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Editor(s): Lee A. Fleisher, MD, FACC, FAHA Lee A. Fleisher, MD, FACC, FAHA

Robert Dunning Dripps
Professor and Chair
Department of Anesthesiology and Critical Care

Professor of Medicine
University of Pennsylvania School of Medicine
| Robert Gaiser, MD Robert Gaiser, MD

Professor of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine

Contributor(s): Joshua H. Atkins, MD, PhD Joshua H. Atkins, MD, PhD

Associate Professor
Department of Anesthesiology and Critical Care
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
| Acknowledgements Acknowledgements

Jeremy D. Kukafka, MD
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Infraclavicular Nerve Block: Ultrasound-Guided Technique
Intercostal Nerve Block: Ultrasound-Guided Technique
Intraoperative Transesophageal Echocardiography
Psoas Compartment Block: Ultrasound-Guided Technique
Supraclavicular Nerve Block: Ultrasound-Guided Technique

Gail A. Van Norman, MD
Clinical Associate Professor
Department of Anesthesiology
Univ of Washington
Seattle, WA

Elizabeth J. Watson, MD
Post-Doctoral Fellow
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

Liang Xue, BS
Research Assistant
Department of Anesthesiology and Critical Care
Univ of Pennsylvania School of Medicine
Philadelphia, PA

  • Requirement for positive pressure ventilation
    • Surgical procedures requiring muscular paralysis
    • Surgical procedures requiring special positioning in which airway management during the case may be challenging, such as prone positioning
  • To maintain a patent airway, such as in patients with trauma to the face or neck
  • Airway protection from secretions, blood, or gastric contents
  • Pulmonary toilet
  • Maintenance of adequate oxygenation and/or ventilation

All contraindications to direct laryngoscopy are relative. In the controlled or elective settings the following contraindications should be considered:

  • Anticipated difficult intubation due to multiple anatomic features or past history (see below)
  • Severe limitation of mouth opening
  • Unstable cervical spine or unstable atlanto-occipital joint (e.g., severe rheumatoid arthritis, trauma, Down syndrome)
  • Major trauma, abnormal anatomy, or tumor of the mandible, maxilla, larynx, neck, mediastinum, or trachea
  • History of extensive radiation therapy of the airway with a fixed larynx
  • History of tracheotomy or tracheal stenosis
  • Active airway bleeding

The operator should be familiar with use of equipment for mask ventilation

  • Face mask and ventilation apparatus with oxygen supply
  • Suction apparatus with Yankauer suction tip
  • Short and long blade handles with batteries
  • Selection of laryngoscope blades (e.g., Miller [straight] sizes 2 and 3; Macintosh [curved] sizes 3 and 4); metal or disposable
  • Dental guard
  • Foam head support/pillow or blankets
  • Endotracheal tube, with or without stylet
  • Stethoscope
  • Clean 10-mL plastic syringe for cuff inflation
  • Capnograph or colorimetric carbon dioxide detector
  • Tape or adhesive device to secure the endotracheal tube
  • Tape or ophthalmic ointment for eye protection

A focused pre-procedure physical exam of the airway will in many cases provide predictive information regarding the anatomy of the airway visualized on direct inspection. The exam should also include assessment and documentation of dentition, including caps; implants; crowns; and loose, missing, or decaying teeth. Identification and removal of any personal ornamentation, such as tongue-piercing ornaments, should occur before undertaking airway manipulation.


The oropharynx includes the structures of the upper airway from the soft palate to the level of the hyoid bone. The oropharynx opens anteriorly into the mouth, is bounded laterally by the two palatine arches and tonsils, and includes the posterior tongue. The laryngopharynx includes the epiglottis and larynx, which in turn consists of the vocal folds and vocal cords; the thyroid, cricoid, and arytenoid cartilages; and the intrinsic muscle of the larynx. The larynx begins where the upper airway divides to form the laryngeal inlet and the upper esophagus. The epiglottis is a cartilaginous flap attached to the posterior tongue, which forms a protective flap between the trachea and the upper esophagus.

Many major nerves contribute to pharyngeal and laryngeal function. Pharyngeal function is governed by cranial nerves IX, X (pharyngeal plexus), and XI (pharyngeal branch), which control elevation and shortening of the pharynx, alterations in palate position, the size of the pharyngeal lumen, and bolus transport of food in the esophagus. Motor innervation of the larynx is via the external and recurrent laryngeal branches of cranial nerve X. In addition, the facial nerve (cranial nerve VII) and cervical spinal nerves (C1-C3) contribute to motor function of the upper airway via actions of the mylohyoid muscle on the hyoid bone to pull the larynx up and the infrahyoid muscles, which pull the larynx down. Mandibular action during phonation is also controlled by the mandibular branch of the trigeminal nerve. Sensory innervation of the larynx is via the internal laryngeal branch of the vagus nerve (cranial nerve X) above the vocal folds and the recurrent laryngeal branch of the vagus nerve below the vocal folds.

Important internal landmarks involved in laryngoscopy and intubation include the epiglottis, the vallecula, the intrinsic cartilages of the larynx (arytenoids, thyroid, and cricoid), the true and false vocal cords, and the hyoid bone.

External Anatomic Features

Important external landmarks include the mental protuberance of the mandible, thyroid cartilage, hyoid bone, and cricoid cartilage. Anatomic features of direct relevance to laryngoscopy include extent of mouth opening, extent of jaw subluxation, ability to flex and extend the neck, neck circumference, tongue size protrusion, ability to visualize the uvula or soft palate with mouth opened and tongue protruded in the sitting posting without phonation (Mallampati score), mandibular size, mentohyoid distance, thyromental distance, and protuberant dentition. These measures are not sensitive or specific enough to predict whether the view will be limited on direct laryngoscopy. Limitations of movement, low Mallampati score, and short anatomic distances may warrant alternative strategies to endotracheal intubation.

The extent of visualization of the glottal opening under direct laryngoscopy is categorized by standardized grade (Cormack-Lehane scale) and is useful for objective description of the view for future airway management.

With a Macintosh blade, upward (axial) force on the hyoepiglottic ligament raises the epiglottis to reveal the glottal opening. With the straight Miller blade, the upward force under and against the epiglottis pulls the entire structure superiorly. External pressure on the cricoid cartilage (located just inferior to the thyroid cartilage and cricothyroid membrane) may in some cases improve the view of an anteriorly displaced larynx. A related intervention on the larynx, the BURP (backward, upward, rightward pressure) maneuver, has also been reported to improve visualization of the vocal cords in some patients.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

  • After placement of the endotracheal tube, the cuff should be inflated with the minimum volume of air to prevent a leak at the peak pressures required for effective ventilation (usually less than 30 cm H2O).
  • Check tube position by auscultating the chest and monitoring an in-line capnograph or colorimetry device while administering several slow breaths. Rapid, large tidal volume ventilation may increase aspiration risk if the tube is malpositioned in the esophagus. If these procedures indicate incorrect placement of the endotracheal tube, the tube should be promptly removed with suction available and mask ventilation resumed. 
  • Once proper placement has been determined, position of the endotracheal tube at the incisors should be noted and tube secured with adhesive tape. The dental guard should be removed and teeth and mouth inspected for injury.

Common General

  • Dental injury
  • Minor bleeding
  • Lip, gum, or tongue trauma

Common Cardiovascular Consequences

  • Tachycardia
  • Hypertension

Uncommon General

  • Eye trauma/corneal abrasion
  • Major bleeding
  • Airway edema
  • Temporomandibular joint dislocation
  • Vocal cord paralysis
  • Laryngospasm
  • Bronchospasm
  • Hypoxemia
  • Esophageal intubation, particularly if undetected
  • Endobronchial intubation

Uncommon Cardiovascular Consequences:

  • Bradycardia, particularly in children
  • Myocardial ischemia as a result of tachycardia in a susceptible patient


  • Esophageal perforation from malpositioned endotracheal tube
  • Arytenoid dislocation
  • Aspiration
  • Cervical spine injury
  • Tracheal perforation
  • Elevated intracranial pressure (especially in patients with already elevated pressure)
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