Contrary to popular culture, abdominal thrusts are not indicated. Strategies may include force air, radiant heat, and heat packs. Retrieved Apr. Salomez F, Vincent J. Drowning: a review of epidemiology, pathophysiology, treatment and prevention. A proximal balloon isolates the hypopharynx, whereas the distal balloon occludes the esophagus or the trachea, depending on its location. 2012;129(2):275281. Because of operational difficulties and risks of aspiration, the bagvalvemask is a temporizing measure under most circumstances. Do not terminate resuscitation prematurely. Pediatrics. Long COVID: Could Mono Virus or Fat Cells be Playing Roles? Ann Emerg Med 2002;40:30, Levitan R et al: Head-elevated laryngoscopy position: Improving laryngeal exposure during laryngoscopy by increasing head elevation. Minerva Anestesiologica. As time submerged increases, hypoxia and hypercarbia set in, the brainstem triggers involuntary breathing, and water enters the lungs whether there was a brief interval of laryngospasm or not. Note that these instructions are not meant to replace CPR training. Remember that the root cause of the arrest is hypoxia. Learning Objectives >> Identify the difference between the terms "drowning," "immersion" and "submersion. 20. 2006 Jun;72(6):577-85. Although providers are typically taught to be aware of possible trauma (e.g. Both are common misconceptions. The pathophysiology of drowning is now better understood. With an. Historically, this was known as a wet drowning. While the frequency of unintentional drowning has decreased over the last generation, roughly 10 people still die of drowning every day in the United States, 20 percent of which are ages 14 and under [1]. (May 30, 2012). 10. This can be fairly easily accomplished with blankets, towels, or other material placed under the patients head/neck, or by using the hand to help elevate the occiput. While sequelae and the management of each may vary somewhat depending on the salinity of the drowning medium, salt versus fresh water makes little difference in the prehospital management of the drowning patient. The initial chest radiograph appearance of a near drowning victim may include: Normal lung fields, Atelectasis, Pulmonary edema. Rescue, resuscitation, and reanimation. Waveform capnography is also an excellent indirect measure of perfusion. It was long believed that a significant percentage of drowning victims suffered prolonged laryngospasm, resulting in the proverbial "dry drowning," but a number of studies have disproven that notion [3, 4]. While attempting to visualize the glottis with the laryngoscope in the left hand, by traditional means, the intubator reaches around the anterior neck with the right hand and manipulates the external larynx in all directions while attempting to find a position in which the glottis can be better visualized. $$ Tube 1 is always ventilated first, when confirming placement of the tube. >> List methods of preventing drowning incidents. Following the specific priorities learned during your CPR training is the easiest way to get CPR started for the drowning (or more accurately, near-drowning) victim. In patients who do not require C-spine immobilization, elevating the head so that the laryngeal structures are roughly level with anterior chest wall can also dramatically improve visualization of the glottic opening. As stated, rescuers of near-drowning victims should always ensure their own safety before attempting any rescue, especially an in-water rescue. Extraglottic devices can be used emergently, if no rapid sequence intubation (RSI) protocol exists or endotracheal intubation fails in the field. In drowning victims in cardiac arrest, waveform capnography can reliably confirm tube placement, gauge effectiveness of chest compressions, detect migration or displacement of advanced airway devicesand detect return of spontaneous circulation [7]. Carefully place the person on their back. small object lodged in the nose or mouth. What is the Incidence and Significance of Dry-Lungs in Bodies Found in Water? Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, 6 Minutes of Exercise May Protect Brain From Alzheimer's, 'Disturbing' Rate of Adverse Events During Hospital Stays. Open the tools menu in your browser. Place your ear next to the person's mouth and nose. Retrieved Apr. 'Reach or throw - don't GO'. It may be inserted over a tongue blade or positioned upside down as it enters the mouth and rotated after the tongue is cleared. For an infant, place two fingers on the breastbone. Favorable prognostic factors in clean water near drowning include: Colder water, Younger age. Make sure not to press on the ribs or the end of the breastbone. Securing the airway and assuring adequate ventilation are the first priorities in the resuscitation of any acutely ill or injured patient. Because of the amount of water aspirated by most drowning patients, pulmonary secretions may be a concern, and frequent suctioning may be required. Contact with fresh water, relatively hypotonic to plasma, results in disruption of alveolar surfactant, while hypertonic salt water creates an osmotic gradient that draws fluid into alveoli, diluting and washing out surfactant. &\begin{array}{llllllll} The victim will likely have swallowed a good deal of water in addition to whatever amount may have entered the lungs. The King LT airway is a single-lumen tube with two cuffs, but both are inflated simultaneously at a solitary site instead of the two required on an ETC. Submersion: Submersion means the entire body, including the airway, is under water. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. A pad beneath the occiput improves flexion of the neck. Prevention
Lifeguards and water rescue-trained personnel can take this a step further and start rescue breathing and initiate resuscitation while in the water, all of which contribute to improved outcomes.10. 1996 Aug;12(4):245-8. Blanch L, Romero PV, Lucangelo U. Volumetric Capnography in the Mechanically Ventilated Patient. An old technique that has resurfaced for use in the last few years, called external laryngeal manipulation (ELM), is probably even more successful at obtaining a better look at the glottis. Keep in mind that supraglottic airways, while convenient and effective short-term alternatives to endotracheal intubation, offer limited protection against further aspiration. In the past, it was common to differentiate salt versus fresh water drownings based upon the premise that aspiration of hypertonic sea water could cause fluid shifts, electrolyte imbalances, and lysis of red blood cells. Important basic airway devices to relieve upper airway obstruction from collapsed pharyngeal tissues. Medical Instructions of the XVIII Century to Resuscitate the Apparently Dead: Rescuing the Drowned to Define the Origins of the Emergency Medicine, Emergency MedicineAn International Perspective. Elsevier: Philadelphia, 2012. The most important and detrimental consequence of submersion is hypoxia. A MILD airway obstruction is a condition in which. The past 4050 years of research and experience have given us improved knowledge of the pathophysiology and treatment of drowning injuries. Murder Charges Filed Against Two IL EMS Providers, NY Responders Restore Pulse of Driver Involved in Crash. If bagvalvemask ventilation must be prolonged for any reason, place a nasogastric tube to reduce gastric dilatation and its consequences. Thus, prehospital providers should focus on oxygenating and ventilating the patient and not on aggressive suctioning. 11, 2012, from www.intechopen.com/books/emergency-medicine-an-international-perspective/medical-instructions-of-the-xviii-century-to-resuscitate-the-apparently-dead-rescuing-the-drowned-to. Water regardless of type entering the lungs disrupts surfactant, resulting in atelectasis, pulmonary shuntingand significant ventilation/perfusion (V/Q) mismatch. Archives of Emergency Medicine. Laosee OC, Gilchrist J, Rudd R. Drowning 2005-2009. The drowning process begins with the victims airway submerged beneath the surface of the water. Rescuers should turn the victim on his/her side and clear the airway with fingers or cloth. The study authors noted that active ventilation is required to aspirate water into the lungs; water does not flow passively into the lungs of drowning victims. If possible keep the victim horizontal during the rescue as shock can occur. ", American Academy of Pediatrics: "Drowning.". About Us Our Team Annual Report Our Culture Contact Disclosures, ALiEMU ALiEM Cards Chief Resident Incubator Faculty Incubator Wellness Think Tank, ACEP Annals of Emergency Medicine EBSCO Health-DynaMed Plus Essentials of Emergency Medicine SAEM The Teaching CoOp US Acute Care Solutions Western Journal of Emergency Medicine. Drowning is defined as a process of experiencing respiratory impairment from submersion/immersion in a liquid medium. Because of this, strategies were devised in the 17th century to try and resuscitate victims of drowning. This device has been demonstrated to be easy to insert with limited prior training. 2009;80(7):778783. 1) the victim indicates an airway problem but is able to speak or cough 2) an adult is conscious and . Drowning cases peak this time of year and represent a leading cause of mortality in children. EMS and the fire service, because of their presence in the community, are uniquely positioned to play a major role in drowning prevention and treatment. In patients with intact airway reflexes, placement of either device may cause emesis, gagging, or laryngospasm. Immediate Management of the Compromised Airway. Brenner RA, Taneja GS, Haynie DL, et al. Without a patent airway and adequate gas exchange, other resuscitative measures will usually be futile. The ETC has found favor in prehospital and emergency department settings. Increased density in both posterior lower lobe areas. For example, drowning represents the leading cause of death in boys ages 5-14 years old, and worldwide, there are 500,000 annual deaths from drowning.1 Hypoxic injury and subsequent respiratory failure represent the primary causes of morbidity and mortality. Take a normal breath, cover the victim's mouth with yours to create an airtight seal, and then give 2 one-second breaths as you watch for the chest to rise. Her glottis spasmed and prevented pool water from entering her lungs. Even if a near-drowning victim has been submerged for a long period, CPR may still be effective especially in cases where the water is cold. Table 104. The CDC, AHA, and other multinational medical associations define drowning as a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium.3 During a drowning event, small amounts of water cause laryngospasm, which leads to hypoxia and loss of consciousness, followed by respiratory failure and cardiac arrest. Drowning causes a large burden of disease and injury, with more than 500,000 deaths worldwide. The effects of a near drowning victim inhaling water into the lungs include: Alveolar consolidation, Bronchospasm, Production of frothy and white secretions. All patients with respiratory symptoms (e.g., dyspnea, foam or rales) require high-concentration oxygen and transport. Check Airway and Breathing. Lexipol. Copyright 2023 EMS1. Ann Emerg Med 2003;41:322. Water is almost always cooler than the patient, and nearly all drowning patients will have some degree of hypothermiaeven in warm weather. The fresh drowning victim was an enigma: They looked relatively well but were dead. The effects of drowning present rapidly, and deterioration occurs within hours, not day to weeks later.13Therefore, it is important to educate patients and families when presenting for evaluation after a possible drowning event or with concerns for dry drowning.. 2005 - 2023 WebMD LLC. It has become the most comprehensive and trusted online destination for prehospital and emergency medical services. Alternatively, the King LT airway is now becoming a popular device due to its ease of use and rapid deployment. Drowning: Update 2009. Management of the compromised airway. Inaudible lung sounds or the presence of abdominal sounds suggest esophageal placement. Even strong swimmers can find it difficult to swim with an unconscious person. 1. The bodys natural response is, "OK, if I can drink the lake first, then Ill be able to breathe." Drowning is the second leading cause of unintentional pediatric deaths in the United . Clinical signs of an upper airway thermal injury include: Facial burns, Mucosal edema, Epithelial sloughing, Which of the following conditions occurs in 20% to 30% of hospitalized fire victims with facial burns, A 10 year old patient has inhaled hot gases, and an inspection of her mouth shows edema and blisters. Otherwise, approach the patient from the right shoulder. Suctioning the airway prior to the intubation attempt may improve the chance of a successful intubation using video laryngosopes. 15. Subbarao, I. AMA Handbook of First Aid and Emergency Care, Random House Reference, 2009. Drowning can present with severe respiratory failure as well as hypothermia. The primary goal in the management and resuscitation of the drowning victim is to reverse the hypoxic insult. Lunetta P, Modell JH, Sajantila A. During bagvalvemask ventilation, proper head position must be maintained to preserve airway patency. Despite the presence of non-sterile water, salt or chlorine, the lungs typically recover, and emergency treatment should therefore be directed at interrupting the drowning process by providing oxygenation and ventilation as quickly as possible. All rights reserved. Son K, Hwang S, Choi H. Clinical features and prognostic factors in drowning children: a regional experience. Rescue, resuscitation, and reanimation. Treatment. The ET can then be advanced over the endoscope into the trachea. 2004 Dec. 25(4):291-301. Occasionally it may be the only form of ventilation available in an apneic patient when an airway cannot be secured. Kelly is a member of the EMS1 Editorial Advisory Board. Resuscitation 2000;47:343, Foley LJ et al: Managing the airway in the critically ill patientBridges to establish an emergency airway and alternate intubating techniques. >> African American: The rate of fatal drownings in African Americans is 1.3 times that of whites. These methods will be discussed in the next section. We strive to reshape medical education and academia in their evolution beyond the traditional classroom. trauma to the airway from an accident. Masks equipped with reservoirs and non-rebreathing valves can deliver oxygen concentrations close to 100% at flow rates of 10 L/min if an adequate seal can be maintained between the mask and face. \hline 1 & 2 & 3 & 4 & 5 & 6 \\ Agro F et al: Associated techniques for tracheal intubation. Drowning is the leading cause of unintentional traumatic death in children ages 1-4, the second-ranked cause of unintentional trauma death in children ages 5-9 years old, and the 5th ranked cause of death in children ages 10-14. You should determine whether the airway is patent, whether respirations are present and whether theres a pulse. Keep in mind that supraglottic airways, while convenient and effective short-term alternatives to endotracheal intubation, offer limited protection against further aspiration. Legal Medicine (Tokyo). The phrase they are not dead until they are warm and dead comes from drowning resuscitation. The mask lies over the larynx and seals around the glottic opening. Advanced airway management, if it can be performed quickly by expert rescuers, should be performed if indicated. New Ambulances Narrowly Approved for IN Ambulance Districts, SUV Dangles Off Cliff Over Ocean in CA Rope Rescue, Hartford (CT) HealthCare Agrees to Purchase American Ambulance in Norwich, Eight People Shot, One Critical at FL MLK Day Event, Baby, Teen Mom Among Six Killed in CA Shooting. Examples of the types of surgical procedures that often result in atelectasis include all of the following EXCEPT: All of the following conditions can lead to atelectasis EXCEPT: Chronic obstructive pulmonary disease (COPD), Which of the following is (are) precipitating factor(s) that can decrease the patients ability to generate negative intrapleural pressure. A non-rebreathing valve permits this reservoir air to enter through a separate port from air that is being expired. Insert it through the least obstructed nostril, advancing it posteriorly along the floor of the nostril until it bypasses the tongue. This aligns the axis of the airway with the mouth and pharynx, facilitating direct visualization of the cords during intubation. Steedman DJ, Robertson CE. &\text { BAC clone }\\ This article was originally posted Mar. Evaluate breath sounds after placement of either device to ensure that obstruction has not occurred. Special Considerations
All these physiological functions are interrelated. A GCS, rectal temperature, blood glucose level, and brief trauma survey should be included in the initial evaluation. In the past, a patient who asphyxiated from laryngospasm or didnt involuntarily gasp prior to asphyxiation was termed a dry drowning. The more typical course described above was called a wet drowning. As discussed later, these terms have little use and are no longer recommended in the medical discussion of drowning. This method may be easier for a single operator, because both hands can be used to seat the mask. finds relevant news, identifies important training information, Before attempting intubation, preoxygenate the patient with 100% oxygen for 5 minutes or have the patient perform eight vital capacity breaths. It was previously thought that this fluid was coming from the lungs, but its now recognized that much of it comes from the stomach. These pulmonary secretions also necessitate vigilant monitoring of capnograph waveforms, and frequent replacement of sidestream capnograph adapter and tubing if it becomes occluded. &\begin{array}{cccccc} American Heart Association: "Hands-Only CPR simplifies saving lives for bystanders. Airway positioning, suction, and administration of 100% oxygen must precede any attempt at advanced airway control. If the patient is alert, inform him or her of your plan. Knowing the benefits and limitations of waveform capnography in these patients and how to troubleshoot equipment will help guide the provision of oxygenation and ventilation. Table 102. If an ETC or King LT airway is in place, it may be used temporarily for continued resuscitation, but a premium should be placed in establishing a cuffed, endotracheal intubation. For the adequately perfusing drowning patient with spontaneous breathing, CPAP may accomplish the same thing. 28, 2016. There are several special considerations in the treatment of drowning victims. While placing gentle traction on the tongue, pass the assembly into the mouth. 5. Modell JH. In the patient with respiratory compromise or arrest, but with adequate perfusion . As the common pathophysiology in all types of drowning death is profound hypoxic insult, oxygenation and ventilation are the most effective tools in managing the drowning patient. Orlowski JP, Szpilman D. Drowning, Rescue, Resuscitation, and Reanimation. In patients with known or suspected cervical spine (C-spine) injury, all assessments and maneuvers should be undertaken with the C-spine immobilized in a neutral position to prevent cord injury. All of the following are risk factors for obstructive sleep apnea EXCEPT: A 10 year old girl was rescued from a school swimming pool, where she was found unconscious, and transported to a nearby hospital, where her lungs were discovered to be dry. cervical spine fracture) when evaluating a drowning case, less than 0.5% of drownings are traumatic.2 The duration of immersion, volume of aspirated fluid, and water temperature dictate clinical outcomes.1 We review the presentation, pathophysiology, and management of drowning to raise awareness about this important public health issue. Even if water enters the lungs during this period, its typically only a small amount (24 mL/kg). Although this chapter focuses on treatment, prevention is possible, and pool fencing has been shown to reduce drowning and submersion injury (Class I). The effects of a near drowning victim inhaling water into the lungs include: Alveolar consolidation, Bronchospasm, Production of frothy and white secretions. Just as in other respiratory-based issues, the bodys systems will shut down due to the lack of oxygen, and can easily result in the rapid onset of brain damage (this usually occurs faster in children than in adults). King County last compiled preventable drowning death statistics for the years 2008-2012 (link to pdf here). The Global Burden of Disease: 2004 Update. Crit Care Clin 2000;16:429, Levitan RM et al: Airway management and direct laryngoscopyA review and update. 11, 2012, from www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. This may be called Tools or use an icon like the cog. A recent retrospective study of 247 patients who received ECLS following a drowning event suggests a 23.4% survival rate of patients placed on ECLS during cardiac arrest.11, Confusing language used by news outlets and spread on social media has led to misguided fear of complications weeks after exposure to water. bacterial . 1990 Sep;7(3):129-34. Remember that the inflammatory cascade triggered by aspirated water contacting pneumocytes may require positive-end expiratory pressure to recruit and retain patent alveoli. Do Not Sell My Personal Information. The laryngeal mask airway (LMA) is a device that has proven to be useful as an alternative for bagvalvemask ventilation and as a rescue option in the difficult airway. In contrast, an adult will struggle for approximately 60 seconds before they become submerged. In: M. Kliegman R, Stanton B, St. Geme J, Felice Schor N, E. Behrman R, eds. After intubation, suction the tracheobronchial tree with a sterile, flexible catheter as necessary. Tracheal placement results in a bright, well-circumscribed area of transillumination at the cricothyroid membrane. 2. All attempts to suction or clear this foam from the airway only delay much-needed oxygenation and go against most dogma of airway managementthe patient is dying from cerebral anoxia and not foam in the upper airways. In the typical medical cardiac arrest, the patient has suffered a cardiovascular event (e.g., heart attack, stroke or arrhythmia). Drowning remains a significant public health concern, as it is a major cause of disability and death, particularly in children. Prehosp Emereg Care. Drowning. Tube 2 (smaller tube) is open distally and gives a direct route to either the lungs or the stomach. Monitor the effectiveness of ventilation closely by frequent assessments of chest wall movement, lung sounds, and gastric dilatation. In one study of 598 autopsied drowning victims, 98.6% had water in their lungs [3]. He has anAssociate of General Studies degree fromLouisiana State University at Eunice, Nunez Community College. Further assessment may include pulse oximetry, arterial blood gas measurement, end-tidal CO2 capnography, and chest radiography. The bagvalvemask unit has a self-inflating reservoir that accepts 15-L/min oxygen flows. If breath sounds are louder on the right than on the left, suspect right mainstem intubation. Make sure not to press on ribs. 2010;103(7):650653. The bagvalvemask unit is the device most commonly used to provide positive pressure ventilation in the emergency department. British Medical Journal. Clear the airway of obstructions, using a rigid suction catheter to remove any blood, vomitus, or secretions from the oropharynx. The stylet is threaded into an ET. allergic reaction. Do . A lighted stylet can also be combined with direct laryngoscopy. Please refer to Chapter 7 for complete discussion of basic laryngoscopy and orotracheal intubation technique. In drowning victims in cardiac arrest, waveform capnography can reliably confirm tube placement, gauge effectiveness of chest compressions, detect migration or displacement of advanced airway devicesand detect return of spontaneous circulation [7]. Pediatrics. Treatment
Suction equipment must be available. The former is preferred in pediatric patients as to prevent trauma to the soft palate. Brenner RA, Saluja G, Smith GS. WebMD does not provide medical advice, diagnosis or treatment. Unconsciousness typically occurs within four to six minutes of submersion. Relative Contraindications for Orotracheal Intubation. Anesthesiology. Place the heel of one hand on the center of the chest at the nipple line. In addition, aspirated fluid produces vagally-mediated vasoconstriction and pulmonary hypertension. Press down at least 2 inches for a child, about 1 and 1/2 inches for an infant. The process of drowning begins when the victims airway is submerged below the surface of the water. Although theres some injury to the lungs during the drowning process, the final common pathway of all morbidity and mortality is hypoxia with resultant anoxic brain injury. Outcomes reporting for drowning was classified as death, morbidityor no morbidity; other non-standard terminology such as dry drowning, wet drowning, near drowning, active or passive drowningor delayed drowning are discarded. A head-elevated laryngoscopy position has also been found to be successful in increasing the view of the glottic opening. If emesis occurs, release pressure on the cricoid to prevent esophageal rupture and aggressively suction the hypopharynx. The primary goal in the management and resuscitation of the drowning victim is to reverse the hypoxic insult. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. 2001;48(3):627646. If adequate personnel and equipment are available, immediately perform endotracheal intubation. As in all conditions, the primary assessment is key to treatment. The most important thing to remember is that for anyone who is unresponsive and isnt breathing, CPR needs to be started immediately. Intubation via this method does require significant practice to become proficient. Thus, attention to the airway must precede or occur simultaneously with any other type of management. Although some patients will present with minimal symptoms, others may have amnesia to the event, or even hypothermia and cardiac arrest in severe cases.4 Witness accounts of the incident are important to obtain, but many drowning cases are unwitnessed and the patient may have little recollection.1, In cases involving a short episode of submersion or a small aspiration event, symptoms may be mild and include coughing, shortness of breath, and nausea or vomiting.1However, longer submersion events put patients at risk for hypothermia, altered mental status, and cardiac arrest. Tube 1 (larger tube) is closed distally with side holes for ventilation. Gathering together the latest research, news, videos, and training, CapnoAcademy is the ultimate resource for EMS professionals interested in learning more about all things Capno related. Mpox Has Faded in the U.S. Who Deserves the Credit? In Centers for Disease Control and Prevention. These devices utilize indirect laryngoscopy and can be particularly useful in difficult airway patients including those airways complicated by large body habitus or limited neck mobility. 21. The tube is inserted blindly and is fairly stiff, so that it usually enters the esophagus. This procedure shares the same complications as other blind techniques: inadvertent malpositioning of the tube, hypoxia, and tissue damage. A ten-year Australian study showed that for the victims who received compressions, 86% vomited. Because of reports of esophageal trauma, some authors recommend Gastrografin swallow or endoscopy after use of an esophageal obturator airway (EOA)-like device. The first person to encounter the patient is often a bystander, first responder (e.g., lifeguard or law enforcement) or EMS provider. In fresh water, osmosis works in the opposite direction, diluting the blood, destroying red blood cells, and altering electrical activity in the heart. The need for aggressive airway management and ventilation along with high-quality chest compressions is the key to the resuscitation of the drowning victim. Two baseballs, each with a mass of $0.148 \mathrm{~kg}$, are separated by a distance of $395 \mathrm{~m}$ in outer space, far from any other objects. Steps for Mouth-to-Mouth Resuscitation. As such, conventional CPR techniques with artificial ventilation should be performed, rather than cardiocerebral resuscitation techniques utilizing passive oxygenation. However, weve learned a great deal about the pathophysiology of drowning during the past 40 years.5. Do 30 chest compressions, at the rate of 100 per minute. While above the water, a child will typically struggle . Cardiol Clin 2002;20:23, Levitan R et al: Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators. Classes are available through the American Red Cross, local hospitals, and other organizations. The mouth-to-mask technique is another method of providing positive pressure ventilation. Retrieved Apr. Its important to understand the differences in treatment priorities in drowning when compared with standard emergency medical care. These pulmonary secretions also necessitate vigilant monitoring of capnograph waveforms, and frequent replacement of sidestream capnograph adapter and tubing if it becomes occluded. 28, 2016. Backward, upward, rightward pressure (also known as the BURP maneuver) on the external larynx by an assistant to the intubator has been used with some success to increase the intubators view of the glottic opening.
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