External Laryngeal Manipulation or ELM is the single most effective maneuver at improving glottic exposure. During video laryngoscopy, ELM facilitates alignment of the glottic opening with the endotracheal tube when using both the KingVision standard and the KingVision channeled blades.
As you can see, the blade tip is properly inserted into the valeculla yet the glottic opening remains slightly anterior, making passage of the tube through the vocal cords difficult at best. In order to correct this issue the laryngoscopist applies gentle downward pressure to move the glottic opening to a more posterior position. Ask the assistant to maintain the position while the tube is placed. The opposing forces applied to the anterior neck drive the tip of the blade deeper into the valeculla activating and stretching the hyoepiglottic ligament. The epiglottis then lifts, precipitating optimal alignment of the glottic opening with the endotracheal tube as shown in the image below.
Ask an assistant to place their hand over the thyroid cartilage before insertion of the blade. During visualization, the laryngoscopists right hand is positioned over top of the assistants hand. By executing subtle movements at the anterior neck the laryngoscopist may achieve an improved laryngoscopic grade (in this case a grade 1), which can easily be maintained by the assistant. Since the assistants hand was placed directly on the thyroid cartilage first, there is no risk of failure to maintain the laryngoscopic grade achieved by ELM.
Combining ELM with a cheek pull and a manual pull of the mandible will ease intubation when using the KingVision standard blade. By asking an assistant positioned on the right to pull out the right cheek and pull open the mandible (POCPOM), you will have ample room to maneuver the tube into the airway and pass the tube through the vocal cords. All of these maneuvers should be queued before the first attempt for optimal results and first pass success.
The cheek pull and mandible pull can be performed separately or together depending on the needs and clinical judgment of the laryngoscopist. As you can see from the image above, there is little room to manipulate the tube in the airway. By pulling open the mandible the laryngoscopist could have gained more ET tube maneuverability, ultimately simplifying endotracheal tube placement.
Video laryngoscopy with the KingVision is a skill that varies considerably from its direct laryngoscopy counterpart. Just getting started can be challenging unless you have adequately rehearsed the skill. Practice makes proficient.
It's a good idea to suction the airway before you begin any attempt at video laryngoscopy. Secretions of any variety can land on the lens and obstruct the view. Position the patient with 20 - 30 degrees head of bed elevation to promote postural drainage of secretions and to prevent blood or vomitus from collecting in the airway. The laryngoscopist can limit the effect secretions will have on obstructing the lens by positioning the distal blade in the valeculla. The valeculla is the highest, most appropriate location for the blade tip.
Getting Going 1
(Above) The laryngoscopist handles the blade gently with the fingertips. 1. Enters the airway by rotating the KingVision blade 90 degrees into the mouth. 2. Tilts the blade forward slightly to move the blade deeper into the airway, guiding and controlling rate of insertion with the right thumb. 3. Gently tilts the blade back to reveal (blade) tip location in the airway. 4. Gently moves blade tip into the valeculla by slowly sliding blade down tongue and glides into place using thumb. Note: the epiglottis remains visible for best results. These steps must not be rushed. Go slowly, identify structures, be successful!
Getting Going 2
Starting the Tube
Tube insertion can begin either as shown in the image above or as shown in the image to the right. In either case, be certain the tube glides next to the blade. You must first look in the mouth to verify the tube has been inserted correctly. In other words, take your eyes off of the screen and physically look into the mouth to be certain the tube is adjacent to the blade and not underneath it. The tube should not go under the blade until after you have started its rotation.
Since the ETT has reached the pillars, rotation towards the screen ensues, and the distal end of the endotracheal tube passes under the blade and rides up into the airway. This helps to explain why the 60 degree ETT shape is critical.
As you can see in the image above, the ETT appears out of alignment with the airway. However, once the tube rotation has been completed, the airway and the endotracheal tube will realign.
A little ELM will result in successful placement of the ETT.