Blind oral and nasal intubation

blind intubation methods

1. Blind Oral And Nasal Intubation Dr ZIKRULLAH

2. Introduction Airway difficulties are a major concern for anesthesiologists. Fiber-optic intubation →generally accepted method for management of difficult airways, has disadvantages—requires patient cooperation, Cannot perform on soiled airway or upper airways with pre-existing narrowing pathology. Fiberoptic bronchoscopy is not available at every medical institution.

3. NECESSITY OF BLIND ORAL/NASAL INTUBATION Highly innovative and versatile airway equipments may not be available at all locations and also their cost of purchase and maintenance is often difficult. Thus for medical personnel who are responsible for airway management , proper training in blind oral/nasal intubation should still be high on priority to reduce the time to perform blind intubations, increase success rate and decrease the incidence of complications.

4. Endotracheal Intubation -----------indications Routine To provide General anaesthesia Emergency Airway obstruction Oxygenation failure (hypoxia) Mental status alteration (GCS<8/15) Emergency Cardio pulmonary resuscitation Respiratory distress Ventilation failure ( hypercarbia ) Flail chest/Pulmonary contusion

5. Blind intubation Blind procedure → intubation →without a laryngoscope or a view of the larynx → with or without a Bougie .

6. USE/ INDICATIONS Cramped environment (e.g. Patient trapped in vehicle) Copious oral fluids Large amount of blood or vomitus in oral cavity, obscuring visualization with laryngoscope.

7. Inability to visualize vocal cords with laryngoscope Decreased mouth opening, TMJ ankylosis , trismus . Severe head/ neck trauma requiring immobilization of cervical spin e USE/ INDICATIONS

8. Awake blind orotracheal intubation Instrumentation of airway is uncomfortable and distressing to conscious patient. An informed and reassured patient adds to the success of awake intubation. A struggling patient markedly reduces the chances of successful intubation, increases morbidity from cervical or cranial fractures, and accentuates the degree of oral, dental, or laryngeal trauma.

9. Irritation of the larynx or tracheal mucosa during attempted intubation causes significant increase in airway resistance, especially in patients with reactive airway disease or those recovering from upper respiratory tract infection. Hypertension, tachycardia, or dysrhythmias secondary to CNS responses may precipitate myocardial ischaemia , as well as unacceptable increases in intraocular and intracranial pressure.

10. The impact of awake intubation can be minimized with judicious use of topical anaesthesia and conscious sedation Opioid analgesics are used to facilitate awake intubation as they provide mild sedation, analgesia and reduction of cough and bronchospasm . Of the narcotics, fentanyl is most suitable and the greatest advantage is the ease of reversibility by naloxone .

11. Benzodiazepine group of drugs is useful adjuvant to narcotics, midazolam being most popular. When awake intubation is planned, a dose of anticholinergic , such as glycopyrrolate 0.2 mg IV is recommended. The commonly used local anaesthetic agents are lignocaine , benzocaine and tetracaine . Lignocaine is available as 2%, 4% solutions, 2% viscous solution, 10% aerosol preparation and 5% ointment.

12. Pre-requisites of awake intubation A co-operative spontaneously breathing patient. Psychological Counselling of the patient. Informed Consent Optimal Premedication Adequate Local Anaesthesia of the airway with or without sedation.

13. Elements of Awake Intubation(AI) Element Underlying Concept or Action Explanation Patients understand Safety Desiccation Dry the Airway Dilatation Prepare the Nose Tropicalization Obtund Reflexes Sedation Maintain the patient’s airway control Procrastination AI Cannot and Should not be RUSHED

14. Premedication…….why and what Desiccate, → “dry”, prior to the manipulation of the airway, it should be free of secretions because Saliva is a protective barrier – it will protect the mucosa from topical agents. Manipulation of the airway produces more secretions these secretions are an airway stimulant, causing more cough, laryngospasm, etc.

15. Saliva dilutes topical local anesthetic, and decreases it’s effectiveness. Glycopyrrolate is the most favoured drug used for antisialogogue action. 0.2mg of Glycopyrrolate should be given intravenously, at least 20 min before intubation.

16. Nasal Preparation It is to be done in all cases, regardless of intent of nasal or oral intubation. During preparation of the nose much of the effect occurs in areas of the oropharynx by both cross innervation , and passive leak of local anesthetic. A vasoconstrictor is used to decongest the nasal mucosa. This widens the space and reduces the risk of bleeding during manipulation. Oxymetazoline , is the most effective and long acting agent.

17. Sedation Judicious titration – do not give significant boluses of the drugs to prevent over-sedation and hypoventilation. 2) Avoid polypharmacy – stay with one or two agents. 3) Have reversal agents available. Drugs like – Midazolam (0.02-0.03mg/kg iv) or Opioids , Droperidol or Dexmedetomideine can be used.

18. Local anaesthetic regimes : Nebulization Direct mucosal Application Nerve Blocks Infiltration Directly through the bronchoscope (Spray – as – you- go – technique)

19. Three basic approaches of blind oro -tracheal intubation Bougie guided blind oral intubation tracking the epiglottis by two fingers. Thumb guided blind oral intubation. Mouth prop guided blind oral intubation.

20. Blind digital intubation with a bougie ----technique. 1.After adequate preparation, the operator stands to the left of the patient, facing him, the patient is asked to protrude out his tongue.

21. 2. The operator now passes two fingers of his left hand over the dorsum of the tongue and tries to hook the epiglottis upwards. Epiglottis feels like a wet earlobe,

22. 3. After the epiglottis is identified by palpating it with the long finger of the left hand, the Bougie is threaded through the glottis and advanced into the trachea. Tracheal clicking elicits tactile vibrations, which confirm tracheal placement of the Bougie .

23. The bougie is withdrawn slightly so that the 25-cm mark is at the corner of the lip. The endotracheal tube is threaded over the bougie while the bougie is stabilized in place.

24. With the bougie held in place, the endotracheal tube is turned a quarter turn to the left and then advanced to an appropriate depth. The tube is held in place while the bougie is withdrawn. Tracheal intubation is then confirmed using capnography or an esophageal detector device.

25. This technique is more suitable for a deeply anaesthesized patient. In this method, the operator stands at the head end of the table and inserts his left thumb into the patients mouth while keeping rest of the fingers over the patient chin. The tip of the thumb makes contact with the base of the tongue as deep as possible.. Thumb guided blind oral intubation .

26. This gives good control of the lower jaw, with which the tongue can be moved forward and backward as needed. The ETT is now guided into the glottis with right hand.

27. Mouth prop assisted technique In this technique, one uses a LONDON HOSPITAL MOUTH PROP. Here the curved ETT is passed blindly through the Prop, which is placed in the mouth. It is important to keep the head of the patient fully extended as intubation is being attempted. Like above, this technique is also suitable more for a anaesthesized patient.

28. Advantages Fast (in experienced hands) No requirement for optimal positioning Minimal c-spine movement for trauma patients Ideal for those predicted to be difficult airway ( eg . underbite , short neck, obese) Can be used if copious secretions/blood in airway and cannot visualize landmarks

29. Disadvantages Requires training (cadaver or simulation lab) Risks operator trauma from patient’s teeth Airway trauma Patient must be paralyzed or comatose/dead Benefits operators with long, slender fingers

30. The Blind Nasotracheal Intubation Valuable for intubating spontaneously breathing patients with or without sedation, or under general anesthesia. It may be used in elective as well as selected emergent situations by the experienced operator, who may expect that more than 75% of patients will be intubated in less than 1 or 2 minutes.

31. Nasal intubation- indications!! Nasal intubation is performed when the surgery is in the oral cavity Or on the mandible and when the oral route is difficult or impossible e.g. temporo-mandibular joint ankylosis , trismus . Visualization of larynx by direct laryngoscopy is poor

32. Potentially difficult Oro-tracheal intubation include 1.patients with dental fractures, 2.arthritis or dislocations of the temporo-mandibular joints, 3. a small mouth, a short neck or a large tongue, 4. a history of previous head and neck surgery, 5. cervical spine immobility

33. Points to consider : The patient should not suffer from a bleeding diathesis from, for example, thrombocytopenia or oral anticoagulants. Moderately severe epistaxis may result. The nasal mucosa should be gently prepared with phenylephrine , oxymetazolone (Afrin), or cocaine .

34. Local anaesthetics should be considered, especially in the awake, sedated patient. Sedation (or even general anesthesia) may be helpful. Intravenous agents, infused continuously, allow for controlled sedation that is independent of airway and breathing. Place patient's head and neck in the "sniffing position" if not contraindicated.

35. It is a bit easier for right handed operators to use the right nares , though either may be used. If both nares are equally patent, the right nostril may be preferable because the bevel of endotracheal tube will face the flat nasal septum when introduced through the right nostril, reducing damage to the turbinates .

36. This minimizes chances of injury to the septum, turbinates and epistaxis . The inferior turbinates limit the size of the endotracheal tube A 6.0 to 6.5 mm ID endotracheal tube for women and 7.0 to 7.5 mm ID endotracheal tube for men are suitable for nasotracheal route.

37. Technique of awake blind nasal Explain the procedure to the patient. Preparation and premedication for awake intubation. Selection of proper ETT size. Lubricate the ETT and nostril with KY-jelly or @% xylocaine jelly. Right sided nares to be preferred.

38. Operator stands on left/head end. Pre-oxygenation with 100% O 2 for 3-5min. Gently introduce ETT into nostril, concavity facing patient’s feet. Thrust the ETT backwards ,not upwards. Resistance encountered when ETT approaches posterior pharyngeal wall→ retract ETT, extend the patient’s neck → gradually advance →keep on hearing breath sounds.

39. To enhance quality of breath sounds, close opposite nostril, ask patient to breath with mouth closed. Ask th e patient to lift the lower jaw, to lift up the epiglottis. Continue to advance the tube during inspirations until one of the five response positions are reached. Decide which position has been reached, then make the appropriate response:

40. ADVANCE, DECIDE, RESPOND: Position T ( T rachea): This is the goal position! Signs are: breath sound continue through tube, tube continues to advance, patient coughs through tube. Response T : Secure tube. Auscultate breath sounds bilaterally. Confirm ETCO2.

41. Position A (Anterior): Position A can be diagnosed by the following signs: breath sounds continue through the tube, the tube stops (unable to advance further), and the patient coughs (mostly through the tube). Response A : Position A can almost always be converted directly to Position T by slight withdrawal and re-advance of tube while the patient's head and neck are gradually flexed toward the chin-on-chest positon .

42. Position L or R (Left or Right pyriform sinus): Signs are: breath sounds through tube STOP, tube stops (unable to advance), there is NO coughing. Occasionally the tube may be palpable on one side of the neck. Response L or R : Position L or R can invariably be converted into one of the other three (T, A or E) by slight withdrawal (to the point where breath sounds through tube resume) and slow rotation (back toward midline) and re-advance.

43. Position E (Esophagus): Signs: breath sounds through tube STOP, tube continues to advance, there is NO coughing. Response E: Position E can most often be converted to position T by withdrawing the tube until breath sounds through tube resume and then employing one or more of the following (separately or together):

44. How to convert to position T 1. Extend patient's head and re-advance. 2. Largely inflate cuff , advance tube until resistance is felt, maintain some advancing pressure on tube while cuff is slowly deflated . 3. Apply posterior pressure on the larynx and re-advance tube. Most often, position T can be achieved. It only takes a minute or two to find out!

45. Complications of nasal intubation. Increased airway resistance and work of breathing- use of smaller diameter ETT for naso -tracheal intubation. The tube tends to soften and kink in the nasopharynx , →increase airway resistance and make passage of suction catheters more difficult→ airway secretions!!

46. There is increased risk of sinusitis and because of these concerns nasotracheal intubation is rarely used for long-term intubation. Nasal intubation may produce a bacteremia and appropriate endocarditic prophylaxis should therefore precede it.

47. Complications are rarely serious, but can include nasopharyngeal haemorrhage , laryngeal trauma, retropharyngeal perforation, and paranasal sinusitis.

48. Contraindications Acute epiglottitis , Apnoea , Basilar skull fractures with or without cerebrospinal fluid rhinorrhoea , Bleeding diathesis,

49. Upper airway foreign body, Large bilateral nasal polyps, Abscesses and severe Laryngeal trauma . Contraindications