Digital Intubation

Digital intubation is an underutilized noninvasive technique for ET tube insertion. The performance of this maneuver requires tactile recognition of the epiglottis. Visual landmarks may be impossible to identify with a laryngoscope because of patient positioning, anatomic disruption, or significant hemorrhage. Tactile digital intubation can avert cricothyrotomy when direct laryngoscopy has failed following neuromuscular blockade. Patients with micrognathia or temporomandibular immobility are poor candidates for the technique.

The patient must be deeply comatose, in cardiac arrest, or in a state of adequate neuromuscular blockade. Prior to insertion, shape the well-lubricated ET tube with a stylet into a J configuration. Then, unless the operator is quite confident, a bite block should be inserted in the opposite side of the mouth. Lift the tongue and pull the mandible forward with your gloved dominant hand. Then insert the lubricated middle and index fingers of the gloved nondominant hand down the middle of the tongue and palpate the cartilaginous epiglottis with the middle finger.

While palpating the epiglottis, insert the well-lubricated J-shaped tube with stylet and slide it along your middle finger. The path from the corner of the mouth opposite the bite block to the epiglottis is the shortest distance. The index finger can help guide the tube from behind. As the larynx is entered, resistance will be encountered. At this point, it is essential to partially withdraw the stylet. Otherwise, the tube will lodge against the anterior wall of the trachea and be difficult to advance. Left mainstem intubation is the unusual complication reported with this technique.

Transillumination

Transillumination with a lighted stylet can facilitate oral or nasal intubation and help to confirm ET tube placement and positioning. This technique is of particular assistance when direct laryngoscopy is anatomically impossible. Oral intubation is easiest with a semirigid stylet. Prior to insertion, transilluminate the patient's cheek. This serves as a check of the ambient light and will predict the laryngeal light intensity. It may be necessary to dim or shield bright ambient light from the neck. Obese patients who do not transilluminate buccally may not do so laryngeally.

For oral insertion, insert the lubricated ET tube with lighted stylet after pulling the tongue forward with a 4- by 4-in. gauze pad. The tube should initially be directed into the ipsilateral pyriform fossa, thus establishing the depth of the epiglottis. Then the tube is slightly withdrawn, and the tip directed toward the midline. The intubator must discriminate between the light emanating from the larynx and the much dimmer light transmitted from the esophagus. Usually the "jack-o-lantern" glow arising from the larynx or trachea is not appreciated when the light source is misplaced in the esophagus. Some manufacturers incorporate timed blinking lights that suggest when it is time for reoxygenation.

For nasal intubation, the flexible stylet or wand instrument is inserted into a directional tip ET tube (Endotrol). After positioning the tube in the retropharynx, very gentle traction is applied on the ring to achieve slight flexion of the tip of the ET tube. Standard training programs for transillumination-guided ET intubation may require didactic, video, and repeated demonstration and practice sessions. 9

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