hi everyone my name is lahiru from abc's of  anesthesia and today we're going to go through  

a couple of really vital really important  things which is laryngospy technique and

intubation this is a laryngoscopy blade this is  a size for macintosh blade it's probably one of  

the most common ones you'll see it's one i go  to pretty much every single time and all it is  

is it's this handle and this handle is a power  source you can check the light by just depressing  

that there and then the blade which comes  in pretty much quite a number of sizes but  

the common sizes in adults are size four and  size three you can just latch it on like that  

what i do then is i check that the light is  working one of the most important things that  

you'll find is that you need a really good light  if this light isn't bright enough you'll be in  

there trying to find the trachea and everything  will be just dark so you really want a bright  

light this is what makes or breaks a difficult  intubation so there's a couple of different sizes  

that you'll be using when intubating adults  there's a size three and a size four now  

in my opinion i go to a size four every single  time a size 4 blade has the length for me to get  

down into the velecular that's that spot just at  the base of the tongue and where the epiglottis  

joins the tongue and that's where you need this to  end up to make sure you get the best view possible  

sometimes you'll be handed a size 3 blade for  smaller adults and females but this i find  

occasionally doesn't get down to the molecular for  that reason i'll go to a size 4 every single time  

the size 3 blade has one advantage in my eyes next  time you when you're in theater try this where you  

get someone to press down on the tip of the on the  tip of the blade and you find that it's far easier  

to lift this up than lift the size 4. the size  4 blade has a much larger lever which means that  

if someone's pressing down and you're trying  to lift here it's far harder to do that  

that said most people will gain the strength and  technique possible to injure anyone with a size  

4. there's quite a few different blades that  you might choose there's the straight miller  

blade the mccoy blade and also the varying types  of blades you can get with video laryngoscopes  

like the d-blade and these are hyper-angulated  blades i'll talk about those in another video  

when i'm intubating the very first thing i do  after patient's anaesthesia patients paralyzed  

is i tilt the head back what that does is it  tilts the head on the atlanta occipital joint  

that opens the mouth slightly and also gives  me a better aperture down into the trachea  

at that point what i do is i then insert the  laryngoscope the luring scope most people tell you  

to insert it like this now what i do is i insert  it slightly to the side you can imagine that in  

some people occasionally this handle might get  in the way or the chest might get in the way of  

this handle if i insert to the side that's never  a problem because there's always space around here  

and once it's in i then tilt it round now the  very next step slide the tongue from the right  

to the left at this point i'm pretty much down  straight back into the oropharynx at this point  

i do a tilting motion what i'm trying to do is  get that tip and just trace down the tongue so  

the tongue is the road down to the molecular i  need to go all the way down into the molecular and  

i'm tilting on this axis just to give you another  view the laryngoscope blade is now inside the oral  

cavity it's straight back down and i'm using that  tip to trace down and rotating it on this axis as  

it traces down the tongue again the tongue is the  road down to the molecular where this tip needs to  

be now after you've found the molecular the best  thing to do to optimize your view is to do this  

lifting motion and that lifting motion it's not  what people normally do naturally which is tilting  

back that's only going to lever against the teeth  and won't provide any kind of aperture down in  

through the oral cavity to the trachea what you  need to do is lift towards the corner of the room  

so what i get my trainees to do is look up at  the corner of the room and literally pull there  

sometimes you still don't get a view and  the very next step is to lift up the head  

that's obviously can be quite difficult i can  get a really good view by just lifting the head  

it opens up everything a lot better but holding  that can be really difficult so what i do then  

is i get my assistant to help me with that by  just holding that head up in the right position  

the final thing i want to go through  is that sometimes you just don't have  

enough momentum or force and what you can  do is you can bring your arm to the center  

and have that resting say on your chest that way  pushing forward even just pushing forward a little  

bit improves the amount of force and amount of  strength that you can have because you're not  

really lifting with your deltoid here there's  a pretty weak muscle in most of us you actually  

just move your body forward and that helps lift  as well sometimes you simply can't get a view in  

spite of everything that you've done there's  obviously a lot of things you need to follow  

i'd follow the das difficult airway society  guidelines to make sure that you manage this  

the absolutely appropriate way now there's a  few things that can happen if you don't get  

the right view now the way i think about this is  apb assistance paralysis burp bougie blade we'll  

go through this in future videos in more detail  but i always ask for assistance especially when  

you're junior you need to have someone helping  you and having extra hands and brains is always  

such an important thing because we're dealing  with people's safety in people's lives here  

so get assistance i think about paralysis is this  patient paralyzed to the absolute right level a  

paralyzed patient is invariably much easier to  treat much easier to oxygenate and ventilate  

and so always consider that again make sure  you've got your boss there your consultant there  

because it's a tough decision to make for anyone  especially if you're junior finally the three b's  

it on the larynx on the thyroid cartilage and  then i move it backwards upwards and rightwards  

and that can improve my view amazingly well  so that's the first thing i do after that  

now i still need my right hand so i get the nurse  to put their hands on the thyroid cartilage and i  

may move the nurse's fingers as i see fit that's  a really good technique so you know exactly where  

the hands are placed and that way it really helps  them because they can't see what you're seeing  

it's really important that they've got their hands  on the larynx so that you can manipulate those  

hands to make sure that you get the right view  and they know exactly where you want that larynx  

after burp i asked for a bougie because often even  with a bad view at grade 3 view i can still get  

the bougie underneath that epiglottis finally the  last step is asking for a blade a different blade  

often these days of video laryngoscope  now just notice the order i had that in  

burp bougie then blade i say birth first because  you've already got your hands you don't need to  

ask for anything else boujee's next because the  bougie is often something that's in the theater  

just nearby but still takes a bit of time to  get out finally a new blade might be in another  

room it might be in the theater complex and will  take time so i often get the theater technician  

or another nurse to go get that while i'm  proceeding down these plans so the last couple of  

tips imagine you've got a really good laryngoscopy  view so you've got a great view of the chords and  

now you're about to place your tube in intuitively  you think that you just want to have the tube like  

this following the contour of your laryngoscope  what i find is that that actually blocks your view  

so you're never really sure if your tube's  in there now it's a really simple maneuver  

you just turn your tube that side so it's  lateral it's horizontal that way i can see  

the larynx i can see the chords and i can see  the tube passing in and it doesn't take any more  

change than simply a lateral rotation clockwise 90  degrees and that's it now sometimes you just can't  

get the angle the end the larynx is maybe anterior  and there's a couple of simple things you can  

do you can have your tube already bent like that  preset or i might just bend the tube on the pillow  

like so and as it slowly recovers its shape i then  place it through the cords so just to demonstrate  

with a video laryngoscope now these first few  steps i had to get my right hand on the head  

and that allows me to just angle the neck back  angle the head back and this opens up the mouth  

giving me a much better trajectory to the trachea  so as i go in i go to the right side of the tongue  

and you kind of sweep the tongue over to the  left it's hard to demonstrate on this mannequin  

because of the tongue being fixed but that's the  step i would take so imagine right now that my  

laryngoscope blade is directly back at this point  i then use the tongue the tongue is again the road  

down to the molecular so i follow the tongue all  the way down to the molecular the next step i want  

to do is lift towards the corner of the ceiling  like so and that opens up everything allows me  

to see down into the trachea after this step  sometimes you might not get a great view what i  

do is i sometimes lift the head like this lifting  the head then allows me to you know improve my  

view and i might get my technician my nurse to  help support there while i get the tube into  

the right spot sometimes my blade might be too far  in if it is and that happens often when you first  

start out all i have to do is slowly trace back  until i can see the velocular and see the chords

now just to demonstrate inserting  this tube if i insert it this way  

it blocks my view completely but if i insert  to the side it can really help my view

i hope you enjoyed those tips and  good luck with your next intubation