The Great techniques of laryngeal mask insertion & ET intubation

LMA insertion technique

Deflate the cuff and ensure no folds near the tip;
With your hand right hand under the head stabilize the head while ensuring the neck is flexed & head extended;
With the left hand, use the middle finger to press down the lower jaw to open the mouth;
Under direct vision press the mask tip upward against the hard palate;
Advance the mask forward into the pharynx while ensuring the tip is flat without touching the tongue;
Grasp the proximal end of the laryngeal mask with your right hand and withdraw fingers of your left hand from the tube;
With your right hand holding the tube, press downward until a resistance is met;
Inflate the cuff to seal around entrance to the larynx, & secure the shaft with a tape to the skin of the face.

Preparation for direct laryngoscopy

Check ETT cuff by inflating with a syringe, to ensure proper cuff & valve function.
Ensure the firmly attachment of the connector into the tube to avoid disconnection.
Insert the stylet in the ETT and then bend to resemble a hockey stick
Firmly attach the desirable blade onto the laryngoscope handle and test bulb function by jiggling the laryngoscope.
Make sure an extra laryngoscope handle, blade, ETT, stylet, and intubating bougie are all available in case of necessity.
Ensure the suctioning unit is available and functional
Make sure the patients head is at the level of your waist or above for comfort
Elevate the patient’s head 7.5cm avg above the surgical table using a soft support, and put in a sniffing position.
Tape the eyes shut after applying an ophthalmic ointment to avoid corneal abrasion.
Preoxygenate the patient

Technique for orotracheal intubation

Open the patient’s mouth, while holding the laryngoscope on your left hand.
Carefully place the blade into the right side of the oropharynx, and avoid touching the teeth.
Displace the tongue to the left, up into the floor of the pharynx using the blade’s flange to get a clear view of the glottis.
Insert the tip of the curved blade into the vallecula;
Raise up the handle, away from the patient in a plane perpendicular to the patient’s mandible to see the vocal cords;
Apply backward, upward, and rightward pressure externally on the thyroid cartilage, to position the glottis posteriorly for better visualization;
Using the right hand, insert the ETT into the open vocal cords. Ensure the cuff lies in the upper trachea, but beyond the larynx;
Carefully withdraw the laryngoscope to avoid tooth damage, and then inflate the cuff moderately;
Secure the endotracheal tube taping or tying.

Alternatives to difficult intubation: reposition the patient; indirect laryngoscopy; FOB; using a stylet or bougie; selecting a different blade; attempting nasal intubation; emergency supraglottic airway; awake intubation; jet ventilation through percutaneous tracheal catheter; retrograde intubation; cricothyrotomy & tracheostomy.

Technique for nasotracheal intubation

Identify and select the nostril the patient properly breaths with for intubation;
Apply phenylephrine 0.5% nasal drop, local anesthetic, spray (for oropharynx);
Consider inserting a large nasal airway (e.g. 36F) into the contralateral nostril, connected to a breathing circuit to supply 100% O₂.
Introduce the lubricated ETT along the nasal floor, below the inferior turbinate at a plane perpendicular to the face; ensure tube’s bevel is directed away from the turbinates;
Pull the proximal end of the ETT cephalad, & then gradually advance it until it’s tip can be seen in the oropharynx;
With the left hand, use the laryngoscope to visualize the open vocal cords;
Using the right hand, push the distal end of the ETT in the trachea. Alternatively, you may use the Magill forceps to direct the tip through the cord carefully to avoid cuff damage.

Preparation and technique for flexible fiberoptic intubation

Inform patients on the need for awake intubation for informed consent;
Identify and select the nostril the patient properly breaths with for intubation;
Apply local anesthetic spray to the airway; vasoconstrictive spray (for nasal FOI);
Consider moderate anesthesia (e.g. with dexmedetomidine) in some other patients;
Ensure oxygenation, & drainage via the suction port of FOB; alternatively, insert a large nasal airway (e.g. 36F) into the contralateral nostril, connected to a breathing circuit to supply 100% O₂;
Introduce the lubricated shaft of bronchoscope into the ETT, and keep the shaft of bronchoscope relatively straight;
The epiglottis or glottis is visible as the tip of FOB advances through the distal end of the ETT;
Manipulate the tip of the bronchoscope to pass through the open vocal cords. Either by grasping the tongue & pulling it forward with a gauze or instructing an assistant to apply cricoid pressure;
Advance the FOB within the carina as it enters the trachea;
Advance the ETT through the bronchoscope up to about 3cm above the carina, & then withdraw the bronchoscope. Secure the ETT.
Oral FOI is done similarly with the help of oral airway devices to direct the FOB (fiberoptic bronchoscope).

Invasive airway technique

Surgical cricothyrotomy: clean & prepare the area for surgical incision (i.e. CTM), which is about 2cm below the thyroid eminence> make a horizontal incision & then insert the tracheostomy tube.

Catheter/needle cricothyrotomy: clean & prepare the area for catheter/needle insertion> attach a 16/14G IV catheter to a 3ml syringe & insert it across the CTM towards the carina & aspirate air> remove the syringe and pass the guidewire through the catheter into the trachea>

remove the catheter and make minor incision at wire entry site> insert the tracheostomy tube/introducer over the guide wire into the trachea & then remove the wire> connect to the breathing circuit.

s/c transtracheal catheter with jet ventilation: clean & prepare the area for catheter/needle insertion> attach a 16/14G IV catheter to a 3ml syringe & insert it across the CTM towards the carina & aspirate air> remove the syringe & attach the jet ventilation system to the catheter> secure the catheter to the skin.

Retrograde intubation: clean & prepare the area for catheter/needle insertion> attach a 16/14G IV catheter to a 3ml syringe & insert it across the CTM cephalad & aspirate air> remove the syringe and pass the guidewire through the catheter until it emerges through the mouth or nose> secure the distal end of the wire with a clamp> insert the wire into an FOB loaded with ETT to ease and confirm placement into the trachea>

Alternatively, you may insert the wire into an airway exchange catheter to facilitate placement of ETT. You may also use the wire to guide entry to the ETT into the trachea.

Extubation technique

Suction the pharynx to prevent aspiration of blood, secretions.
Administer 100% of O2
Untie or untap the ETT, & then deflate the cuff.
Immediately withdraw the ETT, and then deliver oxygen through a face mask.

Do you want to know the Great techniques of laryngeal mask insertion & ET intubation?