AffiliationDepartment of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
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AbstractBACKGROUND: Efficient airway management is paramount in emergency medicine. Our experience teaching tracheal intubation has consistently identified gaps in the understanding of important issues. Here we discuss the importance of the endotracheal tube (ETT) bevel in airway management. DISCUSSION: The ETT bevel orientation is the main determinant of which mainstem bronchus the ETT enters when advanced too distally, despite a common belief that attributes a higher incidence of right mainstem bronchial intubation to the straighter angle sustained by the right mainstem bronchus. Likewise, a bougie- or fiberscope-assisted tracheal intubation can be impeded by the ETT tip hooking onto laryngeal structures; a 90-degree counterclockwise turn of the ETT (such that the bevel is facing posteriorly) prior to advancing it toward the larynx produces a first-pass success rate of 100%. Similarly, a posterior-facing bevel is believed to improve the ease of passage through the back of the nasal cavity when performing nasotracheal intubation. If resistance is met after the ETT tip has reached the laryngeal vicinity, further counterclockwise rotation may change the plane and incident angle of the ETT tip, facilitating passage through the vocal cords. Clockwise twisting of the ETT reduces the incident angle in the sagittal plane, thereby facilitating videolaryngoscopy-assisted tracheal intubation. Finally, a posterior-facing ETT bevel is the least likely to intubate a tracheoesophageal fistula. CONCLUSIONS: Understanding the implications of the ETT bevel direction may significantly change the efficiency of deliberate endobronchial, nasal, and bougie/fiberscope-, and videolaryngoscope-assisted intubations, and while managing the patient with a tracheoesophageal fistula.
CitationHo AM-H, Ho AK, Mizubuti GB. Tracheal Intubation: The Proof is in the Bevel. The Journal of Emergency Medicine. 2018 Oct.
JournalJ Emerg Med
- Effect of 90° counterclockwise rotation of the endotracheal tube on its advancement through the larynx during nasal fiberoptic intubation in children: a randomized and blinded study.
- Authors: Choudhry DK, Brenn BR, Lutwin-Kawalec M, Sacks K, Nesargi S, He Z
- Issue date: 2016 Apr
- [Accidental left bronchial intubation with Parker Flex-Tip Tube].
- Authors: Kitamura S, Kawano T, Yokoyama M
- Issue date: 2013 Jun
- Epistaxis during nasotracheal intubation: a randomized trial of the Parker Flex-Tip™ nasal endotracheal tube with a posterior facing bevel versus a standard nasal RAE endotracheal tube.
- Authors: Earle R, Shanahan E, Vaghadia H, Sawka A, Tang R
- Issue date: 2017 Apr
- [Distance from the laryngeal mask grip to endotracheal tube tip. A crucial point during fiberoptic intubation in children].
- Authors: Mauch J, Haas T, Weiss M
- Issue date: 2012 Feb
- Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation.
- Authors: Johnson DM, From AM, Smith RB, From RP, Maktabi MA
- Issue date: 2005 May