Airway Management Tutorial Overview

Welcome to the October 2026 Airway of the Month.

I'm your host, Andrew Perrotte. I'm an EM physician at the University of

Kansas Health System and Medical Center, joined by my partners, Dr.

Kyle Brown, KU EM as well, Dr. Grabow, EM at

Emory, and Dr. Reba Haj, EM Critical Care at Prisma South Carolina.

Uh, I do have a conflict of interest in

that I'm on the medical advisory board for

Verathon. Otherwise, our teammates have no conflict of

interest.

The Airway of the Month is a free and open access tutorial for best

practices in

video laryngoscopy and airway management, and we mean this to be a just-in-time

educational resource and a great opportunity to expand the

airway enthusiast sphere, but also share best practices,

share common barriers to success.

So today, we're gonna look at

this video.

Remember, I have no idea who did this, what patient was involved.

We draw all this, um, without any identification to the patient

or link to the

providers. So I'm seeing this as you are seeing this.

I don't know the details of the case, just commenting on the airway.

This does look like a glidescope blade. There's that black plastic blade.

Initially,

we get a view that has some airway-relevant

structures.

This is the epiglottis. There's a lot of secretions here.

The initial view is-- looks like the blade is almost

pinning the epiglottis. So sometimes these videos start fairly

early, so,

uh, we don't have, for example, the entry into the teeth. This is uvula.

So uvula down to

epiglottis.

Immediately, the thought I have is this is a, a

kind of push rather than an incremental laryngoscopy.

So, you know, pushing down into the oropharynx

and just trying to hope and see what

you see.

Uh, Dr. Levitan, uh, the airway, Swami and Dr.,

um, Brian Jacobson here at KU, they both talk about incremental

laryngoscopy a lot,

epiglottoscopy.

So you see your structures, and you're working intentionally down to

the structures

rather than just pushing and going and seeing what you got.

So first uvula, then epiglottis, then larynx.

But this is a kind of articulating movement rather than just a push.

And what happens sometimes when you just get down in there like this

is you end up

in all kinds of, uh, uncommon or, or, um, worrisome

positions, and in this one, the epiglottis is pushed down rather than

lifted.

So then you'll see the providers kind of get under the epiglottis,

which is okay, but you're trying to seat the blade,

presumably this is a

Mac blade, as the Miller blades for adults

are not available from Verathon yet.

But you're trying to seat a Mac blade into the vallecula.

Even if this is a hyperangulated blade, then you're also in the vallecula.

It doesn't look like that, though, the way that this blade is moving.

Remember, the hyperangulated blade is a rock back.

The Mac is a move forward and lift. But you'll see,

rather than bisecting the medium molecular fold, this structure here

or the median glossoepiglottic ligament, that's what you want, and that's gonna

create that omega sign where the epiglottis is that nice rounded structure,

flips the glottis into view. This is coming in obliquely left

lateral. You're getting this distorted kind of,

you know, uh,

oblique view of the glottis,

and the epiglottis just won't pick up and move out of the way like you want it

to.

So again, trying to get the epiglottis out of the

way.

Very reasonable to come back out. I like that.

You know, "Hey, I'm not getting where I need to go.

I'm gonna come back out." So, you know, the solution to most airway issues is to

come back, not to go forward, but still encountering the same issue.

So the epiglottis, and I think the misinterpretation here

probably was,

"Hey, I'm not getting the epiglottis out of the

way.

It's not gonna flip like I want it to.

And so I'm gonna use this Mac blade as a Miller," rather than what the providers,

I think, optimally would have done here is,

you know, they need to get everything structured

back into this midline

approach. So instead of this oblique, you know,

kind of probably what's happening

is the blade is sitting kind of right lateral in the mouth,

and the blade's coming

left lateral across the mouth, and that's picking things up left

laterally.

I think you gotta sweep the tongue, and then you gotta move midline again,

and then

that's gonna get your blade seated midline.

Everything's gonna fall into place in a much more optimal way.

But it is what it is. Easy to say it retrospectively,

hard to do it in real time.

But the solution is, I think what many of us will do is, "Well,

let me just pick

the epiglottis up."

The problem with this view is many things, but it hasn't-- the main thing, it

hasn't solved the original issue, which things are, uh, structures

are not midline.

So even if you've got a view, which you do,

but it's now you're still not

getting things midline. You're still kind of trying to come

across, um,

obliquely or lateral to medial. Um,

this is-- these are the arytenoids. The- these are the cords.

The epiglottis is pushed up out of the way, but I don't find this view very,

uh, confident. And so we'll see what happens here.

Endotracheal tube comes in. This is also why I'm a bougie advocate.

I know I've said this before for people listening, but like, okay, here, I don't

know where things are, and the tube is occluding my view.

And here, the balloon is occluding my view.

And here, the balloon is occluding my view.

Bougie is a very complex device, uh, but for me, it works

really wonderfully well. But I think the biggest thing is

if you get confident with

it and use it, uh, there's some visual contrast with it being

blue or orange.

But the main thing is when you're trying to introduce the stylet

or the

bougie into the airway, when it's included in the tracheal tube,

you have these

periods of time when you have no view of the glottis whatsoever,

as opposed to the bougie, you're watching it the whole way in,

and it doesn't

occlude your view. But all that being said, this endotracheal

tube is passed posteriorly into the esophagus.

And so this is the glottis in the airway right here, and

that is the esophagus, or at least posterior structures that

is not in the airway,

uh, which is okay. But, um, you know, I think we all are like,

"Man, I want this to go well." And so it's like I see s-

a place it could go,

but very clearly, this is where it needs to go, and it,

the endotracheal

tube goes posteriorly.

Just about, I mean, it probably just caught their retinoids,

but didn't quite go

in, but that's not the airway. And there's so many things you can do to

tell here when I teach my residents and my medical students,

anybody who'll listen,

airway of the month, but the esophagus is a sphincter

and the glottis is a sharp structure.

It's diamond or triangular shaped.

But even if everything is all edematous and inflamed

and you can't see all

those structures perfectly, you can find the other structures that

are going to

guide you. The main thing here is like, if you pause this, where is everything

right now? This is the epiglottis or very likely these are the

retinoids.

And so it's an anterior structure and then you can almost make out the

triangle

right here. So it's like, even when it's all distorted and inflamed,

it still looks

different. This structure is very indistinct

and I would argue circular and that is the esophagus.

So the endotracheal tube is recognized as being in the

esophagus and

fortunately,

and then suction comes in to try to clear things out, which I think is really

helpful. I probably would have started from the

beginning with some suction,

but now you're getting a better view.

Again, it's like, it's not perfect, but there's that kind of triangular

structure,

the sharp structures, that's a retinoids. This is epiglottis.

There's some sundowning here. The blade is seated in the left side of the

vallecula, again, not midline, but this is better again.

So you're starting to see that this is definitely glottis

and

you'll see an additional pass here

and the cords

are now engaged. There's that little bit of resistance,

but you can see the

endotracheal tube and there's a retinoids posterior to it.

You got epiglottis here.

The stylet comes out. That endotracheal tube is in.

You can see the hinting at the cords there,

but even in the, you know, still not great view,

this structure is that diamond or sharp structures, triangular,

very different. So many things to learn here.

I think optimally,

and I think principally this case is about laryngoscopy

and you really want to

take the time to get midline.

If a Mac blade seated in the vallecula, flip the epiglottis out of the way,

try to identify the structures and always, always before you pass the

endotracheal tube, be certain that's where you're going.

This is the glottis rather than the esophagus. So anyway,

thanks for joining us.

Keep pushing. We'll talk to you next month.