

Dr Levitan is not just deploying a witty throw away line, but firing a first salvo in the mental battleground where he believes all successful intubations start. Doing something smart begins with the process of “micro-dessecting” our laryngoscopy practice so that we can engineer a better one. His approach goes something like this:

1. Divide the process of laryngoscopy into three phases.
   1. Epiglottoscopy
   2. Exposure of the Larynx
   3. Delivery of the tube
2. Identify which phase of laryngoscopy your problem resides in.
3. Choose your solution(s) based on step two.

This simple mental reorganization adds important granularity to the process of laryngoscopy because it’s the first step in building a mental framework that will help you in a moment of crisis identify where your problem resides (epiglottosocopy,  laryngeal exposure, or tube delivery) so you have a more informed basis upon which to act.

This mental framework also passes another important test: it’s built by someone who lives the job, and understands the environment in which his model is being used. Airway knowledge (like much of what we learn as Emergency Physicians) inhabits a rapidly changing and often chaotic environment. If we don’t build mental models that allow us to deploy our skill and knowledge effectively in tough situations, then it’s essentially worthless.

“You know what we need to do in our jobs? We need to make the first step of every procedure we do, something we believe we can do.”  – Dr Richard Levitan

Now that you have this new framework on which to build your laryngoscopy skills, let’s take a look at what each phase looks like. Mastering each of these skills is an essential part of building an airway “toolbox” that will help inoculate you against stress by giving you more confidence to face the challenges encountered during laryngoscopy.

1. I can’t see anything!!!

Problems in the Epiglottoscopy Phase

In the soft, murky world of the oropharynx, the “I can’t see anything!” moment is one of terror, One that piles on stress in an already stressful situation. That increased stress further erodes your situational awareness, by impairing your brain function and making it harder for you to get control of the situation.

Once you’ve identified your in an “I can’t see anything” situation, don’t panic! Instead, think incremental first steps – in this case, epiglottoscopy.  Epiglottoscopy as a concept works because it forces you to approach the problem in a stepwise approach.

The most common cause of the “I can’t see anything!” situation is going too fast and too far with your laryngoscope blade.  So take a deep breath, and forget about trying to see the cords. Then pull back, check your grip and make sure your holding the laryngoscope with a light touch, and start again by thinking epiglottoscopy.

Here is Dr George Kovacs  @kovacsgj  of AIME airway giving some pointers on the “light touch” grip and why it is so important for successful epiglottosocopy.

Once you’ve lightened your grip, open the mouth and distract the jaw. Work your way forward slowly and incrementally: find the uvula which will point your way. Move SLOWLY down the base of the tongue and look for the tip of the epiglottis. Fluids may be obscuring your view in which case reach for the suction.

• Key tips for the “I can’t see anything!” scenario
  • Think epiglottoscopy NOT laryngoscopy
  • Start with a light “two finger” grip
  • Lost? Pull back and start again
  • Find the uvula to point your way
  • Move SLOWLY down the base of the tongue
  • Look for the tip of the epiglottis
  • Fluids? Advance with Suction FIRST

Give your airway suctioning skills an upgrade

A word about airway suction. Over the last few years it has been given a major upgrade by airwaynaut Jim Ducanto MD @jducanto. When faced with an airway where the “I can’t see anything!” scenario is caused by airway fluids, Perform your epiglottoscopy with the suction in your right hand and advance with it into the oropharynx slightly ahead of the  laryngoscope blade. I also highly recommend you add Suction Assisted Laryngoscopy and Decontamination SALAD skills to your repertoire for the “I can’t see anything!” scenario.

2. Problems In the Laryngeal Exposure Phase

The second stage of intubation is exposing the structures of the larynx. This is really what we mean when we say laryngoscopy. Successful tube delivery depends on first being able to get an optimal view of the glottis and surrounding structures.

The quality of your view will significantly affect your intubation success. The Cormack-Lehane grading system below highlight how the quality or your laryngeal exposure impacts intubation success.

What essential maneuvers should be in your toolbox to improve a poor laryngeal view?  For direct laryngoscopy, the most important maneuver is making sure the tip of your blade is properly seated in the Valeculla. This engages the hyoepiglottic ligament. and is critically important for exposing the glottic structures. (shown here in one of my favorite airway anatomy videos by AIME Airway).

If valleculoscopy isn’t enough for a good laryngeal view, the next essential maneuver is external laryngeal manipulation or bimanual laryngoscopy. This will help bring the glottic opening into better view.  Sam Ghali @EM_RESUS shows how effective it can be in the video clip below.

Keys to improving your laryngeal view

• Use a tongue depressor
• Start with Valeculloscopy
• External laryngeal manipulation (bimanual laryngoscopy)
• Elevate the head of the bed or lift the head
• Lean back to improve your line of sight
• Mac as a Miller (get under that epiglottis)
• Mandibular advancement

3. Problems in the Tube Delivery Phase

You have a great view of the glottis, and you’re telling yourself, “almost there now.” You may be tempted to rush the tube delivery, but now is the time for patience. Getting the tube safely and securely past the cords and into the trachea requires some advanced planning (like straight to cuff stylet), and an understanding of what “best view” of the larynx means for optimal tube delivery depending on the laryngoscope being used.

For direct laryngoscopy, getting a full view (grade1) of the glottic opening and making sure you don’t obscure your line of sight to the cords are probably the most important factors in tube delivery.

In contrast, video laryngoscopy can initially give you amazing views of the glottis but this “great view” can actually make it harder to deliver the tube.  When you’re having trouble with tube delivery during VL, pull back from that great view.  @kovacsgj suggests putting the cords in the top 50% of your screen with a 50% view of the glottic opening.

Hyper-angulated blades and rigid stylets can add another wrinkle to the challenges of tube delivery: if you’re seeing the tracheal rings on your screen like the image below you’re approach angle is wrong and may inhibit smooth tube delivery.

Kovacs’ Sign

Sam Ghali @EM_RESUS shows here that in order to get the tube past the cords and into the trachea requires understanding that the “better view” for tube delivery is not the “best view” of the glottic opening. Here is what an optimal view in VL looks like. Particularly when using a hyper-angulated blade.

 Here is a summary the solutions for tube delivery

• Make room for your tube
  • Use a tongue depressor
  • Assistant to hook side of mouth
• Stay out of your line of sight
• Straight to cuff with stylet shaping
• Rotate tube counter-clockwise if bevel is stuck or can’t advance
• Obey the 50/50 rule of video laryngoscopy
• Liberal use of the bougie when needed

Summary: The Smart Airway is

Learning Designed for Humans

The maneuvers listed above are by no means exhaustive. But that’s not the point. The real strength of Dr Levitan’s approach isn’t its list of tips or tricks,  but the sound mental model they’re built upon. A model that will improve your situational awareness, and give you the confidence to effectively  problem-solve during difficult intubations.

This business of succeeding in the face of really sick and dying people under high stress is to simply to set the first step in your brain as something you’ve got. And then you set the next step…” – Dr Richard Levitan

The longer I teach and practice emergency medicine, the more I realize how important  as a physician educator must continue striving to organize our essential knowledge in more effective ways. If we want to collectively provide better care, and pass what we know on to the next generation of physicians we must consider how we learn not only what we learn.

Those of us like Dr Levitan who do this well, and then share it with others are our most valuable resource. His approach brilliantly bridges the space between the classroom and the resuscitation room, and considers the provider and the environment in which this essential airway knowledge is needed. Something I call “learning designed for humans”.

So don’t freak out and just try to do “something different” the next time you encounter a problem during laryngoscopy. Instead you can build yourself a better laryngoscopy practice using Dr Levitan’s “Smart Airway” approach – so you change what you’re doing based on where you are in the process. Then you can say “i’ve got this!” and act on an informed assessment of the situation. Now that’s smart!

The EMBER Deeper Cuts

Want to understand some of thinking behind these concepts better? Here is more great airway wisdom from Dr. Richard Levitan presented by the master himself at DAS SMACC in 2017.

Dr Levitan’s Extreme Airway Talk (Slides)