Twist and Shout your ETT: go Left with Bougie go Right with Stylet

ETT advancement problems are not uncommon scenario but can easily be overcome if you understand the anatomy and cause of the obstruction. It has been well documented that when using a bougie or a flexible intubating scope, ETT hold up proximal to the glottic inlet is from the leading edge of the bevel hitting right sided paraglottic structures. By rotating the ETT (after pulling it back ~ 1cm) to the left by a 1/4 turn (ie. counterclockwise) the leading edge moves medial (to the left), rotating off of the paraglottic structures allowing advancement. If however hold-up occurs using a stylet, (more commonly occuring with VL where the user is too close and looking up at the glottic inlet and with stylet bends >60*) distal to the glottic inlet, the obstruction is form the upward angled leading edge of the ETT against the tracheal rings. In this situation 2 maneuver are effective either alone or in combination. First we recommend a "thumbs up" maneuver by the intubator (or an assistant) pulling back the stylet by 2-3 cm which makes the distal end of the ETT flexible enough that it can advance over the rings. Second by dropping the ETT to the bed/to the right (clockwise), the open face of the bevel is rotated up to the anterior trachea and the held up leading edge of the ETT is taken off of the the rings. It also orients the distal curved end of the styletted ETT in the same, long axis of the trachea making advancement easier.
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