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Direct orotracheal intubation is the most common method of ETI (Figure 3.2). The most common laryngoscope blades used for orotracheal intubation include Macintosh (curved) and Miller (straight) blades, which require slight variations in laryngoscopy technique [24]. The rescuer places the curved Macintosh blade into the vallecula (the space immediately anterior to the epiglottis) to facilitate indirect lifting of the epiglottis and exposure of the vocal cord structures. In contrast, the rescuer uses the broad side of the straight Miller blade to displace the oropharyngeal structures, using the tip of the blade to lift the epiglottis directly. Blade selection is a matter of personal preference; there are no data indicating the superiority of either blade during prehospital ETI.

Orotracheal intubation optimally requires the absence or near‐absence of protective airway reflexes. It is extremely difficult in patients who are awake or have intact airway reflexes. In these situations, drug‐facilitated intubation techniques are often necessary.

In scenarios with potential cervical spine fracture or injury, EMS personnel must perform orotracheal intubation with “manual in‐line stabilization” of the cervical spine, without hyperextension of the head or neck during laryngoscopy (Figure 3.3). This approach requires a second rescuer to hold the cervical spine “in‐line” during laryngoscopy attempts. However, a critical review questions the value of manual in‐line stabilization, suggesting that it significantly impairs laryngoscopy while not affording adequate spinal cord protection [25]. Video laryngoscopy may improve visualization of the glottis while minimizing cervical spine movement during ETI [26].

Figure 3.2 Orotracheal intubation

Figure 3.3 Manual in‐line stabilization for intubation of the patient with suspect cervical spine injury