Airway Management Techniques in Emergency Medicine

Welcome to the September 2026 Airway of the Month.

I'm your host, Andrew Perrotte. I'm an emergency medicine physician at the

University of Kansas Health System and Medical Center,

joined by my colleagues, Dr.

Kyle Brown, also EM at KU; Dr. Reva Hodge, EM critical

care at Prisma in South Carolina; and Dr.

Kristin Grabow, EM and, uh, of the Foundations of

Emergency Medicine at Emory.

The Airway of the Month is a free open-access tutorial on videos

of airways. Um, lots of opportunity here, lots of, uh, back

catalog. Uh, please enjoy. One conflict of interest I announce always

is I am on the medical advisory board of Verathon.

Take that for what you will. And so let's go on to our video here.

So today is a lot of, uh, teaching points.

Number one, this is a GlideScope blade, uh, probably a Mac blade.

It could be hyperangulated, but it looks probably Mac.

But the first thing is, this is a denture line. Um,

and so this happens a lot.

But remember, when you are preparing for airway,

when you're bagging, actually,

dentures can help provide some structure for the BVM to engage.

But when you're actually proceeding with laryngoscopy, the denture should be

removed. They can cause all kinds of trouble,

including difficulty passing the

endotracheal tube, so. But moving forward past the denture line,

this is

epiglottis. Pretty good slow laryngoscopy initially.

I like it incremental.

Dr. Ryan Jacobson, one of my partners, talks about progressive laryngoscopy, and

that's mentioned by many other airway enthusiasts, but it's that first

uvula, then epiglottis, then larynx.

This blade is seated a little bit to the left here, so you'll see you get

a little bit of an oblique view. So rather than bisecting the

median structure, which is the median molecular fold or median

cricotic ligament, it's a little bit left lateral,

so you get this kind of

twisting of the epiglottis.

But still a reasonable view. You can see the arytenoids,

interarytenoid notch,

aryepiglottic folds, some rugae of the tongue.

Not too bad, reasonable and workable.

So,

uh, likely the providers thought that was adequate.

And so-- and this is kind of where the trouble

starts, though.

So, um, reasonable laryngoscopy, but endotracheal tube comes in.

What you'll see repeatedly in this video is what's happening is the

bevel of the endotracheal tube right here is anteriorly engaging the

trachea.

There's a lot of do-- or a lot of things you can do about this,

but essentially,

the anterior trachea has the first tracheal ring and the second tracheal

ring, uh, become a rigid structure.

So when you press on the first tracheal ring, it intussuscepts into the second

tracheal ring and becomes a rigid structure.

So if you're pushing against something that's anterior in the trachea with your

endotracheal tube and it just won't go, it's not going to go.

So the-- you'll see, and see this bevel, it's going very anterior, very likely

engaging the anterior trach-trachea, and that's why it won't go.

This twisting motion is reasonable, but the corkscrewing that Dr.

Levitan talks about, larynx left when you're at the arytenoids,

rings right when

you have the trachea, it is benefited by coming back just a

little bit. So continuing to push forward

and twisting can

work, but it's the solution to almost all things

airway is to

come back. You see this pretty clearly here

when the providers pull the

endotracheal tube back, and then they try to push it again

forward, and it's

hitting that anterior structure.

So really, in this scenario, it's time to bail.

So you can see the endotracheal tube even pops away from the glottis entirely,

really kind of struggling. But, you know, this was already-- we're a minute and

seven seconds in. This is a long time to keep trying the same

thing.

I usually tell my residents one or two passes, that means, like, one

or two pushes

with endotracheal tube, then it's time to bail

and change modalities, change

laryngoscopy, change blade, downsize endotracheal tube.

This is not gonna work. You could also try a bougie here.

I'm a bougie advocate, uh, as those who listen to this know,

but don't just

keep pushing that. It, it's-- you get in a cognitive space where it's

like, "That's

all I can do," but it's really not. So second pass,

you see the dentures again,

epiglottis, uvula,

um, uvula, and then epiglottis, excuse me.

But again, this almost exactly the same blade

placement.

So there's the median molecular fold right there, and the blade is left

lateral. That's creating a fair amount of

challenge.

I think it was reasonable to start initially, but after that first initial

pass not going well, I probably would be more intentionally

sweeping the

blade to c-contain the tongue and getting a more

central view. But again, left lateral blade placement.

This time, uh, Ducanto suction catheter comes in,

does a nice job removing the

secretions. Ducanto is amazing. We have no conflict of interest there,

but he's

awesome, and so is his device.

Um, so better view now. You've got almost a great one

view. You can almost see the anterior

commissure, but the same thing's happening.

And actually, this is causing some sundowning of the

epiglottis, so it's eroding

the view. But this right here, it's again, it's like, okay, you have a good view.

This could be a hyperangulated blade, but I think it's a Mac because you can see

the malleable stylet and the endotracheal tube.

But the solution is not to continue to do the same thing.

So if I'm encountering this again, I'm immediately like, "Okay,

we've got to bail.

We've got to change blade. We've got to change endotracheal tube."

Or I think in

this situation, I would simply either try to improve my

laryngoscopy or just switch

to a bougie, because I think the bougie would probably

be able to bypass this.

Providers try to remove stylet, which is a reasonable move to try to get the

endotracheal tube to drop down into the trachea.

But again, that requires essentially to come back

with the endotracheal

tube. So ultimately, what I think causes success of the airway

is

that, you know, that pushing is not going to, but the stylet comes out,

and then

you'll see a little retraction of the endotracheal tube.

And I don't know if it was intentional or not, but I think that was actually the

key, whether it was meant to be done or not.

But right here, you'll see it kind of pulls back,

and then it flattens out, and

the bevel disengages the anterior structure of the trachea.

So lots to learn.

Ultimately, a successful airway. Thank you, everyone, for listening.

Keep pushing.

We'll see you next month.