Airway Management Techniques in Emergency Medicine

Hello, everyone, and welcome to the July 2026 Airway of the Month.

I'll be your host, Andrew Perreault.

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 here at KU,

Dr. Reba Hodge, EM Critical Care at PRISMA in South Carolina, and Dr. Kristen

Gribble Moore at Emory EM.

So Airway of the Month is a tutorial and a free open access teaching

to optimize airway management.

We are sorting through some of the logistics and

production that makes Airway of the Month so dynamic.

But while we do that, these last month and this month,

we'll see in the next coming months,

essentially, there's a little more old school where you just get me with my head

talking and the screen.

And so bear with us as we sort that out.

So today, we'll talk about a difficult endotracheal tube passage.

There's a lot of layers to this one.

So initially, this looks like a Glidescope blade.

I am on the medical advisory board for Glidescope,

so I do have a conflict of interest.

But I think the black video laryngoscope blade is likely Glidescope.

So moving this forward, pretty large tongue.

But initially, the issue here is that the tongue is being pinned rather than swept.

You'll hear some clinicians say you don't need to sweep

when using video laryngoscopy.

I still think it's very meaningful.

But probably you could slide down the midline of this tongue

and get a good glottic view.

But I think reasonably to sweep this out of the way.

Going down once the

providers do get past the tongue,

you'll see there's uvula,

pretty small uvula, a lot of redundant and inflamed soft tissue, maybe a little bit

of thrush on the tongue there.

The laryngoscopy initially is pretty right lateral. This is epiglottis.

This view itself is okay.

We talk a lot about this in the area of the month, but there's a lot that

could be improved,

which I think would subsequently improve the intertracheal tube passage.

This blade is coming in right laterally and kind of oblique, obliquely.

So if you look at this, the epiglottis, it's not in the midline of the blade.

This is the area of the glottic fold,

the arytenoids, the vocal cords, there's a lot of inflammation.

This patient may have aspirated,

it's hard to say retrospectively, but this is inflamed tissue.

The blade is coming right to left across and

not bisecting the midline structures exactly like that can create.

than unique angles when you're trying to pass the endotracheal tube.

So first thing I would say when I see this is, if I have any trouble with the

endotracheal tube, I'm going to optimize my laryngoscopy before I really

troubleshoot a lot of endotracheal tube issues.

So it's also probably could use a sweep of suction with a Ducanto.

So right here is a good view, if I can get that paused,

of where we're not quite midline.

It's right there.

So you see this is the median follicular fold or median glossopiglottic ligament,

very right lateral.

So maybe 10 of the blade

is midline and 90 is right lateral, and that creates that challenging view.

So even though you can see cords, it's not optimal for endotracheal tube passage.

You'll see this here, endotracheal tube comes in,

but look at this kind of odd angle.

So we're coming right to left with the blade, and then the endotracheal

tube is almost on the left side of the screen,

which suggests it may be coming in and underneath a blade, or maybe it's

bowing to the side,

but you're creating a lot of challenging angles because you're,

instead of keeping everything midline, you're engaging the glottis right to left.

So the trachea may be going,

for example, in a different direction than expected, but

then your endotracheal tube is coming in from this kind of left angle.

So a lot of layers to this.

The tube does not initially advance.

I think looking at this,

probably you're engaging the right vocal cord more than you want to.

But the biggest thing here is the tube is not going,

and so my teaching with my own residents and fellows and students is,

at this point, you need to change.

So continuing to push with the endotracheal tube is not going to change things.

So bring out the endotracheal tube, try a bougie, downsize the endotracheal tube,

optimize your laryngoscopy,

something, but essentially one or two pushes, that's it.

You're just going to traumatize the soft tissue further by continuing to push.

The solution in airway management is very rarely trying harder, pushing harder.

It's almost always changing modalities, changing views, coming back.

And so in this scenario, it'd be like, hey, just stop, bail,

let's get a bougie, let's downsize the endotracheal tube.

But I think a lot of the problem encountered here is the laryngoscopy,

and then the endotracheal tube is having trouble making up for that.

But you see there's some bleeding now, so the tissue has been a little traumatized.

Again, I think a sweep of suction would go a long way.

This is kind of a sundowning view,

that's where the epiglottis starts kind of falling down.

The ventricle tube comes back in, and again, kind of to the left, a little bit,

maybe a better rotation, and a little bit of steady pressure.

Ultimately, you'll see the tube does get past the cords, but not super confidently.

And then ultimately, a successful airway,

but really a lot of opportunity there,

I think, to enhance laryngoscopy,

change modalities,

suction, and a lot of opportunity to improve there.

But ultimately, a successful airway. So, thank you again.

Keep pushing. We'll see you next month.