What is the recommended technique for intubation using a video laryngoscope?

Video Laryngoscope Intubation Technique

Use videolaryngoscopy with optimal patient positioning, adequate neuromuscular blockade, and a bougie or stylet for tube advancement, limiting attempts to a maximum of three while maintaining continuous waveform capnography confirmation. 1

Pre-Intubation Preparation

Patient Optimization:

• Position the patient with head elevation and alignment of oral, pharyngeal, and laryngeal axes (ramped positioning improves laryngeal view) 2
• Ensure thorough pre-oxygenation with apneic oxygenation techniques to extend safe apnea time 2
• Achieve full neuromuscular blockade before attempting intubation to optimize conditions 1, 2
• Confirm adequate depth of anesthesia 1

Equipment Setup:

• Use a videolaryngoscope with a separate screen visible to all team members to facilitate external laryngeal manipulation 1
• Have immediate access to a bougie or stylet (mandatory for hyper-angulated videolaryngoscopes and recommended for Grade 2b-3a views) 1
• Ensure waveform capnography is ready for immediate tube placement confirmation 1
• Position the operator with direct line of sight to patient, video monitor, and patient monitor 1

Intubation Technique

Device Selection:

• Choose a videolaryngoscope with which you are most familiar and trained 1
• For ICU intubations, videolaryngoscopes should be used either initially (especially if MACOCHA score ≥3) or after failed direct laryngoscopy 1
• In children with anticipated difficult intubation, use videolaryngoscopy as first option after ensuring adequate mouth opening 1

Laryngoscopy Execution:

• One blade entry into the oral cavity constitutes one attempt 1
• Limit attempts to a maximum of three to prevent airway trauma and progression to cannot-intubate-cannot-oxygenate (CICO) 1, 2
• After first failed attempt, immediately ensure front-of-neck access (FONA) equipment is at hand and summon senior help 1

Optimization Maneuvers Between Attempts:

• Reposition the patient's head 1
• Perform optimal external laryngeal manipulation or backwards-upwards-rightward pressure (BURP), facilitated by screen visibility 1
• Partially withdraw the blade to facilitate wider field of view 1
• Apply suction as needed 1
• Reduce or release cricoid force 1
• Consider different operator 1
• Switch to different device or blade 1

Tube Advancement:

• Use a bougie or stylet when laryngeal opening is poorly seen (Grade 2b or 3a views) 1
• For hyper-angulated videolaryngoscopes, a specific rigid stylet is mandatory per manufacturer instructions 1
• When using videolaryngoscopes without a lateral channel, use a non-traumatic preformed guide to direct the tube toward the glottic aperture 1
• Avoid blind tube passage attempts with Grade 3b and 4 views as they are potentially traumatic 1

Confirmation and Rescue

Mandatory Confirmation:

• Use waveform capnography to confirm intubation—absence of recognizable waveform indicates failed intubation unless proven otherwise 1
• Auscultation and chest wall movement observation are unreliable in critically ill patients 1
• Bronchoscopy via the tracheal tube can also confirm tracheal placement 1

Rescue Strategy:

• If videolaryngoscopy fails, consider alternative techniques (e.g., flexible bronchoscopy) 1
• A combined approach using both videolaryngoscopy and flexible bronchoscopy has been described for complex scenarios 1, 3
• Second-generation supraglottic airway devices should be immediately available as rescue oxygenation 1, 2

Critical Pitfalls to Avoid

• Do not attempt multiple videolaryngoscopy passes without optimization—switch techniques after 1-2 failed attempts 1, 2
• Do not use videolaryngoscopes if mouth opening is inadequate, cervical spine is fixed in flexion, or upper airway obstruction with stridor is present 1
• Do not rely on videolaryngoscopy alone in full stomach patients—intubation time may be longer and unpredictable 1
• Do not forget to note the time as induction commences—significant time may pass unnoticed during airway crises 1
• Do not use unfamiliar equipment in crisis situations—regular training with videolaryngoscopes is essential 2

Special Considerations

Awake Videolaryngoscopy:

• Awake tracheal intubation using videolaryngoscopy has comparable success rate and safety profile to flexible bronchoscopy (98.3% each) 1
• Selection between techniques depends on patient factors (e.g., limited mouth opening, large tongue, neck flexion deformity favor flexible bronchoscopy; airway bleeding favors videolaryngoscopy) 1
• Adequate topicalization is essential for awake techniques 1, 4, 5

Device-Specific Notes:

• Single-use flexible bronchoscopes have similar safety profiles to reusable ones 1
• McGrath Mac and C-Mac videolaryngoscopes are well-validated for ICU intubations, showing superiority over direct laryngoscopy 1
• No single videolaryngoscope has been proven superior to all others—use local availability and operator experience to guide selection 1