Airway control is the first and most critical action of the Emergency
Physician. The “A” in the ABCs demands that no
other action may take place until the airway is secure. Endotracheal
intubation inserts an artificial airway connecting the respiratory
system to the outside world and gives definitive control of the
airway. Once the tube is in place, all methods of support can be
applied. If the airway is not secure, nothing can help the patient.
Endotracheal intubation can be accomplished by a variety of methods.
The method of choice will be dictated by physician preference and
experience, the patient’s condition, and the type of equipment
available. The most common method of endotracheal intubation is
orotracheal intubation. There are no good alternatives to intubation
when oxygenation and ventilation are threatened. All actions should
be focused on two objectives: to get the tube in quickly and in
the right place. The proper preparation, practice, and personnel
can assure that the “nightmare airway” is an extremely
For the purposes of intubation, our discussion of the anatomy
starts at the lips and travels inward to end at the right mainstem
bronchus. As you approach the patient, visualize the normal structures
expected and match them with what is seen. Distortion occurs from
edema or trauma. Structures may be hidden by vomit or blood. Since
all structures are viewed upside-down, from the position over the
head of the patient, the potential for disorientation multiplies.
Begin at the face and move inward (Figures 5-1 and 5-2). The
philtrum of the upper lip will be located at the 6 o’clock
(bottom) position. Symmetrical swelling, carbon deposits, blistering,
or signs of trauma to the lips can indicate that the inner anatomy
of the airway may be altered and the intubation more difficult.
Moving inward, open the patient’s mouth and check the teeth
for fractures, size, and the presence of removable dental devices.
Large upper incisors and/or limited jaw opening will make
endotracheal intubation more difficult. The tongue hangs down from
the floor of the lower jaw (mandible) and ends with the tip against
the upper (maxillary) incisors (Figure 5-2). Visualize the tongue
as a hanging oval of tissue with two “tips” (Figure
5-2). The first is the anterior tip of the tongue proper. The second
is the epiglottis. The anatomic “floor” of this
view is formed by the hard and soft palates, which end at the palatopharyngeal
arch (Figure 5-2). The uvula is located inferiorly and in the midline.
The palatoglossal arch and palatopharyngeal arch form twin vertical
pillars that lie posterior to the molars of the upper teeth (Figure
5-2). All of these structures are potential sources of obstruction
and must be evaluated for swelling, deformity, or trauma. The “back
wall” is the posterior wall of the pharynx (Figure 5-2).
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