Airway Management Techniques in Emergency Medicine

Hello everyone Welcome to the May

2026 Airway of the Month I'm Andrew Parot I'm an emergency medicine physician at the

University of Kansas in Kansas City joined by my partners Dr Kyle Brown KUEM

Dr Reba Haj EM Critical Care

at Prisma and South Carolina and Dr Kristen Grabo Moore EM at Emory

We are going to do an interesting airway this month which

is a troublesome intertracheal tube

passage The Airway of the Month is a tutorial to discuss the devils in the details

Really as we do this with our free open access database

it allows teaching on airways rather than just discussing them or using mannequins

or using diagrams we can all see what's going on with the provider And it helps

us all be better as we go forward in our own airway management As

always I have a conflict of interest with GlideScope Verithon I am on the medical

advisory board Take that for what you will So let's get going here

So it looks like probably a MAC blade

Some issues initially with laryngoscopy So right here look at the body

of the tongue you know vitilary laryngoscopy still requires sweeping the tongue You

do not have to do so as aggressively with

DL but you do need to still control the tongue

Getting down to the epiglottis here This is a probably grade 2A

maybe 2B view but you see you've got arytenoids inter arytenoid notch This

is epiglottis You can see the cords clearly This is that

diamond shaped structure that we talk about rather than the circular structure of

the esophagus Definitely airway but

not the best view You don't really have much control There's

some secretions There's some tongue engagement

I'm not super confident with this view

You'll see there is

looks like there is good paralysis though The cords are nice and open

The endotracheal tube comes in and misses just by a millimeter or

so and you'll see it's engaging the right arytenoids there

This could be a number of reasons This could be positioning of the body but look

at this view that this is creating now So the laryngoscopy remember laryngoscopy

and endotracheal tube passage are different procedures The laryngoscopy here

is not optimal and it's creating all these issues but now when we're trying to pass

the endotracheal tube we're having trouble We've actually now occluded our view

So looking at this like now

is not the time to continue to try to pass this endotracheal tube It is to

you know the solution in most airway problems is to

back up So for me this is hey let's get rid of the endotracheal tube let's suction

let's optimize our laryngoscopy and then let's try again So like for example these

secretions are not thick but they're definitely in the way This is kind of

unusual ring like secretion here which I initially thought was like foreign body or

an OG tube or something but again trying to go with endotracheal tube which is okay

I think back at this stage though right now I'm just working on laryngoscopy I

might be switching blades Remember you get into this cognitive space where you're

like well I can see cords Therefore I have to keep going It's like why not Why not

switch from a MAC blade to a hyperangle blade for example Or

bring in a Ducanto suction catheter Clear everything out

But endotracheal tube comes back in What's happening here is it's engaging the

right vocal cord So you see how that's coming kind of obliquely left to

right across which is unusual Usually things are right to

left that are stylettes or bougies or endotracheal tubes So how that came left to

right I'm not sure It does make me question if the provider is holding the blade in

the right hand and then tracheal tube in their left which has its own issues

And so but difficulty passing this tube Now it's

probably hanging on the tracheal rings

Remember this is when you're kind of rather than just pushing

rotating the tube You see the stylette starting to be retracted here a little bit

which is reasonable practice And ultimately this is a successful airway But I

think for me you know when you're having trouble at this point

I'm kind of starting over in my mind Hey let me switch blades Let me clear suction

Let me do bimanual laryngoscopy Let me change position of the bed

Let me kind

of rethink this because this is not optimal laryngoscopy to ultimately get through

endotracheal tube passage And then even down through here there is issue

with this And I would

argue that rather than the endotracheal tube being the issue which it is sometimes

but I think the laryngoscopy is the chicken here and the endotracheal tube passage

difficulty is the egg So thinking about them separately they of course go together

but really optimizing your laryngoscopy first before you're trying to pass that

tube And if you're having trouble not being afraid to switch modalities So thank

you See you all next month