Change Something...

Sometimes, in spite of our best efforts to achieve first pass success in intubation, our first attempt still gets burned. The reasons can range from anything from incomplete decontamination with SALAD all the way to our positioning may have been suboptimal.

 The mantra that we are taught in our initial education and (at least in my experience) nearly every airway management course since then is:

 "If you miss on the first attempt… change something."

In fact, that change had to be documented in the PCR so that it was clear to the reviewers and medical director that we had made an attempt to change something and improve our chances. It is sound logic, but the guidance is left wide open to interpretation as to what exactly we should change. I have heard all sorts of guidance that ranges from change blades, change tube sizes, change devices and so on.

Sometimes this leads operators to select a different blade size when they actually had the correct size at first, or they switch from VL to DL assuming that it will be THE change that makes the next attempt successful. Switching devices or tube sizes and then reintroducing the blade and getting a view of the glottic opening can take a minute or more (and could actually be a waste of time).

I think that there is a better way to "change something" rather than indiscriminately reaching for a size smaller or larger tube, blade, or changing the device altogether. Dr. Lauria would call this an ERAD or an Emergency Reflex Action Drill (see his blog article on emcrit.org). It is essentially a series of deliberate steps that progressively address and correct problems.

Dr. Weingart et al created a list of these problems that should prompt an ERAD:

 • Failure to identify anatomical landmarks.

 • Failure to engage/identify the valecula

 • Failure to deliver the tube

Change Something…

Instead of indiscriminately reaching for a new blade size or ditching the video laryngoscope in an effort to "change something," run this drill and work through these things that may actually improve your situation.

1.) A quick double check to ensure that you are midline and in the valecula properly engaging the hyoepiglottic ligament… if not, change that first.

2.) Change the positioning of the patient and ensure that the chin is not flexed toward the chest and that the head is in the HELP (head elevated laryngoscopy position) position. This is easy to do if the operator only puts pillows behind the head and does not "build a ramp" from the shoulders to the occiput.

3.) Change the head position by lifting it the occiput to improve the view.

4.) Change the position of the larynx by using external laryngeal manipulation.

Some other honorable mentions are things like suctioning, which frankly should already have been completed by using the SALAD method before introducing the VL blade; some folks out in the world have seen some success by overdriving the epiglottis and using the "mac as a miller" approach (which is not my favorite, but it is out there); or elevating the patient's head, which is another one of those steps that should have already been completed prior to the first attempt.

References:

 • HELP is an acronym from Dr. Richard Levitan's many teachings on the topic.

 • Hayes-Bradley C, Gemal H, Miller M, Ware S. Describing the Challenges of Prehospital Rapid Sequence Intubation by Macintosh Blade Video Laryngoscopy Recordings. Prehosp Disaster Med. 2022 Aug;37(4):485-491. doi: 10.1017/S1049023X22000851. Epub 2022 Jun 3. PMID: 35656724; PMCID: PMC9280066.

 • Weingart SD, Barnicle RN, Janke A, Bhagwan SD, Tanzi M, McKenna PJ, Bracey A; Resuscitationists Research Group. A taxonomy of key performance errors for emergency intubation. Am J Emerg Med. 2023 Nov;73:137-144. doi: 10.1016/j.ajem.2023.08.035. Epub 2023 Aug 23. PMID: 37657143.

 • Mike Lauria. The Necessity of Emergency Reflex Action Drills. EMCrit Blog. Published on April 24, 2018. Accessed on December 18th 2025. Available at [https://emcrit.org/emcrit/emergency-reflex-action-drills/ ].