Non-Visual Intubation

Techniques

Orlando Hung

Departments of Anesthesia, Surgery

and Pharmacology, Dalhousie UniversityHalifax, Nova Scotia

ObjectivesObjectives

• Non-visual techniquesNon-visual techniques• Light-guided intubationLight-guided intubation• Blind nasal intubationBlind nasal intubation• Retrograde IntubationRetrograde Intubation• Digital IntubationDigital Intubation

Why Do We Need Non-Why Do We Need Non-visual Intubation visual Intubation

Techniques?Techniques?

Why Do We Need non-visual Why Do We Need non-visual Intubation Techniques? Intubation Techniques?

Difficult laryngosopic intubation 1 – 3% Difficult laryngosopic intubation 1 – 3% patients patients

Alternative techniques have been developed Alternative techniques have been developed to overcome this difficultiesto overcome this difficulties

Many of these techniques require expensive Many of these techniques require expensive equipment, and special skill and training. equipment, and special skill and training. Additionally, a lot of these techniques may be Additionally, a lot of these techniques may be difficult to employ in emergency situations, difficult to employ in emergency situations, and in patients with copious secretions, and in patients with copious secretions, vomitus, or blood in the oropharynx. vomitus, or blood in the oropharynx.

Would it not be safer to place a Would it not be safer to place a tracheal tube using a technique tracheal tube using a technique

that is under direct vision?that is under direct vision? In principle, the placement of an In principle, the placement of an

endotracheal tube into the trachea endotracheal tube into the trachea under direct vision ought to be safer.under direct vision ought to be safer.

Intubation is not always possible Intubation is not always possible under vision.under vision.

Most procedures performed in Most procedures performed in medicine are in fact medicine are in fact blindblind techniques. techniques.

Tips to Enhance Oral Trachlight Tips to Enhance Oral Trachlight IntubationIntubation

Positioning:Positioning: head and neck neutral or extendedhead and neck neutral or extended

Adjusting ambient light and retracting Adjusting ambient light and retracting chest tissues for obese patientschest tissues for obese patients

Look for the “cone of Look for the “cone of light”light”

LimitationsLimitations of Light-guided of Light-guided intubationintubation

Blind Nasal IntubationBlind Nasal Intubation

Nasal IntubationNasal Intubation

Occasionally, to Occasionally, to lift the tip of lift the tip of the ETT the ETT anteriorly, it is anteriorly, it is necessary to necessary to inflate the cuff inflate the cuff with 20 mL of with 20 mL of airair

Retrograde IntubationRetrograde Intubation In 1960, Drs. Butler and Cirillo In 1960, Drs. Butler and Cirillo

reported the first retrograde reported the first retrograde intubation in surgical patients through intubation in surgical patients through an existing tracheostomy opening.an existing tracheostomy opening.

The technique was subsequently The technique was subsequently modified by Waters who performed a modified by Waters who performed a cricothyroid membrane puncture cricothyroid membrane puncture using a Touhy needleusing a Touhy needle

Limitations of retrograde Limitations of retrograde IntubationIntubation

The major difficulty of the technique The major difficulty of the technique relates to the inability in determining relates to the inability in determining the location of the tip of the location of the tip of endotracheal tube during intubation. endotracheal tube during intubation. In some situations, the epidural In some situations, the epidural catheter or guide-wire is removed catheter or guide-wire is removed even though the tip of the tube is even though the tip of the tube is mistakenly placed in the vallecula.mistakenly placed in the vallecula.

Modifications of the Modifications of the TechniquesTechniques

Subcricoid punctureSubcricoid puncture

Modifications of the Modifications of the TechniquesTechniques

Subcricoid punctureSubcricoid puncture Through the Murphy eye of ETTThrough the Murphy eye of ETT

Modifications of the Modifications of the TechniquesTechniques

Subcricoid punctureSubcricoid puncture Through the Murphy eye of ETTThrough the Murphy eye of ETT Pull through using a silk suturePull through using a silk suture

Modifications of the Modifications of the TechniquesTechniques

Subcricoid punctureSubcricoid puncture Through the Murphy eye of ETTThrough the Murphy eye of ETT Pull through using a silk suturePull through using a silk suture Flexible bronchoscopeFlexible bronchoscope

Modifications of the Modifications of the TechniquesTechniques

Subcricoid punctureSubcricoid puncture Through the Murphy eye of ETTThrough the Murphy eye of ETT Pull through using a silk suturePull through using a silk suture Flexible bronchoscopeFlexible bronchoscope Light-guided using transilluminationLight-guided using transillumination

Limitations of Retrograde Limitations of Retrograde IntubationIntubation

Any situation that makes it Any situation that makes it difficult to perform a difficult to perform a cricothyrotomy will also be cricothyrotomy will also be difficult to perform a difficult to perform a retrograde intubation.retrograde intubation.

Digital intubationDigital intubation

Tactile digital intubation was Tactile digital intubation was probably first described by Herholdt probably first described by Herholdt and Rafn in 1796.and Rafn in 1796.

Although digital intubation is seldom Although digital intubation is seldom the intubation technique of choice in the intubation technique of choice in modern airway management, this modern airway management, this technique can be life-saving in some technique can be life-saving in some situations.situations.

SummarySummary Laryngoscopic intubation remains a Laryngoscopic intubation remains a

challenge in a small percentage of the challenge in a small percentage of the population. population.

While many alternative techniques are While many alternative techniques are available, they are expensive and not available, they are expensive and not particularly useful for emergency situations particularly useful for emergency situations with limited resources. with limited resources.

Non-visual intubating techniques can play an Non-visual intubating techniques can play an important role in airway management. important role in airway management.

Over the last several decades, these non-Over the last several decades, these non-visual techniques have been shown to be visual techniques have been shown to be effective and safe in securing an airway. effective and safe in securing an airway.

Non-Visual Intubation

Techniques

Orlando Hung

Departments of Anesthesia, Surgery

and Pharmacology, Dalhousie UniversityHalifax, Nova Scotia