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Adult Airway in the Operating Room (Hands-On Annual Instruction Course with Links to Protocols)

last modified on: Mon, 07/31/2023 - 09:13

Adult Airway Day- August 22, 2017

                   Annual conference with hands-on experience with faculty led stations - as below.

"The difficult airway is simply one that cannot be quickly obtained" (Burgess 2022)

See also:

Pediatric Airway Session - May 31, 2011
Microdirect Laryngoscopy case example
Microdirect Laryngoscopy (Suspension Microlaryngoscopy or Direct Laryngoscopy)
Pediatric Direct Laryngoscopy
Laryngeal Surgery (Benign Disease) Protocols
Subglottic stenosis
Pediatric Foreign Body Removal
Pediatric Airway Sizing
Microscopic Laser Laryngoscopy (CO2)

Difficulty airway management- adult awake fiberoptic intubation

Jet Ventilation Anesthesia - Transoral for Laryngeal Surgery

Emergency Airway Cart video describing cart

Heliox for the difficult airway


Station #1: Direct laryngoscopy, fiberoptic intubation with mannequin

  • ENT direct laryngoscopes
    First-line laryngoscopes: Dedo & Lindholm (most H&N staff), Kleinsasser (DVD)

click for more information re:  Dedo Laryngoscope


 Lindholm Adolescent Scope -click here for more information re: Lindholm Laryngoscope

 Hollinger anterior commissure scope- use for better exposure anteriorly

Not Shown: Jackson “sliding” laryngoscope- has removable component to facilitate insertion of endotracheal tubes

Weerda laryngoscope- useful for supraglottic laryngectomies - click here for more information re: Weerda Laryngoscope

Not Shown: Rudert laryngoscope- triangular shape (used in past by Dr. Trask)

  • Objectives

Recognize the different types of laryngoscopes and their uses.

Be able to set up a direct laryngoscope (Dedo) with light source and jet ventilation (also discussed in table 3)

Appreciate the relationship of the anterior commissure scope with a cuffed 5-0 MLT ET tube

Understand the proper technique for a flexible fiberoptic intubation.

Difficulty airway management- adult awake fiberoptic intubation


Station #2: Rigid bronchoscopes, telescopes, and foreign body removal

Rigid bronchoscopes

Storz bronchoscopes (2): adult (6.5 & 7.5 x 43 cm; 8.5 available but in separate location), adolescent (5.0 & 6.0 diameter x 40 cm)

If you can, try to use at least a 6.5 bronchoscope, because your optics will be much better (with the corresponding 5.5 mm telescope); if you need to use a 6.0 or smaller bronchoscope, you will unfortunately be forced to use a 2.8 mm telescope.

Adult Pilling bronchoscope (7.0 & 8.0 diameter x 40 cm)

Mostly used for airway dilatations

Key maneuver: At level of vocal cords, rotate bronchoscope clockwise 90 degrees, so that longer edge of bevel is on the right.  Advance scope w/ bevel tip in center of larynx and shorter edge of bevel sliding against left cord, to avoid catching and traumatizing right cord with bevel tip.

Two methods to place rigid bronchoscope: 1) Directly.  2) Use Jackson sliding or anesthesia laryngoscopes to guide bronchoscope to level of vocal cords

Sample rigid bronchoscope:

Single combo unit with eyepiece, rubber telescope adaptor, and suction port.  Dr. Funk does not like this and uses the smaller individual units.


A. (Direct view) Bridge adaptor for endoscope vs. glass eyepiece vs. rubber telescope adaptor (for quick transfer b/w endoscope & optical forceps)

B. (Top) Prism with connection to light cable

C. (Oblique) Instrument guide for flexible suction catheter vs. jet ventilation cannula (though we usually don’t jet through bronchs)

D. (Bottom) Adaptor for respirator


Foreign body instrumentation

Storz optical forceps (preferred): adult or adolescent

Nonoptical forceps- rarely used

If there is concern about the foreign body fitting through bronchoscope, you should brace the foreign body against end of bronchoscope and remove both together as one unit.  You do not want to shear the foreign body off the end of the bronchoscope.


Be able to put together all the different parts of a bronchoscope and to use optical forceps and rigid endoscope with the bronchoscope.


Station #3: Advanced Techniques: Jet ventilation, endotracheal tubes.

  • Jet ventilation:

It is important to note that there are 2 different proximal jet cannulas (adaptors that connect the laryngoscope to the jet ventilator), one for the Dedo laryngoscope and one for the Kleinsasser laryngoscope.  If the one you are given doesn’t seem to fit, ask for the other one!

Picture (below, left) shows a Kleinsasser laryngoscope with (A) = light source adaptor and (B) = jet ventilation.  Note that the jet ventilation always goes off to the right because it always goes towards the side that anesthesia is on.
Picture (below, right) shows the jet ventilation machine (B).

  • Special intubation techniques
    1. Flexible fiberoptic laryngoscope for intubation (need to be at least a __ size ETT)
  • Types of ET tubes: standard, MLT, oral RAE, nasal intubation, laser-safe, EMG laryngeal monitoring, cuffed vs. uncuffed
  • Laryngeal mask airway (LMA)
  • Anesthesia direct laryngoscopes= MacIntosh, Miller, Wisconsin/Wis-Hipple

In kids, the Wisconsin 1.5 blade provides a nice intermediate size blade between the more commonly available Miller 1.0 and Miller 2.0 straight blades.

  • Glide scope


Understand the proper setup of a Dedo scope for Jet ventilation.

Recognize and understand when to use the different types of endotracheal tubes, so that you can appropriately communicate with your anesthesia colleagues

Understand the role of the LMA and different anesthesia laryngoscopes in airway management


Station #4: Adult emergency airway cart

Emergency Tracheotomy Tray Emergency Tracheotomy Set

  • Objectives:  
  • To familiarize oneself with the role of the airway cart in the various settings
  • To become familiar with the content of the cart and how best to utilize it.
  • To recognize the necessary equipment for achieving a surgical airway

click to see:

Needle Cricothyroidotomy



Burgess MB, Schauer SG, Hood RL, De Lorenzo RA. The Difficult Airway Redefined. Prehosp Disaster Med. 2022 Dec;37(6):723-726. doi: 10.1017/S1049023X22001455. Epub 2022 Nov 9. PMID: 36349956.


    1. Benjamin B, Lindholm CE.Ann Otol Rhinol Laryngol Systematic direct laryngoscopy: the Lindholm laryngoscopes  2003 Sep;112(9 Pt 1):787-97.
    2. Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy--a systematic review.

      Scand J Trauma Resusc Emerg Med. 2013 May 31;21:43. PMID: 23725520

    3. Emergency airway management: the difficult airway.

      Nemeth J, Maghraby N, Kazim S. Emerg Med Clin North Am. 2012 May;30(2):401-20. PMID: 22487112