King Tube Placement

King Tube Placement

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This high quality video demonstrates King Tube Placement. One of the most commonly performed hospital based procedures, King Tube Placement is shown step by step. Clinical pearls and common pitfalls associated with King Tube Placement are discussed in detail. King tube insertion is an example of intermediate airway placement.  The video is not downloadable but may be accessed indefinitely by internet from any computer, smart phone, or tablet. Click below for a preview of the King Tube Placement.


We’re now going to demonstrate how to place a King airway tube for rescue airway management. This is often placed by emergency medical personnel in pre-hospital airway management, but can also be used by hospital personnel as a rescue airway if endotracheal tube placement is not possible.

The King airway tube is angled in such a way so that it is always placed into the esophagus. It has two cuffs, a distal cuff which inflates in the esophagus and a more proximal cuff which inflates in the oropharynx just above the vocal cords. The port that inflates these two cuffs is right here and we always want to test the cuffs prior to placement of the King tube. You will screw on the syringe and you will inflate the cuffs with a volume depending on the size of the King tube.

On each King tube, there are volumes listed on the side—and this one says, 60-80 milliliters, which is the amount of air that is used for inflation of the cuffs.

We will now deflate the cuffs. The King tube has a blue line which helps you direct the King tube anteriorly so eventually this blue line will be directed towards the chin.

Between the two cuffs, there is an opening which will eventually reside just above the vocal cords to allow ventilation of the lungs. When we insert the King tube, we want to lubricate these cuffs with a small amount of water soluble jelly.

The King tube is a stable airway for 8 hours and is a safe rescue airway for transport even from one hospital to another. If you did want to exchange the King tube for an endotracheal tube, you can use an Eschmann stylet which is an intubating stylet and has a short hockey stick curve at one end.

You will insert the stylet with the hockey stick directed towards the blue line of the King tube and it will come out the opening in the tube. Because the stylet comes out angled downwards, you have to first withdraw the King tube further until you have only a small amount of ventilation. Then, when you insert the Eschmann stylet, it can pass easily through the vocal cords.

When you insert the King tube, you want to use your non-dominant hand to pull the tongue forward and then place the King tube with the blue line directed towards the right angle of the mouth. Once the tip of the tube is past the tongue, you will rotate the tube so the blue line is directed towards the chin.

Then you’ll advance the tube all the way down until this red connector is at the level of the teeth. We will then inflate the cuff with the appropriate amount of air, which is 70 milliliters in this size 4 King tube. We then insert a bag valve mask device and you’ll find that it is difficult to ventilate the patient.

With the cuffs of the King tube inflated, you will gradually pull the King tube back one centimeter at a time bagging at each interval. Once the King tube opening is withdrawn over the vocal cords, you will see that you have good chest wall rise and good breath sounds bilaterally.

You can then secure this King tube in place and it is a stable airway for 8 hours. If you do want to exchange the King tube for an endotracheal tube, you have to pull the King tube back even further until you see very little chest wall rise. We will then take off this bag valve mask and we’ll insert the Eschmann Stylet with the curve directed towards the blue line and advance the stylet until it hangs up at the carina.

We then deflate the King tube cuffs. Take off the syringe. And, withdraw the King tube leaving the stylet in place.

Now that the Eschmann Stylet is in place, you can move it towards the right side of the mouth, and use a laryngoscope blade to pull the tongue forward. You do not necessarily need to visualize the cords at this point.

We can now insert the endotracheal tube over the stylet and keep advancing that until you get to the appropriate depth of insertion which is about 23 centimeters in men or 21 centimeters in women. We can then hold the tube in place as we pull out the stylet. At this point, we will inflate this cuff with about 7-8 milliliters of air.

Then, you can attach the bag valve mask to the tube and you get good inflation of both lungs and no air going into the stomach. That is how you exchange a King tube for an endotracheal tube.