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Clinical Summary

Optimizing First-Pass Intubation Success

Laryngoscopic orotracheal intubation is divided into two distinct processes: glottic visualization and endotracheal tube (ETT) delivery, with the majority of the effort spent on visualization. An intubation attempt is defined as any time a laryngoscope blade enters the mouth. The probability of successful intubation (tube in the trachea without hypoxia) diminishes with successive attempts. Optimizing controllable variables increases first-pass intubation success rates. As in the airline industry, preprocedural checklists and “time outs” provide a consistent process to complex and dangerous procedures, such as landing a plane or endotracheal intubation. Checklists communicate to all involved and allow others to speak out if a process is violated. A prearrival checklist (see Fig. 22.13) ensures equipment availability and confirms function. An intubation equipment place map (see Fig. 22.12) provides a quick visual aid to determine if all necessary equipment is present. A preinduction time out checklist (see Fig. 22.14) confirms that all the tasks prior to medication administration are in order. Team members are encouraged to speak out if the preparatory tasks are incomplete.

Patient Positioning

The optimal position to maximize laryngoscopic visualization of the larynx is:

  1. The head is extended.

  2. The neck is flexed.

  3. The base of the ear is aligned with the sternal notch (see Fig. 22.15).

  4. The facial plane is horizontal, parallel to the ceiling (see Fig. 22.15).

  5. The facial plane should be positioned between the laryngoscopist’s xyphoid process and umbilicus (see Figs. 22.19A and 22.19B).


Incorrect Intubating Height. An incorrect working height creates poor body mechanics, making glottic visualization and tube passage more difficult, especially for prolonged intubation times. (Photo contributor: Lawrence B. Stack, MD.)


Correct Intubating Height. Optimal height for intubation is typically when the plane of the patient’s face is between the laryngoscopist’s umbilicus and xyphoid process. (Photo Contributor: Lawrence B. Stack, MD.)

This position most closely replicates in a supine posture that position which the patient would assume sitting up. Large individuals or those with morbid obesity often require creation of a textile ramp of blankets, sheets, or towels to raise the head and shoulders to achieve ear-to-sternal notch alignment.

Preoxygenation and Passive Apneic Oxygenation

Preoxygenation, when possible, is used to create an oxygen surplus in the blood and tissue, which permits a period of apnea to occur without arterial oxygen desaturation (see Fig. 22.20). This process hopefully begins in the prehospital setting with the placement of a non-rebreather mask with high-flow oxygen on the patient. This continues in the emergency department (ED) in the event intubation is required. In addition, a nasal cannula on high flow (15 ...

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