Endotracheal Intubation When You Can’t See the Cords: the Bougie is Your Friend
This is a problem that every emergency physician or hospitalist faces on occasion and if you haven’t encountered this problem then you haven’t done enough intubations. There are times when you are performing direct laryngoscopy and you can’t see anything identifiable.
There are a few hints to optimize your success during direct laryngoscopy. The first piece of advice is to make sure that the patient is optimally positioned. Make sure that the head is elevated so that the external auditory canal is at the level of the sternal notch and the head is maximally extended into a good “sniffing position”. This aligns the oropharyngeal axis with the pharyngeal axis to give you your best chance to visualize the vocal cords.
The second hint is to make sure that you are controlling the tongue with your laryngoscope to get the best view possible. With the Macintosh (curved) laryngoscopy blade, I like to place the blade at the far right side of the mouth and use the lateral edge to push the tongue to the left. With a Miller (straight) blade, you can advance the blade at a slight angle with the shaft slightly towards the left side of the tongue and the tip towards the right side of the tongue as you advance the blade.
The last hint is to SLOWLY advance the blade and look for the epiglottis. Once you see the epiglottis, advance the tip of the Macintosh blade to the end of the vallecula (the space just anterior to the epiglottis). At this point, a lifting motion up and out away from you should give you your best view of the glottis. With a Miller blade, advance the tip under the epiglottis and lift the blade up and out away from you should give you a view of the glottis.
However, there will be times when the patient has a very anterior larynx and you will not be able to see the cords despite performing all these maneuvers. In these circumstances, the use of an intubating stylet (e.g., an Eschmann stylet, a Frova stylet, or a gum elastic Bougie) will be your best friend. All of these intubating stylets have a hockey stick configuration on one end. Insert the stylet with the hockey stick directed anteriorly and place this under direct visualization just above the corniculate tubercles (which are the pink fleshy bumps just posterior to the vocal cords). The curve of the stylet will guide it into the trachea. Clues that you are in the trachea include a “washboard” feel as the stylet bounces over the tracheal rings and the “hang up sign” when the stylet hits the carina. Once the stylet is in place, keep the laryngoscope blade in the mouth holding up the tongue as an assistant loads an endotracheal tube over the stylet and you can advance this to an appropriate depth of an insertion before pulling out the stylet.
I have a Bougie (or Eschmann stylet) available for all my intubations as you never know when you will encounter this situation.