Video Laryngoscopy: Uses and Benefits in Airway Management

Video laryngoscopy is an airway management technique that uses a laryngoscope with a camera to improve visualization of the larynx during endotracheal intubation. Instead of relying only on a direct line of sight from the clinician’s eye to the vocal cords, the airway image is displayed on a screen.

This can make intubation easier when the airway is difficult to see because of limited mouth opening, restricted neck movement, obesity, trauma, swelling, or unusual anatomy.

For respiratory therapists, video laryngoscopy is important because it supports safer airway establishment, better teamwork, and improved recognition of difficult airway situations.

What Is Video Laryngoscopy?

Video laryngoscopy is a method of visualizing the upper airway during intubation using a laryngoscope that contains a camera or optical system. The camera is usually located near the distal tip of the blade. As the blade is inserted into the mouth, the camera sends an image of the airway to a screen. This screen may be built into the handle or connected to a separate monitor.

The goal is to help the operator identify the epiglottis, glottic opening, vocal cords, and surrounding structures so the endotracheal tube can be guided into the trachea. This makes video laryngoscopy an indirect visualization technique. The clinician does not need to see the vocal cords directly with the naked eye. Instead, the clinician uses the video image to guide the procedure.

This differs from traditional direct laryngoscopy, where the operator must align the oral, pharyngeal, and laryngeal axes well enough to directly view the vocal cords. Direct laryngoscopy can work well in many routine airways, but it becomes more difficult when the patient cannot be positioned properly or when the anatomy limits the view.

Video laryngoscopy does not replace basic airway management principles. The patient still needs careful assessment, preoxygenation, positioning, monitoring, and confirmation of tube placement. The device improves visualization, but it does not guarantee successful intubation.

Purpose of Video Laryngoscopy

The primary purpose of video laryngoscopy is to improve visualization of the airway during endotracheal intubation. Better visualization can help the provider guide the tube through the vocal cords and into the trachea rather than the esophagus.

This matters because endotracheal tube placement must be accurate. A misplaced tube can lead to inadequate ventilation, severe hypoxemia, gastric insufflation, aspiration, or cardiac arrest. Even when the tube enters the trachea, it may be inserted too deeply into the right mainstem bronchus, which can cause unequal ventilation and decreased breath sounds on the left side.

Video laryngoscopy is especially useful when difficult intubation is expected. It can help when a direct line-of-sight view is poor because of limited neck mobility, restricted mouth opening, obesity, an anterior glottis, excessive epiglottic tissue, swelling, trauma, or cervical spine precautions.

Another purpose is team visibility. Since the airway image appears on a screen, other clinicians in the room can see the same view as the operator. This can help assistants anticipate the next step, provide suction, adjust positioning, pass equipment, or help guide tube insertion. It also makes the procedure easier to teach because instructors and students can observe the airway anatomy in real time.

Direct Laryngoscopy vs. Video Laryngoscopy

Direct laryngoscopy depends on the operator obtaining a direct view of the vocal cords. To do this, the clinician places the laryngoscope blade in the mouth, displaces the tongue and soft tissues, lifts the blade, and attempts to align the airway axes. If alignment is successful, the operator can see the vocal cords and pass the tube under direct vision.

Video laryngoscopy changes this process by placing a camera near the blade tip. The operator may not need to align the airway axes as completely because the camera can look around anatomical curves better than the human eye can from outside the mouth. This can improve the laryngeal view, especially when traditional positioning is limited.

However, seeing the vocal cords on the screen does not always mean the tube will pass easily. Sometimes video laryngoscopy provides an excellent view, but tube delivery remains difficult because of airway angles, limited mouth opening, or resistance from soft tissue. Many video laryngoscopes require a specially shaped stylet or tube-guiding channel to help direct the endotracheal tube toward the glottis.

Note: For this reason, video laryngoscopy should be understood as an intubation-assist tool, not simply a viewing device. It helps the clinician see the airway, but the operator still must know how to advance the tube safely and recognize when another method is needed.

Indications for Video Laryngoscopy

Video laryngoscopy may be considered whenever intubation is expected to be difficult or when direct visualization is poor. Common indications include limited mouth opening, restricted neck movement, obesity, suspected cervical spine injury, facial trauma, airway swelling, abnormal anatomy, and previous failed direct laryngoscopy.

It is also useful when a patient cannot be positioned in the usual sniffing position. Direct laryngoscopy often depends on good head and neck positioning. If the neck cannot be extended because of trauma or cervical spine precautions, the view may be limited. A videolaryngoscope can help visualize the larynx while allowing the head and neck to remain closer to neutral alignment.

Video laryngoscopy may also be used when the glottis is anterior. An anterior glottis can be difficult to see with direct laryngoscopy because the vocal cords sit higher and farther forward than expected. A camera near the blade tip can improve the view and help the provider guide the tube.

Note: It may be selected as part of a difficult airway plan before the first attempt, or it may be used after a failed direct laryngoscopy attempt. In either case, the goal is to secure the airway while limiting repeated attempts, preventing oxygen desaturation, and reducing the risk of trauma.

Difficult Airway Assessment

Video laryngoscopy is closely related to difficult airway assessment. Before intubation, the clinical team should evaluate whether the airway is likely to be difficult. This helps the team prepare the right equipment and avoid unnecessary delays.

One commonly taught approach is the L-E-M-O-N mnemonic. It includes looking externally, evaluating airway anatomy, using the Mallampati classification, considering obesity or obstruction, and assessing neck mobility. These factors can help predict difficulty with visualization or tube placement.

External clues may include facial trauma, a large neck, a small jaw, abnormal facial structure, swelling, burns, blood, or masses. Evaluation of anatomy may include mouth opening, jaw movement, dentition, and the distance from the chin to the neck structures. The Mallampati classification estimates how much of the oropharyngeal anatomy can be seen when the patient opens the mouth and protrudes the tongue. A higher Mallampati class suggests a more difficult oral intubation.

Obesity and obstruction are especially important. Obese patients may have reduced lung volumes, shorter safe apnea time, a large neck, and more difficult airway positioning. Airway obstruction from swelling, secretions, trauma, tumors, or foreign material can also interfere with ventilation and visualization.

Note: Neck mobility is another major factor. Patients with cervical spine precautions, trauma, arthritis, or limited extension may not tolerate the positioning usually needed for direct laryngoscopy. In these cases, video laryngoscopy may be considered early as part of the airway plan.

Video Laryngoscopy in Obese Patients

Obese patients often present special challenges during intubation. They may have a large neck, reduced functional residual capacity, limited mobility, difficult mask ventilation, and rapid oxygen desaturation during apnea. These factors increase the importance of preparation, positioning, and preoxygenation.

Video laryngoscopy can be especially helpful in obese patients because it may improve the laryngeal view when direct laryngoscopy is difficult. It should be strongly considered when the patient’s body habitus, neck anatomy, or airway exam suggests a difficult intubation.

Positioning is essential. The ramped position is commonly used for obese patients. In this position, the upper body and head are elevated so that the external ear and sternum are horizontally aligned. This can improve both laryngoscopic view and respiratory mechanics. Better positioning can increase lung volume during preoxygenation and give the clinician more time before oxygen desaturation occurs.

Preoxygenation is also critical. Obese patients may desaturate quickly once ventilation stops. Providing 100% oxygen before intubation helps increase oxygen reserves. In some cases, CPAP or noninvasive support during preoxygenation may help increase the time available for intubation before hypoxemia develops.

Note: Even with video laryngoscopy, a backup airway plan is necessary. Improved visualization does not guarantee tube placement. The team should have suction, alternative airway devices, supraglottic airways, stylets, bougies, and emergency airway equipment available.

Video Laryngoscopy in Trauma and Cervical Spine Precautions

Trauma patients may require intubation because of reduced consciousness, traumatic brain injury, airway compromise, facial injuries, shock, or respiratory failure. These patients can be difficult to intubate because their anatomy may be distorted by injury, blood, swelling, or debris.

Cervical spine precautions add another challenge. If cervical spine injury is suspected, clinicians should minimize movement of the head and neck. Manual inline stabilization is commonly used to maintain neutral alignment. However, this may limit the ability to position the patient for direct laryngoscopy.

Video laryngoscopy may help in this situation because it can improve the view of the larynx without requiring as much head extension. It may be used along with other devices such as fiberoptic bronchoscopes, lighted stylets, or other specialized airway tools.

However, trauma airways can be unpredictable. Blood, vomitus, and secretions can block the camera lens. Facial fractures or soft tissue swelling can limit access. A videolaryngoscope may improve the view, but the team must still prepare for suctioning, failed intubation, difficult ventilation, and emergency surgical airway access if needed.

Equipment Used in Video Laryngoscopy

Video laryngoscopy systems vary by device, but most include a handle, blade, camera or fiberoptic lens, light source, power supply, and viewing screen. The monitor may be attached to the handle or placed separately.

Some common examples include systems such as Glidescope, C-Mac, Airtraq, and Bullard-style video laryngoscopes. Some devices look similar to standard laryngoscopes, while others have more curved blades or channels to help guide the endotracheal tube. A channel or groove can hold the tube and stylet in position, helping direct it toward the trachea once the larynx is visualized.

The respiratory therapist may be responsible for helping assemble and check the equipment before use. This includes confirming that the device has working batteries, the monitor turns on, the camera image is clear, the blade is properly attached, the light source works, and the system is ready before the intubation attempt begins.

Note: If a separate monitor is used, it should be connected, powered, positioned where the operator can see it, and checked before the procedure. Equipment failure during an airway emergency can delay intubation and increase patient risk.

Role of the Respiratory Therapist

The respiratory therapist plays an important role before, during, and after intubation. The RT may not be the person inserting the tube in every setting, but the therapist is often responsible for preparation, monitoring, ventilation, equipment support, and confirmation of tube placement.

Before intubation, the RT should help gather and check equipment. This may include the endotracheal tube, syringe, stylet, laryngoscope, video laryngoscope, suction, bag-valve-mask device, oxygen source, carbon dioxide detector, ventilator circuit, securing device, and backup airway equipment. The RT may also check the endotracheal tube cuff for leaks and prepare the tube with water-soluble lubricant if appropriate.

The therapist should help assess the airway, remove dentures or oral appliances if needed, assist with patient positioning, and provide preoxygenation. During the procedure, the RT monitors oxygen saturation, heart rate, respiratory status, and overall clinical condition. The therapist may assist with suctioning, cricoid pressure if ordered and appropriate, equipment exchange, or manual ventilation between attempts.

After intubation, the RT helps inflate the cuff, secure the tube, ventilate the patient, and confirm placement. The therapist should assess bilateral breath sounds, observe chest rise, check for epigastric sounds, monitor oxygen saturation, and use carbon dioxide detection when available. The RT also helps connect the patient to the ventilator and assess the patient-ventilator system.

Preparation Before Intubation

Preparation is one of the most important parts of airway management. Video laryngoscopy can improve the view of the airway, but it cannot compensate for poor planning.

The team should first identify whether intubation is needed and whether any contraindications or treatment limits exist, such as a do-not-intubate order. The patient should be assessed for difficult airway features, hemodynamic instability, oxygenation status, aspiration risk, and possible trauma.

Preoxygenation should be performed before the attempt. This helps reduce the risk of hypoxemia during apnea. In unstable or high-risk patients, ventilation and oxygenation should be optimized as much as possible before sedatives or paralytics are given.

Suction should be ready and functioning. Secretions, vomit, or blood can obscure both direct and video views. A video laryngoscope lens can become blocked quickly, so suction must be immediately available.

The team should also prepare backup devices. These may include a gum elastic bougie, alternative blades, supraglottic airway, fiberoptic bronchoscope, lighted stylet, intubating laryngeal mask airway, or cricothyrotomy kit. A difficult airway plan should include what to do after failed attempts, not only what device to try first.

Intubation Time Limits and Safety

Video laryngoscopy does not eliminate the risks of intubation. Emergency airway management can cause tissue trauma, hypoxemia, hypercapnia, bradycardia, aspiration, and cardiac arrest. These risks increase when attempts are prolonged or repeated without adequate oxygenation.

Intubation attempts should be time-limited. If the tube cannot be placed quickly, the attempt should stop and the patient should be reoxygenated and ventilated. In many exam-based airway scenarios, attempts should not last longer than about 20 seconds, and the patient should receive oxygenation and ventilation between attempts when needed.

Repeated attempts can worsen airway swelling, bleeding, and trauma. This can make later attempts even more difficult. If direct laryngoscopy fails or difficulty is anticipated, video laryngoscopy may be recommended early. If video laryngoscopy fails, the team should move to the difficult airway protocol according to institutional policy.

Note: The priority is not simply placing the tube. The priority is maintaining oxygenation and ventilation while establishing a secure airway.

Troubleshooting Video Laryngoscopy

Video laryngoscopy can fail for several reasons. One common problem is a fogged or contaminated lens. If the lens becomes covered with secretions, blood, or condensation, the screen may show a poor or useless image. The correct response is to remove the blade and clear the lens, not continue blindly.

Another issue is equipment failure. The battery may be dead, the monitor may not be connected, the camera may not transmit an image, or the blade may not be properly attached. This is why the device must be checked before use.

A third issue is poor tube delivery. The clinician may see the vocal cords clearly but have difficulty advancing the endotracheal tube through them. This can happen if the tube angle does not match the blade curvature, if the stylet is shaped incorrectly, or if the tube catches on airway structures. In these cases, the operator may need to adjust the tube angle, use a different stylet, rotate the tube, slightly withdraw and redirect, or choose another device.

Secretions, vomit, and blood can also create problems. Suction must be available, especially in trauma or emergency airways. In some cases, a direct approach, fiberoptic technique, supraglottic airway, or surgical airway may be needed if visualization cannot be restored.

Confirming Endotracheal Tube Placement

After video laryngoscopy is used to guide the tube into the trachea, placement must be confirmed. Seeing the tube pass through the vocal cords is helpful, but it is not enough by itself. Confirmation requires clinical assessment and objective monitoring.

Important signs of successful tracheal intubation include chest rise, bilateral breath sounds, absence of epigastric gurgling, improvement in oxygen saturation, airflow through the tube, condensation in the tube, and detection of exhaled carbon dioxide.

Waveform capnography is the preferred method for confirming tracheal placement when available. A continuous capnography waveform indicates that carbon dioxide is being exhaled through the tube, supporting tracheal placement and effective ventilation. A colorimetric carbon dioxide detector may be used when waveform capnography is not available.

Auscultation is also important. Breath sounds should be heard bilaterally. If breath sounds are decreased on the left side and chest movement is reduced on the left, right mainstem bronchus intubation should be suspected. The tube may need to be withdrawn slowly until bilateral breath sounds are present.

If epigastric gurgling is heard, esophageal intubation should be suspected and corrected immediately. Ventilating through an esophageal tube can insufflate the stomach, increase aspiration risk, and fail to oxygenate the patient.

Note: Chest radiography is used to confirm final tube depth. The endotracheal tube tip is commonly positioned several centimeters above the carina. If the tube is too deep, it may enter the right mainstem bronchus. If it is too shallow, it may become displaced.

Connection to Mechanical Ventilation

Video laryngoscopy is often part of the pathway to invasive mechanical ventilation. When a patient cannot maintain oxygenation, ventilation, airway protection, or secretion clearance, an artificial airway may be needed. Once the endotracheal tube is placed, the patient can be connected to a ventilator.

However, successful intubation is not the endpoint. After the tube is inserted, the respiratory therapist must assess the entire patient-ventilator system. This includes the tube position, cuff pressure, breath sounds, ventilator settings, exhaled tidal volume, airway pressures, oxygen saturation, carbon dioxide monitoring, circuit connections, alarms, and patient comfort.

The endotracheal tube becomes part of the ventilator system. If it is kinked, obstructed, leaking, too deep, too shallow, or poorly secured, ventilation can fail. If the cuff pressure is too low, a leak may occur and aspiration risk may increase. If cuff pressure is too high, tracheal injury may occur.

Airway care continues after intubation. The RT must monitor for secretions, ventilator-associated pneumonia risk, tube obstruction, cuff problems, accidental extubation, and patient-ventilator asynchrony. Video laryngoscopy may help establish the airway, but safe ventilation depends on ongoing bedside assessment.

Advantages of Video Laryngoscopy

The main advantage of video laryngoscopy is improved visualization of the airway. This can be especially helpful when direct laryngoscopy is difficult because of anatomy, positioning limits, obesity, trauma, or cervical spine precautions.

Another advantage is shared visualization. A separate screen allows other team members to see the airway during the procedure. This helps with teaching, supervision, teamwork, and real-time assistance.

Video laryngoscopy may also reduce the difficulty of intubation in certain high-risk patients. It can provide a better view of the glottis and may reduce the need for repeated attempts when used appropriately. In difficult airway situations, fewer attempts can reduce trauma, bleeding, swelling, and oxygen desaturation.

It can also help with confirmation of tube passage through the vocal cords. While capnography and clinical assessment are still required, visualizing the tube entering the trachea provides useful immediate information during the attempt.

Limitations of Video Laryngoscopy

Video laryngoscopy has limitations. It can improve the view but may not make tube insertion easy. A clinician may see the vocal cords clearly but still struggle to pass the tube because of airway angles or poor alignment between the tube and glottic opening.

The device also depends on functioning equipment. Batteries, screens, light sources, cameras, and cables must work properly. If the screen fails or the lens becomes obscured, the device may become ineffective.

Blood, vomit, and secretions are major limitations. They can cover the lens and eliminate the video view. This is especially important in trauma and emergency airways.

There is also a learning curve. Operators must learn how to coordinate the video image with hand movements, tube advancement, stylet shape, and blade position. Looking at the screen instead of directly into the mouth can feel different from traditional laryngoscopy.

Note: Video laryngoscopy is not a substitute for airway planning. A failed airway can still occur. Clinicians must be prepared with backup strategies and emergency airway access.

Exam Tips for Respiratory Therapy Students

For board exam purposes, video laryngoscopy should be remembered as a difficult-airway tool. When a scenario describes poor visualization of the larynx, failed direct laryngoscopy, cervical spine precautions, obesity, anterior glottis, excessive epiglottic tissue, or unusual airway anatomy, video-assisted laryngoscopy is an appropriate recommendation.

It is also important to remember that video laryngoscopy is one option among several. Other difficult airway tools may include fiberoptic bronchoscopy, supraglottic airways, intubating laryngeal mask airways, gum elastic bougies, lighted stylets, fiberoptic stylets, and cricothyrotomy kits.

If the exam asks about the respiratory therapist’s role, focus on preparation and support. The RT should gather and check equipment, preoxygenate the patient, assist with positioning, provide suction, monitor the patient, ventilate between attempts, confirm tube placement, and recommend the difficult airway protocol when appropriate.

If visualization is lost during video laryngoscopy, think about a fogged or obstructed lens. The blade may need to be removed so the lens can be cleared.

Note: If tube placement is uncertain, do not assume the tube is correct just because video laryngoscopy was used. Confirm with breath sounds, chest rise, absence of epigastric sounds, carbon dioxide detection, waveform capnography when available, and chest x-ray for final position.

Clinical Priorities

The most important clinical priorities during video laryngoscopy are oxygenation, ventilation, visualization, tube placement, and confirmation. The device helps with visualization, but the patient’s physiologic status remains the main concern.

A patient who is difficult to intubate can deteriorate quickly. Hypoxemia, hypercapnia, bradycardia, and cardiac arrest may occur if attempts are prolonged. The team should stop unsuccessful attempts, ventilate the patient, and move to backup options when needed.

Proper positioning improves success. Preoxygenation increases safety. Suction protects the view. Equipment checks prevent delays. Capnography confirms ventilation. Chest radiography confirms tube depth. Each step matters.

Note: Video laryngoscopy works best when it is part of a complete airway plan, not when it is used as a last-minute rescue without preparation.

Video Laryngoscopy Practice Questions

1. What is video laryngoscopy?
Video laryngoscopy is an airway management technique that uses a laryngoscope with a camera to display the airway on a screen during intubation.

2. What is the main purpose of video laryngoscopy?
The main purpose of video laryngoscopy is to improve visualization of the larynx and vocal cords during endotracheal intubation.

3. How does video laryngoscopy differ from direct laryngoscopy?
Direct laryngoscopy requires a direct line-of-sight view of the vocal cords, while video laryngoscopy uses a camera and screen to provide an indirect view.

4. Where is the camera typically located on a videolaryngoscope?
The camera is typically located near the distal tip of the laryngoscope blade.

5. Why is video laryngoscopy helpful during difficult intubation?
It helps the clinician see the glottic opening when direct visualization is limited by anatomy, positioning, trauma, swelling, or restricted mobility.

6. What airway structures can be visualized with video laryngoscopy?
Video laryngoscopy can help visualize the epiglottis, larynx, vocal cords, glottic opening, and surrounding airway structures.

7. What is one advantage of displaying the airway image on a screen?
A screen allows other clinicians in the room to see the airway and assist during the intubation procedure.

8. Why is video laryngoscopy useful for teaching intubation?
It allows instructors, students, and assistants to view the same airway anatomy during the procedure.

9. When should video laryngoscopy be strongly considered?
Video laryngoscopy should be strongly considered when difficult intubation is expected or direct visualization is likely to be poor.

10. What are common causes of difficult intubation?
Common causes include limited mouth opening, poor positioning, unusual airway anatomy, obesity, swelling, trauma, and restricted neck mobility.

11. Why can limited neck mobility make intubation difficult?
Limited neck mobility can prevent proper airway alignment, making it harder to see the vocal cords with direct laryngoscopy.

12. How can video laryngoscopy help patients with restricted neck movement?
It can improve visualization of the larynx without requiring as much head and neck movement as direct laryngoscopy.

13. Why is video laryngoscopy useful in obese patients?
Obese patients may have difficult airway anatomy, reduced lung volumes, and rapid desaturation, making improved visualization especially helpful.

14. What is the ramped position?
The ramped position elevates the upper body and head so the ear and sternum are horizontally aligned.

15. Why is the ramped position useful before intubation?
The ramped position can improve the laryngoscopic view, improve respiratory mechanics, and increase lung volume during preoxygenation.

16. What is the purpose of preoxygenation before intubation?
Preoxygenation increases oxygen reserves and helps delay oxygen desaturation during the intubation attempt.

17. How can CPAP help during preoxygenation in obese patients?
CPAP can improve oxygenation and increase the amount of time the patient can tolerate apnea without becoming hypoxemic.

18. Why does video laryngoscopy not replace airway management principles?
It improves visualization, but clinicians must still assess the airway, preoxygenate, position the patient, limit attempts, and confirm tube placement.

19. What is the most common complication of emergency airway management?
The most common complication is tissue trauma.

20. What are serious complications of emergency airway management?
Serious complications include acute hypoxemia, hypercapnia, bradycardia, and cardiac arrest.

21. Why should intubation attempts be limited in duration?
Prolonged attempts can worsen hypoxemia, hypercapnia, bradycardia, and airway trauma.

22. What should be done between unsuccessful intubation attempts?
The patient should be oxygenated and ventilated before another attempt is made.

23. How is video laryngoscopy related to difficult airway protocols?
It is one of the tools that may be used when conventional laryngoscopy fails or difficult intubation is expected.

24. What other devices may be included in a difficult airway plan?
Other devices may include supraglottic airways, fiberoptic bronchoscopes, gum elastic bougies, lighted stylets, and cricothyrotomy kits.

25. What is the respiratory therapist’s role before video laryngoscopy?
The respiratory therapist helps assess the airway, gather equipment, check device function, prepare suction, and assist with preoxygenation.

26. What should be checked before using a videolaryngoscope?
The battery, screen, camera, light source, blade attachment, image clarity, and overall device function should be checked before use.

27. Why must suction be ready during video laryngoscopy?
Suction must be ready because secretions, vomit, or blood can obstruct the airway view or cover the camera lens.

28. What can happen if the lens of a videolaryngoscope becomes fogged?
If the lens becomes fogged, the clinician may lose visualization of the airway structures on the screen.

29. What should be done if the video laryngoscope lens is blocked by secretions or blood?
The blade should be removed and the lens should be cleared before another attempt is made.

30. Why should clinicians avoid continuing blindly if the video image is lost?
Continuing blindly increases the risk of trauma, esophageal intubation, failed tube placement, and delayed oxygenation.

31. What does a separate video monitor allow during intubation?
A separate video monitor allows multiple team members to view the airway and follow the intubation procedure.

32. Why is video laryngoscopy considered an indirect visualization technique?
It is considered indirect because the clinician views the larynx on a screen rather than through a direct line of sight.

33. Can video laryngoscopy be used for both oral and nasal intubation?
Yes. Video or fiberoptic visualization devices may support either oral or nasal endotracheal intubation, depending on the patient and provider plan.

34. What is one reason video laryngoscopy may be useful with an anterior glottis?
An anterior glottis can be difficult to see directly, and video laryngoscopy may provide a better view of the glottic opening.

35. What is one reason excessive epiglottic tissue can make intubation difficult?
Excessive epiglottic tissue can obstruct the view of the vocal cords during laryngoscopy.

36. What should the RT recommend if difficult intubation is expected?
The RT should recommend appropriate corrective strategies, which may include repositioning, video-assisted laryngoscopy, fiberoptic intubation, or use of a difficult airway protocol.

37. What is the L-E-M-O-N mnemonic used for?
The L-E-M-O-N mnemonic is used to help predict a difficult airway before intubation.

38. What does the “L” in L-E-M-O-N stand for?
The “L” stands for Look externally for signs that the airway may be difficult.

39. What does the “M” in L-E-M-O-N stand for?
The “M” stands for Mallampati classification, which helps estimate oral intubation difficulty.

40. What does the “O” in L-E-M-O-N stand for?
The “O” stands for Obesity or obstruction, both of which can make airway management more difficult.

41. What does the “N” in L-E-M-O-N stand for?
The “N” stands for Neck mobility, which is important because limited movement can make direct laryngoscopy harder.

42. Why is Mallampati classification important before intubation?
Mallampati classification helps estimate how difficult it may be to visualize airway structures during oral intubation.

43. What Mallampati classes suggest a more difficult airway?
Higher Mallampati classes, especially Class 3 and Class 4, suggest a more difficult airway.

44. Why can facial trauma make intubation more difficult?
Facial trauma can distort anatomy, increase bleeding or swelling, and interfere with visualization of the airway.

45. Why can cervical spine precautions make direct laryngoscopy harder?
Cervical spine precautions limit head and neck movement, making it harder to achieve the positioning needed for direct visualization.

46. What is manual inline stabilization?
Manual inline stabilization is a technique used to keep the head and neck in neutral alignment during airway management.

47. Why might video laryngoscopy be helpful during cervical spine precautions?
It may improve visualization of the larynx while reducing the need for excessive head and neck movement.

48. What are examples of videolaryngoscope devices?
Examples include Glidescope, C-Mac, Airtraq, and Bullard-style video laryngoscopes.

49. What feature may help guide the endotracheal tube in some video laryngoscopes?
Some video laryngoscopes have a channel or groove that helps guide the endotracheal tube toward the trachea.

50. Why does improved visualization not always guarantee successful intubation?
The clinician may see the vocal cords clearly but still have difficulty advancing the tube because of airway angles, resistance, or poor tube positioning.

51. What is one reason tube delivery can be difficult during video laryngoscopy?
Tube delivery can be difficult if the tube angle does not align well with the glottic opening.

52. Why may a specially shaped stylet be needed during video laryngoscopy?
A specially shaped stylet may help direct the endotracheal tube toward the vocal cords when using a curved video blade.

53. What is the purpose of a gum elastic bougie during difficult intubation?
A gum elastic bougie can help guide the endotracheal tube into the trachea when tube passage is difficult.

54. What should be done if video laryngoscopy provides a good view but the tube will not pass?
The clinician may need to adjust the tube angle, use a stylet or bougie, reposition slightly, or switch to another airway technique.

55. Why is video laryngoscopy not always the first choice for every routine intubation?
It is most emphasized for difficult or anticipated difficult airways, while routine intubation may be managed with standard direct laryngoscopy.

56. What is the main risk of esophageal intubation?
Esophageal intubation prevents ventilation of the lungs and can lead to hypoxemia, gastric insufflation, aspiration, and cardiac arrest.

57. What finding suggests esophageal intubation after tube placement?
Epigastric gurgling during ventilation suggests that the tube may be in the esophagus.

58. What should be done if esophageal intubation is suspected?
The tube should be removed or repositioned immediately, and the patient should be oxygenated and ventilated.

59. What finding may suggest right mainstem bronchus intubation?
Decreased breath sounds or decreased chest movement on the left side may suggest right mainstem bronchus intubation.

60. How is right mainstem bronchus intubation corrected?
The tube is slowly withdrawn until bilateral breath sounds and equal chest movement are confirmed.

61. What is the preferred method for confirming endotracheal tube placement when available?
Waveform capnography is the preferred method for confirming endotracheal tube placement when available.

62. What does waveform capnography confirm after intubation?
Waveform capnography helps confirm that the tube is in the trachea and that ventilation is occurring.

63. What is an acceptable alternative when waveform capnography is not available?
A colorimetric carbon dioxide detector is an acceptable alternative when waveform capnography is not available.

64. Why is auscultation still important after video laryngoscopy?
Auscultation helps assess bilateral breath sounds and detect problems such as esophageal or right mainstem intubation.

65. What does chest rise help confirm after intubation?
Chest rise helps confirm that air is entering the lungs during ventilation.

66. Why is chest x-ray used after endotracheal intubation?
Chest x-ray is used to confirm the final depth and position of the endotracheal tube above the carina.

67. Where should the endotracheal tube tip generally be positioned on chest x-ray?
The endotracheal tube tip should generally be positioned several centimeters above the carina.

68. What is a common x-ray target range for ET tube depth above the carina?
A common target is about 4–6 cm above the carina, depending on the patient and institutional guidance.

69. Why is seeing the tube pass through the cords not enough by itself?
The tube position must still be confirmed with clinical assessment, carbon dioxide detection, and chest x-ray for final depth.

70. What should the RT do after the endotracheal tube is inserted?
The RT should help inflate the cuff, secure the tube, ventilate the patient, and confirm proper placement.

71. Why is cuff inflation needed after endotracheal intubation?
Cuff inflation helps create a seal for positive-pressure ventilation and reduces the risk of aspiration.

72. What can happen if the endotracheal tube cuff pressure is too low?
A low cuff pressure can cause an air leak and increase the risk of aspiration.

73. What can happen if the endotracheal tube cuff pressure is too high?
A high cuff pressure can damage tracheal tissue.

74. Why must the tube be secured after intubation?
The tube must be secured to prevent displacement, accidental extubation, or changes in tube depth.

75. Why is video laryngoscopy connected to mechanical ventilation?
Video laryngoscopy helps place the endotracheal tube, which allows invasive mechanical ventilation to be delivered through an artificial airway.

76. What should be assessed after connecting an intubated patient to the ventilator?
The RT should assess ventilator settings, exhaled tidal volume, airway pressures, oxygen saturation, carbon dioxide monitoring, alarms, and patient response.

77. Why is video laryngoscopy only one part of airway management?
It helps with visualization, but safe airway management also requires oxygenation, ventilation, positioning, monitoring, and backup planning.

78. What can happen if a patient deteriorates after successful video laryngoscopy and intubation?
The patient may have a tube problem, ventilator problem, lung problem, or a combination of these issues.

79. What tube problem may cause a low-pressure ventilator alarm after intubation?
A disconnection, cuff leak, or tube displacement may cause a low-pressure ventilator alarm.

80. What tube problem may cause a high-pressure ventilator alarm after intubation?
A kinked tube, biting, retained secretions, bronchospasm, or decreased lung compliance may cause a high-pressure alarm.

81. Why is secretion management important after intubation?
Secretions can obstruct the artificial airway, increase airway resistance, interfere with ventilation, and contribute to infection risk.

82. How is video laryngoscopy related to ventilator-associated pneumonia prevention?
Video laryngoscopy helps place the tube, but VAP prevention depends on proper airway care, suctioning, oral hygiene, positioning, and secretion management after intubation.

83. Why should a difficult airway kit be nearby during high-risk intubation?
A difficult airway kit provides backup equipment if standard or video-assisted intubation fails.

84. What is the purpose of a cricothyrotomy kit in a difficult airway plan?
A cricothyrotomy kit provides emergency airway access when ventilation and intubation cannot be achieved by other methods.

85. Why should dentures or dental appliances be removed before intubation when appropriate?
They can interfere with visualization, obstruct tube passage, become dislodged, or increase the risk of airway obstruction.

86. Why is patient positioning important even when video laryngoscopy is used?
Good positioning improves airway visualization, supports preoxygenation, and may make tube passage easier.

87. What should the RT monitor during intubation with video laryngoscopy?
The RT should monitor oxygen saturation, heart rate, rhythm, vital signs, ventilation status, and overall patient condition.

88. What adverse effects may need monitoring if moderate sedation is used?
The RT should monitor for hypotension, nausea, respiratory depression, and other signs of clinical instability.

89. Why should rapid-sequence intubation be considered in some difficult airway situations?
Rapid-sequence intubation may help facilitate tube placement when the patient requires sedation and paralysis for airway control.

90. What is the strongest exam takeaway about video laryngoscopy?
When direct visualization is expected to be difficult, video-assisted laryngoscopy is an appropriate intubation-assist device.

91. Why is video laryngoscopy useful when direct laryngoscopy has failed?
It provides an indirect camera view that may reveal the larynx when direct line-of-sight visualization is inadequate.

92. What is the role of airway anesthesia during awake intubation?
Airway anesthesia helps reduce discomfort and reflex responses while allowing the patient to remain cooperative.

93. Why can awake intubation be challenging in critically ill obese patients?
It requires proper airway anesthesia, patient cooperation, team coordination, and careful management of oxygenation.

94. Why can blood in the airway be a major problem during video laryngoscopy?
Blood can cover the camera lens, obscure the screen image, and prevent visualization of the glottis.

95. What should be done if three intubation attempts are unsuccessful?
The RT should recommend moving to the difficult airway protocol according to institutional policy.

96. Why is intubation preparation especially important in emergency airways?
Emergency airways can deteriorate quickly, and missing equipment or poor planning can delay oxygenation and airway control.

97. What does proper tube placement help prevent?
Proper tube placement helps prevent inadequate ventilation, hypoxemia, aspiration, gastric insufflation, and cardiac arrest.

98. Why is team communication important during video laryngoscopy?
Team communication helps coordinate suctioning, positioning, equipment handling, oxygenation, and backup airway decisions.

99. What is the difference between visualizing the airway and securing the airway?
Visualizing the airway means seeing the structures, while securing the airway means successfully placing, confirming, and stabilizing the tube.

100. What is the final goal after using video laryngoscopy for intubation?
The final goal is safe, effective oxygenation and ventilation through a correctly placed and properly managed artificial airway.

Final Thoughts

Video laryngoscopy is a valuable airway management tool that improves visualization of the larynx during endotracheal intubation. It is especially useful when direct laryngoscopy may be difficult because of obesity, limited neck movement, trauma, swelling, poor mouth opening, or abnormal airway anatomy.

For respiratory therapists, the key is to understand when the device is appropriate and how to support its safe use. The RT should help assess the airway, prepare equipment, preoxygenate the patient, assist during the attempt, confirm tube placement, and monitor the patient after intubation.

Video laryngoscopy improves the view, but safe airway management still depends on preparation, oxygenation, teamwork, and confirmation.