Troubleshooting Difficult Intubations

Have you ever been able to see the vocal cords during direct laryngoscopy but you weren’t able to pass the endotracheal tube cuff beyond the cords?  This occurs not too infrequently during endotracheal intubation and I am going to share a trick for this.

All endotracheal tubes are beveled tubes and sometimes the bevel gets caught on a tracheal ring in the subglottic space.  When this happens, the tube will get caught making it difficult to advance the endotracheal tube cuff beyond the cords.

If you encounter this problem, just remember the mantra “Rings Right”, meaning turn the tube to the right (clockwise) when it hits the “rings”.  Once you rotate the tube 90 degrees clockwise, the bevel will change orientation and allow easy passage down the trachea (see the figure 1 below).


Figure 1:  A:  Endotracheal tube meets resistance when the bevel catches on tracheal rings.

B:  Endotracheal tube rotated clockwise 90 degrees to allow free passage down trachea.


Used with permission from Stephanie Baum, Copyright 2014: Hospital Procedures Consultants

Read all articles in Endocrinology, Featured Procedure, King Tube, medical procedures, Respiratory diseases
Tags: airway management, direct laryngoscopy, endotracheal intubation, endotracheal tubes, HPC updates, intubation

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