The guidelines from the Project for Universal Management of Airways for preventing unrecognised oesophageal intubation is a comprehensive and vital piece of work [1]. There is an important emphasis on shared communication regarding tracheal tube placement and a simple, sequential, process to follow in the absence of sustained exhaled carbon dioxide. However, we believe there are additional simple steps that should be included in the process and these guidelines, that can help further reduce the risk of unrecognised oesophageal intubation.

With the advent of videolaryngoscopy, there is scope for an altered sequence to tracheal intubation. Historically, with direct laryngoscopy when the tracheal tube is advanced through the vocal cords, the laryngoscope is removed from the patient's mouth, followed by cuff inflation, circuit connection and verification of correct placement. This practice of immediate removal of the laryngoscope originates from the possible obscurement of the larynx once the tracheal tube has been introduced. It is likely due to muscle memory that most anaesthetists also perform and teach videolaryngoscopic tracheal intubations in this manner. However, the use of videolaryngoscopy can result in an improved view of the glottis [2, 3] and therefore lends itself to a modified technique. The whole process of tracheal intubation through to confirmation of correct placement by demonstration of sustained exhaled carbon dioxide, can be performed with continuous laryngeal visualisation.

Observing cuff inflation under video guidance enables immediate identification of cuff herniation and the potential dislodgement and oesophageal migration that could occur. Furthermore, as the view of the larynx can be maintained even once the tracheal tube is passed through the vocal cords with a videolaryngoscope, it makes sense that this is visualised continually until sustained exhaled carbon dioxide is shown. Only at this point should the laryngoscope be removed and the process of tracheal intubation considered complete.

If sustained exhaled carbon dioxide is not observed, the view of the tracheal tube can be immediately verified by a two-person check, without the need to reinsert the scope and obtain the view of the larynx, all of which is time-consuming in a patient with evolving hypoxia.

This technique may result in a reduced need to remove the tracheal tube, as advised by the guidance [1]. It may also identify oesophageal intubation earlier, as it allows more time for the anaesthetist and assistant to examine and confirm correct placement on the video screen. The technique does not eliminate the issue of glottic impersonation, but with a prolonged videoscopic view it may increase the chance of abnormal or unusual anatomy being recognised. Reducing the hurriedness of this phase may also allow time to enable those with less training to feel empowered to verbalise their concerns.

The ergonomics of this technique of ‘total videoscopic tracheal intubation’ are slightly different to the traditional approach but can still be performed easily with two people. Following placement of the tracheal tube through the vocal cords and cuff inflation, the circuit can be connected by the assistant, who can then hold the tracheal tube while the anaesthetist continues to hold the laryngoscope in one hand and ventilates the patient's lungs with the other. This is then followed by a two-person check of sustained exhaled carbon dioxide under continuous videoscopic guidance. The technique can be more challenging when the assistant is applying cricoid force, or in the absence of an airway assistant. However, the ergonomics of the tracheal intubation process may be significantly altered, and we recommend practising this in a simulation scenario first.

Although this is a small and subtle modification to the standard technique, we believe it is a sensible way of increasing safety. The technique facilitates a process of deliberate practice and could be considered as the standard method of teaching trainees.

用于预防未被发现的食管插管的气道通用管理项目指南是一项全面且重要的工作 [1]。重点强调有关气管插管放置的共享沟通，以及在没有持续呼出二氧化碳的情况下要遵循的简单、连续的过程。但是，我们认为，该过程和这些指南中还应包括其他简单的步骤，这有助于进一步降低未被发现的食管插管的风险。

随着视频喉镜检查的出现，气管插管的顺序发生了改变。从历史上看，在直接喉镜检查中，当气管导管穿过声带时，将喉镜从患者嘴中取出，然后进行袖带充气、电路连接和验证正确放置。这种立即移除喉镜的做法源于引入气管插管后喉部可能被阻塞。可能是由于肌肉记忆，大多数麻醉师也以这种方式进行和教授视频喉镜气管插管。然而，使用视频喉镜可以改善声门的视野 [2， 3]，因此适合于改进技术。从气管插管到通过持续呼出的二氧化碳证明确认正确放置的整个过程，都可以通过连续的喉部可视化进行。

在视频引导下观察袖带充气可以立即识别袖带突出以及可能发生的潜在移位和食管迁移。此外，由于即使使用电子喉镜将气管插管穿过声带，也可以保持喉部的视野，因此在显示持续呼出的二氧化碳之前，可以持续观察这一点。只有在此时，才应取出喉镜并认为气管插管过程已完成。

如果未观察到持续呼出的二氧化碳，则可以立即通过两人检查来验证气管插管的视图，而无需重新插入内窥镜并获得喉部的视图，所有这些都在持续性缺氧患者中非常耗时。

按照指南[1]的建议，这种技术可以减少拔除气管插管的需要。它还可以更早地识别食管插管，因为它让麻醉师和助手有更多时间检查和确认视频屏幕上的正确位置。该技术并不能消除声门模拟的问题，但长时间的视频观察可能会增加识别异常或不寻常解剖结构的机会。减少这个阶段的匆忙也可能让那些受过较少培训的人感到有能力用语言表达他们的担忧。

这种“全视频气管插管”技术的人体工程学与传统方法略有不同，但仍然可以由两个人轻松进行。通过声带放置气管插管并给袖带充气后，助手可以连接回路，然后助手可以握住气管插管，而麻醉师继续一只手握住喉镜，另一只手为患者的肺部通气。然后，在连续视频镜引导下，两人对持续呼出的二氧化碳进行检查。当助手施加环状肌力或没有气道助手时，该技术可能更具挑战性。然而，气管插管过程的人体工程学可能会发生显著改变，我们建议先在模拟场景中进行练习。

虽然这是对标准技术的一个小而微妙的修改，但我们相信这是提高安全性的明智方法。该技术促进了刻意练习的过程，可以被视为教授学员的标准方法。