During intubation, in which direction should the tongue be pushed to facilitate visualization of the vocal cords?

Proper Tongue Positioning During Intubation

During intubation, the tongue should be pushed anteriorly (forward) to facilitate visualization of the vocal cords. This technique is essential for successful endotracheal tube placement and reducing complications.

Proper Technique for Tongue Manipulation

• When using a laryngoscope, the blade should be inserted in the midline with the bevel anterior, then advanced to pass under the epiglottis 1
• After insertion, the laryngoscope should be rotated 90 degrees to allow atraumatic passage through the vocal cords 1
• Once the trachea is entered, the bronchoscope should be rotated back 90° and advanced toward the lower airways 1
• The operator's finger or a plastic tooth protector should be used to protect the upper teeth during insertion 1

Key Considerations During Intubation

• Proper head positioning is crucial - partial extension of the patient's head optimizes the view of the vocal cords 1
• To examine one of the bronchial trees, the bronchoscopist should rotate the patient's head toward the contralateral shoulder 1
• In an intubated patient, the bronchoscope can be advanced along the endotracheal tube to the level of the vocal cords 1
• Using a laryngoscope to lift the epiglottis anteriorly facilitates passage of the bronchoscope to the level of the vocal cords 1

Importance of Minimizing Interruptions

• During CPR, providers should minimize interruptions in chest compressions, with a goal to limit interruptions to no more than 10 seconds 1
• Compressions should be interrupted only for the time required by the intubating provider to visualize the vocal cords and insert the tube - ideally less than 10 seconds 1
• The intubating provider should be prepared to begin the intubation attempt with the laryngoscope blade and tube ready at hand 1
• If the initial intubation attempt is unsuccessful, a second attempt may be reasonable, but early consideration should be given to using a supraglottic airway 1

Advanced Techniques and Equipment

• Video laryngoscopy provides superior views of the glottis compared to direct laryngoscopes in patients with both normal and difficult airways 2
• When using video laryngoscopy, a rigid stylet (such as GlideRite®) can facilitate endotracheal tube delivery through the vocal cords 3
• Articulating video stylets with operator-controlled articulating ends and additional cameras at the tip may be used, though they may require slightly longer intubation times 3
• Optical stylets can be helpful in difficult intubations in both adults and children by allowing visual control of passage through the vocal cords 4

Common Pitfalls and How to Avoid Them

• Multiple and prolonged attempts at laryngoscopy and tracheal intubation are associated with morbidity and mortality - limit the number and duration of attempts 1
• The maximum number of laryngoscope insertions should be limited to four to prevent trauma and development of a 'can't ventilate' situation 1
• If direct laryngoscopy fails, alternative techniques that allow continuous ventilation and oxygenation should be implemented (Plan B) 1
• Failure to recognize tube misplacement or displacement can lead to hypoxemia - always use both clinical assessment and devices to confirm endotracheal tube location 1

Confirmation of Proper Placement

• Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube 1
• When waveform capnography is not available, colorimetric and nonwaveform exhaled CO2 detectors can be used in addition to clinical assessment as the initial method for confirming correct tube placement 1
• All confirmation devices should be considered adjuncts to other confirmation techniques 1