August 2025
INTRODUCTION —
The endotracheal tube (ETT) introducer is an effective and inexpensive adjunct to difficult airway management that is easy to use. We recommend that an ETT introducer be readily available in every emergency department.
This topic will review the types of ETT introducers, indications and contraindications for their use, proper technique for using the devices during emergency tracheal intubation, and evidence of their effectiveness. Other airway devices and aspects of emergency airway management are discussed separately. (See "Devices for difficult airway management in adults for emergency medicine and critical care" and "Overview of advanced airway management in adults for emergency medicine and critical care" and "Rapid sequence intubation in adults for emergency medicine and critical care" and "Emergency airway management in children: Unique pediatric considerations".)
TERMINOLOGY AND EQUIPMENT —
Several terms are used to describe the classic endotracheal tube (ETT) introducer. Although the phrase "gum elastic bougie" is common, we find it inaccurate and confusing since the ETT introducer is neither gum nor elastic and is not used as a bougie (ie, dilator). In this topic, we will refer to the device as an ETT introducer.
The ETT introducer consists of a 50 to 70 cm stylet with the distal tip bent at a 30-degree angle. The coudé shape allows the intubator to direct the tip anteriorly under the epiglottis and through the vocal cords, which may not be visible.
ETT introducers come in several sizes:
●Adult ETT introducers are typically 15 French (external diameter approximately 5 mm) and can accommodate an ETT as small as size 6.
●Pediatric ETT introducers are 10 French (external diameter approximately 3.3 mm) and can accommodate an ETT as small as size 4.
●Neonatal ETT introducers are 5 French (external diameter approximately 1.7 mm) and can accommodate an ETT as small as size 2.5.
Dimensions and use are comparable among the four main types of ETT introducers available:
●Eschmann – Woven Dacron rod with resin coating; can be sterilized and reused. This is commonly referred to as a "gum elastic bougie" (picture 1).
●Standard disposable (several manufacturers) – Solid ETT introducer made with various materials and coatings (picture 2 and picture 3).
●Steerable-tip – Allows intubator to flex the tip of the ETT introducer anteriorly to facilitate entry into the larynx, and then posteriorly to aid passage down the trachea.
●Frova – Hollow, single-use, plastic introducer with fenestrated tip to allow oxygenation; includes 15-mm adapter for standard bag-valve assembly (picture 4).
Although the Eschmann introducer is more expensive, it can be used multiple times, so the average cost per intubation is comparable to that of a single-use introducer. Nevertheless, some clinicians prefer single-use introducers because multiple-use introducers are sometimes inadvertently thrown away. The material of several single-use ETT introducers allows "memory" so J-shaped anterior curvatures can be maintained for use with hyperangulated video devices. (See "Devices for difficult airway management in adults for emergency medicine and critical care", section on 'Advanced laryngoscopes'.)
CLINICAL USE —
We concur with the authors of the largest randomized trials of endotracheal tube (ETT) introducers performed to date and suggest that an ETT introducer be used to assist emergency intubation in the following settings [1,2]:
●Incomplete view of glottis – The glottis is not clearly visible or only partly visible.
●Glottis difficult to reach – The glottis is anterior and difficult to reach with an ETT and stylet; however, the intubator can bend the ETT introducer to reach the glottis.
●Obstruction – There is laryngeal edema or some other potential obstruction to ETT passage; however, the intubator can pass the ETT introducer and use it as a guide for ETT insertion (ie, "railroad" ETT).
●Anatomically difficult airway – ETT introducer can be helpful in a wide range of difficult airway scenarios (eg, spinal immobilization, displaced larynx, distorted airway).
In addition, an ETT introducer may be incorporated into routine intubation procedure as a first-pass device.
Traditionally, the ETT introducer has been used for intubations when the epiglottis was visible but the glottis was not (Grade III Cormack-Lehane view (figure 1)) [3]. In these circumstances, visual confirmation of correct ETT placement was impossible, so tactile confirmation of ETT introducer placement in the trachea was required before advancing an ETT over the ETT introducer.
ETT introducers are most effective when used with standard geometry (straight or curved) laryngoscope blades during either direct or video laryngoscopy. The ETT introducer is more difficult to use with hyperangulated video laryngoscope blades because the bend required for the introducer to reach the larynx inhibits its advancement into the trachea. ETT introducers with greater shape "memory" (eg, Frova, Intersurgical Universal Stylet Bougie) maintain a more consistent curve that may allow successful tracheal cannulation when using a hyperangulated laryngoscope blade [4].
ADVANTAGES —
Listed here are several advantages gained by performing tracheal intubation using an introducer rather than a standard endotracheal tube (ETT) with a stylet inserted.
●Clear view of larynx – The ETT introducer has a small diameter and does not block the clinician's view of the larynx during intubation. The ETT, particularly the reflective ETT cuff, can block the view of the larynx at key moments of tube insertion (picture 5), possibly leading to inadvertent esophageal intubation.
●Tactile confirmation of correct placement – In cases when the larynx cannot be fully visualized, the ETT introducer can be used to cannulate the trachea, using tactile findings to confirm correct placement (movie 1). This is how the tool has traditionally been used. In cases where the larynx is obscured by fluid or debris (movie 2), this approach can enable success on the first attempt at intubation.
These advantages have led some airway management experts to advocate a "bougie first" approach for all patients requiring emergency intubation. Competency using an introducer is an important skill for all airway managers, and using introducers routinely helps develop the skill necessary when facing a difficult airway scenario.
CONTRAINDICATIONS AND PRECAUTIONS —
There are no absolute contraindications to using an endotracheal tube (ETT) introducer.
An ETT introducer should be used with caution when there is known or possible laryngeal or tracheal injury. In such cases, the ETT introducer may exacerbate the injury or be advanced outside the airway into adjacent structures. In these situations, endoscopic intubation is preferred as it provides direct visualization of ETT placement into the trachea past the level of injury. If endoscopic intubation is not possible, using an ETT introducer may be the preferred method since the small diameter may be less likely to disrupt damaged structures, and the ETT can then be advanced gently over the introducer.
An ETT introducer is unlikely to be beneficial when no part of the airway can be seen (Grade IV Cormack-Lehane view (figure 1)). Blind insertion of an ETT introducer through an extraglottic airway (EGA) to cannulate the trachea (with the intention of converting an EGA to an ETT) risks perforation of glottic structures and is not recommended.
PREPARATION —
Lubricant may be applied to the endotracheal tube (ETT) introducer if the ETT is a tight fit. Lubrication allows the ETT to pass over the ETT introducer more easily. If the fit is not tight, lubricant is not recommended, as it can make the ETT introducer difficult to grasp and control.
Some practitioners prefer the ETT introducer to be straight, while others prefer to introduce a curve. Either shape is acceptable.
●Using a straight introducer – If used straight, the ETT introducer should enter and remain in the right corner of the mouth, far off midline and away from the incisors and dental arch. This allows the angle of approach to the larynx to remain as anterior as possible. The base of the tongue is an obstruction that the ETT introducer must circumvent to reach the larynx. Approaching the base of the tongue from a shallow angle (ie, as close as possible to horizontal and aligned with the trachea) is advantageous, as it ensures that the tip of the ETT introducer tracks as anteriorly as possible.
In contrast, if the ETT introducer is placed in the midline, it will impact against the incisors, forcing a steeper angle of approach towards the base of the tongue. If it is advanced in this manner, the introducer will strike the base of the tongue, forcing the coudé tip to track posteriorly into the hypopharynx and miss the larynx.
●Creating and using a bend in the introducer – To avoid these difficulties, some practitioners place an anterior bend in the ETT introducer, specifically in the distal 10 to 20 cm, to allow it to be inserted more midline and curve around the base of the tongue to approach the larynx. This curve can be induced by bending the introducer by hand just prior to use. Introducers are made of materials (polyvinyl chloride or polyethylene) with "memory" and will hold a curve transiently. Another method is to pinch the ETT introducer firmly between the thumb and finger about 15 cm from the distal tip and then "strip it," in other words, move the thumb and finger distally while maintaining a tight pinch. The friction from this maneuver slightly heats and stretches the material, inducing a bend. With either method, the bend should not exceed about 30 degrees, or the distal coudé tip will angle too anteriorly and catch on the tracheal rings, preventing advancement into the trachea.
TECHNIQUE
Standard two-person technique — Placement of the endotracheal tube (ETT) introducer and the subsequent advancement of the ETT over it are performed as described here. A video clip demonstrating the technique is provided (movie 1).
●Identify the epiglottis. External laryngeal manipulation (picture 6) or other positioning techniques may be needed to find the epiglottis (figure 2 and picture 7 and picture 8) depending upon the device being used for laryngoscopy and the clinical scenario.
●Place the ETT introducer. Advance the ETT introducer, with its tip pointing anteriorly and under the epiglottis, into the trachea. When advancing the ETT introducer, be sure to maintain the tip in the midline with its anterior orientation (do not allow it to rotate to either side); if it rotates significantly, the anteriorly located tracheal rings may not be appreciated. Care must be taken to avoid forceful insertion as this can cause injury (ie, bleeding or perforation).
●Confirm placement of the ETT introducer. Two tactile sensations suggest correct placement in the trachea [3,5]. One sign is the feeling of vibrations or "clicks" as the tip of the ETT introducer is advanced over the tracheal rings. However, it is important to remember that the angled tip of the ETT introducer must be oriented anteriorly for it to encounter the rings.
Another sign is resistance to further insertion. As the introducer advances between 24 and 40 cm from the teeth, the distal tip becomes lodged in smaller airways and cannot advance. This is sometimes referred to as the "stop sign" or "hard stop." In contrast, if the ETT introducer is in the esophagus, the tracheal rings cannot be felt, and the introducer advances easily into the stomach, far past the 40 cm mark where the "stop sign" would normally occur if the ETT introducer were in the tracheobronchial tree.
When advancing the ETT introducer, avoid applying too much pressure if resistance is encountered. Excessive force can traumatize the airway [6]. In addition, it may be helpful to withdraw the introducer several centimeters before railroading the ETT over the introducer (next step in the technique) to avoid forceful advancement.
●Place the ETT. Once the ETT introducer is in the trachea, place the distal end of the ETT over the free end of the ETT introducer and advance it using a Seldinger-like technique. This generally requires an assistant to place the ETT on the proximal end of the introducer. Advance the ETT over the introducer and into the trachea while keeping the laryngoscope in place. This prevents the tongue from obstructing ETT advancement. When the ETT is at the proper insertion depth, inflate the cuff.
●Withdraw the ETT introducer. Once the ETT is advanced the appropriate distance, withdraw the introducer.
●Confirm that the ETT is in the trachea. Confirmation proceeds as usual, and we recommend the use of an end-tidal carbon dioxide (EtCO2) detector. (See "Confirmation of correct endotracheal tube placement in adults".)
One-person techniques — Alternative techniques for intubating with an ETT introducer that do not require a second person to thread the ETT over the ETT introducer have been described.
●Preloaded introducer – In one such technique, the ETT is preloaded onto the ETT introducer, with the proximal tip of the ETT introducer inserted through the Murphy eye of the ETT to secure it ("Kiwi-D grip"). Once the ETT introducer is confirmed to be in the trachea, the proximal end of the ETT introducer is released, allowing it to straighten, and the ETT is then advanced over the ETT introducer and into the trachea (movie 3).
A potential problem with this technique is inadequate introducer length. If the ETT introducer is 60 cm, and the ETT is 30 cm, then approximately only 28 cm of the introducer will extend beyond the end of the ETT. This may prevent clinicians from being able to use the "stop sign" to confirm correct placement, as the limit to advancing the introducer typically exceeds 30 cm. Signs for confirming placement, including the stop sign, are described just above. An ETT introducer 70 cm or longer may prevent this problem. (See 'Standard two-person technique' above.)
●90-degree bend – Another technique using an introducer bent 90 degrees can be performed as described here (movie 4). Although more complex than pre-threading the ETT, the advantage to this technique is that the ETT introducer is lighter and easier to manipulate.
•Prebend the ETT introducer to 90 degrees at its midpoint, in the same plane as the bent tip. This allows the clinician to maintain rotational control of the introducer.
•Hold the ETT introducer at the midpoint bend, keeping the tip directed anteriorly, and insert the ETT introducer into the trachea.
•When tracheal clicks and/or a stop sign are felt, transfer the ETT introducer to your left hand, capturing it while holding the laryngoscope in place.
•With your freed right hand, advance the ETT over the ETT introducer into the trachea.
•When the ETT is fully advanced, transfer it to the left hand and secure it against the laryngoscope handle while removing the ETT introducer.
Tips for placing tracheal tube over introducer — The following suggestions and techniques may facilitate placement of the ETT over the introducer:
●Maintain proper laryngoscope position – Throughout the procedure, the operator should maintain proper position of the laryngoscope with the left hand. The tendency is to remove the laryngoscope once the introducer is in the trachea, but doing so allows the tongue to fall posteriorly and potentially hinder ETT passage, among other potential problems.
By keeping the laryngoscope blade in place, the operator can visualize the entire procedure from introducer placement to intubation to cuff inflation and confirmation of placement with capnography. Visualization allows confirmation that the inflated cuff is in the trachea and not herniating through the vocal cords. Troubleshooting any problems with capnography is easier if the ETT is visualized through the larynx. Once proper placement and function are confirmed, the laryngoscope blade can be withdrawn and the ETT secured. (See "Confirmation of correct endotracheal tube placement in adults".)
●Rotate introducer tip clockwise if it catches – If the coudé tip of the introducer gets caught on a tracheal ring after passage through the vocal cords and will not advance, the operator can rotate the tip clockwise to disengage it.
●Use ETT and introducer close in size – Passage of the ETT is easier if it is close in size to the introducer. The greater the disparity, the more likely the leading edge of the ETT will protrude and catch on the arytenoids or aryepiglottic folds during insertion. This may require using a smaller ETT than would be ideal, but this is a small price to pay for success in a difficult airway scenario.
ETTs with subglottic suction may be more prone to this problem because they have a larger outer diameter to accommodate the suction channel above the cuff. One way to overcome the problem entirely is to use a Parker Flex-Tip ETT, which has a beak-like shape that helps fill the gap between the ETT and the introducer.
●Rotate ETT if tip catches – If the ETT tip catches on the arytenoids and will not advance, the operator can withdraw the ETT slightly to disengage the tip from the arytenoids and then carefully rotate the ETT counterclockwise while relaxing cricoid pressure (if used). This can facilitate passage of the ETT. A video clip demonstrating the technique is provided (movie 5).
Many practitioners recommend performing a slight counterclockwise rotation of the ETT while advancing it over the larynx during all tracheal intubations involving an introducer to prevent the tip from catching. This approach makes rotation a natural part of the procedure.
●Once past the vocal cords, the ETT bevel can sometimes get caught on the tracheal rings. In this case, the operator can rotate the ETT clockwise (as they would if the introducer tip catches). This maneuver can release the tip and allow the ETT to advance into the trachea.
●"Left for the Larynx, Right for the Rings" is a simple mnemonic for these maneuvers. If the ETT tip is caught on the larynx (letter "L"), rotate left (letter "L", or counterclockwise); if ETT tip is caught on the tracheal rings (letter "R"), rotate right (letter "R", or clockwise).
PEDIATRIC CONSIDERATIONS —
The techniques described above can be used in children. Pediatric endotracheal tube (ETT) introducers can be used with ETT sizes down to 4 to 5.5, and neonatal ETT introducers can be used in ETT sizes 2.5 to 4. (See "The difficult pediatric airway for emergency medicine".)
EVIDENCE OF EFFECTIVENESS —
Although randomized trials report inconsistent results during routine intubation, evidence suggests that use of an endotracheal tube (ETT) introducer is associated with improved intubation success rates among patients undergoing emergency intubation, especially those with impaired glottic views or features associated with a difficult airway [1,3,7-12].
The strongest evidence supporting the use of ETT introducers for emergency intubation comes from a systematic review and meta-analysis of 18 studies in which the use of an introducer was associated with a higher overall rate of successful first-pass intubation (risk ratio 1.11, 95% CI 1.06-1.17) [13]. When analysis was limited to randomized trials (n = 12), the success rate was slightly lower (relative risk [RR] 1.09, 95% CI 1.02-1.17). First-pass success rates were higher using an introducer regardless of the method of intubation (ie, direct versus video laryngoscopy) or where intubation was performed (eg, emergency department, intensive care unit [ICU], prehospital). The ETT introducer was most effective in patients (n = 585 in five studies) with a Cormack-Lehane III or IV view (figure 1) (RR 1.60, 95% CI 1.40-1.84). The authors noted that all studies included in the systematic review were at moderate to high risk of bias.
In a single-center trial of over 750 adults undergoing emergency intubation in the emergency department, use of an ETT introducer while performing video laryngoscopy with a Macintosh blade resulted in a higher overall first-pass success rate when compared with video laryngoscopy performed with a standard ETT and stylet (98 versus 87 percent, respectively) [1]. In addition, higher first-pass success rates were noted in patients with at least one characteristic of a difficult airway (96 versus 82 percent, respectively), such as obesity, short neck, small mandible, large tongue, need for cervical spine immobilization, airway obstruction or edema, secretions obstructing the glottic view, or facial trauma.
The authors concluded that the high success rate when using an ETT introducer might be due to improved visibility, as an ETT can block the view of the glottis when it passes in front of the camera at the tip of the video laryngoscope blade. An ETT introducer has a smaller diameter and does not obscure the view of the glottis. The small diameter of the ETT introducer may also be advantageous when anatomic distortion, such as glottic edema or tracheal strictures, creates an obstacle to ETT placement. The smaller ETT introducer, if able to pass the obstruction, can act as a guide for the ETT to follow into the trachea. The center where the study was performed uses an ETT introducer for most intubations. Thus, operators are familiar with their use, and therefore, the reported first-pass success rates are among the highest ever published.
A subsequent multicenter randomized trial by the same research group investigated the routine use of an ETT introducer for over 1100 intubations performed in the emergency department and ICU [2]. This study found no significant difference in first-pass success rates between intubations performed with an ETT introducer and those performed with a standard ETT and stylet, including those performed in difficult airways (80 percent with an ETT introducer versus 83 percent with an ETT and stylet). The intubators in this study were from both the emergency department and ICU, had variable levels of training with an ETT introducer, and used both video and direct laryngoscopy.
The results of these well-performed studies suggest that intubation using an ETT introducer can contribute to high first-pass success rates in hospitals with a culture of frequent ETT introducer use and requisite training. However, it may be inappropriate to extrapolate these high success rates to institutions and operators who use ETT introducers less frequently.
Little training is needed before introducers can be used successfully [12,14,15]. This is likely because of the similarity to standard intubating technique and familiarity with the Seldinger technique.
COMPLICATIONS —
Complications from endotracheal tube (ETT) introducers are uncommon and involve mechanical trauma to airway structures [16,17]. Excessive force while advancing the ETT introducer or the ETT might damage the larynx, trachea, or branches of the airway [6]. The ETT might catch on the arytenoids during placement and impede advancement. Forceful advancement can then dislocate the arytenoid cartilage or cause other trauma to the airway.
OTHER USES —
Additional uses of endotracheal tube (ETT) introducers include the following:
●Distinguishing tracheal from esophageal ETT placement – This approach has been advocated in cardiac arrest patients, where end-tidal carbon dioxide (EtCO2) concentrations may not be high enough to change the color of a colorimetric capnography device. However, there is insufficient evidence to recommend that introducers be relied upon as the sole indicator of proper ETT placement [5,18]. In a study using 20 human cadavers, clinicians without prior experience using an ETT introducer were able, using the techniques described above, to determine esophageal placement in 95 percent of cases (95% CI 88-98) and tracheal placement in 93 percent (95% CI 86-97) [5]. (See 'Technique' above.)
●Adjunct for cricothyrotomy – Evidence supporting "bougie-aided cricothyrotomy" is growing. In this procedure, after the cricothyroid membrane is incised, an ETT introducer is advanced caudally down the trachea to confirm tracheal placement with palpable "clicks" and the "stop sign." Then the tracheal tube is placed over the ETT introducer and advanced into the trachea. (See "Emergency cricothyrotomy (cricothyroidotomy)".)
●ETT exchanger – If an intubated patient has a malfunctioning ETT (eg, cuff leak), an ETT introducer may be advanced through the ETT to maintain a track into the trachea, over which the malfunctioning ETT may be removed and a new ETT placed (movie 6). This is known as an intraluminal exchange with an ETT introducer. However, this technique can be problematic, as the length of most ETT introducers is 60 to 70 cm, which barely allows the full length of the ETT to leave the mouth. Furthermore, the stiffness of the ETT introducer, especially when contained within an ETT, may cause injury of the trachea from the coudé tip. Standard airway exchange catheters are 80 cm long and better suited to this task.
An alternative approach, known as an extraluminal exchange with an ETT introducer, can be performed as follows (movie 7):
•Perform laryngoscopy with the malfunctioning ETT left in place and visualize the larynx
•Advance an ETT introducer alongside the ETT and through the vocal cords until the tip of the introducer strikes the cuff of the ETT
•Deflate the cuff of the ETT and further advance the introducer
•Remove the malfunctioning ETT while keeping the introducer in place in the trachea
•Advance a new ETT over the ETT introducer
●Adjunct for video laryngoscopes – Some manufacturers (King Vision, Pentax AWS) advocate the use of an ETT introducer to assist with difficult intubations [19,20]. In some video laryngoscopes (CoPilot VL), a specific channel for ETT introducers has been created to assist with routine intubations. This approach is different than using hyperangulated rigid stylets with hyperangulated blades, which is the recommended technique for hyperangulated video intubations. (See "Devices for difficult airway management in adults for emergency medicine and critical care", section on 'Video laryngoscopes'.)
●Adjunct with blind digital intubation – Some practitioners prefer to use an ETT introducer, rather than an ETT, when performing digital intubations since the smaller diameter and malleability allow for easier manipulation within the oropharynx when directing the tip towards the glottic opening [21]. In addition, when the ETT introducer enters the trachea, palpable clicks and a positive "stop sign" help to confirm proper placement, as opposed to digital intubations without an ETT introducer in which tactile confirmation of tracheal placement may not be possible. This technique is shown with external (movie 8) and internal (movie 9) views for demonstration.
●Adjunct to convert an extraglottic device (EGD) to an ETT – In patients being ventilated with an EGD, replacing it with an ETT can be complex and potentially dangerous if difficult airway characteristics are present. If the EGD is designed to be used as a conduit for intubation, a flexible endoscope is typically used to intubate "intraluminally" through the EGD. It may be tempting to place an ETT introducer blindly down an EGD to "find" the trachea, but this approach is not recommended due to the risk of the introducer perforating glottic structures.
Alternatively, some EGDs can be exchanged for an ETT "extraluminally" using a video laryngoscope with either a standard or hyperangulated blade [22]. To do so, the video laryngoscope is introduced into the oropharynx with the EGD in place, pushing the EGD slightly to the left side of the mouth to make room for the laryngoscope blade. If the EGD has a cuff, it is deflated and the epiglottis is visualized. The blade tip is advanced into the vallecula, and the epiglottis elevated, bringing the glottis into view. Under video laryngoscope visualization, the ETT introducer is then placed alongside the EGD and into the glottis, the EGD is removed, and an ETT is advanced over the ETT introducer into the trachea. This procedure is shown in a manikin (movie 10) and in a patient undergoing cardiopulmonary resuscitation (CPR) (movie 11).
●Intubation in conjunction with a large-bore suction catheter for airway debris – Large-bore suction catheters, such as the DuCanto Suction Catheter, Hi-D "Big Stick" Suction Tip, and Big Yank Bulb Tip Suction System, are over 6 mm in internal diameter and can easily accommodate an ETT introducer through their lumen. If a transient or clear view of a soiled airway is obtained during suctioning, the suction catheter tip can be introduced through the vocal cords into the larynx, the suction disconnected, and the ETT introducer advanced through the device into the trachea (movie 12). The suction catheter is then removed, and an ETT is advanced over the ETT introducer [23].
●Intubation using large-bore suction catheter for hyperangulation – This method for intubation uses an ETT introducer preloaded into a DuCanto Suction Catheter with the coudé tip exposed. The catheter is not hooked up to suction and is used primarily to replicate the shape of a hyperangulated laryngoscope blade that allows the introducer to reach the larynx. Once the larynx is visualized using laryngoscopy with a hyperangulated blade, the DuCanto Suction Catheter with the preloaded ETT introducer is placed into the larynx, and the ETT introducer is advanced through the suction catheter into the trachea (movie 13). The suction catheter is then removed over the introducer, which is kept in the trachea, and the ETT is advanced over it [24].
SUMMARY AND RECOMMENDATIONS
●Definitions – The endotracheal tube (ETT) introducer is a simple, effective, and inexpensive adjunct to difficult airway management. ETT introducers should be readily available in every emergency department. The ETT introducer consists of a 50 to 70 cm stylet with the distal tip bent at a 30-degree angle (picture 1 and picture 4). The bend allows the intubator to direct the tip anteriorly under the epiglottis and through the vocal cords. This orientation is required for the tip to encounter the anteriorly located tracheal rings and produce palpable "clicks" when advancing into the trachea to help confirm proper placement.
●Clinical uses – The ETT introducer is a useful tool for intubation, particularly in the following situations:
•Incomplete view of glottis
•Glottis difficult to reach
•Obstruction
•Anatomically difficult airway
The ETT introducer can be used in conjunction with laryngoscope blades that have standard curvature but can be difficult to use with hyperangulated blades. (See 'Clinical use' above and 'Advantages' above.)
●Contraindications – There are no absolute contraindications to ETT introducer use.
An ETT introducer should be used with extreme caution when there is possible laryngeal or tracheal trauma, as insertion may exacerbate such injury. An ETT introducer is unlikely to be beneficial when no part of the airway can be seen (Grade IV Cormack-Lehane view (figure 1)). Blind insertion of an ETT introducer through an extraglottic device to cannulate the trachea risks perforation of glottic structures and is not recommended. (See 'Contraindications and precautions' above.)
●Technique and confirmation of placement – Several techniques for inserting the ETT introducer and using it for placement of an ETT are described in detail in the text and demonstrated in accompanying videos (see 'Technique' above):
•Standard two-person technique (movie 1).
•One-person technique (movie 3).
•One-person 90-degree bend technique (movie 4).
Two tactile sensations confirm correct placement in the trachea. One is the feeling of vibrations or "clicks" as the tip of the ETT introducer is advanced over the tracheal rings. Another is resistance to further insertion.
Other potential uses for the device are also described with accompanying video demonstrations, including as an adjunct for video laryngoscopy (movie 11) and use with a large-bore suction device (movie 12 and movie 13). (See 'Other uses' above.)
●Use for cricothyrotomy – ETT introducers may be used for cricothyrotomy, which is reviewed in detail separately. (See "Emergency cricothyrotomy (cricothyroidotomy)".)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Aaron E Bair, MD, MSc, FAAEM, FACEP, now deceased, who contributed to an earlier version of this topic review.
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