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AIRWAY MANAGEMENT IN
CRITICAL CARE MEDICINE
Rüdiger NOPPENS, MD, PhD
Associate Professor
Tim PIEPHO, MD, PhD

Associate Professor
Department of Anesthesiology
Medical Center of the
Johannes Gutenberg
University, Mainz, Germany
4 Airway Management in Critical Care Medicine
Illustration: Airway Management in Critical Care Medicine

Yvan Freund, 67000 Straßburg, France Rüdiger Noppens, MD, PhD, Associate Professor
www.yvanfreund.com Tim Piepho, MD, PhD, Associate Professor
Medical Center of the Johannes Gutenberg University,
Mainz, Germany
Correspondence address of the author:

Rüdiger Noppens, MD, PhD, Associate Professor
Tim Piepho, MD, PhD, Associate Professor
Medical Center of the Johannes Gutenberg University,
Important notes: Mainz, Germany
Medical knowledge is ever changing. As new research and clinical Langenbeckstr. 1, 55131 Mainz, Germany
experience broaden our knowledge, changes in treatment and therapy E-mail: r.noppens@gmail.com
may be required. The authors and editors of the material herein have piepho@uni-mainz.de
consulted sources believed to be reliable in their efforts to provide
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Airway Management in Critical Care Medicine 5
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Devices with an Esophageal
Special Issues in Critical Care Medicine . . . . . . . . . . . 9 and Oropharyngeal Cuff . . . . . . . . . . . . . . . . . . . . . . . . . 31
The Critically Ill Patient . . . . . . . . . . . . . . . . . . . . . . . 9 Combitube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Incidence of Difficult Airways EasyTube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
in Critical Care Medicine . . . . . . . . . . . . . . . . . . . . . . 9 Laryngeal Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Laryngeal Tube Suction (LTS) . . . . . . . . . . . . . . . . . . 34
Definition of the Difficult Airway . . . . . . . . . . . . . . . . . . 10
Complications of Endotracheal Intubation Flexible Endoscopic Intubation . . . . . . . . . . . . . . . . . . . 34
in Critical Care Medicine . . . . . . . . . . . . . . . . . . . . . . 11 Flexible Endoscopic Intubation
Special Problems in the Intensive Care Unit . . . . . 11 in the Awake Patient . . . . . . . . . . . . . . . . . . . . . . . . . 35
Training of ICU Physicians Oxygenation during Flexible
in Airway Management . . . . . . . . . . . . . . . . . . . . . . . 11 Endoscopic Intubation . . . . . . . . . . . . . . . . . . . . . . . 35
Patient Sedation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Equipment for Airway Management . . . . . . . . . . . . . . . 12 Flexible Nasotracheal Endoscopic Intubation . . . 37
Predictors of a Difficult Airway . . . . . . . . . . . . . . . . . . . 14 Flexible Orotracheal Endoscopic Intubation . . . . . 39
Flexible Endoscopic Intubation
Securing the Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
in the Anesthetized Patient . . . . . . . . . . . . . . . . . . . . 40
Preoxygenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Endotracheal Intubation . . . . . . . . . . . . . . . . . . . . . . 16
of an Unanticipated Difficult Airway . . . . . . . . . . . . 40
Induction Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Flexible Endoscopic Intubation
Hypnotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Through the Laryngeal Mask . . . . . . . . . . . . . . . . . . 41
Neuromuscular Blockade . . . . . . . . . . . . . . . . . . . . . 16 Flexible Endoscopically Assisted Percutaneous
Opioids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Dilatational Tracheotomy . . . . . . . . . . . . . . . . . . . . . 42
Positioning the Head. . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Invasive Airway Access in Patients
Orotracheal Intubation . . . . . . . . . . . . . . . . . . . . . . . . . . 18 with Failed Oxygenation or Patients
Direct Laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . 18 with Failed Oxygenation and Ventilation . . . . . . . . . . . 44
Verification of Tube Placement . . . . . . . . . . . . . . . . 20 Surgical Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Management of Difficult Direct Laryngoscopy . . . 21 Needle Cricothyrotomy . . . . . . . . . . . . . . . . . . . . . . . 46
Transtracheal Jet Ventilation (TJV) . . . . . . . . . . . . . 47
The C-MAC® Video Laryngoscope . . . . . . . . . . . . . . . . 22 Evaluation of Various Invasive
Technique of Video Laryngoscopy . . . . . . . . . . . . . 23 Airway Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Glottic Visualization and Intubation Success
with the Video Laryngoscope . . . . . . . . . . . . . . . . . . 25 Emergency Algorithm for Airway Management
Video Laryngoscopy in Critical Care Medicine . . . 26 in the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Mainz Emergency Algorithm for an
Supraglottic Airway Devices . . . . . . . . . . . . . . . . . . . . . 26 Unanticipated Difficult Airway . . . . . . . . . . . . . . . . . 50
Laryngeal Masks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Classic Laryngeal Mask . . . . . . . . . . . . . . . . . . . . . . 28
Laryngeal Masks with an Esophageal Lumen . . . 29
Laryngeal Masks for Endotracheal Intubation . . . 30
Introduction Endotracheal intubation is usually performed with a laryngo-

scope and Macintosh blade4 (Fig. 2). This technique is also
The principal reason for admitting a critically ill patient to an called direct laryngoscopy because it affords a direct view
intensive care unit (ICU) is respiratory failure1. A vast array of of the laryngeal inlet (Fig. 3). But as several authors have
techniques and equipment are available in modern critical pointed out, securing the airway in an ICU is associated with
care medicine for the management of respiratory dysfunction. more complications and a higher rate of difficult intubations
In recent years, noninvasive ventilation with a face mask or than in anesthesiology5, 6. As a result, there have been
helmet has become an increasingly important ventilatory increasing efforts in recent years to develop devices that
modality in critical care settings2 (Fig. 1). Nevertheless, some can improve visualization of the glottic plane even in patients
patients with conditions such as acute lung failure (ARDS) with a difficult airway7. Most of these innovative devices do
will continue to require urgent endotracheal intubation, and a not require a direct line of sight to visualize the vocal cords,
variety of strategies must be available for providing invasive relying instead upon a camera or optical system that
ventilation3. Besides ventilation with a face mask or classic displays an eyepiece or monitor image of the laryngeal inlet
endotracheal tube, supraglottic airway devices are also
available. These devices are useful for providing short-term
ventilation and oxygenation, especially in emergency
situations. Examples are the laryngeal mask and laryngeal
tube. These devices cannot replace the endotracheal tube in
everyday clinical care, however, and serve only as adjuncts
until a definitive airway can be established by endotracheal
intubation or tracheotomy. The advantages of securing the
airway with a cuffed tube include:
the prevention of gastric insufflation

relative protection from tracheal aspiration of fluids and
solid foreign bodies
allows for special ventilatory techniques such as high-
frequency oscillatory ventilation (HFOV)
allows for controlled ventilation at high positive pressures
(e.g., PEEP)
allows for selective tracheal or bronchial administration of
pharmacologic agents through the indwelling tube
provides access for bronchoscopy and bronchial lavage
permits the selective sampling of tracheal secretions for
microbiological testing
2 Laryngoscope with a Macintosh blade.
1 Noninvasive ventilation with a CPAP 3 Visualization of the glottis by direct laryngoscopy.

helmet.
(Figs. 4, 5). This technique is often called indirect laryngo- applications such as elective general anesthesia. When these
scopy, therefore. Available data suggest that indirect devices are used routinely, the practitioners will already have
laryngoscopy will find growing applications in the everyday a high degree of expertise when confronted with an emer-
practice of critical care. Because complications are especially gency situation, since every instrument and device will have
likely to arise during the airway management of critically ill its own learning curve. Consequently, intensivists familiar with
patients with decreased physiologic reserves, every ICU airway management should be trained in the use of these
should stock a number of alternative devices for establishing devices.
a secure airway. The specific assortment of devices will de-
pend on local circumstances. No single conventional device It is not practical to stock a variety of airway adjuncts at every
is suitable for every conceivable situation that may occur patient bed in the ICU. A better solution is to employ rugged
during airway management. Multiple techniques and devices airway carts that can be individually outfitted and wheeled
should be on hand for managing any complication that may quickly to the bedside, delivering all materials and equipment
arise during endotracheal intubation. Experience has shown necessary for elective or emergency airway management
that it is best to stock devices that can be used for routine (Fig. 6).
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4 Video-assisted intubation with the C-MAC video laryngoscope. 6 Portable airway cart for in-hospital use.
5 Video-assisted fiberoptic intubation in the awake patient.

A common procedure in critical care medicine is bronchos- are being ventilated. Ideally, this instrument should be kept on
copy for the diagnosis and treatment of conditions such the airway cart so that it will be quickly available when needed
as atelectasis due to retained secretions8. Percutaneous (Fig. 7). The use of a battery unit and portable light source has
dilatational tracheotomy under endoscopic guidance has also proven helpful (Fig. 8). Immediate accessibility is crucial in the
become a fairly standard procedure in critical care settings9, 10. management of an unanticipated difficult airway. The optional
Thus, a bronchoscope or at least a large-bore intubation use of a monitor system is particularly useful in performing a
endoscope should be available in every ICU where patients percutaneous dilatational tracheotomy (Fig. 9).
7 Flexible intubation fiberscope, kept in a 8 Flexible intubation fiberscope with attached battery light source.
special “quiver” on the airway cart.
9 Percutaneous dilatational tracheotomy guided by video endoscopy.

Special Issues in Critical Care Medicine Incidence of Difficult Airways

in Critical Care Medicine
The Critically Ill Patient
In our own study of 140 endotracheal intubations in an
ICU patients are generally very sick and have greatly anesthesia-led ICU, we documented a 21% incidence of
diminished physiologic reserves. Many of them will require difficult intubation, defined as a Cormack-Lehane grade
circulatory and respiratory support. Patients in respiratory of III or IV11 (Fig. 10). In 7% of the patients, more than two
failure are frequently admitted to the ICU. Once improved intubation attempts were necessary to secure the airway. A
past the critical stage, patients are weaned from the ventilator group of French authors reported a 12% incidence of difficult
and finally extubated. Some of these patients will have to intubation in ICU patients6. One study in over 3400 patients
be reintubated because their general health status does not found a 10.3% incidence of difficult endotracheal intubation
allow for adequate spontaneous breathing. Intensivists, then, in all nonoperating-room intubations, with 3% of patients
must have a broad knowledge of circulatory and respiratory requiring three or more attempts12. Another study in more
therapies. Clinical experience and detailed background than 1000 patients found that more than two intubation
knowledge are essential to ensure that anesthesia induction attempts were needed13. By contrast, the incidence of
and airway management by endotracheal intubation can be difficult intubation in the operating room is only about 5%14.
successfully accomplished in this complex subset of patients. The incidence of difficult airways in prehospital emergency
The problems of scant respiratory and cardiovascular settings is comparable to that in the ICU: 15–19% with a
reserves are often compounded by an associated impairment Cormack-Lehane grade of III or IV15, 16. These figures clearly
of consciousness. Since many of these patients are not demonstrate that airway management in the ICU is a very
fasted, they are also susceptible to the aspiration of gastric demanding task with a high complication rate. For these
contents. Due to their critical health status, therapeutic reasons, intensivists must have comprehensive training
decisions must be made quickly and purposefully to ensure and experience that will enable them to manage critically ill
the provision of appropriate care. patients safely and effectively.
This is in contrast to the majority of patients who are treated

electively in an operating room setting. These patients are
usually well prepared, fasted, and rarely have a life-threatening
illness. Anesthesia induction is not urgent in most cases and
– unlike the conditions in an ICU – can be performed with
optimum staffing, equipment, and working space.

Grade I Grade II

Grade III Grade IV
10 The Cormack-Lehane classification of laryngoscopic airway views.
(Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39:1105-11.)
Grade I The vocal cords are fully visible. Grade III Only the epiglottis is visible.
Grade II Only the arytenoid area and posterior part of the Grade IV View is limited to the soft palate (pharyngeal structures
glottic opening are visible. cannot be seen).
Definition of the Difficult Airway Inability to intubate often presents as a difficult direct laryn-
goscopy in which the glottic plane cannot be visualized well
Various definitions of a difficult airway have been presented enough to allow safe placement of the endotracheal tube.
in the literature. According to the guidelines of the German
If failed intubation is accompanied by failure of bag-and-
Society of Anesthesiology and Intensive Care Medicine
mask ventilation, a “cannot ventilate – cannot intubate”
(DGAI), a difficult airway is present when an anesthesiologist
situation exists that is acutely life-threatening to the patient.
of average training experiences difficulty with mask ventilation
Instead of wasting time with more failed intubation attempts,
or tracheal intubation4.
the intensivist should change to an alternative technique as
Intubation is classified as difficult if successful endotracheal shown in the Noppens-Piepho Algorithm for Emergency Air-
tube placement by conventional laryngoscopy requires more way Management (see diagram).
than three attempts or takes longer than 10 minutes.
Noppens-Piepho Algorithm for Emergency Airway Management

Adequate mask ventilation
possible?
YES NO
Maximum of 3 intubation attempts EMERGENCY: Call for help.

(by SP); if possible: Consider neuromuscular blockade;
video laryngoscope; call for help SP: one intubation attempt
(video laryngoscope)
Successful?
Successful?
NO
NO
Adequate mask ventilation Return to spontaneous breathing

possible? NO
is possible – wake the patient?
Consider antagonists
YES (e.g., sugammadex, naloxone)
Video laryngoscope / Flexible or rigid

alternative blades Supraglottic airway device
intubation endoscope
Successful? NO NO Successful?
Successful? ONE alternative
NO
Return to spontaneous breathing

is possible – wake the patient? Video Flexible or Supraglottic
laryngoscope /
Consider antagonists alternative blades rigid endoscope device
(e.g., sugammadex, naloxone)
NO
YES Adequate mask ventilation

possible? Successful?
NO NO
Surgical or percutaneous cricothyrotomy
In-hospital algorithm for the management of an unanticipated difficult airway. Mask ventilation is the starting point because it generally represents
the first backup option. The selection of a particular device is based on availability and experience. SP = specialist.
Complications of Endotracheal Intubation Training of ICU Physicians

in Critical Care Medicine in Airway Management
Various life-threatening complications may arise during The physician staffing of ICUs varies widely at different
endotracheal intubation (see Table 1). in a multicenter study institutions18. In Germany, it has been found that staffing
of 250 ICU patients, at least one life-threatening complication ICUs with physicians trained in critical care is associated
was documented in 28% of endotracheal intubations. with significantly better patient outcomes. Based on available
Severe hypoxia occurred in 26% of these patients, severe data on airway management complications in critical care
hypotension in 25%, and cardiac arrest in 2%. Other medicine, physicians who work in a critical care setting
complications were cardiac arrhythmias (10%), esophageal should receive competent training in airway management19.
intubation (5%), and aspiration (2%)6. Another study also To date, however, this requirement has not been implemented
found a high incidence of potentially life-threatening on a broad scale and many doctors who work in ICUs are not
complications, with severe hypoxia occurring in 19% of the adequately trained in airway management. One reason for
patients, severe hypotension in 10%, esophageal intubation this may lie in different specialty backgrounds: In Germany,
in 7%, and aspiration in 6%5. The incidence of cardiac arrest various specialties such as internal medicine, surgery,
during airway management is significantly higher outside the pediatrics, and anesthesiology are concerned chiefly with the
operating room: 17.2% of the patients in the study suffered provision of intensive care. Few of these specialties devote
cardiac arrest, and severe hypoxia (SaO2 < 70%) was much attention to the practice of airway management. This
identified as the cause in most cases. The risk of cardiac led some authors to conclude that critical airway situations
arrest was increased in cases where regurgitation, aspiration, should be handled only by an anesthesiologist, who is an
esophageal intubation, or bradycardia occurred during “airway specialist”20. Currently, however, there is no scientific
intubation. evidence to support this requirement. In principle, specialty
training in critical care medicine does not ensure proficiency
Severe hypoxia (SpO2 < 80%) in successful endotracheal intubation. The ability to secure an
Severe hypotension airway is gained chiefly through clinical experience. Expertise
Cardiac arrest in airway management is based on comprehensive medical
Cardiac arrhythmia and pharmacologic knowledge and on clinical experience
with the various methods of establishing an airway. Studies
Esophageal intubation
indicate that 50 to 100 endotracheal intubations performed
Aspiration
under supervision with a laryngoscope and Macintosh blade
Table 1 Frequent complications of intubation in the ICU. are necessary to become fully proficient in this technique21, 22.
The practical implementation of an airway management
Special Problems in the Intensive Care Unit algorithm, a standard protocol for anesthesia induction,
and easy access to airway devices and alternatives have
Because of space limitations, it is more difficult to establish
proven helpful in reducing serious complications of airway
an airway in the ICU than in the operating room. The patient
management 23, 24.
is surrounded by myriad devices such as the ventilator,
monitors, hemofiltration devices, and infusion pumps. Infu-
sion lines and cables may hamper direct access to the head
of the ICU bed (Fig. 11). Moreover, special beds (e.g., ICU
beds with an integrated air mattress) and devices immobiliz-
ing the cervical spine can hamper access to the patient’s
head and make it difficult to position the head for intubation.
Space constraints may hinder assisting personnel in provid-
ing patient care. Often the available space is already occupied
by ICU devices, making it a challenge to get the airway cart
close to the patient.
11 Typical ICU equipment layout, with limited patient access.

Learn basic theory.

In dealing with each of the available devices and adjuncts,
the operator must gain enough practice to be able to use
Practice basic principles on an airway trainer.
the devices immediately, successfully, and safely even in
Perform the technique or procedure in a patient under emergency settings.
supervision.
Perfect the acquired skills. Place an airway in patients with The airway management guideline of the DGAI describes
an anticipated difficult airway. Participate in continuing a four-step process for learning the principles of airway
education and training. management4. These principles are applicable to all
techniques and procedures for airway management in critical
Table 2 Sequence of steps in learning the principles of airway care medicine (Table 2).
management.
Equipment for Airway Management

Every ICU should be equipped with a standard airway cart
to ensure the rapid availability of necessary airway devices
and adjuncts. One survey conducted in the U.S. found that
only 75% of the ICUs polled had equipment for endotracheal
intubation available in the ICU as a set25. Fifty percent of
the ICUs reported having a difficult-airway cart or tote bag
available within the unit. A survey conducted in Great Britain
found that basic equipment for endotracheal intubation
(ventilation bag, laryngoscope, laryngeal mask) was available
in all of the ICUs26. Surprisingly, however, only 32% of the
units routinely used capnography for the verification of tube
placement after endotracheal intubation. This is unusual when
we consider that since 1991, the American Society of Anes-
thesiologists (ASA) has recommended the measurement of
end-tidal CO2 level as a basic monitoring test after anesthesia
induction (Fig. 12).
12 Infinity Delta XL patient monitor (Dräger Medical GmbH, Lübeck,

Germany) with capnographic display.
The end-tidal CO2 level measured for 60 seconds is a Endotracheal intubation is the gold standard in critical care
reliable indicator of successful ventilation and thus provides medicine for treating an oxygenation deficit that cannot be
an indirect sign of successful intubation. For years, managed by noninvasive ventilation. The ICU should be
therefore, capnography has been a recognized standard in equipped with suitable instruments for anesthesia induction,
anesthesiology, and a capnometer should be available in all therefore (Fig. 13).
settings where patients are intubated. It is noteworthy that
current German standards stipulate that rescue vehicles with
a physician on board must be equipped with a capnometer
for monitoring intubations in prehospital emergency settings.
Device Comments Device Comments

Ventilation mask Various sizes should be available Supraglottic devices: The unit should be equipped with
(e.g., mask sizes 3, 4, and 5) such as the laryngeal the supraglottic device that is most
Ventilation bag Should be available at every patient mask, intubating familiar through clinical use
bed. FiO2 capacity should be > 0.9 laryngeal mask,
(e.g., oxygen reservoir, demand laryngeal tube,
valve) and Combitube
Devices for maintaining Various sizes should be available Alternative The use of video laryngoscopy as
a patent airway: Guedel (e.g., Guedel tube sizes 3, 4, and 5) laryngoscopes a standard procedure offers many
tubes, Wendl tubes McCoy blade, advantages over conventional
Laryngoscope handle Regularly check the battery charge video laryngoscope direct laryngoscopy (see Video
Laryngoscope blade Macintosh blades in at least two Laryngoscopy in Critical Care
sizes: No. 3 and No. 4. Straight Medicine, p. 26)
Miller blades may also be used, Flexible intubation Intubation endoscope with a light
depending on in-house protocols endoscope source (e.g., a battery-powered LED
Suction device Check for function before every light source)
endotracheal intubation Cricothyrotomy set An instrument set for surgical
Suction catheter Various sizes cricothyrotomy should always be
Stylet Various sizes. Choose the stylet available in addition to a needle
that fits the inner diameter of the cricothyrotomy kit
endotracheal tube. Gum elastic Table 4 Adjunctive devices for managing a difficult airway.
bougies may also be used
Capnometer E.g., a portable capnometer or
one integrated into the monitoring
system
Endotracheal tubes Various sizes (e.g., ID 6.5–9.0 mm)
plus a 10-mL inflation syringe
Pulse oximeter For monitoring oxygenation during
airway management.
Due to the delayed fall in oxygen
saturation, especially after good
preoxygenation, pulse oximetry
is not useful for verifying correct
endotracheal tube placement
Table 3 Essential devices for airway management in the ICU.
13 Instrument set for anesthesia induction.

Predictors of a Difficult Airway Predictors of a difficult airway

Mouth and Limited mouth opening (< 3 cm)
If time allows, every endotracheal intubation should be pharynx Limited range of TMJ motion
preceded by a review of the patient’s records and a (lower incisors cannot be moved
comprehensive airway examination4. Airway assessment anterior to the upper incisors)
should also precede “urgent intubations” (for respiratory Dental status: long upper incisors
failure that worsens over a period of hours). Generally there (“buck teeth”)
is no time available for airway assessment in emergency High, narrow palate
intubations (for sudden respiratory arrest). (“gothic-arch” palate)
Macroglossia (Fig. 14)
The anesthesia protocol may provide an important clue to
an anticipated difficult airway. Especially in surgical patients, Uvula not visible with the patient sitting
and the tongue protruded (Fig. 15)
the anesthesia protocol will generally yield important
Jaw proportions
information on the airway history. It may document possible
Retrognathia
complications during airway management such as difficult
Prognathia
mask ventilation, difficult intubation, or the use of alternative
Upper airway tumors
airway devices.
Face Congenital anomalies (e.g., trisomy 21,
Airway assessment should always include an evaluation Lenz-Majewski syndrome)
of the mouth, face, teeth, jaw, tongue, neck, and cervical Scars
spine (Table 5). This process takes very little time (about 15 Trauma (e.g., midfacial fracture)
seconds) and can prevent potentially serious complications. Edema
Neck Limited cervical spine motion
Pronounced ankylosing spondylitis
Large tumors displacing the trachea
Prior surgery, scarring
(e.g., neck dissection)
Obesity with a short neck (Fig. 16)
Table 5 Predictors of a difficult airway.
If one or more predictors of difficult intubation is found,

the intubation should always be performed by a physician
experienced in endotracheal intubation. The procedure of
first choice for anticipated difficult intubation is awake flexible
fiberoptic intubation (see Flexible Endoscopic Intubation,
p. 35). Spontaneous respiration should be maintained
in these patients until the endotracheal tube has been
placed in the trachea4. This procedure, done under topical
anesthesia, is successful in a high percentage of cases
and can be performed at low risk27. Uncooperative patients
may be carefully sedated (e.g., with opioids) to facilitate the
procedure. The sedative dosage should be low enough to
preserve spontaneous breathing.
14 Macroglossia in a patient with Lenz-Majewski syndrome.
15 Mallampati class IV: With the patient sitting and the tongue 16 Morbidly obese patient with a short, thick neck.
protruded, the uvula is not visible. Only the hard palate can be
seen.
Securing the Airway The use of a ventilation bag with oxygen delivery
(reservoir bag or demand system) is a simple and effective
preoxygenation method that can reduce the risk of severe
Preoxygenation hypoxia during airway placement. Preoxygenation before
anesthesia induction should be continued for 3–4 minutes28.
Every critically ill patient in the ICU should be adequately
There appears to be no benefit to extending the preoxy-
preoxygenated before anesthesia induction. Preoxygenation
genation period to more than 4 minutes29.
washes nitrogen (approximately 78% content in ambient air)
from the lungs and maximizes the functional residual capacity
Especially in obese patients with an anticipated rapid fall in
while producing maximum oxygen saturation in the blood.
oxygen saturation, noninvasive ventilation (pressure support:
The patient is preoxygenated by administering 100% oxygen 6 cm H2O, PEEP: 4 cm H2O) during preoxygenation was found
through a ventilation mask placed firmly over the face. When to produce a markedly improved oxygen content in the arterial
a ventilation bag is used, the oxygen flow should be at least blood30. In another study of hypoxemic patients requiring
15 L/min and a reservoir bag should be attached to the circuit intubation, it was found that preoxygenation by noninvasive
to achieve the highest possible oxygen concentration (> 90%) ventilation led to significantly fewer hypoxic events during
(Fig. 17). The reservoir provides for oxygen enrichment in the intubation compared with conventional preoxygenation31.
ventilation bag. After each ventilation the attached reservoir Preoxygenation was performed for 3 minutes using 100%
refills the ventilation bag with 100% oxygen. oxygen, pressure support ventilation with a tidal volume
Another option is ventilation bags that can be connected to a of 7–10 mL/kg body weight, and a PEEP of 5 cm H2O. This
demand system (Fig. 18). This arrangement can deliver a high study also demonstrated a positive effect on oxygenation for
FiO2 concentration within a short time. up to 5 minutes after endotracheal intubation.
The use of a nasal cannula or oxygen reservoir mask is
inadequate for preoxygenation. These systems can provide Thus, the recommended preoxygenation method for critically
only oxygen enrichment, so even with high oxygen flow they ill patients in respiratory failure is noninvasive ventilation on
are very limited in the maximum inspiratory oxygen content 100% oxygen, pressure support of at least 6 cm H2O (target
that can be achieved (FiO2 = 30–75%, depending on the = 7–10 mL/kg b.w.), and a PEEP of at least 4 cm H2O for a
system used). period of 4 minutes (Fig. 19).
17 Preoxygenation by bag-and-mask ventilation with an attached

reservoir bag.
18 Ventilation bag connected to a demand system. 19 Preoxygenation by noninvasive CPAP ventilation with a mask.
Endotracheal Intubation Induction Agents

The principal indications for endotracheal intubation in critical
care medicine include the following: Hypnotics
Maintaining a patent airway The need for hypnotics during anesthesia induction
Oxygenation is markedly decreased in critically ill patients who are
Controlled ventilation hemodynamically unstable. Also, it is advisable to use drugs
Protection from aspiration that cause as little cardiovascular suppression as possible
(Fig. 20). The use of propofol for emergency intubation is
Access for bronchial lavage
associated with a higher risk of hypotension than etomidate32.
As a general rule, critically ill patients are assumed to have a On the other hand, induction with etomidate causes
full stomach. Hence, there is always a risk of regurgitation and adrenocortical suppression and may be harmful for patients in
aspiration during airway management. septic shock33, 34. For these reasons, ketanest (0.5–1 mg/kg)
is being used increasingly as a hypnotic agent for anesthesia
To reduce the likelihood of aspiration, rapid sequence induc- induction in hemodynamically unstable patients24. Propofol is
tion (RSI*) should always be performed during endotracheal excellent for anesthesia induction in hemodynamically stable
intubation. patients.
Neuromuscular Blockade
* So named because the normal sequence of intubation is shortened
and some steps are omitted. Neuromuscular blockade is induced with muscle relaxants
to improve the intubation conditions and obtain better
visualization of the glottic plane. Currently two drugs are
available for rapid sequence induction: succinylcholine and
rocuronium (Fig. 21). Both agents have a rapid onset at the
proper dosage and provide good intubation conditions.
Succinylcholine (1–1.5 mg/kg) is a short-acting depolarizing
muscle relaxant (approximately 7 minutes) with a rapid onset
of action (30–60 seconds). A number of side effects and
contraindications have been reported (Table 6). Many of the
contraindications relate to critically ill patients in intensive
care.
Hyperkalemia (> 5 mmol/l)

Burns
Stroke
Spinal injuries
Multiple sclerosis
Guillain-Barré syndrome
Degenerative or dystrophic muscle diseases
Immobilized patient (bed-confined for >3 days)
20 Hypnotic agents for anesthesia induction (etomidate and
ketanest).
Table 6 Important contraindications to the use of succinylcholine.
Rocuronium is a non-depolarizing muscle relaxant. This

drug has a rapid onset of action (60–90 seconds) when
administered at high dosage (0.9–1.2 mg/kg), although this
will also prolong the duration of the neuromuscular blockade
(approximately 120 minutes). Sugammadex (16 mg/kg) can
completely reverse the effect of rocuronium within 3 minutes
(Fig. 22)35. The effects of succinylcholine and rocuronium
were compared in a Cochrane meta-analysis36. Both drugs
were found to produce equivalent intubation conditions, but
succinylcholine was deemed superior based on its short
duration of action.
21 Muscle relaxants for rapid sequence induction (succinylcholine

and rocuronium).
Neuromuscular blockade should be induced for every

intubation in ICU because it significantly improves the
intubating conditions.
The use of succinylcholine is limited to selected cases
due to its many possible side effects. When sugammadex
is available, rocuronium (0.9–1.2 mg/kg) should be used
routinely for neuromuscular blockade during endotracheal
intubation in critical care medicine.
Opioids
Opioids are traditionally used for anesthesia induction and
the maintenance of sedation. Because tracheal intubation is
a very potent stimulus, opioids (e.g., sufentanil at 0.2–0.4 μg/
kg) are often administered as adjuncts to anesthesia induction
22 Sugammadex can be administered for the prompt reversal of
(Fig. 23). neuromuscular blockade by rocuronium.
It should always be noted, however, that all drugs (opioids,
hypnotics) administered in a sufficiently high dose may
cause hemodynamic instability in critically ill patients with a
coexisting intravascular volume deficit.
Positioning the Head

Before endotracheal intubation, the patient’s head should be
placed in the “sniffing position” or modified Jackson position.
This is done by placing the head on an approximately 10-cm-
high cushion or pillow and hyperextending the neck (Fig. 24).
When the head is correctly positioned, direct laryngoscopy
can provide the intubator with a straight line of sight past
the upper incisors and through the oral cavity to the larynx
(Fig. 25).
23 Sufentanil can be used for anesthesia induction and the

maintenance of sedation.
24 The head has been placed in the “sniffing position.” 25 Creating a direct line of sight to the glottis.
Orotracheal Intubation the “crossed fingers” or “scissor” maneuver with the thumb
and middle finger of the right hand placed in the right-hand
corner of the mouth (Fig. 28). The thumb is placed firmly
Direct Laryngoscopy against the lower teeth while the middle finger pushes upward
on the upper teeth. This grip can also be used to gently
Orotracheal intubation under direct vision is the standard
extend the head. The laryngoscope with attached blade is
procedure used for most patients. The Macintosh blade
taken in the left hand, which typically holds the handle at its
is most commonly used (Fig. 26). Use of the straight Miller
distal third (Fig. 29). The laryngoscope blade is introduced into
blade (Fig. 27) differs in some respects from the technique
the right corner of the opened mouth and is moved into the
with the Macintosh blade.
midline, pushing the tongue to the left (Fig. 30).
After positioning, preoxygenation, and pharmacologic
anesthesia induction, the next step is to open the mouth with
26 Macintosh blades for direct laryngoscopy. 27 Miller blades in assorted sizes.
28 Demonstration of the “crossed fingers” or “scissor” maneuver for 29 With the laryngoscope handle in the left hand, the blade is
opening the mouth with the thumb and middle finger of the right introduced at the right-hand corner of the mouth.
hand.
30 The laryngoscope blade is introduced into the right side of the

opened mouth, and the tongue is pushed slightly to the left to
move the tip of the blade into the midline.
At this point the epiglottis, a critical landmark, should come dental injury (Fig. 33). Next the prepared endotracheal tube
into view. When a curved Macintosh blade is used, the tip of is carefully advanced through the glottis under vision. We
the blade is advanced into the vallecula, or the depression recommend advancing the tube down the right side of the
between the base of the tongue and the epiglottis (Fig. 31). mouth (retromolar route) so that the vocal cords can be kept
Exerting gentle traction along the axis of the laryngoscope in view. In all cases the cuff of the tube must be positioned
handle will lift the epiglottis out of the sight line and bring the within the trachea, and ideally the tube tip should be in the
glottis into view (Fig. 32). The handle should always be pulled middle third of the trachea. The tube is typically inserted to a
along its axis, never rotated or “levered” as this might cause depth of 21 to 23 cm from the incisor teeth (Fig. 34).
31 The tip of the blade is positioned above the epiglottis. 32 By pulling gently on the laryngoscope handle, the intubator lifts the
epiglottis and brings the glottis into view.
33 The laryngoscope should not be “levered,” as this could cause 34 Ideally the tip of the endotracheal tube is in the middle third of the
dental injury. trachea, at an insertion depth of 21–23 cm from the incisor teeth.
Verification of Tube Placement Bilateral auscultation of the chest in the axillary line
(symmetrical breath sounds?) and auscultation over the
After successful orotracheal intubation, the tube cuff is epigastrium (no ventilation sounds?) should be performed
inflated and correct tube placement is verified. Unrecognized after every intubation. Auscultation should not be omitted,
esophageal intubation is the most serious complication of as it can exclude placement errors such as a unilateral
endotracheal intubation. Table 7 lists typical reliable and endobronchial position of the tube tip.
unreliable signs of correct tube placement in the trachea.
Besides the direct visual monitoring of tube insertion,
Unreliable signs Reliable signs the most reliable sign of endotracheal tube placement is
Breath sounds on auscultation Capnometry/capnography. end-tidal CO2 detection by capnography. This procedure is
of the chest This modality cannot detect also explicitly recommended in the international guidelines
unilateral bronchial placement of the European Resuscitation Council (ERC) after every
or tube tip placement above endotracheal intubation37.
the glottis A capnometer allows for continuous, noninvasive monitoring
Absence of ventilation sounds Intubation under vision of the carbon dioxide concentration in the expired air. The
on auscultation of the stomach (watching the tip of the tube measured CO2 level is displayed in relation to the total gas
pass between the vocal mixture (in volume percent) or as an end-tidal partial pressure
cords) (etpCO2 in mm Hg). While capnography cannot trace the
progression of CO2 values over the respiratory cycle (Fig. 35),
Rising and falling of the chest Bronchoscopy with positive it can provide a graphic display of the CO2 level at the end of
during ventilation identification of the trachea each breath (Fig. 36).
(cartilage rings) and carina
The frequency of esophageal reintubation in critical care has
Fogging in the tube Chest radiography
a reported range between 1.3% and 9%6, 12, 32, 38, 39. These
(films are often not available
figures underscore the need for end-tidal CO2 monitoring
right away; the tip of the tube
during every intubation in critical care settings. On the other
in adults should be 5 cm
hand, it may be difficult for capnometry to confirm correct
above the carina)
endotracheal tube placement in patients who are in cardiac
Pulse oximetry Esophageal detector devices arrest. Due to the scant lung perfusion during chest compres-
(fall of SaO2 is often delayed sions, only low end-tidal CO2 levels are measurable in this
with misdirected intubation) subset of patients. As a result, it is difficult to distinguish
Table 7 Unreliable and reliable signs of tube placement in the trachea. tracheal from esophageal intubation40.
®
35 Waveform displayed on a portable capnometer. 36 Capnogram displayed on the Infinity Delta XL stationary patient
monitor (Dräger Medical GmbH, Lübeck, Germany).
Esophageal detection devices provide a reliable and cost-

effective means of verifying tube placement (Fig. 37). The
rubber bulb of the device is compressed, connected to the
endotracheal tube, and released. The trachea, unlike the
muscular esophagus, will not collapse in response to the bulb
suction because it is stabilized by cartilage rings. If the tube is
endotracheal, the bulb will reinflate; if it is in the esophagus,
the bulb will not reinflate because it cannot aspirate air from
the collapsing esophagus41. The bulb method is reliable in
patients with or without a circulation but may be misleading
in morbidly obese patients, in late pregnancy, severe asthma,
and in the presence of heavy tracheal secretions. Under these
conditions the trachea may also collapse in response to the
negative pressure from the bulb42, 43.
At least one reliable sign of endotracheal tube placement 37 Esophageal detection device with a self-inflating bulb.
should be detected after every endotracheal intubation. If a
reliable sign is not found, the sum of the “unreliable” signs
should all be consistent with endotracheal placement. If
doubt exists, laryngoscopy or bronchoscopy should be
repeated so that passage of the tube through the glottis or
tracheal structures can be visualized.
Finally it should be noted that end-tidal CO2 detection, endo-
tracheal intubation under vision, and esophageal detection
devices are not 100% reliable in verifying tube placement.
None of these methods can exclude the possibility of
unilateral tube placement in a main bronchus.
Management of Difficult Direct Laryngoscopy Measures for improving intubation conditions

If direct laryngoscopy is difficult or impossible on the first Place the head in an optimum position
attempt, various measures can be taken to improve visualiza- (“sniffing” or modified Jackson position)
tion and intubation conditions (Table 8)4. An essential step is Manipulate the larynx to align it more closely with the visual
an early call for help from a physician experienced in airway axis of the intubator:
management. The presence of an attending anesthesiologist OELM (optimal external laryngeal manipulation)
is associated with a decreased overall incidence of complica-
BURP (backward upward rightward pressure on the
tions44. The airway care delivered by an experienced anesthe-
thyroid cartilage)
siologist is distinguished not only by the type of care provided
but also by the pharmacology of anesthesia induction. Use an alternative introducer (e.g., gum elastic bougie)
It should also be emphasized that repeated intubation Prebend the tube tip 90° on a stylet
attempts are associated with higher complication rates. (“hockey stick” configuration)
According to a study by Mort, the incidence of severe Use a video laryngoscope
complications rises sharply when more than two failed
Use alternative intubation blades
intubation attempts are performed45. The incidence of
(e.g., McCoy, Henderson blade)
severe hypoxia (SaO2 <80%) is increased by a factor of 14,
aspiration by a factor of 4, and cardiac arrest by a factor Table 8 Measures that can improve intubation conditions.
of 7. The management of these cases should include the
early consideration of alternative airway techniques. The
goal of airway management in most ICU patients is the
placement of an endotracheal tube. But if direct laryngoscopy
proves difficult or impossible, the intubator should not cling
stubbornly to that procedure. It is better to switch to an
alternative technique than risk additional airway trauma.
The C-MAC® Video Laryngoscope The C-MAC® video laryngoscope has a modular design that
can accommodate various reusable stainless-steel blades with
Advances in digital photographic and video technology an integrated LED light source and camera. Macintosh blade
in recent years have led to the development of innovative sizes 2, 3, and 4 and Miller blade size 1 are currently available
laryngoscopes that differ from conventional devices by (Fig. 40). The Macintosh blades have been slightly modified for
eliminating the need for a direct line of sight to the glottis (Fig. use with the C-MAC®: The blades have a thinner profile (maxi-
38)7. Indirect visualization of the glottic plane is accomplished mum 1.4 cm) and a beveled shoulder. They may be equipped
with a small digital camera that is mounted at the distal end of with an optional guide channel for introducing a suction cath-
the laryngoscope blade and transmits the image electronically eter to maintain a clear visual field. The special “dBLADE®” is
to an LCD video monitor (Fig. 39). additionally available for difficult intubations (Fig. 41). Its distal
tip has a 40° angulation that is designed to improve visualiza-
tion of the glottis in anatomically difficult intubations.
38 Unlike conventional laryngoscopy, video laryngoscopy can “see 39 The glottis is displayed on the 2.4-inch LCD monitor of the
around the corner” (light blue area). C-MAC® PM video laryngoscope.

40 The C-MAC PM video laryngoscope, ; C-MAC with Macintosh

® ®
41 C-MAC fitted with a dBLADE for difficult intubation.
® ®
blade sizes 2–4, – ; and C-MAC® with a Miller blade, .
®
42 External 6.7-inch LCD monitor for the C-MAC video laryngoscope, 43 The slot on the top of the LCD video monitor accommodates a
displaying the glottis. standard SD memory card.
The camera window is prewarmed by the LED light source allows approximately 2 hours of operation. Since the C-MAC®
to prevent fogging. The color image is transmitted by cable was designed for use under difficult conditions, the casing is
from the camera chip to a 6.7-inch (17-cm) diagonal external made of impact-resistant plastic that protects against dust and
video monitor (Fig. 42). The monitor image always shows the splashes.
tip of the blade, allowing for accurate placement of the blade The C-MAC© Pocket Monitor (PM) that incorporates a 2.4-inch
tip in the vallecula. The C-MAC® video laryngoscope allows LCD screen (Fig. 44) is a part of the video airway manage-
still pictures and video sequences to be recorded and stored ment system that is available as an alternative to the larger
digitally on an SD memory card (Fig. 43). Both the monitor monitor. This ultra-portable system is compatible with any
and the laryngoscope handle have buttons that allow the KARL STORZ video laryngoscope blade. It can operate for
operator to capture still images and video sequences. The approximately one hour without recharging. The small screen is
system is powered by a rechargeable lithium ion battery that for live viewing only and cannot capture stills or video.
Technique of Video Laryngoscopy help optimize the glottic view (Fig. 46). As a rule, the view
of the blade provided by video laryngoscopy is superior to
When the C-MAC® video laryngoscope is used with a direct visualization with a Macintosh blade46. Additionally,
Macintosh-type blade, intubation employs the same tech- the modified shape of the C-MAC® Macintosh blade allows
nique as a conventional intubation. The system can be used the epiglottis to be carefully lifted on the tip of the blade,
for conventional direct laryngoscopy as well as video-guided analogous to the technique with a straight Miller blade, to
laryngoscopy (Fig. 45). Combining a Macintosh-type blade obtain a better view of the vocal cords47.
with a camera at the blade tip makes the system more similar
to direct laryngoscopy than other video laryngoscopes. When the dBLADE® is used, the intubation technique must
Thus, the C-MAC® video laryngoscope makes it possible to be modified to accommodate the unique blade design (Fig.
perform conventional intubation under continuous guidance, 47). As with most other video laryngoscopes that have an
which is advantageous for training and continuing education. upturned blade tip (e.g., the GlideScope®, McGrath®), the
Also, an assistant can monitor the effect of external laryngeal dBLADE® is introduced in the midline for advancement toward
pressure and can actively apply suitable manipulations to the glottis. Analogous to direct laryngoscopy, the intubator
45 The C-MAC can be used for conventional direct laryngoscopy ()

®
44 The 2.4-inch LCD monitor of the C-MAC PM, shown here
®
mounted on the dBLADE®. as well as video-assisted laryngoscopy using the LCD monitor ().
®
46 An assistant can observe the effect of external laryngeal 47 Insertion of the dBLADE .
manipulations and apply pressure as needed to optimize the
glottic view.
should always try to identify the epiglottis so that the blade assessment of the users (Fig. 49)53. This result is supported
tip position can be assessed. This is done to ensure that the by a study on a simulated airway using the C-MAC® video
blade tip itself does not encroach upon the glottic inlet. laryngoscope and Macintosh blade54. When the tube was
introduced on a stylet prebent to a 90° angle, the time to
Due to the upward angulation of the dBLADE® tip, it is
endotracheal intubation was shorter in all the simulated
important to learn the proper use of the device. Studies with
scenarios (normal airway, immobilized cervical spine, swollen
devices having a similar blade shape have shown that 5 to 8
tongue, and immobilized cervical spine plus a swollen
intubations are necessary to become proficient in the use of
tongue). Especially in scenarios with a very difficult airway
special blades48–51.
(immobilized cervical spine plus a swollen tongue), intubation
Although the glottic plane can be visualized by video with the hockey-stick configuration was faster and more
laryngoscopy with a high success rate, problems may arise. successful than intubation without a stylet. A stylet prebent to
Despite an excellent view, it may be difficult to direct the a hockey-stick shape should definitely be used with all curved
endotracheal tube through the vocal cords. This is true of all blades (including the dBLADE®) to facilitate accurate tube
systems that do not have an integrated tube guide. With the advancement to the glottic plane.
blade positioned in the oral midline, the tongue may hamper
Another alternative is the primary video-laryngoscopic
advancement of the tracheal tube (Fig. 48).
placement of a guide such as a gum elastic bougie or Frova
In contrast to conventional laryngoscopy, the intubator intubating stylet. The tracheal tube is then advanced over the
does not require a straight line of sight from the oral cavity preplaced guide (Fig. 50)56, 57.
to the vocal cords7. Since it is unnecessary to align the oral,
pharyngeal and tracheal axis, the tube must be advanced Other problems may arise even after the tube has passed
“around the corner.” Thus, whenever indirect laryngoscopy through the vocal cords. For example, the extreme prebent
is performed with a device that does not have an integrated configuration of the stylet within the tube can make further
tube guide, endotracheal tube insertion should always be tube advancement difficult. This often results from the fact
aided by a stylet53–55. that the tube is pointed toward the anterior part of the larynx
(Fig. 51). In this case it may be helpful to advance the tube
One study found that prebending the endotracheal tube 90° while simultaneously withdrawing the stylet. Rotating the tube
to a “hockey stick” configuration on a malleable stylet allowed 180° after removing the stylet may also help to advance the
for easier endotracheal placement based on the subjective tip more deeply7, 53.
®
48 With the dBLADE in the oral midline, the tongue may hamper
advancement of the tube.
49 The tracheal tube is prebent 90° on a malleable stylet (“hockey 50 The endotracheal tube is introduced over a guide (e.g., Frova
stick” configuration) to facilitate endotracheal placement. intubating stylet) preplaced under video laryngoscopic guidance.
Glottic Visualization and Intubation Success the glottic plane in most patients. As a result, use of the C-
with the Video Laryngoscope MAC® with Macintosh blade can be recommended for every
intubation that is performed outside the operating room.
One study found that the use of a video laryngoscope with
In patients with a simulated difficult airway involving limited
a Macintosh blade improved glottic visualization in 44% of
cervical spine motion and limited mouth opening due to the
patients compared with direct laryngoscopy (n=300)58. There
placement of a cervical immobilization collar, use of the
were a few cases, however, in which video laryngoscopy
C-MAC® video laryngoscope could significantly improve the
gave a poorer view than direct laryngoscopy. Endotracheal
view of the glottis (Fig. 53)60. The vocal cords were visible
intubation with the video laryngoscope was not possible in a
by direct laryngoscopy in 30% of cases, while use of the
total of 4 patients (1.3%). In another study of patients whose
C-MAC® video laryngoscope with Macintosh blade provided
glottis could not be visualized by direct laryngoscopy (CL
a clear view of the glottis in 86% of the patients. External
grade III or IV, Fig. 52), the monitor of the video laryngoscope
laryngeal manipulation (BURP maneuver) improved the glottic
provided an improved glottic view in 84% of the cases46.
view in 95% of cases.
The incidence of difficult intubation was reduced from 14%
to 3% in this study. The KARL STORZ video laryngoscope In our own study, the C-MAC® video laryngoscope with
was also found to improve glottic visualization in patients with Macintosh blade was used in patients with unanticipated
anticipated difficult intubation59, although this study did not difficult intubation (CL grades III and IV) as an alternative to
include cases with a CL grade IV view (epiglottis and glottis direct laryngoscopy61. The C-MAC® with Macintosh blade
not visible). The incidence of CL grade III (only the epiglottis is improved visualization of the vocal cords in 94% of the
visible) was lower compared with conventional laryngoscopy, patients. It did not improve the glottic view in 6%. Tracheal
and 99% of the patients could be successfully intubated intubation was successful in 94% of patients using the C-
by video laryngoscopy. These data clearly indicate that the MAC® video laryngoscope. These cases required a maximum
use of a video laryngoscope can improve visualization of of three intubation attempts.
51 An endotracheal tube prebent to a “hockey stick” shape points

toward the anterior wall of the larynx.

®
52 Grade III and grade IV views in the Cormack-Lehane classification. 53 The C-MAC video laryngoscope can significantly improve the
Grade III , only the epiglottis is visible. glottic view in patients who have a difficult airway due to an
Grade IV , no pharyngeal structures are visible. immobilized cervical spine.
No large clinical studies have yet been done on the use of An optimum video laryngoscope must meet the specific
the curved dBLADE® for difficult airways. In one study of 20 requirements of an ICU setting:
patients with difficult laryngoscopy in which the glottis was
not visible (CL grades III and IV), use of the dBLADE® was Rapid accessibility without the complicated assembly of
found to improve visualization in every case (to CL grade I components.
or II)47. Intubation was successful in 14 patients on the first Rugged construction. Dropping the device, which may
attempt. The remaining six patients required a maximum of well occur in an emergency setting, should not cause
four additional attempts for successful intubation. The high- significant damage.
curvature dBLADE® is particularly intended for use on the Easy to use, with a short learning curve.
unanticipated difficult airway. Studies of video laryngoscopes Flexibility of use. The device should be usable in a range
with a similar blade shape found improved visualization in of patients; various blade sizes and types should be
almost all patients with difficult direct laryngoscopy7, 62. The available.
McGrath® Series 5 and GlideScope® had success rates of
A large monitor. This will allow all members of the intensive
94–95% in cases of failed direct laryngoscopy with a conven-
care team to observe the intubation and, if necessary,
tional Macintosh blade.
render assistance with minimal communication (e.g.,
laryngeal manipulation).
Video Laryngoscopy in Critical Care Medicine Fast and effective reprocessing. The multitude of
Endotracheal intubation is considerably more difficult in multidrug-resistant organisms that exist in critical care
critical care settings than in the structured routines of an settings makes it imperative to achieve a thorough
operating room. Complications during airway management decontamination.
are common. Given these circumstances, it should be
assumed that every critically ill patient in ICU who requires Use of the C-MAC® video laryngoscope with a Macintosh
endotracheal intubation will have a difficult airway. Previous video blade in the ICU was able to reduce the incidence of
studies on video laryngoscopy have shown conclusively that difficult intubation from 20% with direct laryngoscopy to 7%
the use of a video laryngoscope with a Macintosh-type blade with the C-MAC®63. Use of the C-MAC® also resulted in more
is justified for every intubation in critical care medicine in successful intubations on the first attempt (88%) compared
order to protect patients from potential hazards. with direct laryngoscopy (80%).
Supraglottic Airway Devices In principle, supraglottic airway devices provide an alternative

to face-mask ventilation and endotracheal intubation (Table
Proficiency with alternative techniques of oxygenation and 9). Because they do not pass through the glottis, the DGAI
ventilation is of critical importance when endotracheal also refers to them as “pharyngeal airway devices”4.
intubation fails. Supraglottic airway devices have gained
an established role as alternative methods for securing Supraglottic airway devices Examples (see Fig. 54)
a difficult airway in prehospital emergency medicine and Classic laryngeal masks Ambu AuraOnce ()
anesthesiology4, 37. To date, supraglottic techniques have LMA Classic
been used only sporadically in critical care medicine64.
A British study on the availability of airway equipment in Laryngeal masks with an LMA Supreme ()
ICUs found that only about 50% of the care units were esophageal lumen LMA ProSeal®
equipped with supraglottic airway devices26. The main I-Gel® ()
reason for this is the need to ventilate critically ill patients Laryngeal masks that Fastrach intubating LMA
invasively and for an extended period, which generally can allow blind endotracheal ()
be accomplished only with an endotracheal tube. Moreover, intubation
intensivists with no background in anesthesiology often lack Devices with an esophageal Combitube
the clinical experience and training necessary to use the and oropharyngeal cuff EasyTube ()
devices safely and effectively. On the other hand, intensive LTS-D laryngeal tube ()
training with supraglottic devices and a protocol based on
standard guidelines and algorithms will enable practitioners Table 9 Typical supraglottic airway devices.
to recognize typical airway problems quickly and institute
appropriate measures without delay. Even less experienced and novice users can successfully
use these devices for ventilation and oxygenation with
little training. In one study, 50 subjects with no experience in
endotracheal intubation were trained in the use of the LMA
Supreme® laryngeal mask on an airway manikin65.
In the next phase the participants inserted the laryngeal mask I-gel® supraglottic airway are specifically recommended for
in anesthetized patients. All 50 subjects were able to place the ventilation of patients in cardiac arrest. It should be noted,
the laryngeal mask successfully, and 86% required only one however, that none of the supraglottic devices is a cure-all
attempt. and none can establish ventilation and oxygenation in every
situation.
The LTS-D laryngeal tube was successfully inserted by novice
users in 74% of anesthetized patients within 45 seconds66. While many of the supraglottic devices can be placed blindly,
In another study, first-month anesthesia residents were they do not allow the airways to be inspected for trauma,
trained briefly in ProSeal® laryngeal mask airway insertion on bleeding, foreign bodies, or other pathology. As a general rule,
a manikin and were then able to place the LMA in patients all supraglottic techniques are contraindicated in patients who
with a higher success rate than conventional laryngoscopic have upper airway pathology that involves severe swelling
intubation (100% versus 65%) and with a shorter effective (e.g., acute inflammatory diseases such as epiglottitis) or large
airway time (42 s versus 89 s)67. Similar data were reported tumors. On the other hand, these contraindications should
for LTS laryngeal tube insertion in an airway manikin: the be considered relative in situations where there have already
LTS could be placed faster and with a higher success rate been multiple failed attempts at endotracheal intubation.
compared to endotracheal intubation68. In a large study the
None of the aforementioned devices may be considered a
Combitube could be placed successfully on the first attempt
substitute for endotracheal intubation. Instead, supraglottic
in 82% of cases69.
airway devices should be considered a temporizing measure
In summary, these data indicate that all supraglottic airway in critical care settings72. While it is true that ventilation can
techniques are easy to learn. It should be emphasized, often be achieved, a supraglottic airway cannot effectively
however, that training on an airway simulator and on patients protect against aspiration. The general aspiration risk during
is essential before the devices can be used safely and ventilation with a classic laryngeal mask is reported to be
proficiently. 1:5000 in routine anesthesiologic practice70. The laryngeal
mask significantly reduces the risk of aspiration compared
Especially in critical situations involving failed intubation in
with conventional bag-and-mask ventilation71.
the ICU, supraglottic airway devices can provide temporary
oxygenation and ventilation until a physician experienced Once oxygenation and ventilation have been established,
in airway management is available. The guidelines of the an individual decision can be made on how best to secure
European Resuscitation Council (ERC) recommend that a definitive airway. In principle, this can be accomplished by
personnel who lack experience in endotracheal intubation creating a surgical airway or by flexible endoscopic intubation.
should use a supraglottic airway device as an alternative37. An ENT surgeon, for example, can easily perform an elective
The Combitube, classic laryngeal mask, laryngeal tube, and tracheotomy while a supraglottic device is in place.

54 Ambu AuraOnce (), LMA Supreme (), I-gel airway (), Fastrach intubating LMA (), EasyTube (), LTS-D laryngeal tube ().
®
The blind insertion of an endotracheal tube through a classic

laryngeal mask has a low success rate. It is recommended,
therefore, that secondary intubation be performed with a
flexible intubation endoscope73. First, a flexible intubation
rod (e.g., Aintree intubating catheter) is positioned within
the trachea. Then, the laryngeal mask is removed and the
endotracheal tube is introduced over the intubation rod
(Fig.| 55)74. When a Mainz adapter is used, ventilation of the
patient can be continued during placement of the rod (see
also Flexible Endoscopic Intubation).
55 Once a flexible intubation rod has been placed, the laryngeal mask
can be removed and an endotracheal tube can be introduced over
the rod.
Laryngeal Masks Many airway algorithms rank the laryngeal mask as an

alternative device to be used in cases of failed intubation
or difficult face-mask ventilation76, 77. It should be noted,
Classic Laryngeal Mask however, that during the ventilation of a patient with a classic
laryngeal mask (e.g., Ambu AuraOnce, LMA Unique), gas leak
Since first described in 198575, the laryngeal mask airway has
often occurs at airway pressures of approximately 18–20 cm
been utilized throughout the world in a variety of anesthetic
H2O or higher78, 79. This limits the quality of ventilation that
procedures. According to its inventor, the laryngeal mask
can be achieved in patients with low pulmonary or thoracic
is intended to provide a hybrid technique between mask
compliance.
anesthesia and endotracheal anesthesia.
The laryngeal mask has a cuff that seals off the space around
the epiglottis from the posterior side, thus enabling the patient
to be ventilated without passing a tube through the glottis.
The distal tip of the cuff should engage against the upper
esophageal sphincter.
With some experience, the user can manually place the
laryngeal mask swiftly and without additional aids. As in
anesthesia induction before endotracheal intubation, the
patient must be anesthetized or deeply unconscious. The
ideal head position is the sniffing or modified Jackson
position. One way to place a laryngeal mask is to open the
patient’s mouth, tilt the head back (Fig. 56), and advance the
device along the hard palate into the pharynx. When the tip of
the mask engages the upper esophageal sphincter, a definite
resistance will be felt, which confirms correct placement.
56 The head is tilted back and the laryngeal mask is inserted along
the hard palate into the pharynx.
Laryngeal Masks with an Esophageal Lumen successfully placed in 5% of the patients. In all, 50% of the
I-gel® laryngeal masks produced an airtight seal at a
A recent development is laryngeal masks with a separate ventilation pressure of 20 cm H2O. No significant difference
lumen that connects directly to the esophagus. This provides in airway leak pressures was found between the I-gel® device
access for various actions such as inserting a gastric tube and the classic laryngeal mask (LMA Unique®): 25 vs. 22 cm
after successful placement of the laryngeal mask. The airway H2O82.
and esophagus can be separately ventilated and drained
through the extra lumen. This significantly reduces the risk of The I-gel® laryngeal mask was successfully used for the
aspiration. Three laryngeal masks with an esophageal lumen ventilation of a patient with failed intubation (CL grade III)83.
are currently available: Also, a thin endotracheal tube was passed into the trachea
through the laryngeal mask under fiberoptic guidance.
The I-gel® is a single-use, uncuffed laryngeal airway made The LMA Supreme® and LMA ProSeal® were correctly placed
of a gel-like material (Fig. 57). The laryngeal part conforms on the first attempt with a high success rate (92–95%) in
to the anatomy of the hypopharynx and has a drainage anesthetized patients84. The same study found airway leak
channel that permits the insertion of a thin gastric tube. pressures of 29 cm H2O for the LMA ProSeal® (cuff pressure
The LMA ProSeal® is a reusable laryngeal mask with 45 cm H2O) and 26 cm H2O for the LMA Supreme® (cuff
an extra lumen for a gastric tube. It has a modified cuff pressure 65 cm H2O). Gastric tube insertion was successful
designed to create a better seal than the classic LMA in all cases.
Unique®.
In one case report, the LMA Supreme® laryngeal mask was
The LMA Supreme® is a single-use laryngeal mask with an successfully used for ventilation, oxygenation, and drainage
esophageal lumen. It has an anatomical shape designed of gastric contents in a critically ill, nonfasted patient with a
for easier placement (Fig. 58). Like the ProSeal®, it difficult airway (CL grade III)85. The LMA ProSeal® was also
reportedly creates a better airway seal than the classic used successfully in two patients with an unanticipated
laryngeal mask. difficult airway as an alternative to endotracheal intubation
(airway edema with CL grade III and failed intubation in an
In one clinical study, the I-gel® laryngeal mask was success- obese patient with CL grade III)86.
fully placed on the first attempt with a success rate of 78%80.
The I-gel® was correctly placed in all anesthetized patients In principle, the ICU should always be equipped with the type
after a maximum of two additional attempts. The airway leak of laryngeal mask with which personnel have had the most
pressure in the I-gel® group was reported to be 27 cm H2O. clinical experience.
In another study the I-gel® laryngeal mask was successfully Available data indicate that the LMA Supreme® and ProSeal®
placed on the first attempt in 83% of cases81. It was correctly allow for higher ventilation pressures and easier placement
placed after 3 attempts in 95% of cases and could not be than the I-gel® laryngeal mask.
® ®
57 I-gel single-use supraglottic airway with drainage channel. 58 LMA Supreme single-use laryngeal mask with esophageal lumen.
Laryngeal Masks for Endotracheal Intubation by bag-and-mask ventilation (36 s versus 44 s) and with a
higher success rate (98% versus 86%)88. Also, endotracheal
The Fastrach intubating laryngeal mask airway (ILMA) is an intubation was successful more often with the ILMA (92%)
advanced version of the classic laryngeal mask. The Fastrach than with conventional direct laryngoscopy (40%). In patients
is specially designed for endotracheal tube placement and with a difficult airway, experienced anesthesiologists were
permits a special spiral-wound tube with a soft silicone tip to able to place the ILMA with an 89% success rate on the first
be passed blindly through the vocal cords (Fig. 59). attempt89. Ventilation was accomplished in three attempts
One feature that distinguishes the ILMA from a classic or fewer in all patients. The success rate for blind intubation
laryngeal mask is its shortened, rigid shaft. The shaft, or through the ILMA was 97%. The remaining patients were
airway tube, is curved at almost a 90° angle and conforms to successfully intubated under fiberoptic guidance. In a
the anatomy of the pharynx. Attached to the shaft is a rigid European multicenter study, blind intubation through the
handle (Fig. 60, ). A small rubber lip, called the epiglottic ILMA was accomplished in 96.2% of cases after a maximum
elevating bar, is automatically raised during endotracheal tube of three attempts90.
insertion and, when the ILMA is correctly positioned, enables
Successful use of the ILMA has also been documented
the spiral tube (up to size 8.0 I.D.) to enter the trachea (Fig.
in patients with known airway access difficulties such as
60, ).
decreased mouth opening, limited cervical spine motion, or
The ILMA is available in sizes 3–5 for patients with a body an unanticipated difficult airway91.
weight of 30–100 kg. Unlike other laryngeal masks, the ILMA
is designed mainly for use in anticipated or unanticipated Airway leak has been described with the ILMA at peak
difficult airway situations. ventilation pressures of 24–27 cm H2O92, 93. Currently there
are no data on the incidence of aspiration with the ILMA
An important advantage of the ILMA is the ability to carry compared with endotracheal intubation. In one published
out a two-step procedure in emergency patients. In the first case, aspiration occurred during the use of an ILMA in a
step the ILMA is placed much like a classic laryngeal mask patient with a previously unknown axial hiatal hernia94.
to oxygenate and ventilate the patient. In the second step
the trachea can be intubated via the ILMA if necessary. But Use of the ILMA is limited in patients with upper airway
if problems arise during advancement of the tracheal tube, abnormalities such as tumors, abscesses, or foreign bodies,
the tube can be withdrawn while ventilation of the patient is because additional airway injury cannot be ruled out in this
continued. “blind” intubation technique91.
Various studies have been published on the successful use Owing to its ease of placement in the pharynx, reasonably
of the ILMA. Medical students inexperienced in the use of good airway seal during ventilation, and the added option
laryngeal masks were able to place the ILMA faster than a of semi-blind endotracheal intubation, the ILMA provides an
classic laryngeal mask and achieved adequate ventilation effective alternative for failed intubation cases. Even in this
with a higher success rate87. Tracheal intubation via the ILMA application, however, the ILMA should not be used as an
was successfully completed by 67% of the participants. “ad hoc” rescue device for emergencies. It should be used
In another study, inexperienced participants were able to only after adequate training and practice in an unhurried
ventilate anesthetized patients faster with an ILMA than atmosphere.
59 Special spiral-wound endotracheal tube with a soft silicone tip, 60 The Fastrach intubating laryngeal mask airway (ILMA).
used with the Fastrach intubating laryngeal mask airway (ILMA).
Devices with an Esophageal In more than 95% of cases the tip of the blindly inserted
Combitube will enter the esophagus, and therefore initial
and Oropharyngeal Cuff ventilation is delivered through the longer, blue lumen
following blind insertion. With positive end-tidal CO2 detection
and positive auscultation of the lungs, ventilation is simply
Combitube continued through that lumen, which has side openings at the
The Combitube consists of a cuffed, double-lumen tube. One level of the larynx. The transparent limb can be used to pass a
lumen resembles a conventional endotracheal tube with a gastric tube into the esophagus or stomach.
distal cuff. The other lumen is closed at its distal end, has
In the event of negative end-tidal CO2 detection and lung
multiple side openings, and has a proximal cuff at the level
auscultation, ventilation can still be provided through
of the oropharynx that seals the oronasal airway (Fig. 61)95.
the shorter, transparent lumen without repositioning the
The dual-lumen design allows for ventilation after either
Combitube. Positive auscultation and CO2 detection will con-
esophageal or endotracheal placement.
firm that the distal end of the tube has entered the trachea.
The Combitube is classified as a backup device for use on
When placed in the esophagus, the Combitube produces
unanticipated difficult airways and especially in cannot
an effective airway seal up to a ventilation pressure of
intubate-cannot ventilate scenarios. It can secure the airway
approximately 40 cm H2O. It should be noted, however, that
and provide rapid oxygenation and ventilation in emergency
this can be achieved only with a very high pharyngeal cuff
settings despite difficult anatomy, unfavorable lighting, a
pressure greater than 250 cm H2O98. Owing to its tight seal,
confined space, and limited equipment96.
the Combitube can also be used during cardiopulmonary
The Combitube is available in two sizes – 37 F-SA (“small resuscitation without having to interrupt chest compressions
adult”) and 41 – and can be used in patients who are at least for ventilation99.
122 cm tall. Whenever possible it should be placed under
In one study the Combitube was successfully placed on
direct vision with the aid of a laryngoscope to reduce the risk
the first attempt in 82% of 1594 patients in cardiac arrest69.
of injury97. The Combitube can also be placed semi-blindly.
Seven percent of the patients could not be ventilated even
This is done by opening the mouth, lifting the lower jaw by
with multiple attempts, however. In anesthetized patients, the
the Esmarch maneuver, and passing the Combitube into the
Combitube was successfully placed on the first attempt in
pharynx96. Two markings on the tube shaft indicate the correct
84% of cases98. Adequate ventilation could not be achieved
insertion depth.
in 10% of the patients, even with multiple attempts.
The Combitube can secure the airway without manipulation
of the cervical spine. The technique can be quickly learned,
especially by personnel inexperienced in endotracheal
intubation100.
Obstruction of the side openings by mucosa can hamper or
prevent ventilation101. Another limitation is the material used:
Because the cuffs contain latex, the Combitube cannot be
used in patients with a latex allergy. Relative contraindications
exist in patients with intact bite or swallowing reflexes.
The tube should not be used without laryngoscopic visual
guidance in patients with diseases of the esophagus or after
the ingestion of caustic substances.
61 Functional principle of the esophagotracheal double-lumen airway

(Combitube).
EasyTube After primary direct laryngoscopy and tracheal placement

(Fig. 64), the patient is ventilated through the clear-colored
The EasyTube (EzT) was developed for in-hospital and lumen. If direct laryngoscopy and endotracheal intubation
prehospital use in all patients with an anticipated or are not possible, the tip of the EzT can be placed in the
unanticipated difficult airway. It permits the oxygenation and esophagus blindly or under visual control with a laryngoscope.
ventilation of patients who are trapped in wreckage or difficult In this case the patient can be ventilated through the shorter,
to reach. It is also recommended in cases where direct laryn- blue-colored lumen.
goscopy is difficult or impossible due to bleeding or vomiting. In a study comparing the EzT with direct laryngoscopy in
anesthetized patients, the EzT could be placed faster and
The EzT is a single-use device that combines the basic
more easily103. The initial placement attempt was successful
features of an endotracheal tube with those of a supraglottic
in 95% of the patients. With both the EzT and endotracheal
airway device102. It is available in two sizes, 28 and 41 Ch, and
tube, airway leak occurred at a ventilation pressure of 35 cm
can be used in patients at least 90 cm in height. The principle
H2O. When used in prehospital settings, the EzT achieved a
of the EzT is analogous to that of the Combitube: It is a
high success rate in the ventilation of difficult airways104. In a
double-lumen tube that can provide ventilation when placed
clinical comparison with the laryngeal tube and LMA ProSeal®
in either the trachea or the esophagus. The large proximal
laryngeal mask, the EzT was successfully placed on the first
cuff seals the oropharyngeal and nasopharyngeal airways.
attempt in 41% of cases (versus 82% for the laryngeal tube
The single distal lumen of the tube is equivalent to a standard
and 68% for the LMA ProSeal®)105. The EzT had a reported
endotracheal tube with an inner diameter of 7.5 mm (41 Ch)
cuff pressure of 320 to 350 mm H2O when inflated with
or 5.0 mm (28 Ch) (Fig. 62).
70–90 mL of air. Cuff leak occurred at ventilation pressures of
Compared with the Combitube, the esophageal and tracheal 18–22 mm H2O in this study.
lumens of the EzT are shaped much like an endotracheal As with the Combitube, relative contraindications exist in
tube. Even when the distal tip of the tube is positioned in the patients with intact bite or swallowing reflexes. Laryngoscopic
esophagus, the trachea is still accessible through the second placement under vision is particularly indicated in patients
lumen (Fig. 63). The EzT allows the passage of a flexible with diseases of the esophagus or after the ingestion of
endoscope into the trachea, permitting an exchange for a caustic substances. Due to its rigid construction, upper
definitive endotracheal tube. airway trauma cannot be ruled out during use of the device.
62 The EzT combines the basic features of an endotracheal tube with 63 With the EzT in place, an endoscope can be passed into the
those of a supraglottic airway device. trachea to enable the placement of an endotracheal tube.
64 After direct laryngoscopy and tracheal placement of the EzT,

the patient is ventilated through the clear-colored lumen.
Laryngeal Tube
The laryngeal tube (LT) consists of a single-lumen tube with a
larger oropharyngeal cuff and smaller esophageal cuff (Fig.
65). The proximal end of the tube is fitted with a color-coded
standard connector. The color of the connector depends on
the size of the LT. The distal esophageal end is closed and
fitted with a low-pressure cuff. The oropharyngeal cuff seals
off the upper airways, allowing respiratory air to flow through
the anterior opening toward the blade. Both cuffs are inflated
simultaneously with a large syringe after placement. Color
markings on the inflation syringe match the color of the LT
connector so that even in an emergency, the cuff can be quickly
inflated with an air volume appropriate for the size in use (Fig.
66). The reusable LT is made of silicone, and the disposable
version is made of polyvinylchloride. 65 The laryngeal tube (LT) consists of a single-lumen tube with an
oropharyngeal and esophageal cuff.
It is recommended that the patient’s head be placed in
a modified Jackson position for successful placement of
the laryngeal tube. The cuff of the LT should be completely
deflated and well lubricated. The mouth is opened, the head
is tilted back, and the laryngeal tube is inserted in the midline
along the hard palate and into the pharynx until a slight
resistance is felt. The middle black line on the tube should
be between the upper and lower teeth (Fig. 67). Correct
placement is verified by end-tidal CO2 detection and lung
auscultation. The cuff pressure should not exceed a value of
60 cm H2O106.
The LT can be placed with a high initial success rate of
97–100%107. Ease of placement is similar to that of a laryngeal
mask. The airway leak pressure of the LT is reported to be
2 cm H2O higher than that of a classic laryngeal mask
(laryngeal mask: 18–20 cm H2O, LT: 20–22 cm H2O). This 66 Color markings on the inflation syringe correspond to the
difference is probably not relevant in clinical use, however. In connector of the laryngeal tube, ensuring that the cuff can be
quickly inflated to the proper air volume in an emergency.
a comparative study the LT was placed on the first attempt
as successfully as the LMA ProSeal®108, although five patients
could not be successfully ventilated with the LT. Both devices
produced a comparable airway seal. The placement of the
LT had to be repeatedly adjusted and optimized, however.
The LMA ProSeal® achieved a higher tidal volume than the
LT at equal ventilation pressures. In another comparative
study, the LT could not be optimally placed in two patients109.
Again, both devices were found to have comparable airway
leak pressures (24 cm H2O for the LT, 26.5 cm H2O for the
ProSeal®).
Compared with the classic laryngeal mask airway, the
LT protects better against aspiration owing to its distal
esophageal cuff. To date, no instances of aspiration have
been reported during routine use of the LT.
67 Successful placement of the LT: The middle black line on the shaft
As with the laryngeal mask, an intubation catheter can is between the upper and lower teeth.
be passed through the ventilation lumen of the LT under
fiberoptic guidance, and an endotracheal tube can be
prehospital endotracheal intubation111. The authors conclude
advanced over the catheter into the trachea110.
that the LT provides a reliable rescue device when intubation
The LT permits oxygenation and ventilation in patients with has failed. The LT can also be used as an initial airway in
previous failed attempts at endotracheal intubation. The emergency settings by rescuers less experienced with
LT was used with a high success rate (97%) after failed endotracheal intubation.
The LT also provides an alternative to face-mask ventilation. One disadvantage of the LT is the inability to drain the
Paramedics working in cardiac arrest situations could stomach through a gastric tube. Also, a mouth opening of
successfully insert the LT on the first attempt in 90% of all approximately 2.3 cm is required to introduce the shaft into
cases112. Ventilation could be performed in 95% of the the oral cavity. The cuffs are both large and thin-walled and
resuscitations. In another study, ventilation was performed may tear on sharp teeth, for example, during placement 114.
exclusively with an LT during cardiopulmonary resuscitation Relative contraindications to use of the LT exist in patients
by rescuers instead of bag-and-mask ventilation113. It was with intact bite or swallowing reflexes.
found that effective ventilation could be provided after
successful placement.
Laryngeal Tube Suction (LTS)

The LTS is an advanced version of the LT. It has a second
lumen that allows for decompression of the esophagus
in case of regurgitation and provides access for inserting
a gastric tube (Fig. 68). The esophageal drainage tube
additionally reduces the risk of aspiration.
The LTS has been used repeatedly and successfully in
critically ill patients, seriously injured patients, and in the of
cardiopulmonary resuscitation115, 116.
68 The LTS has a second lumen allowing the insertion of a gastric tube.

Kink guard Wire guide
Flexible endoscopy is a widely used technique for endo-
Drive Control lever tracheal intubation in both unanticipated and anticipated
train
Eyepiece difficult airways (see Predictors of a Difficult Airway). In a
classic flexible endoscope (also called a “fiberscope”), optical
fiber bundles extend to the eyepiece for image transmission
and toward the distal end for light transmission, accompanied
Control wires by deflection control elements (Fig. 69). Recent developments
Wire guide include endoscopes that employ CMOS (complementary
metal oxide semiconductor) sensor technology for imaging,
Gears Test valve so that the terms “fiberoptic” and “fiberoptic intubation” are
no longer applicable to these endoscopes117.
Light post
69 Diagram illustrating the components of a classic flexible endoscope.
Nevertheless, the terms “flexible endoscopic intubation” and In principle, intubation with a flexible endoscope can be
“fiberoptic intubation” still refer to the same technology and performed by either the nasal or oral route. Nasal intubation
can be used interchangeably. is technically easier because usually the epiglottis and glottis
are more easily visualized after the scope passes through the
Few contraindications exist to flexible endoscopic intubation.
nasopharynx118. The flexible endoscope can be used through
They include all airway strictures and stenoses that cannot
either access route (oral or nasal) in the awake or anesthetized
be crossed with the endoscope and endotracheal tube. Also,
patient.
vision may be obscured due to blood or secretions. When
active bleeding is present, key landmarks generally cannot be
identified, resulting in a failed intubation.
Flexible Endoscopic Intubation Basic protocol for awake endoscopic intubation

in the Awake Patient 1. Secure informed consent
Flexible endoscopic intubation of the awake patient is the 2. Administer nose drops containing a vasoconstrictor and
procedure of first choice for an anticipated difficult airway4. local anesthetic (wait 5 minutes!)
Spontaneous breathing is preserved, allowing the patient to 3. Oxygen administration
remain oxygenated until the endotracheal tube is placed.
4. Conscious sedation (e.g., remifentanil at 0.1–0.5 μg/kg/min)
The procedure is explained to the patient, and informed
5. Visualize the glottic plane and apply local anesthetic to the
consent is obtained. A cooperative patient during intubation
glottis; wait for onset of anesthesia
is a key factor in completing a successful procedure.
Initial topical anesthesia of the airways is indicated to blunt 6. Insert the endoscope into the trachea and apply local
protective reflexes (coughing, gagging) and make the anesthetic. Retract above the glottic plane, wait for onset
procedure more comfortable for the patient. of anesthesia
7. Reinsert the intubation endoscope into the trachea, and
The success of this procedure depends greatly on the
advance the endotracheal tube over the endoscope
preparation of the patient and the necessary materials. In
contrast to laryngoscopy, accurate positioning of the patient 8. Proceed with general anesthesia
is not strictly necessary119, although the upper body of an ICU Table 10 Basic protocol for awake endoscopic intubation.
patient should be elevated to support spontaneous breathing.
The first procedural step in
awake nasotracheal intuba-
tion is to place nose drops
into both nostrils (Table 10).
Nose drops containing a
local anesthetic (e.g., lido-
caine 3%) plus a vasocon-
strictor (e.g., phenylephrine
0.25%) can desensitize the
nasal mucosa and also pre-
vent bleeding during intuba-
tion120 (Fig. 70). The operator
70 Nose drops with a local
should wait approximately anesthetic and vasoconstrictor.
2–5 minutes for the agents
to take effect before introducing the endoscope121.
Oxygenation during Flexible

Endoscopic Intubation
Immediately after the nose drops are administered, oxygen
should be insufflated via nasal cannula (approximately 4 L/
min) (Fig. 71). With an ICU patient who is hypoxic or at risk for
hypoxia, noninvasive ventilation can also be performed during
flexible endoscopic intubation122.
71 Oxygenation is administered through a nasal cannula in the

contralateral nostril.
A snug-fitting CPAP mask or ventilation mask can be

used with a Mainz adapter placed between the mask and
ventilation hose (Fig. 72). This adapter allows continuous
oxygenation and ventilation to be maintained during endo-
scopic intubation. The mask can be secured to the face and
head with flexible straps (Fig. 72, ).

Another option is to use an endoscopy face mask (Fig. 73),
although this type of mask is difficult to secure to the patient’s
head. When an endoscopy mask is used, an assistant should
be delegated to hold the mask in place on the patient’s face.
Intubating the patient through a face mask requires a user
experienced in endoscopic intubation. The advantage is the
ability to ventilate the patient on as much as 100% oxygen
during the procedure. Another option is to provide noninvasive
72 Placed between the ventilation hose and mask, the Mainz adapter positive-pressure ventilation (NPPV) during intubation.
enables continuous oxygenation and ventilation during endoscopic
intubation. Ventilatory parameters of CPAP 4 cm H2O, PSV 17 cm
H2O, and FiO2 1.0 during bronchoscopy in NPPV-ventilated
patients have been described as adequate parameters122.
Patient Sedation
Generally sedation should enable the patient to tolerate the
procedure well while still allowing spontaneous breathing. Low
doses are sufficient in hypoxic, critically ill patients. Short-
acting benzodiazepines (e.g., midazolam 0.03–0.05 mg/kg)
combined with opioids (e.g., fentanyl 1–1.5 μg/kg) have been
successfully used for sedation, anxiolysis, and analgesia123.
The use of an opioid also has the side effect of suppressing
airway reflexes during endoscopic intubation. Remifentanil
administered by infusion pump has also been successfully
used for sedation and analgesia during awake endoscopic
intubation (0.1–0.5 μg/kg/min)124. The use of remifentanil
73 Alternatively, an endoscopy mask can be used for simultaneous was characterized by good patient tolerance with high
oxygenation and ventilation.
hemodynamic stability. Ketamine (0.2–0.5 μg/kg) may also be
administered instead of an opioid125. Ketamine combined with
midazolam permits adequate spontaneous breathing without
circulatory depression while providing good analgesia and
sedation.
74 An anti-fogging agent is applied to the lens. 75 Lubricant is applied to the endoscope shaft before insertion.
Flexible Nasotracheal Endoscopic Intubation

The lens should always be pretreated with an anti-fogging
agent before the endoscope is used (Fig. 74). We also
recommend applying a lubricant (e.g., silicone oil) to
the endoscope shaft (Fig. 75). This is necessary so that
the endotracheal tube can be easily advanced over the
endoscope shaft following successful placement of the
endoscope. Before the endoscope is inserted into the nose,
an endotracheal tube with its cuff deflated is loaded onto the
endoscope shaft and secured (Fig. 76). Spiral-wound tubes
have proven excellent for endoscopic intubation owing to
their flexibility, atraumatic tip, and kink resistance in routine
anesthesiologic use125. The inner diameter of the endo-
tracheal tube should be at least 1.5 mm larger than the outer
diameter of the flexible endoscope. At the same time, the
inner diameter should not be too large relative to the selected
flexible endoscope, as this could lead to problems during
tube placement.
Nose drops can be administered for initial topical anesthesia of
the nasal mucosa, and the
pharynx can be anesthetized
with lidocaine spray (Fig. 77).
Before the endoscope is
inserted, both nostrils are
inspected and the larger
opening is used for intubation
(Fig. 78). As the endoscope
is passed into the nostril, the
inferior meatus is identified
as it will be the route for
endoscope insertion (Fig. 79). 77 lidocaine pump spray. 76 Before the endoscope is inserted into the nose, an endotracheal
tube with deflated cuff is loaded onto the endoscope shaft and
secured.
78 The larger nostril opening is used for intubation. 79 The inferior meatus is identified.

Oropharynx with uvula Epiglottis
Glottis Trachea
The endoscope should never be advanced blindly as this

could cause airway bleeding and injuries. A key to successful
intubation is the identification of landmarks on the way to
the trachea (Table 11). If orientation is lost, the endoscope
should be slowly retracted until an anatomic landmark can
be positively identified. After the scope has passed through
the choana and nasopharynx, the epiglottis is identified as
the first key anatomic landmark (). The tip of the endoscope
is now positioned just outside the glottis (landmark) (). It
may be helpful at this point to ask the patient to protrude the
tongue and inhale deeply. This maneuver mobilizes the base
of the tongue from the posterior pharyngeal wall and often
improves visualization of the vocal cords.

Tab. 11 Anatomic landmarks for nasal endoscopic intubation.

Bifurcation ().
The next step is topical anesthesia of the vocal cords: 2 mL

of lidocaine 2% is applied to the glottis through the working
channel of the flexible endoscope (Fig. 80). We recommend
preparing 2 mL of lidocaine 2% with 3 mL of air in a 5-mL
syringe. The air in the syringe will push all of the lidocaine
solution through the working channel. Two minutes are
allowed for the anesthetic to act, then the tip of the endo-
scope is advanced through the glottis and into the trachea
(next landmark). The tracheal lumen is easily identified and
distinguished from the esophagus by the presence of tracheal
rings (Table 11, ). Next, a second dose of lidocaine 2%
(2 mL, same as for the glottis) is injected through the working
channel. Then the tip of the endoscope is pulled back past
the glottic plane, and another 2 minutes are allowed for the
anesthetic to numb the tracheal mucosa. Now the endoscope
is readvanced through the glottis into the trachea and the final 80 Lidocaine 2% is applied to the glottis for topical anesthesia of the
vocal cords.
landmark, the tracheal bifurcation, is identified (Table 11, ).
The endotracheal tube is then carefully advanced through
the nostril, which should be well lubricated. A constant
endoscopic view of the bifurcation should be maintained
during advancement of the tube. It may be difficult to pass
the tube through the glottis. Occasionally the tip of the tube
becomes snagged at the level of the arytenoid cartilage. If this
occurs it is often helpful to retract the tube slightly, rotate it
90° clockwise, and readvance it over the endoscope126, 127.
With adequate analgesia and sedation, it is usually possible to
pass the tube through the nose and into the trachea without
difficulty and then proceed with the induction of general
anesthesia.
In the final step, the distance from the carina to the tip of the
endotracheal tube is measured for an accurate assessment
of tube position. Final positioning is done by advancing the
81 The distance from the carina to the tip of the endotracheal tube is
endoscope tip to the carina and using two fingers to mark measured for the accurate assessment of tube position.
the insertion depth on the instrument shaft (Fig.|81, ). The
instrument is then retracted until the tip of the tube appears in
the endoscopic field (Fig.|81, ). The distance from the carina
to the tube tip should be 3–5 cm.
Flexible Orotracheal Endoscopic Intubation

Endoscopic intubation by the oral route is similar to naso-
tracheal intubation. Initial topical anesthesia of the mucosa
can be done with nose drops and by numbing the pharynx
with a 4% lidocaine spray (see Fig. 77).
Orotracheal intubation is technically more difficult because
the tip of the intubation endoscope must negotiate a 90°
angle in the pharynx on its way to the glottis, and the insertion
is not guided by a natural anatomic channel as in the nasal
approach. A bite block must be used to protect the instrument
in case the patient bites down during the intubation (Fig. 82 A bite block must be used during orotracheal endoscopic intubation.
82). Also, it is often difficult to visualize the epiglottis in the
transoral approach.
It is helpful to have the patient protrude the tongue or apply

manual traction to the tongue in order to lift the tongue base
from the posterior pharyngeal wall and expose the pharyngeal
space. Another option is to place a guide tube to help direct
the endoscope through the mouth (Fig. 83).

in the Anesthetized Patient
Endoscopic intubation of an anesthetized patient requires
the presence and help of a second physician experienced in
the technique to monitor the patient, render assistance, and
ventilate the patient if necessary.
Both nasotracheal and orotracheal endoscopic intubation can
83 Alternatively, the endoscope can be inserted through a guide tube be performed in the anesthetized patient. Although topical
bonded to a bite block (Optosafe®) during flexible orotracheal anesthesia of the mucosa is not strictly necessary in the
endoscopic intubation. transnasal approach, it is still a good idea to administer nose
drops with a vasoconstrictor in order to prevent bleeding.
Because general anesthesia relaxes muscle tone in the upper
airways, the epiglottis often cannot be visualized through the
collapsed pharyngeal space. Endoscopic intubation can be
performed through an endoscopic face mask or through a
ventilation mask fitted with a Mainz universal adapter (Fig. 84)
to maintain ventilation and oxygenation during the procedure.
Often it is helpful to have an assistant perform an Eschmach
maneuver to lift the tongue base away from the posterior
pharyngeal wall so that anatomic landmarks can be identified.
Pharyngeal adjuncts such as the Optosafe® tube (Fig. 83) can
help to keep the pharyngeal space open while guiding the
orotracheal intubation.

of an Unanticipated Difficult Airway
In many airway algorithms, flexible fiberoptic or endoscopic
intubation is presented as an airway management option
after failed laryngoscopy4, 76. An experienced user can perform
orotracheal intubation more rapidly then nasotracheal
intubation125.
84 Ventilation and oxygenation can be maintained with a face mask, It is important to remember that oxygenation generally takes
shown here with a Mainz universal adapter, during endoscopic precedence over endotracheal intubation. Thus, flexible
intubation. endoscopic intubation after failed laryngoscopy should be
performed through a ventilation mask fitted with a Mainz
universal adapter (Fig. 84) or through an endoscopy face
mask to secure ventilation and oxygenation.

Through the Laryngeal Mask
When unexpected difficulties arise during airway manage-
ment, it is often helpful to place a laryngeal mask or ILMA
to secure oxygenation and ventilation (see Supraglottic
Airway Devices). With the aid of a Mainz adapter, a tube can
be placed endoscopically in the trachea while ventilation
is continued. This endoscopic placement of the tube has a
higher success rate than a blind technique128–130. The set for
the LMA Fastrach device includes a spiral-wound tube that
is excellent for endoscopic placement. The connector on the
spiral tube can be easily removed after successful intubation
to facilitate removal of the laryngeal mask (Fig. 85).
During insertion of the flexible endoscope, the epiglottic 85 Endoscopic placement of an endotracheal tube through an
elevating bar of the ILMA may hamper advancement of the intubating laryngeal mask.
endoscope tip into the trachea. This can be resolved by
passing the endoscope to one side of the obstacle, then
advancing it into the trachea. Another option is to pass an
endotracheal tube over the endoscope as far as the epiglottic
bar, then elevate the bar with the tube so that it no longer
blocks the endoscope.
An intubation endoscope can also be passed into the trachea
through a classic laryngeal mask128, although problems may
result from the relatively long, narrow shaft and the tight
airway connector of most laryngeal masks. Given these
restrictions, often only a relatively small endotracheal tube
can be passed through a classic laryngeal mask. Often the
laryngeal mask cannot be safely removed when the proximal
end of the endotracheal tube is just above the connector
and the distal end of the tube is just below the glottis. This
problem can be solved by first passing an intubation rod
(e.g., Aintree® catheter) into the trachea endoscopically (see
Fig. 55)74. Once inside the trachea, the long catheter will
enable the laryngeal mask to be removed without difficulty. An
endotracheal tube can then be introduced over the catheter
and its placement confirmed by flexible endoscopy.
86 A large monitor enables all participants to view the progress of the

procedure.
Flexible Endoscopically Assisted Percutaneous

Dilatational Tracheotomy
The number of percutaneous dilatational tracheotomies
(PDTs) has increased markedly in recent years131. The visual
monitoring of PDT using fiberoptics or a flexible intubation
endoscope can prevent life-threatening complications during
the procedure.
A video monitor provides optimum guidance for a PDT. It
not only guides the procedure itself but also permits the
whole team to follow the procedure and give assistance
where needed (Fig. 86). The endoscope is passed into the
endotracheal tube through a Mainz adapter, for example. The
trachea is then inspected and any secretions are suctioned as
87 Flexible endoscopic view of the tracheal lumen. required. The tracheal cartilage rings should be clearly visible
(Fig. 87).
The carina is visualized by bronchoscopy, and the tip of the
endoscope is positioned level with the tip of the endotracheal
tube, which should project approximately 0.5 cm past the
endoscope tip. The edge of the tube should be visible but
should not restrict the field of view (Fig. 88).
Now the tube is retracted under bronchoscopic vision to a
level just above the glottic plane. The tube can also be slowly
retracted under video laryngoscopic guidance. This technique
is advantageous in that it reduces the risk of accidental
extubation because the tube tip and cuff remain below the
glottis (Fig. 89).
After key landmarks have been identified on the anterior side
of the neck, the proposed puncture site is transilluminated
(Fig. 90). Ideally the puncture site is located between the
second and fourth tracheal cartilages. Large blood vessels in
the anterior neck can also be located by transillumination.
To prevent bleeding from small cutaneous vessels, a local
anesthetic with a vasoconstrictor (e.g., prilocaine 1% plus
epinephrine) is injected in the area of the proposed puncture
88 Bronchoscopic view of the trachea. The edge of the endotracheal site, which has been marked on the skin.
tube projects approximately 0.5 cm past the endoscope and
should not restrict the field of view. Next the introducer needle is passed into the trachea under
endoscopic control (Fig. 91). The operator can check the
89 The tube is slowly withdrawn to a level just past the glottic plane 90 External anatomic landmarks are identified, and the proposed
under video laryngoscopic guidance. puncture site is transilluminated.
position of the puncture site

by viewing the monitor. For
this step the endoscope
should be retracted into the
endotracheal tube to avoid
accidental puncture of the
endoscope shaft. Ideally
the trachea is punctured in
the midline between the 10
and 2 o’clock positions (Fig.
92). If strong resistance is
felt as the needle enters the
92 Correct puncture site in the
trachea, the puncture site trachea.
should be checked as this
usually means that the needle has struck the endotracheal
tube. In the next step, a 1.5- to 2-cm-long skin incision is 91 Endoscopically controlled puncture of the trachea with the
introducer needle.
made at the marked position. The skin tract is then bluntly
dissected and predilated with a nasal speculum or Griggs
dilating forceps. Next a Seldinger wire is introduced and
advanced toward the carina.
Depending on the system, the next step is dilation of the

puncture site. The single-dilator technique will be described
here as an example. After dilating the tract with a small dilator,
a guide catheter is passed into the trachea over the Seldinger
wire under endoscopic control (Fig. 93).
This is followed by single-step dilation of the tract with a

Blue Rhino® tapered dilator (Fig. 94). This process should be
monitored bronchoscopically so that any injuries or excessive
compression of the trachea can be promptly recognized and
the procedure modified as needed.
After dilation is completed, the tracheostomy tube is

introduced into the trachea over the guide catheter under
endoscopic vision and the cuff is inflated (Fig. 95). The flexible
endoscope is now passed into the trachea through the
tracheostomy tube to verify correct endotracheal placement
of the tube. It is important to identify the carina so that the tip 93 A Seldinger wire is introduced through the Teflon cannula.
of the tracheostomy tube can be positioned 3–5 cm above
the carina under endoscopic control. Attention should also be
given to possible intraluminal bleeding sites.
94 One-step dilation of the tract under endoscopic control. 95 The tracheostomy tube is passed into the trachea over the catheter
under endoscopic guidance, and the cuff is inflated.
Endoscopic control offers a number of advantages over blind Ciaglia kit133, 134. In this study a bronchoscope with a 5.8-mm
PDT: outer diameter was used in an endotracheal tube with an
8.0-mm inner diameter.
It provides guidance for the endotracheal tube. If
When flexible endoscopes are introduced through the endo-
accidental extubation occurs, the tube is easily reinserted
tracheal tube, vision may be significantly obscured due to
into the trachea over the endotracheal endoscope.
secretions. There is also a risk of inadvertent puncture of the
Transillumination can reduce the risk of injury to large
endotracheal tube cuff, which would jeopardize oxygenation
blood vessels.
and ventilation.
Visual control of the puncture site within the trachea
allows for midline placement of the tracheostomy tube The placement of a laryngeal mask for PDT is a possible
and virtually eliminates the possibility of paramedian alternative to an endotracheal tube. A randomized study
placement. found that the use of a laryngeal mask was associated with
Dilation is performed under visual control. a 33% incidence of complications (inadequate ventilation,
Correct position of the tracheostomy tube can be
loss of airway) versus 9.9% with an endotracheal tube135. One
confirmed after placement. limitation of this study is that the male and female laryngeal
mask sizes were too small. Contrary to these results, another
study found that the use of a laryngeal mask for PDT was
A meta-analysis found that the complication rate of PDT
associated with a lower incidence of hypercapnia (38.5%)
without endoscopy was 16.8%, compared with a rate of
than the use of an endotracheal tube (56.7%)136. In summary,
8.3% when endoscopic control was used132.
we may conclude that the use of a LMA can significantly
The greatest risks associated with endoscopically controlled improve ventilation and can positively affect the visualization
PDT are hypoxia and hypercapnia. A fall in oxygen saturation of anatomic structures in the trachea. On the other hand, the
during dilatational tracheotomy has a reported incidence of user of the LMA must be thoroughly familiar and proficient
3%132. Hypoventilation, hypercapnia, and respiratory acidosis with the device in routine clinical use. Data available at present
with hemodynamic deterioration have been described as appear insufficient to justify a general recommendation or
a result of continuous bronchoscopy during PDT with the rejection of this technique64.
Invasive Airway Access in Patients

with Failed Oxygenation or Patients
with Failed Oxygenation and Ventilation
Invasive airway access is an emergency procedure and a
last-resort option for rescuing a patient from severe hypoxia
and death137. It generally consists of a cricothyrotomy and
is performed whenever oxygenation and ventilation cannot
be established by other available means such as mask

ventilation, supraglottic airway placement, or video laryngos-
copy (“cannot intubate-cannot ventilate”).

The classic procedure in adults is a surgical cricothyrotomy.
Since complications are more frequent with an emergency
tracheotomy, a cricothyrotomy is always preferred in
emergencies138. Often the key anatomic landmarks for a

cricothyrotomy can be reliably identified.
The cricothyroid membrane is the most superficial part of

the airway and is located between the laryngeal prominence
and cricoid cartilage (Fig. 96). Typically the membrane is
2.2–3.3 cm wide and 0.9–1 cm high. The principal vessel at

this level is the superior thyroid artery, which often runs at the
lateral edge of the membrane.
96 Anatomy of the larynx. Epiglottis , hyoid bone , thyrohyoid

membrane , thyroid cartilage , laryngeal prominence ,
cricoid cartilage , tracheal cartilage
, superior thyroid artery ,
cricothyroid artery , median cricothyroid ligament .
A cricothyrotomy may be necessary in the following typical

situations:
Massive swelling of the hypopharynx or oropharynx

(e.g., hereditary angioedema following the use of ACE
inhibitors.
Very severe allergic reactions involving the supraglottic
airways.
Very severe burns or caustic injuries of the face and
airways.
Large tumors or inflammatory masses in the upper
airways.
A cricothyrotomy can be performed by one of two principal

methods: surgical dissection or needle techniques. Regard-
97 The patient is positioned with the head extended and a cushion
less of the method used, extension of the neck will make it beneath the shoulders to expose the neck and its landmarks.
easier to perform the cricothyrotomy. It may also be helpful
to place a pad beneath the shoulders (e.g., a bed pillow) to
support and maintain the extended head position during the
procedure (Fig. 97).
An emergency cricothyrotomy should be converted within
hours to a surgical tracheotomy, or an orotracheal or naso-
tracheal airway should be established to prevent serious late
sequelae such as tracheal stenosis137.
Surgical Airway
The operator palpates the larynx and immobilizes it with one
hand after locating the thyroid and cricoid cartilages139. A
longitudinal skin incision is made in the midline, starting over
the middle of the thyroid cartilage and ending over the cricoid
cartilage (Fig. 98). The larynx and cricothyroid ligament in
obese patients can be felt with the scalpel by noting a loss of
tissue resistance.
Next the subcutaneous fatty tissue is bluntly spread open 98 The longitudinal skin incision starts over the middle of the thyroid
with a dissecting scissors or nasal speculum (Fig. 99). A cartilage and ends over the cricoid cartilage.
transverse incision is made in the cricothyroid membrane, and
that incision is spread open with a nasal or Killian speculum.
Next an endotracheal tube with stylet (inside tube diameter =
5.0–6.0 mm) is passed into the trachea. This is easiest when
the stylet protrudes slightly past the end of the tube139. The
nasal speculum is slowly withdrawn during tube insertion to
make more room for advancing the tube.
Following successful insertion into the trachea, the cuff of the
tube is inflated, the stylet is removed, and correct tube place-
ment is verified by end-tidal CO2 detection and auscultation.
Potential complications include bleeding and injury to
laryngeal structures. Failed attempts at tube placement most
commonly result from inadequate surgical access.
99 The subcutaneous fat is bluntly spread open with a nasal speculum,

and a transverse incision is made in the cricothyroid membrane.
Needle Cricothyrotomy For one-step dilatation with the Portex Crico Kit (PCK®), the
skin is incised and the cricothyroid membrane is punctured
Various systems are available for performing a needle crico- with an integral needle/dilator/tracheal tube assembly based
thyrotomy. They are based either on the Seldinger technique on the principle of the Veress needle. As the needle is inserted,
(e.g., Melker Universal Emergency Cricothyrotomy Catheter the tissue resistance pushes a guide sleeve away from the
Set, Cook Medical, Fig. 100) or a one-step dilatation principle needle, allowing the sharp steel needle to penetrate the tissue.
(e.g., Portex® Crico Kit, Smiths Medical, Fig. 101; QuickTrach® Entry into the trachea is confirmed by a red indicator ring in
set, VBM Medical, Fig. 102) 137, 139. the needle hub. The device is advanced until loss of needle
In the Seldinger technique (Melker®), a longitudinal skin incision resistance occurs and the red indicator ring disappears. The
is made with a scalpel over the cricothyroid membrane, set is now angled approximately 35° caudally and advanced
analogous to the surgical airway approach. The skin incision toward the bifurcation. When it reaches the posterior tracheal
should be approximately 1.5–2 cm long. Next a catheter-over- wall, the increased resistance causes the red indicator ring to
needle unit with a syringe attached is passed into the trachea reappear. The puncture needle and dilator are now removed,
while continuous aspiration is applied with the syringe. Ideally and the tube is advanced into the trachea. The cuff is inflated,
the syringe should contain some sterile saline solution: air ventilation is initiated, and correct placement is verified.
bubbles rising in the syringe will denote passage into the The QuickTrach® set embodies another technique for a one-
trachea. After the assembly has been placed, the needle and step dilatational cricothyrotomy (Fig. 102). The cricothyroid
syringe are removed, leaving the catheter in place. Now a membrane is identified by palpation, a small skin incision is
guidewire is advanced down the catheter toward the tracheal made, and the needle with attached syringe is passed into the
bifurcation. The Teflon catheter is removed, and a tracheal trachea. A stopper on the puncture needle limits the insertion
tube loaded onto a dilator is passed over the Seldinger wire depth to prevent injury to the posterior tracheal wall and
into the trachea. The Seldinger wire and dilator are withdrawn, esophagus. After air is aspirated with the attached syringe, the
and the cuff of the tracheal tube is inflated. This is followed stopper is removed and the tracheal tube is advanced over the
by ventilation with verification of placement by end-tidal CO2 puncture needle into the trachea. The cuff is inflated, ventilation
detection and auscultation. is initiated, and correct tube placement is verified (auscultation,
capnometry).
®
100 Melker Universal Emergency Cricothyrotomy Catheter Set 101 Portex Crico Kit (Smiths Medical).
(Cook Medical).
Transtracheal Jet Ventilation (TJV) The Manujet III (VBM Medical) is a technically streamlined,
manually controllable device for transtracheal jet ventilation
Another, less invasive method for temporary emergency (Fig. 105). Ventilation is performed through a supplied
oxygenation is transtracheal jet ventilation. TJV is considered Ravussin catheter with extra side openings at the tip to
a temporizing procedure for emergency oxygenation; it can- ensure oxygen delivery with the tube in place. The device
not provide ventilation4. The cricothyroid membrane can be is connected to a pressurized oxygen source via an ISO
punctured with a special needle (e.g., Ravussin) or with a adapter. A control knob can set the ventilation pressure to
standard large-bore i.v. catheter (e.g., 14 G) (Fig. 103). After any desired value from 0 to 50 psi, which is indicated on a
the membrane is identified, the trachea is punctured while color-coded pressure gauge. Jet ventilation should always be
continuous aspiration is placed on an attached syringe started at a low ventilation pressure, which is then adjusted to
containing some sterile saline solution. When air bubbles in obtain the desired ventilation effect.
the syringe confirm entry into the trachea, the syringe and
needle are withdrawn and the Teflon catheter is advanced When this procedure is used, it must be certain that the
toward the bifurcation. In an emergency, oxygen can be expired air can be safely vented through the upper airways
quickly insufflated through the catheter with a simple setup: to reduce the risk of barotrauma. This limits the use of this
a high-flow three-way stopcock with 2.5- to 3-mm apertures technique in patients with large tumors or massive swelling of
connected to the catheter hub and an oxygen source. With an the upper airways.
oxygen flow rate of 15 L/min, the open port of the stopcock
can be intermittently occluded to provide oxygenation and
minimal ventilation (Fig. 104)140, 141.
®
102 One-step dilatational cricothyrotomy with the QuickTrach set 103 A Ravussin needle is passed through the cricothyroid membrane.
(VBM Medical).
104 The open port of the three-way stopcock is intermittently occluded 105 Manujet III (VBM Medical) for transtracheal jet ventilation.
with the thumb to direct oxygen flow down the tracheal catheter,
providing temporary oxygenation and minimal ventilation.
Evaluation of Various Invasive Airway Techniques established faster with the Seldinger system with an equally
high success rate (88% versus 84%)144. The surgical approach
Only a few controlled comparative studies have been done on was associated with more frequent injuries, however.
different techniques of invasive airway management. This is
probably due to the fact that most of these procedures are As for transtracheal jet ventilation, the Manujet system (VBM
used only in extreme emergency situations. Available studies Medical) was tested in a simulated airway without a proximal
have been done mostly in animals or cadavers. It is difficult, constriction and delivered a minute volume (MV) of 3.4 L/min
therefore, to evaluate and compare the relative utility of speci- using a cannula size of 14 G145. Adequate ventilation was
fic techniques. In a recent study, needle cricothyrotomy and not achieved via a three-way stopcock or with a ventilation
surgical cricothyrotomy were compared with each other bag attached to the cannula. In the presence of a proximal
in a porcine larynx model142. The highest success rate was constriction above the puncture site, an MV of 12.5 L/min was
achieved by needle cricothyrotomy using the Seldinger achieved with the Manujet and 5.3 L/min with the three-way
technique (100% with the Melker® device), followed by stopcock. This was another scenario in which a ventilation
surgical cricothyrotomy and the QuickTrach® set (95% each). bag was unable to supply adequate ventilation.
The Portex Crico Kit® (PCK®) achieved a success rate of 60%.
The following three-step process is recommended for learning
Insertion was fastest with the QuickTrach® (52 s) and surgical
an invasive airway management technique:
approach (59 s) (Melker® set: 94 s, PCK®: 180 s). Another,
smaller study compared surgical cricothyrotomy with the
Melker® and PCK® sets in a porcine model143. The Melker® 1. Identify a preferred method of invasive airway management
set could be correctly placed in all attempts. The surgical 2. Practice the method yearly on an airway simulator.
technique (55%) and PCK® (30%) were less successful. The Five repetitions are recommended146, 147.
different techniques were the same in time to completion
(47–63 s). A study in cadavers compared a Seldinger system 3. If possible, practice the preferred method on cadavers
with surgical cricothyrotomy and found that ventilation was (with consent!).
Emergency Algorithm for The goal of algorithms is to guide and support practitioners
in specific clinical situations. A statistical analysis found that
Airway Management in the ICU implementation of the ASA Airway Guidelines was followed
by a decline in serious malpractice claims relating to difficult
The level of anesthesiologic care available in an operating airway management148.
room is not easily transferred to a critical care setting. A
great many international algorithms and guidelines have Table 12 lists possible preparations and techniques of
been developed, but not all of them do reflect the most anesthesia induction in critically ill patients based on current
recent developments in airway management. Moreover, they recommendations23. The goal of these practice points is to
often fail to address the specific requirements of critical care reduce serious complications such as severe hypoxia and
medicine 4, 76. cardiovascular instability.
Preparations Anesthesia induction

(rapid sequence induction)
Confer with the ICU team. (Plan who does what and how.).
Propofol (1–2 mg/kg) with an opioid
Two physicians should be present (e.g., sufentanil 0.2–0.4 μg/kg) – or – ketanest 1–2 mg/kg.
(one should be experienced in endotracheal intubation). Ketanest is preferred in hemodynamically unstable patients.
Careful volume replacement in patients without left-sided Neuromuscular blockade: succinylcholine 1–1.5 mg/kg
heart failure (e.g., 500 mL complete electrolyte solution, (caution: side effects) – or – rocuronium 0.9–1.2 mg/kg.
250 mL colloidal solution). Rocuronium is preferred if sugammadex is available.
After endotracheal intubation
Preoxygenate with 100% O2 for 3–4 min. With existing
oxygen deficit: NPPV with pressure support of 5–15 cm Verification of tube placement: capnometry/capnography,
H2O, CPAP 5 cm H2O (target: tidal volume of 6–8 mL/kg). bilateral auscultation of the lungs.
Catecholamines if mean arterial pressure is < 65 mm Hg;
Prepare emergency medications
e.g., norepinephrine titrated to response.
(e.g., catecholamines, atropine).
Start sedation (e.g., propofol, sufentanil)..
Start lung-protective ventilation: tidal volume 6 mL per kg
Table 12 Preparations for intubation and anesthesia induction in
critical care medicine (modified from Jaber et al. 201023). ideal body weight.
An emergency algorithm for airway management in the ICU a difficult airway are noted before anesthesia induction (see
is also helpful for taking appropriate actions in an emergency Predictors), the procedure of choice is flexible endoscopic
situation (Fig. 106). The algorithm shown here is based on intubation in the awake, spontaneously breathing patient.
existing guidelines and also takes into account new airway Flexible endoscopic intubation can even be performed during
management devices (video laryngoscopes) and new noninvasive ventilation with a CPAP mask by using the Mainz
pharmacologic agents such as sugammadex for the prompt universal adapter (see Flexible Endoscopic Intubation in the
reversal of rocuronium. The algorithm is intended for use only Awake Patient, p. 35).
in patients with an unanticipated difficult airway. If signs of
Noppens-Piepho Algorithm for Emergency Airway Management

Adequate mask ventilation
possible?
YES NO
Maximum of 3 intubation attempts EMERGENCY: Call for help.

(by SP); if possible: Consider neuromuscular blockade;
video laryngoscope; call for help SP: one intubation attempt
(video laryngoscope)
Successful?
Successful?
NO
NO
Adequate mask ventilation Return to spontaneous breathing

possible? NO
is possible – wake the patient?
Consider antagonists
YES (e.g., sugammadex, naloxone)
Video laryngoscope / Flexible or rigid

alternative blades Supraglottic airway device
intubation endoscope
Successful? NO NO Successful?
Successful? ONE alternative
NO
Return to spontaneous breathing

is possible – wake the patient? Video Flexible or Supraglottic
laryngoscope /
Consider antagonists alternative blades rigid endoscope device
(e.g., sugammadex, naloxone)
NO
YES Adequate mask ventilation

possible? Successful?
NO NO
Surgical or percutaneous cricothyrotomy
106 In-hospital algorithm for the management of an unanticipated difficult airway. Mask ventilation is the starting point because it generally
represents the first backup option. The selection of a particular device is based on availability and experience. SP = specialist.
Mainz Emergency Algorithm for an should be decided whether it is feasible to return the patient
Unanticipated Difficult Airway to spontaneous breathing and discontinue general anesthe-
sia. Endoscopic intubation, for example, can be reattempted
at a later time in the awake, spontaneously breathing patient.
Adequate Mask Ventilation is Possible
If you reach a point at which oxygenation and ventilation
The Mainz Emergency Algorithm starts with mask ventilation are no longer possible, go to the right side of the algorithm
because bag-and-mask ventilation is always the first fallback (Fig.|106).
option when problems arise during endotracheal intubation.
Even with rapid sequence induction, mask ventilation Adequate Mask Ventilation is Not Possible
should always be used for oxygenation if initial endotracheal
intubation fails, despite the increased aspiration risk. If the patient cannot be adequately ventilated and oxygenated
with a face mask at any time during airway management, a
If adequate mask ventilation is possible (left side of the life-threatening emergency exists. Help from an experienced
algorithm), there is not an immediate threat of hypoxia. airway manager should be summoned without delay. If
There is sufficient time to improve the intubation conditions endotracheal intubation and mask ventilation are both
(e.g., position the head) and, if not already done, place a unsuccessful, a “cannot intubate – cannot ventilate” situa-
video laryngoscope for endotracheal intubation. If multiple tion exists. It should be determined whether a return to
intubation attempts have failed, it is time to call in a physician spontaneous breathing is an option for oxygenation (see
experienced in endotracheal intubation. It is important to Neuromuscular Blockade, p. 16). If the answer is no, only
limit the number of intubation attempts (no more than three) one more intubation attempt should be made to achieve
because the risk of severe, life-threatening complications oxygenation and ventilation at this time (Fig. 106). Often the
increases with the number of intubation attempts45. If patient is already severely hypoxic at this stage (Fig. 107), so
laryngoscopic intubation is not successful, it should be you should turn to the device that is most familiar and offers
asked whether adequate mask ventilation is still possible. If the best chance of achieving oxygenation. Given the acute
the answer is yes, alternative intubation devices should be life-threatening situation, the placement of an endotracheal
tried (Fig. 106). The instruments and devices of first choice tube is no longer a main priority. The only goal at this point
are always those with which personnel have had the most is to oxygenate the patient with a supraglottic or alternative
clinical experience and are available on the airway cart of the device (Fig. 106). If this is successful, the next step is to
ICU. At this point in the algorithm it must be decided whether establish a definitive airway (e.g., a tracheostomy) with
endotracheal intubation with an intubation endoscope or expert help. If oxygenation cannot be accomplished with a
a video laryngoscope with an alternative blade is a suitable supraglottic or alternative device, the patient is at an acute
option. If intubation cannot be achieved with these methods, risk of death without further action. This situation is marked
a supraglottic airway device should be inserted. Afterward clinically by severe hypoxia (Fig. 108) and often by initial
an endotracheal tube can be placed through the laryngeal signs of cardiovascular decompensation. The only remaining
mask with a flexible intubation endoscope, for example (see option is invasive airway management by cricothyrotomy (see
Flexible Endoscopic Intubation Through the Laryngeal Mask, Invasive Airway Access in Patients with Failed Oxygenation
p. 41). If an airway still cannot be secured at this time, it and Ventilation, p. 44).
107 Vital signs in a patient with hypoxia. 108 Vital signs in a patient with very severe hypoxia.
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OZAKI M. Comparison of the intubating laryngeal mask airway and
108. BRIMACOMBE J, KELLER C, BRIMACOMBE L. A comparison of the
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paralyzed anesthetized adult patients undergoing pressure-controlled
93. THEE C, SEROCKI G, DOERGES V, ILIES C, WALLENIUS K, BEIN B, ventilation. Anesthesia and analgesia. 2002 Sep;95(3):770–6, table of
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able, Fastrach laryngeal mask and Fastrach laryngeal mask dispos-
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able during elective surgery: a randomized controlled comparison be-
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Tube during anaesthesia with controlled ventilation. British journal of
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anaesthesia. 2003 Nov;91(5):678–83.
94. KELLER C, BRIMACOMBE J, BITTERSOHL J, LIRK P, VON GOEDECKE A.
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95. FRASS M, JOHNSON JC, ATHERTON GL, FRUHWALD FX, TRAINDL
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Video Systems for Airway Management
KARL STORZ offers a complete armamentarium of options – for dealing with a standard or unexpectedly
instruments and videoendoscopic devices, that is tailored difficult intubation. In addition, all of our fiberscopes are
to a wide range of airway management modalities. The powered by an LED battery light source to make sure that
broad scope of KARL STORZ products gives you all even in an emergency you will never be left in the dark.
OR 1™ Monitor
C-MAC® Monitor
C-MAC® PM
Laptop Airway Cockpit
C-HUB®
C-CAM® C-MAC® S Imager E-Module
FIVE C-MAC® S
(Flexible Intubation Endoscopes/Fiberscopes Video Laryngoscope, C-MAC®
Video Endoscope) (eyepiece) for|single use Video Laryngoscope
It is recommended to check the suitability of the product for the intended procedure prior to use.
C-MAC® Video Laryngoscope

for visual endotracheal intubatio
Monitor/Electronic Module
Special Features:
Resistant ABS plastic housing World power supply 100 – 240 VAC, 50/60 Hz
Splash-proof according to IP54 Operation with line voltage and rechargeable
7" TFT wide view angle display with resolution lithium-ion batteries
of|800 x 480 pixels Processing of the electronic module: Suitable
Ready for use within seconds and validated for the following low-temperature
Documentation of still images (JPEG) and reprocessing methods up to bis max. 60 °C:
videos|(MPEG4) on SD memory card manual/machine cleaning and disinfection,
VESA 75 norm for connecting and attaching racks sterilization with Steris® AMSCO VPRO 1, Sterrad®
Soft keys enable use within seconds
(50S, 100S, 200S, NX, 100NX) and EtO gas;
High-Level Disinfection (HLD) acc.|to US standards
Cinch video output for connecting external monitor
Additional standards:
System open for further components
RTCA/DO-160F, EMI Test Report
Operating time with lithium-ion batteries of|about (German air rescue service DRF Luftrettung)
2 hours
8403 ZX 8402 X
8403 ZX C-MAC® Monitor für CMOS Endoscopes, screen size 7"

with 1280 x 800 pixel resolution, two camera inputs,
a USB and a HDMI port, optimized user interface,
video and image capturing in real time on SD card,
playback of recorded video clips and still images,
data transfer from SD card to USB flash drive possible,
splash-proof according to IP54, suitable for wipe disinfection,
shock-resistant ABS plastic housing, intelligent power
management with rechargeable Li-Ion batteries,
VESA 75 mounting option, power adaptor for EU, UK, USA
and Australia, power supply 110 - 240 VAC, 50/60 Hz
8402 ZX Monitor for CMOS Endoscopes, screen size 7",
documentation can be stored directly on SD card,
rechargeable Li-Ion batteries, power adaptor for EU, UK,
USA and Australia, power supply|110|– 240 VAC, 50/60 Hz,
additional standards: RTCA/DO-160F, EMI|Test Report
(German air rescue service DRF|Luftrettung),
suitable for wipe disinfection
8402 X Electronic Module, for C-MAC® Monitor 8402 ZX,
for use with C-MAC® video laryngoscopes
Accessories included in delivery with 8402 ZX:
8401 YCA VESA 75 Quick Clip, with 4 fixation screws,

for mounting C-MAC® to tube up to diameter 25 mm
8401 YCA
BERCI-KAPLAN C-MAC® Video Laryngoscope

for visual endotracheal intubation
Video Laryngoscope
Special Features: MACINTOSH

European closed laryngoscope blade design For direct and indirect laryngoscopy
Angle of view approx. 80° Original English MACINTOSH blade shape
Ergonomically designed handle
D-BLADE
CMOS technology with LED illumination Special curved blade shape for difficult intubation
Proximal slanted blade
MILLER
Available with or without suction For pediatrics and neonatology in the day-to-day
Processing video laryngoscopes: suitable and clinical routine, teaching and training as well
validated for the following low-temperature difficult airway management
reprocessing methods up to bis max. 60 °C:
manual/machine cleaning and disinfection,
sterilization with Steris® AMSCO V-PRO 1, Sterrad®
(50S, 100S, 200S, NX, 100NX) and EtO gas;
High-Level Disinfection (HLD) acc. to|US standards
Blade tips of all blade types visible for|safe
navigation
8401 DXC/GXC
8401 KXC/AXC/BXC
n 8401 DXC MILLER C-MAC® Video Laryngoscope, CMOS technology, size 0,

for use with Electronic Modules 8401 X and 8402 X
n 8401 GXC Same, size 1
8401 KXC BERCI-KAPLAN C-MAC® Video Laryngoscope #2, CMOS technology,
with MACINTOSH laryngoscope blade, size 2, for use with Electronic
Modules 8401 X and 8402 X
8401 AXC Same, size 3
8401 BXC Same, size 4
BOEDEKER-DÖRGES C-MAC® Video Laryngoscope

for visual endotracheal intubation
8401 AX/BX
8401 HX
8401 AX BOEDEKER-DÖRGES C-MAC® Video Laryngoscope #3,

CMOS technology, with MACINTOSH laryngoscope blade, size 3,
with catheter introduction sizes 14 – 16 Fr.,
8401 BX Same, size 4, with catheter introduction sizes 16 – 18 Fr.
8401 HX C-MAC® Video Laryngoscope D-BLADE, CMOS technology,
with DÖRGES laryngoscope blade, for difficult intubation,
with catheter introduction sizes 16 – 18 Fr.,
C-MAC® S Video Laryngoscope n
Video Laryngoscope for Single Use
Special Features: C-MAC® S Imager:

Blade and handle form one continuous piece: Handling oriented towards hygiene
optimum protection against infections Reprocessing of the imager: suitable and validated
D-BLADE with short handle for the following low-temperature reprocessing
Original English MACINTOSH blade shape methods up to bis max. 60 °C: manual/machine
cleaning and disinfection, sterilization with EtO
Sturdy plastic material
gas; High-Level Disinfection (HLD) acc. to US
Compatible with C-MAC® monitor standards
Blade tip always under direct view for safe Compatible with C-MAC® monitor
navigation Blade can be exchanged within seconds
Ergonomically designed handle
Compact design
051113-10
051114-10
051113-10* BERCI-KAPLAN C-MAC® S Video Laryngoscope MAC #3,

with|MACINTOSH laryngoscope blade, size 3, for single use,
sterile, package of 10, for use with C-MAC® Monitor 8402 ZX
and C-MAC®|S Imager 8402 XS
051114-10* Same, size 4
* mtp medical technical promotion gmbh,

Take-Off GewerbePark 46, D-78579 Neuhausen ob Eck, Germany
C-MAC® S Video Laryngoscope n
051116-10
051116-10* C-MAC® S Video Laryngoscope D-BLADE,

with|DÖRGES laryngoscope blade, sterile,
package of 10, for use with|C-MAC® Monitor
8402 ZX and C-MAC®|S Imager 8402 XS
8402 XS
8402 XS C-MAC® S Imager, for C-MAC® Monitor 8402 ZX-1, suitable for
manual and mechanical disinfection up to 60 °C and High-Level
Disinfection (HLD) acc. to US standards, for use with C-MAC®
S-Video Laryngoscopes 051113-10, 051114-10 and 051116-10
* mtp medical technical promotion gmbh,

Take-Off GewerbePark 46, D-78579 Neuhausen ob Eck, Germany
C-MAC® PM – The Pocket Monitor n
Special Features:
Exchange of video laryngoscope within seconds Important for preclinical use: classified for
Compatible with all C-MAC® video laryngoscopes protection class IPX8
(D-BLADE, MACINTOSH sizes 2-4, Due to the closed design, the entire pocket monitor
MILLER sizes 0 & 1) unit can be fully immersed in disinfection solution
One hour operating time which allows for easy and smooth reprocessing
Rechargeable Li-ion battery with capacity control Suitable and validated for the following
and intelligent power management low-temperature reprocessing methods up to max.
High-resolution 2.4" LED display with
60 °C: manual/machine cleaning and|disinfection
240 x 320 pixels for optimal view Additional standard: RTCA/DO-160F
No additional on/off buttons thanks to the

“Open-to-Intubate-Display”(OTI)
8401 XDK 8401 XDL
8401 XDK C-MAC® Pocket Monitor, Set, unit with LCD monitor and power supply
for all C-MAC® laryngoscopes, screen size 2.4", monitor movable via
two rotation axis, rechargeable Li-Ion batteries, 1|h|operation time,
2 h charging time, power management with|capacity indicator: switches
off automatically after 10 min, protection class IPX8, additional standard:
RTCA/DO-160F, validated for up to a max. of 60 °C, manual/mechanical
cleaning and disinfection, for use with C-MAC® video laryngoscopes
including:
Protection Cap
8401 XDL Charging Unit, for C-MAC® Pocket Monitor 8401 XD,
with fix integrated power supply and adaptor for EU,
UK and USA, power supply 110 – 240 VAC, 50/60 Hz,
FIVE – Flexible Intubation Video Endoscope for|C-MAC® n
Special Features:
Compatible with C-MAC® monitor and C-HUB® Integrated LED light source
Compact design Suitable and validated for the following
Ergonomically designed handle low-temperature reprocessing methods up to max.
60 °C: manual/machine cleaning and disinfection,
Lightweight at 385 g
sterilization with Sterrad® (100S, NX, 100NX)
High image resolution and EtO gas; High-Level Disinfection (HLD)
Video imaging in 4:3 format acc. to US standards
Possible to exchange components within seconds
11301 BNXK
11301 BNXK Flexible Intubation Video Endoscope 5.5 x 65,

CMOS technology, with suction valve, for use with
C-MAC® Monitor 8402 ZX and C-HUB® 20 2901 01
Deflection up/down: 140°/140°
Direction of view: 0°
Angle of view: 85°
Working length: 65 cm
Total length: 93 cm
Working channel inner diameter: 2.3 mm
Distal tip outer diameter: 5.5 mm
Accessories
Flexible Intubation Video Endoscopes
Accessories included in delivery:
29100 Plug, for LUER-Lock connector

for cleaning, black, autoclavable,
package of 10
11301 CD1 Irrigation Adaptor, for machine cleaning,

reusable, for Flexible Intubation Video Endoscope
11301 BNX
11301 CE1 Suction Valve, for single use, package of 20,

for use with Flexible Intubation Video Endoscope
11301 BNX
10309 Bronchoscope Insertion Tube, size 4,

with integrated mouthpiece, for single use,
sterile, insertion length 85|mm,
made from EVA, package of 10
sterile, insertion length 65|mm,
made from EVA, package of 10
11301 CFX Tube Holder, for use with Flexible Intubation

Video Endoscope 11301 BNX
27677 FV Case
11025 E Pressure Compensation Cap,

for|ventilation during gas sterilization
13242 XL Leakage Tester,

with bulb and manometer
27651 B Cleaning Brush, flexible, round,

outer diameter 3|mm, for|working channel
diameter 1.8 – 2.6 mm, length 100 cm
8401 YZ Protection Cap, for the C-MAC® video

laryngoscope and electronic module,
to protect plug contact during reprocessing,
cap is reusable
Accessories
Flexible Intubation Video Endoscopes
Optional Accessories:
11001 KL Biopsy Forceps, flexible, spoon-shaped,

round, double action jaws,
diameter 1.8 mm, working length 120 cm
11002 KS Grasping Forceps, flexible, alligator jaws,
double action jaws, diameter 1.8 mm,
working length 120 cm
11301 CA Leaflet Valve, for single use,

package of 20
11301 CB1 Suction Valve, reusable, for use with Flexible

Intubation Video Endoscope 11301 BNX
39405 AS Plastic Container for Flexible Endoscopes,

specially suited for gas and hydrogen peroxide
(Sterrad®) sterilization and storage, for use with
one flexible endoscope, external dimensions
(w x d x h): 550 x 260 x 90 mm
11301 BM Adaptor, for leakage test,

for Belimed washer-disinfectors
11301 FF2 Adaptor for MIELE Cleaning Machines,

with safety valve, for automatic leakage test
of flexible KARL STORZ endoscopes
11301 GG2 Adaptor, for cleaning and disinfecting the irrigation

and working channels of flexible endoscopes,
for MIELE-ETD washer-disinfectors
11301 HH Adaptor for BHT Cleaning Machines,

for automatic leakage test of flexible
KARL STORZ endoscopes
11301 KK2 Adaptor, for working channel of flexible endoscopes,

for MIELE-ETD 03 washer/disinfectors
Please note: Adaptors 11301 FF2 and 11301 GG2
have to be ordered separately!
6927691 Adaptor for Two-Way Stopcock,

LUER-Lock, with O2 tube connection
600007 LUER-Lock Tube Connector,

male, tube diameter 6 mm
Accessories
8401 YA
8401 YAA
8401 YAB
8401 YB
8401 YA Stand, for C-MAC® monitor, height 120 cm, rollable with five
feet and antistatic castors, crossbar 25 cm x diameter 25 mm,
for positioning the monitor, with tray for laryngoscopes,
dimensions (w|x|d x h): 30 x 20 x 10 cm
8401 YAA Crossbar, for Stand 8401 YA, 50 cm x diameter 25 mm,
or positioning C-MAC® Monitors 8401 ZX and 8402 ZX
with VESA 75 Quick Clip 8401 YCA
8401 YAB Same, 70 cm x diameter 25 mm
8401 YB Clamp, VESA 75 standard, for fixation of C-MAC® monitor
to round profile with diameter 20 – 43 mm and square profile with
diameter 16 – 27 mm, for use with Monitors 8401 ZX/8402 ZX
Accessories
809125
809120
8402 YD 8402 YD-1
8402 YD-2
39501 LC2 8401 YZ 8402 YD-3
8402 YD* Protective Bag, blue, for C-MAC® system, made of water-resistant
and sturdy material, washable, separate compartments for the monitor
and two C-MAC® video laryngoscopes with electronic module
8402 YD-1* Same, red
8402 YD-2* Same, orange
8402 YD-3* Same, NATO-olive
809125 MAGILL Forceps, modified by BOEDEKER, length 25 cm,
suitable for endoscopic foreign body removal,
for use with video laryngoscopes size 2 – 4
n 809120 MAGILL Forceps, for children, modified by BOEDEKER, length 20 cm,

for use with video laryngoscopes size 1 and 2
39501 LC2 Wire Tray for Cleaning, Sterilization and Storage for two
C-MAC® and D-BLADE video laryngoscope blades incl. electronic
module, with holder for fixing and sealing electrical connections,
external dimensions (w x d x h): 260 x 120 x 170 mm
8401 YZ Protection Cap, for the C-MAC® video laryngoscope
and electronic module, to protect plug contact during
reprocessing, cap is reusable
* Crash test carried out by Furtwangen University of Applied Sciences (Germany): C-MAC® system
in|a|protective bag dropped from a height of 5 – 9 meters showed no noteworthy damage.
Please note: The instruments displayed are not included in the sterilization and storage tray.
C-CAM® and C-HUB®
Nothing could be easier!

C-CAM® transforms the C-MAC® video laryngoscope into The C-HUB® is the interface for computer and/or monitor
an all-round system unit for complete airway management. connectivity. The signal from the front end is transmitted
The C-MAC® monitor is at the core of all imaging directly to a computer or monitor with the aid of the
systems. C-CAM® is a high-grade CMOS camera with C-HUB®. The enhanced output can be directly linked to
VGA resolution which can be connected to all KARL any computer via a USB/S-VHS connection. Thanks to
STORZ endoscopes with eyepieces. Illumination is the safety offered by galvanic isolation in the C-HUB®,
ensured through the Power-LED battery light sources. medical products can now be connected to non-medical
Consequently, this is the first battery-powered video products (e.g. computer/ monitor).
system to guarantee high-quality documentation. KARL C-HUB® is the perfect signal converter from C-MAC®/
STORZ has once again proven that high quality and C-CAM® to USB or S-Video.
mobility are not mutually exclusive.
C-CAM® and C-HUB®
20 2901 32/20 2901 31
20 2901 32 C-CAM® Camera Head, 8-pin, one-chip CMOS camera head,

resolution 640 x 480, focal length f = 20 mm,
compatible with| C-HUB® 20 2901 01 and C-MAC® 8402 ZX
20 2901 31 C-CAM® Camera Head, 6-pin, one-chip CMOS camera head,
resolution 640 x 480, focal length f = 20 mm,
compatible with C-MAC® 8401 ZX
20 2901 01
20 2901 01 C-HUB® Camera Control Unit, for use with

C-CAM® 20 2901 32, Electronic Module 8402 X or
compatible CMOS video endoscopes, Interfaces:
USB 2.0, S-Video output (NTSC), power socket
including:
C-HUB® Power Supply
S-Video (Y/C) Connecting Cable
USB Connecting Cable
Intubation Fiberscopes
Eyepiece Versions
KARL STORZ provides the instruments you need to Our versatile intubation fiberscopes can be used in
meet the special challenges of patients who cannot be all clinical settings whether in intensive care units or
intubated with conventional methods. Nasopharyngeal emergency rooms as well as for patients with anticipated
awake intubation is regarded as the gold standard of difficult airways during induction. The various sheath
difficult airway management. We offer solutions for any diameters enable you to select the ideal instrument for
challenge! your patient and allow a swift reaction thanks to the
compact, flexible LED light sources.
Special Features:
Sheath stiffness adapted to anesthesiological Various outer diameters: 2.8; 3.7; 5.2|mm
requirements Diameter of working channel ranging from
Suitable for both fiber optic intubation and 1.2 to 2.3|mm
bronchoscopy Extremely bright, white light due to the LED light
Patented sheath surface special treatment source with rechargeable Li-Ion batteries
requires only minimal lubrication and provides Intubation fiberscope can be directly connected to
optimal tube insertion the C-MAC® monitor with the mobile camera head
Developed for use in the OR, ICU, ER C-CAM®
Even safer tube introduction due to video-assisted Suitable and validated for the following
control on the monitor low-temperature reprocessing methods up to a
Tube position of ETT, LMA, DLT can be verified max. of 60 °C: manual/mechanical cleaning and
Video-assisted monitoring for percutaneous
disinfection, sterilization with Steris® AMSCO
VPRO 1, Sterrad® (50S, 100S, 200S, NX, 100NX)
tracheostomy
and EtO gas; High-Level Disinfection (HLD)
Adaptable for foreign body removal or bronchial acc.|to US standards
lavage
11301 BN1
Intubation Fiberscopes – eyepiece version, with optional LED battery light source
Eyepiece Versions
2.8 x 65 Intubation Fiberscope with optimized imaging Benefits:

Intubation Fiberscope 11301 AA1 is ideal for use in Effective suction possible via the 1.2 mm
neonatology due to its small outer diameter of 2.8 mm. working channel
This fiberscope is the only one of its size that has a Suitable for use with endotracheal tubes
working channel with 1.2 mm. as of 3.5 mm
Increased stiffness and smoother passage
Intubation Fiberscope 11301 AA1 features a connector
of the|ETT
for suction valves for single or multiple use.
Ready for immediate use and easy to clean
The special sheath surface combined with increased and reprocess
stiffness improves the gliding properties of the ETT over Optimized for use with mobile light sources
standard intubation fiberscopes. Intubation fiberscope can be connected
The use of a mobile LED light source enables independent to the C-MAC® monitor via the mobile C-CAM®
work under optimal lighting conditions. camera head
Practical tube fixation via special adaptor
11301 AA1
11301 AA1 Intubation Fiberscope 2.8 x 65,

Angle of view: 90°
Eyepiece Versions

The 3.7 x 65 intubation fiberscope is a universal working Effective suction possible via 1.5 mm
instrument as it provides gold standard intubation for both working channel
adult and pediatric patients. Due to its small diameter, it Suitable for use with endotracheal tubes
is an excellent tool for the placement of double lumen as of 4|mm
tubes. Using a mobile LED light source and C-CAM®, Increased stiffness and smoother passage
the intubation fiberscope can be directly connected to of the ETT
the C-MAC® monitor for a monitor-assisted intubation Practical tube fixation via special adaptor
solution that is both mobile and flexible – also suitable Ready for immediate use and easy to clean
for electronic documentation. and reprocess
Optimized for use with mobile light sources
Intubation fiberscope can be connected
to the C-MAC® monitor via the mobile C-CAM®
camera head
11302 BD2
11302 BD2 Intubation Fiberscope 3.7 x 65,

Angle of view: 90°
Eyepiece Versions

The 5.2 x 65 intubation fiberscope creates an ideal Effective suction possible via the large 2.3 mm
balance between image size, working channel size and working channel
fiber optics. Effective suction is possible via the 2.3|mm Suitable for use with endotracheal tubes
working channel. The fiberscope is also suitable for as of 5.5 mm
removing foreign bodies or for bronchial lavage in the Increased stiffness and smoother passage
intensive care unit. Using a mobile LED light source of the endotracheal tube
and C-CAM®, the intubation fiberscope can be directly Practical tube fixation via special adaptor
connected to the C-MAC® monitor for a monitor-assisted Ready for immediate use and easy to clean
intubation solution that is both mobile and flexible – also and reprocess
for electronic documentation. Optimized for use with mobile light sources
Intubation fiberscope can be connected
to the C-MAC® monitor via the mobile C-CAM®
camera head
11301 BN1
11301 BN1 Intubation Fiberscope 5.2 x 65,

Angle of view: 110°
Eyepiece Versions
Order No.
r
ete
es
am
cop
of* ETT
n
ow
r di
iew
iam anne
rs
ter nded
p/d
h
ibe
e
ngt
of v
ew
ete
out
er d ch
u
th
F
as
e
f vi
g le
ion
ion
eng
dia mm
ion
tip
inn rking
ce
le o
t
rkin
bat
pie
flec
ect
al l
tal
o
me
Rec
Ang
Wo
Intu
Dis
Eye
Tot
Dir
Wo
De
140°
2.8|x 65 11301 AA1 0° 90° 65 cm 98 cm 1.2 mm 2.8 mm 3.5 mm

140 °
140°
3.7 x 65 11302 BD2 0° 90° 65 cm 93 cm 1.5 mm 3.7 mm 4.5 mm

140 °
140°
5.2 x 65 11301 BN1 0° 110° 65 cm 93 cm 2.3 mm 5.2 mm 5.5 mm

140 °
27677 A Case
11025 E Pressure Compensation Cap,
for|ventilation during gas sterilization
13242 XL Leakage Tester, with bulb and manometer
11025 E 13242 XL 11301 CF LIPP Tube Holder, for intubation fiberscopes
27651 A Cleaning Brush, flexible, long,
for working channel diameter 1.2|mm,
working length 150 cm
11301 CF 27651 A/B 27651 B Cleaning Brush, flexible, round,
outer diameter 3|mm, for|working channel
diameter 1.8 – 2.6 mm, length 100 cm
29100 Plug, for LUER-Lock connector for cleaning,
black, autoclavable, package of 10
29100 11301 CD
2x 11301 CD Irrigation Adaptor, for machine cleaning,
reusable, for fiberscopes
11301 CE Suction Valve, for single use, package of 20
11301 CE sterile, insertion length 85|mm, made from EVA,
package of 10
10309/10310 10310 Same, size 2, insertion length 65|mm
Eyepiece Versions
Accessories (included in delivery) Add. Accessories
s
cep
For
ap
or
r
lde
nC
ion cope
t
er
g
sh
dap
spin
s
ve
est
Ho
Tub
cep
Bru
atio
Val
A
Gra
eT
ube
For
Ins ncho
Co ssure
ion
ens
ng
tion
kag
ible
PT
ani
psy
gat
ert
mp
se
Bro
g
Pre
Suc
Lea
Flex
Cle
Plu
LI P
Bio
Irri
Ca
2x
27677 A 11025 E 13242 XL 11301 CF 27651 A 29100 11301 CD 11301 CE 10309 11003 MA 11003 MB
10310
2x
27677 A 11025 E 13242 XL 11301 CF 27651 A 29100 11301 CD 11301 CE 10309 11003 MA 11003 MB
10310
2x
27677 A 11025 E 13242 XL 11301 CF 27651 B 29100 11301 CD 11301 CE 10309 11001 KL 11002 KS
11003 MA Biopsy Forceps, flexible, oval, double action jaws,

diameter|1|mm, length|110|cm
11003 MB Grasping Forceps, flexible, double action jaws,
diameter 1|mm, length|110|cm, for flexible bronchoscopes
11001 KL Biopsy Forceps, flexible, spoon-shaped, round,
double action jaws, diameter 1.8 mm, working length 120 cm
11002 KS Grasping Forceps, flexible, alligator jaws,
double action jaws, diameter 1.8 mm, working length 120 cm
* Please note that the accuracy of the ETT diameter may vary depending on the manufacturer’s quality.
BONFILS Retromolar Intubation Endoscopes

Eyepiece Versions
The expert instrument for multiple applications in airway management combines technical sophistication
with utmost reliability
Unexpected difficult airways are always a challenge in vision and the possibility of simultaneous application of
airway management. With the BONFILS intubation oxygen provides more safety. Moreover, KARL STORZ
endoscope and its versatile intubation techniques, this offers a solution to meet the most stringent hygiene
situation can be brought back to a controlled status. The requirements – the autoclavable SILVER|LINE.
endotracheal tube is guided into the trachea under direct

Eyepiece Versions
Special Features:
SILVER LINE – autoclavable Connect and intubate – thanks to the mobile
Particularly suitable for the unexpected LED|“Power of Light” light source
difficult airway Quick and easy cleaning
Use in the case of minimal mouth opening Suitable and validated for the following
(>|1|cm)|possible low-temperature reprocessing methods up to
Introduction of the tube under visualization: bis max. 60 °C: manual/machine cleaning and
What|you|see|is what you get! disinfection, sterilization with Steris® AMSCO
VPRO 1, Sterrad® (50S, 100S, 200S, NX, 100NX)
Continuous O2 flow via tube adaptor between
and EtO gas; High-Level Disinfection (HLD)
tube and instrument acc. to US standards
One-person intubation possible
Recommended for video-assisted intubation
with C-CAM® to C-MAC® monitor
10332 B1
10330 B1
10331 B2K
10332 B1 BONFILS Retromolar Intubation Endoscope, outer diameter 3.5 mm,

for ETT 4 – 5.5 mm, usable sheath length 35 cm, distal bending 40°,
with movable eyepiece, including Tube Holder 10332 BA for tube fixation
and O2 application
n 10331 B2K BONFILS Retromolar Intubation Endoscope, autoclavable,

outer|diameter 5 mm, for ETT > 5.5 mm, usable sheath length 40|cm,
distal bending 40°, with movable eyepiece,
with Tube Holder 10331|BA for tube fixation and|O2 application
10330 B1 BONFILS Retromolar Intubation Endoscope, outer diameter 5 mm,

for ETT > 5.5 mm, usable sheath length 40 cm, distal bending 40°,
working channel diameter 1.2 mm, including Tube Holder 10331 BA
for tube fixation and O2 application

Eyepiece Versions
pes Order No.

sco
ndo
g
din
E
ben
ion
ce
bat
pie
tal
Intu
Eye
Dis
BONFILS
10332 B1
3.5 x|35
BONFILS
10330 B1
5 x|40
BONFILS
10331 B2K
5 x|40
27677 BM Case, internal dimensions (w|x|d|x|h):|490 x 290 x 85 mm

27677 C Plastic Case, without inserts, internal dimensions
(w|x|d|x|h): 480 x 285 x 80 mm
10332 BA Tube Holder for ETT, with O2 application connection,
10332 BA/10331 BA
inner diameter 3.5 mm
10331 BA Tube Holder, inner diameter 5 mm
27651 AE 27651 AE Cleaning Brush, for Intubation Endoscope 10330 B1


Eyepiece Versions
r
Accessories
ete
(included in delivery)
ter
m
dia
am
of* ETT
r di
nel
ter ended
sh
h
e
han
ngt
ew
out
Bru
gth
er
as
g le
f vi
gc
dia omm
old
tip
ng
len
le o
rkin
rkin
eH
ani
tal
me
se
al
Rec
Ang
Wo
Tub
Dis
Tot
Cle
Wo
Ca
90° 35 cm 52 cm – 3.5 mm 4 mm 27677 BM 10332 BA –
110° 40 cm 52 cm 1.2 mm 5 mm 5.5 mm 27677 C 10331 BA 27651 AE
110° 40 cm 54 cm – 5 mm 5.5 mm 27677 BM 10331 BA –
39501 F Wire Tray for Cleaning, Sterilization and

Storage of|one rigid BONFILS endoscope,
including holder for light post adaptors,
silicone telescope holders and lid,
external dimensions (w x d x h): 570 x 80 x 52 mm
39501 F
* Please note that the accuracy of the ETT diameter may vary depending on the manufacturer’s quality.
LIPP/GOLECKI Airway Management Set

Basic Set
Recommended Set for Difficult and Standard Intubation
11300 B3 LIPP/GOLECKI Airway Management Set, for the difficult airway

including:
Intubation Fiberscope, 3.7 mm x 65 cm
BONFILS Retromolar Intubation Endoscope, 5 x 40, autoclavable
Battery Light Source LED for Endoscopes
Mask Adaption “MAINZ Adaptor”, blue, package of 5
Laryngeal Tube, size 4
Laryngeal Tube, size 3
Spiral Tube, size 6, for single use
Bronchoscope Insertion Tube, size 4
Laryngeal Mask, standard, reusable, size 1
Intubation Laryngeal Mask, reusable, size 3
Intubation Laryngeal Mask, reusable, size 4
Laryngeal Mask Tube, diameter 7 mm
Laryngeal Mask Tube, diameter 7.5 mm
LMA Tube Stabilizer
MAGILL Forceps, length 25 cm
Scalpel, for single use, package of 10
COTTLE Nasal Speculum, blade length 55 mm, length 13 cm
DÖRGES Emergency Laryngoscope Blade, cold light, universal size
Handle Sleeve, ISO 7376
Battery Insert, with 2 Batteries 121306 S and Xenon Lamp 8546 XA
Case
Intubation Set -C22-, ULM Model n

Basic Set
8400 B Intubation Set -C22-, ULM model

including:
BOEDEKER-DÖRGES C-MAC® Video Laryngoscope, MAC #3
BOEDEKER-DÖRGES C-MAC® Video Laryngoscope, MAC #4
C-MAC® Video Laryngoscope D-BLADE
C-MAC® Pocket Monitor Set
Charging Unit, for C-MAC® pocket monitor
Protective Cap
Handle Sleeve, ISO 7376
DÖRGES Emergency Laryngoscope Blade, cold light
Battery Insert Set LED, with cap
Bag for Intubation Set -C22-, ULM model
MAGILL Forceps, modified by BOEDEKER
8402 YE Bag for Ulm Intubation Set -C22-, made of water-resistant and sturdy material,
washable, including two compartments with several holding facilities for C-MAC®
video laryngoscope blades with C-MAC® pocket monitor and conventional
laryngoscopes, for use with C-MAC® Pocket Monitor 8401 XD, C-MAC® video
laryngoscopes and conventional laryngoscopes
Emergency Tracheobronchoscopy Set

Basic Set
Recommended Set for Difficult and Standard Intubation
10330 F Emergency Tracheoscope Set

including:
Emergency Bronchoscope, size 6, length 30 cm
Emergency Tracheoscope, size 9, length 25 cm
FLUVOG Adaptor
Adaptor for Ventilation
DÖRGES Emergency Laryngoscope Blade, cold|light, universal size
2x Handle Sleeve, ISO 7376
2x Battery Insert, with 2 Batteries 121306 S and|Xenon|Lamp 8546 XA
Xenon Lamp, package of 6
Forceps, for peanuts and soft foreign bodies
Forceps, alligator, for hard foreign bodies
YOUNG Tongue Seizing Forceps
Suction Tube, diameter 3 mm, length 35 cm
Suction Tube, diameter 4 mm, length 35 cm
Suction Tube, diameter 5.5 mm, length 35 cm
Case
Battery Light Source LED BRITE LITE

Accessories for Intubation Fiberscopes and Endoscopes
Special Features:
Battery light source with extremely high light LED provides up to 50,000 hours
intensity >100 lm / > 150 klx lifetime
Available as battery and rechargeable version Burning time of 120 min
Absolute white light due to LED technology Waterproof, fully immersible for cleaning
Special light focus allows optimal light and|disinfection (11301 D1/D3)
adjustment at the endoscope connector
11301 D1/D3/DE/DF 11301 DG
11301 D1 Battery Light Source LED for Endoscopes, with fine screw thread,
brightness > 100 lm / > 150 klx, burning time > 120 min,
weight approx. 150 g, waterproof and fully immersible for manual
cleaning and disinfection, with 2 Photo Batteries 121306 P
11301 D3 Same, with coarse thread
121306 P Photo Battery, lithium, 3 V, CR 123 A
11301 DE Battery Light Source LED for Endoscopes, rechargeable,

with click connection, brightness > 110 lm / >150 klx,
color temperature 5500 K, lithium-ion batteries,
charging time 60 min, burning time at 100% brightness 40 min,
weight approx. 150 g ready for use, suitable for wipe disinfection
11301 DF Same, with fast screw thread
11301 DG Charging Unit, for 11301 DE/11301 DF, for two LED battery light sources,
with fixed integrated power supply and adaptor for EU, UK,
USA and Australia, power supply 110|– 240|VAC, 50/60 Hz,
11301 DH Holder, for Charging Units 11301 DG, 8546 LE and 8401 XDL
MACINTOSH Laryngoscope Blades

Cold Light, with Replaceable Fiber Optic Light Carrier
Special Features:
KARL STORZ blades and handles meet the highest The KARL STORZ laryngoscope blades are the only
cleaning and hygienic standards such products currently commercially available that are
Chromium-plating gives the laryngoscope blades autoclavable and show no noticeable reduction in light
a compact, smooth surface; edges are rounded, intensity, even after several hundred cleaning cycles**.
thus preventing the formation of microcracks, The Xenon lamps in the fiberoptic light carriers
fission or sharp edges which can harbour germs generate a neutral white light which is 30 – 40%
Handles are not knurled brighter than standard halogen light.
(problematic concerning hygiene), Laryngoscopy blades and handles comply with the
instead have an ergonomic shape ISO 7376 standard.
and smooth surface. On request, additional markings can be etched on
Handles can be supplied with LED “BRITE LITE” the laryngoscope/handle free-of-charge
power system with > 50.000 lux and Li-Ion (such as, e.g., “1-83-2/Case“ or „Christoph 77/Rucksack”)
rechargeable batteries.
**) MJL BUCX, HM de GAST, J VELDHUIS,

LH HASSING, A|MEULEMANS, A KAMMEYER:
The effect of mechanical cleaning and
thermal disinfection on light intensity provided
8546 by fibrelight Macintosh laryngoscopes.
8546 A Anaesthesia 58: 5, 461-465 (2003).
8546 LD
8541 AA MACINTOSH Laryngoscope Blade,

size 5
8541 A Same, size 4
8541 B Same, size 3
8541 C Same, size 2
8541 D Same, size 1
8541 AA-E 8541 E Same, size 0
MILLER Laryngoscope Blades

Cold Light, Fiber Optic Light Carrier Incorporated
8546
8546 A
8546 LD
8537 A MILLER Laryngoscope Blade,
size 4
8537 B Same, size 3
8537 C Same, size 2
8537 D Same, size 1
8537 E Same, size 0
8537 A-E
Handles with LED Light Source

for Cold Light Laryngoscope Blades
Special Features:
Rechargeable lithium-ion batteries Special lens system allows optimal light adjustment
Extremely bright LED of more than at the blade connector
50 lm/> 100|klx LED provides a lifetime of more than 50,000|hours
Absolute white light due to LED technology Burning time up to 240 min at 100% brightness
(5500|K) Charging via inductive technology
Small handle with photo battery ISO 7376 compatible
8546 8546 LD1 8549 LDX 8548 8548 LDX1
8546 Handle Sleeve, ISO 7376, 8548 Handle Sleeve, ISO 7376,
autoclavable, length 12 cm, length|6|cm, autoclavable,
for use with Battery Inserts 8546|A, for use with Battery Insert Set
8546 LD, 8549 LD and cold light 8548|LDX
laryngoscopes
8548 LDX1 Battery Insert Set, length 6 cm,
8546 LD1 Battery Insert, rechargeable, for|Handle Sleeve 8548,
length 12 cm, for Handle Sleeve with high-power LED,
8546, with high-power LED, > 56 lm/> 100 klx, burning time
56|lm/> 100 klx, lithium-ion battery at 100% brightness >|120|min
insert, burning time at 100% including:
brightness 240 min, charging via
Inductive Charging Unit 8546 LE Battery Insert, high-power LED
Photo Battery, CR 123 A
Cap
n 8549 LDX Battery Insert Set LED, length 12 cm,
for Handle Sleeve 8546 and cold light
laryngoscopes, with high-power LED,
> 56 lm/ >100 klx, burning time at 100%
brightness > 120 min
including:
Battery Insert, high-power LED
2x Battery, Mignon-Cell, LR 06, 1.5 V
Cap
Handles with Xenon Light Source

for Cold Light Laryngoscope Blades
8546 Handle Sleeve, ISO 7376, autoclavable,

length 12 cm, for use with Battery Inserts
8546|A, 8546 LD, 8549 LD and cold light
laryngoscopes
8546 A Battery Insert, length 12 cm, with 2|Batteries
121306 S and Xenon Lamp 8546 XA
121306 S Batteries, Baby-Cell, LR 14, for Battery Inserts
8544 A and 8546 A, package of 2
8546 XC Xenon Lamp, 2.5 V, for Battery Inserts 8546 A,
8547 A and 8547 B, package of 6
8546 8546 A
Especially suitable for use with blades sizes 0 and 1
8547 Handle Sleeve, ISO 7376, length|12 cm,

autoclavable, for|use with Battery Inserts
8547 A and 8547 B
8547 A Battery Insert, length 12 cm, including 2|Batteries

121306 KS and Xenon Lamp 8546 XA
121306 KS Batteries, Mignon-Cell, LR 06, 2 Batteries 121306 K,

for Battery Inserts 8545 A, 8547 A and Battery Insert
Set High-Power LED 8549 LD
8547 B Rechargeable Battery Insert, length|12|cm,
for|Handle Sleeve 8547,
with Xenon Lamp 8546|XA, charging via
Inductive Charging Unit 8546 LE
8546 XC Xenon Lamp, 2.5 V, for Battery Inserts 8546 A,
8547 A and 8547 B, package of 6
8547 8547 A 8547 B

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®

Tim PIEPHO, MD, PhD

Illustration: Airway Management in Critical Care Medicine

Correspondence address of the author:

Introduction Endotracheal intubation is usually performed with a laryngo-

the prevention of gastric insufflation

2 Laryngoscope with a Macintosh blade.

1 Noninvasive ventilation with a CPAP 3 Visualization of the glottis by direct laryngoscopy.

5 Video-assisted fiberoptic intubation in the awake patient.

9 Percutaneous dilatational tracheotomy guided by video endoscopy.

Special Issues in Critical Care Medicine Incidence of Difficult Airways

This is in contrast to the majority of patients who are treated

Noppens-Piepho Algorithm for Emergency Airway Management

Maximum of 3 intubation attempts EMERGENCY: Call for help.

Adequate mask ventilation Return to spontaneous breathing

Video laryngoscope / Flexible or rigid

Successful? ONE alternative

Return to spontaneous breathing

YES Adequate mask ventilation

Surgical or percutaneous cricothyrotomy

Complications of Endotracheal Intubation Training of ICU Physicians

11 Typical ICU equipment layout, with limited patient access.

Learn basic theory.

Equipment for Airway Management

12 Infinity Delta XL patient monitor (Dräger Medical GmbH, Lübeck,

Device Comments Device Comments

13 Instrument set for anesthesia induction.

Predictors of a Difficult Airway Predictors of a difficult airway

If one or more predictors of difficult intubation is found,

14 Macroglossia in a patient with Lenz-Majewski syndrome.

17 Preoxygenation by bag-and-mask ventilation with an attached

Endotracheal Intubation Induction Agents

Hyperkalemia (> 5 mmol/l)

Rocuronium is a non-depolarizing muscle relaxant. This

21 Muscle relaxants for rapid sequence induction (succinylcholine

Neuromuscular blockade should be induced for every

Positioning the Head

23 Sufentanil can be used for anesthesia induction and the

26 Macintosh blades for direct laryngoscopy. 27 Miller blades in assorted sizes.

30 The laryngoscope blade is introduced into the right side of the

Esophageal detection devices provide a reliable and cost-

Management of Difficult Direct Laryngoscopy Measures for improving intubation conditions

40 The C-MAC PM video laryngoscope, ; C-MAC with Macintosh

blade sizes 2–4, – ; and C-MAC® with a Miller blade, .

45 The C-MAC can be used for conventional direct laryngoscopy ()

51 An endotracheal tube prebent to a “hockey stick” shape points

Supraglottic Airway Devices In principle, supraglottic airway devices provide an alternative

The blind insertion of an endotracheal tube through a classic

Laryngeal Masks Many airway algorithms rank the laryngeal mask as an

61 Functional principle of the esophagotracheal double-lumen airway

EasyTube After primary direct laryngoscopy and tracheal placement

64 After direct laryngoscopy and tracheal placement of the EzT,

Laryngeal Tube Suction (LTS)

Flexible Endoscopic Intubation

69 Diagram illustrating the components of a classic flexible endoscope.

Flexible Endoscopic Intubation Basic protocol for awake endoscopic intubation

Oxygenation during Flexible

71 Oxygenation is administered through a nasal cannula in the

A snug-fitting CPAP mask or ventilation mask can be

Flexible Nasotracheal Endoscopic Intubation

Oropharynx with uvula Epiglottis

The endoscope should never be advanced blindly as this

Tab. 11 Anatomic landmarks for nasal endoscopic intubation.

blade sizes 2–4, – ; and C-MAC® with a Miller blade, .