Case study: Use direct laryngoscopy

The most effective means of tracheal intubation in the ED is by direct laryngoscopy, argues Richard M. Levitan, MD, an attending ED physician at the Hospital of the University of Pennsylvania in Philadelphia.

"No other means of tracheal tube insertion is faster, simpler, or more successful under ED conditions," Levitan says. He notes that while many devices and adjunctive techniques are now available, and there are alternative means of ventilation such as the laryngeal mask airway (LMA) and Combitube, manufactured by Tyco-Kendall in Mansfield, MA, direct laryngoscopy is used for more than 99% of intubations in the ED. In fact, only one in 500 airways requires use of a surgical airway or nonstandard device such as a fiberoptic scope, or rescue device.1-2

Although many of these alternative devices and techniques are used routinely in the operating room, they do not work well under the circumstances of ED airway management, asserts Levitan. The following case study illustrates this point:

Levitan treated a morbidly obese man who had been shot in the chest four times and arrived hypotensive, hypoxic, and combative — requiring six people to get IV access. For elective surgery, this case would have been handled with awake flexible fiberoptic intubation using light sedation and topicalization, says Levitan. "Prior to the OR, he would have been given anti- sialogogues and been NPO overnight," he explains. "He would have arrived to the OR sedated and cooperative."

The ED presentation was the antithesis of this situation, according to Levitan. "Blood and secretions in his airway would make fiberoptics difficult, if not impossible, as would his lack of cooperation," he says. "He would have died of exsanguination and/or hypoxia during the prolonged efforts at fiberoptic intubation." Instead, rapid sequence intubation was used, and the man was intubated successfully with direct laryngoscopy. "He was intubated in minutes and up in the operating room within 20 minutes," reports Levitan.

The "difficult airway" begins with failed or difficult direct laryngoscopy, says Levitan. "I believe as a specialty we have been too focused on the toys of the difficult airway’ and not focused enough on the details of direct laryngoscopy," he adds. Simple maneuvers, such as bimanual laryngoscopy (the operator uses his or her right hand to manipulate the larynx for a better view), proper shaping of the stylet (straight back to the cuff, then bent upward at 45-60 degrees), and increasing head elevation (neck flexion, not atlanto-occipital extension) all were critical in the above case, he says.

There is a role for rescue ventilation devices, such as the LMA and the Combitube, Levitan acknowledges. "However, improved laryngoscopy skills and successful intubation on the first attempt obviates the need for rescue devices or alternative intubation techniques in almost all circumstances," he says.


1. Levitan RM, Kush S, Hollander JE. Devices for difficult airway management in academic emergency departments: Results of a national survey. Ann Emerg Med 1999; 33:694-698.

2. Levitan RM. Myths and realities: The "difficult airway" and alternative airway devices in the emergency setting. Acad Emerg Med 2001; 8:829-832.