Dual-Mode Intubation: Video Laryngoscopy and Flexible Bronchoscopy

Welcome to the November 2026 Airway of the Month. I'm your host, Andrew Perrotte.

I'm an emergency medicine physician at the University of Kansas Medical Center and

Health System, joined by my partner, Dr.

Kyle Brown, also EM at KU, Dr. Reeba Hodge, EM critical care

at Prisma in South Carolina, and Dr.

Kristin Grabow, who is EM at Emory and, uh, foundations

leader.

So, the Airway of the Month is a free open access tutorial use, uh,

using the

airway video database, which is a open access,

de-identified airway repository.

And for those of us who have joined us before, we have a dual-mode airway today,

which will be very dynamic. I do have a conflict of interest I always

need to

share, which is I am on the medical advisory

board for Verathon.

Do with that what you will. So let's go on to our airway.

So lots here. So this is a dual mode.

Um, so video laryngoscopy on the left, bronchoscopy or flexible

bronchoscopy on the right.

Let's get going here. Really good view on the left here.

So that's a grade two A view. Everything except the anterior commissure

is evident.

Arytenoids, aryepiglottic folds, epiglottis,

really great view. So you got what you need on the left,

and then the bronch is

coming in on the right.

Remember, educationally, my advocacy and our advocacy is to do this

before you need it. So yes, dual mode is the use of the

video laryngoscopy and flexible bronchoscopy,

and it's a product of GlideScope, but

there are other pathways to do this, which is a

laryngoscope plus a flexible bronch.

And-- But the point is, you don't only do it

when there's a difficult

airway. It's you need to practice this

when there's a regular, you know, medical

airway, for example, um, and so you keep your skills up,

or you develop your

skills. So, um, please be thinking about that.

I think it's very impactful.

So going forward here, first and foremost, we encounter the very

real issue, which is this patient is not paralyzed.

And so great view on the left, a little bit left lateral seating of the

blade, and

you see that kind of oblique tweaking of the epiglottis, but still very good

tracheal rings evident. Also good view on the right.

Uh, you know, a little different resolution, which

is interesting when you look at

these two, you know, similar structures, but they appear differently.

Lighting is different. Uh, looks like maybe a little bit of watery

edema

of the posterior structures.

But the bottom line is this patient is not intubated.

And so the teaching that, uh, is my typical

advocacy is do everything you need to do

other than intubating the patient.

So you-- if you're in on video laryngoscopy

or direct laryngoscopy, you take the

endotracheal tube or bougie, and you hang right above the cords.

If you're using dual mode or flexible laryngoscopy--

flexible bronchoscopy,

excuse me, then you're bringing the bronch all the

way down to where you're just

about ready to intubate, and then you go.

This is also the DSI concept, where it's like you're giving ketamine,

for example,

and then you're getting everything right down to the cords before you intubate,

before you push the paralytic. So it's-- the idea is you're essentially confirming

you can get to where you need to go before you actually pass into the glottis.

So these providers, looks like the cords were still in

motion, and so appropriately hanging, kind of waiting for this.

But remember, this patient is apneic, and so, um, only a

certain period of time can be waited here.

Um, so but, uh, presumably apneic oxygenation is evolving,

which is the

nasal cannula in place during apnea.

And so the patient is passively oxygenating,

so there can be many minutes actually

of safe apnea time. So I think likely, you know, the cords

look like they're starting to open up here and paralyze.

And so the providers are like, "Okay, this-- the paralytic is finally hitting."

Remember, especially if this is rock, this can take sixty to seventy-five

seconds

to fully take effect. I often recommend timing this actively,

not

just estimating it. Somebody looking at their smartwatch

or a clock on the wall.

So it looks at this point, the providers think, you know, okay,

things are moving

forward. So start approaching the glottis with the

bronch and-- but then there

starts to be that spasm, that, that appropriate response.

You know, the glottis is preventing a foreign body from coming

down.

So, okay, you know, looks like this patient probably isn't

fully

paralyzed.

Coming back in, there is a, um, you know, still

good laryngoscopy on the left, a little bit of sundowning where that,

you know, you

start losing the optimal view, but still very good.

You're still seeing some kind of spasms, intermittent motion of the vocal cords.

Um, and so bronch comes back in, a little bit of secretion accumulation in

the

posterior oropharynx here from the esophagus.

Ultimately, the decision must have been, been made that a, a sufficient

duration had, uh, evolved, that this patient simply needed to be

intubated. Um, and I don't know exactly what

was going on, but

ultimately, the bronch is placed down through the cords.

You see the vocal cords still spasming on the bronch,

um, not profoundly. So it's like, you know, maybe there was some partial

paralysis, but, um, it's hard to know for sure.

But the bronch is being passed. The, the issue is you can cause, um, you know,

glottic and tracheal and periglottic injury if the patient's

not fully paralyzed. Also, it can prevent appropriate intubation

where the

patient is, you know, they can cough out the bronch

or the endotracheal tube.

So, um, somewhat challenging and perilous here, but ultimately, bronch

is passed. This is carina. This is one of the powers of the dual-mode

airway

where, you know, you're passing the bronch all the way down

into the trachea.

The problem with most

bronchoscopies, you get this nice video laryngoscopy,

the spasming vocal cords like

we talked about, but right here is where you need to hang up.

So on bronchoscopy and almost everybody

when they're learning, go ahead and

passes this right down to the right mainstem bronchus.

And so, um, again, uh, you know,

uh, a-- this is a manageable issue, uh, but it

is that like this kind of, okay, I see carina, and my recommendation here

is just stop right here. And what happens to many people is it's

kind of continues to go on, and it's like, so now again, maybe, maybe this

was kind of pulled back appropriately, but often it'll start bifurcating.

Uh, you get down to the right mainstem

But regardless, now you're looking at the endotracheal

tubes.

You see, okay, now my eyes are going off of the tracheal side and the

flexible bronchoscopy side over to the video laryngoscope side.

I'm seeing the endotracheal tube pass down in past the glottis,

balloon is past the cords.

Which is great.

And that's a seven oh tube.

Now you see the tube coming into place right above the carina.

And so I think there has been some kind of depth change of the bronch, which is

okay. But ultimately it's, you know, it's like, where am I?

So then after this airway, so you see it's intact here,

the endotracheal tube

in place-- is in place here, endotracheal tube is in place on this

side, that

dual mode, that dual confirmation.

And following this, um, our own practice is, uh,

flexible bronchoscopy, essentially just as, uh, this

is not diagnostic,

this is confirming your endotracheal tube, it's an airway adjunct, but you can

use a bronch adapter, so you're still oxygenating

and ventilating the tube or the

patient while you pass the, uh, flexible bronch.

And this is confirming your location of your endotracheal tube.

So passing this

nice and slow

down the endotracheal tube and coming out the distal end

and looking, okay, where am I? And to me, this looks a little deep.

That's carina. And so instead of waiting for your chest

X-ray,

in real time, you can say, for example, you know, "Hey, I need to retract this

a, a centimeter or two." Um, and there are hash

marks on the flexible bronchs as well, which you can use to guide

that. Uh, but this gives you immediate feedback.

So it looks like the provider's then right there.

See, so they said, "Okay, I am too deep, right up next to the-- against the

carina."

And again, instead of waiting for the chest X-ray,

just pull the bronch back a

little bit and then retract your endotracheal tube.

And you'll see the providers do that.

So they're gonna pull the endotracheal tube back. There you go.

And now that looks, uh, more appropriately positioned above the

carina.

And remember, you're using that bronch adapter,

so this whole time you're

oxygenating and ventilating.

Um, and again, important to be coordinating with, uh,

the whole team as you

do this, describing what you're doing. This is that, again, okay,

this looks good.

This position looks reasonable.

And taking a look at, you know, there's-- looks like there

is, you know, some secretions here. But essentially,

I know exactly where I'm at.

This is, um, not only in the trachea, but the positioning looks reasonable.

And then, of course, you can compare to the chest X-ray.

So lots there, lots of teaching points, lots of, uh,

troubleshooting issues, and the reality of, you know, the--

what was

going on with paralysis, the challenge of the laryngoscopy

and the flexible

bronchoscopy tube placement. So much there.

So but the point is, we keep talking about it.

We share, um, in these Airways of the Month,

essentially what we're seeing

in real time, and then everyone can keep pushing

together to make airway

management safer for patient, provider, and everyone. So thank you all.

Talk to you next month.