Direct laryngoscopy

Overview

• Used to facilitate intubation
• Provides direct line of sight of vocal cords (as opposed to video laryngoscopy)
• Most often utilizes Mac or Miller Blade

Indications

• Patients requiring endotracheal intubation

Contraindications

• Glottic or supraglottic pathology requiring surgical airway interventions

Equipment Needed

• Handle with light source
• Macintosh or Miller Blade
• A Macintosh 3 blade or Miller 2 blade are appropriate for most adults

Macintosh Blades 1-5, from bottom to top

Procedure (Macintosh Blade)

1. Place patient into sniffing position
2. Use "scissor" technique with right hand to open mouth
3. Insert laryngoscope blade into right side of mouth
4. Slowly advance blade into mouth while performing "tongue sweep"
5. Identify epiglottis
6. Advance tip of blade into vallecula
7. Lift upward and away from operator to expose glottis
8. If needed, perform bimanual laryngoscopy to optimize Cormack-Lehane view

Optimizing Laryngoscopy

• Ensure patient is in sniffing position
  • Extension of cervical spine
  • Flexion of atlanto-occipital joint
• Bimanual laryngoscopy
  • Have assistant place hand over trachea
  • Use right hand to apply pressure over assistants hand and manipulate trachea until cords are visualized
  • Have assistant maintain position as you deliver tube
• If epiglottis is "floppy" (common in peds), retract blade slightly and lift epiglottis with blade (similar to how Miller blade is used)
• Can use right hand to lift patients head off bed, when view obtained, have assistant place fist under patient head and use right hand to deliver tube

Complications

• Dental Trauma (minimize risk while lifting blade upward and away from operator)
• Laryngeal Trauma
• Sympathetic nervous system stimulation leading to tachycardia and hypertension

See Also

Airway Pages

• Pre-intubation
  • Predicting the difficult airway
  • Bag valve mask ventilation
    • Oropharyngeal airway
    • Supraglottic airway
  • Apneic oxygenation
    • EBQ:ED Preoxygenation
• Induction
  • Critical care quick reference
  • Rapid sequence intubation
  • Delayed sequence intubation
• Intubation
  • Intubation (peds)
  • Direct laryngoscopy
  • Video Laryngoscopy
  • Bougie
  • The difficult airway
  • Advanced airway adjuncts
    • Supraglottic airway
  • Non-traditional intubation
    • Awake intubation
    • Nasal intubation
    • Blind digital intubation
• Surgical airways
  • Surgical cricothyrotomy
  • Needle cricothyrotomy
  • Pediatric jet ventilation
• Post-intubation
  • Mechanical ventilation (main)
  • Deterioration after intubation (DOPE)

External Links

• https://litfl.com/direct-laryngoscopy/

References

1. Peterson K, Ginglen JG, Valenzuela FI, et al. Direct Laryngoscopy. [Updated 2020 Mar 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513224/[Category:Procedures]]