Preface

Tracheal intubation is one of the cornerstones of anesthesiology. To the layperson, and even many surgeons, intubation appears to be a somewhat simple procedure. Indeed, intubation is easy 95% of the time. The incidence of difficult direct laryngoscopy these days is about 5%, with rates of difficult or failed intubation much lower.

This book is a reference tool that presents the most up-to-date information on advances in tracheal intubation. Chapters discuss advanced tracheal intubation techniques such as video laryngoscopy, ultrasound use for airway management, the video-assisted intubating stylet technique, and airway management techniques for obstetric patients. All the chapters highlight the advances, successes, and continued challenges that we face with tracheal intubation. It is our hope that the information contained herein will help practitioners achieve 100% success with endotracheal tube placement.

> **Jessica A. Lovich-Sapola, MD, MBA, FASA and Kasia P. Rubin, MD, MBA, FASA** Cleveland Clinic, Cleveland, Ohio, USA

**Michael D. Bassett, MD and Kelly Lebak, MD, FASA** MetroHealth Medical Center, Cleveland, Ohio, USA

**1**

**Chapter 1**

*Kelly Lebak*

**1. Introduction**

obstetrics.

ETT placement.

pulmonary pathology including pneumothorax.

Introductory Chapter: Advances in

Tracheal intubation is one of the cornerstones of anesthesiology. To the lay person, and even our surgical colleagues, it should not be that difficult …just put a narrow tube in the trachea; no big deal. Indeed, we as a profession make it look easy, and 95% of the time it is. The incidence of difficult direct laryngoscopy these days is only 4.9% [1] with difficult or failed intubation much lower than this at 0.33% and 0.01% respectively [2]. This book will look at four different aspects of advanced tracheal intubation including videolaryngoscopy, ultrasound use for airway management, the video-assisted intubating stylet technique, and airway management in

Without question, videolaryngoscopy (VL) has changed the practice of endotracheal tube (ETT) placement and the practice of anesthesiology. Much of the time, VL makes ETT placement look easy (to the lay person). First introduced in 2001 [3], it has grown ubiquitous in ETT placement. In fact, aside from "practice" or the need to "keep our skills up," do many/any of us, who grew up in the days of direct laryngoscopy (DL) or early days of VL, DL anymore? Can anyone imagine how we intubated patients with "anterior" cords atraumatically? Given all the advantages of VL including successful ETT placement in difficult airways, multiple clinicians' ability to view the airway, and documentation of airway findings, it is no wonder that VL has gained a prominent place in the American Society of Anesthesiologists Practice Guidelines of Difficult Airway Management [4]. There are still disadvantages with VL, namely the dreaded "blind zone" where injuries can occur, a bulkier design if a channeled blade is used, and increased cost compared with DL, but it has forever changed the practice of

VL is one of the indispensable tools in our arsenal, and ultrasound may be the next. It is commonly used by anesthesiologists for invasive line placements, nerve blocks, and point-of-care ultrasound. Not surprisingly, given its success in these realms, it is starting to be used for airway management. There is work being done using the US to predict difficult mask ventilation or intubation by measuring tongue thickness or soft tissue thickness at the vocal cords, predict proper ETT size in pediatric patients or patients with obesity, identification of airway nerves for awake fiberoptic blocks, identification of upper airway inflammation including epiglottitis and sinusitis (useful for nasal ETT placement), guidance of the ETT to the correct depth in the trachea, confirmation of ETT and supraglottic airway placement, lung ultrasound as an indirect sign of correct ETT placement, surgical airway guidance via visualization of the cricothyroid membrane and trachea, and evaluation of other

Tracheal Intubation
